Mobile Health: A Brave New World

November 26, 2013

 Andrew Isham and Dr. Bret Shaw, mobile health researchers at the Center for Health Enhancement Systems Studies (CHESS) and NIATx, have co-authored a chapter in a new book, Health Communication: Strategies for Developing Global Health Programs.

The chapter, titled “Developing and Testing Mobile Health Applications to Affect Behavior Change: Lessons from the Field,” focuses on how to design mobile (mHealth) applications that can be potentially powerful tools for behavior change. The authors are also part of the team that has developed A-CHESS, the mobile phone-based relapse-prevention system that offers support to alcohol and drug dependent people when and wherever it is needed.
In the Q&A that follows, Isham shares his experiences related to this rapidly expanding field of research.

Q: Who is the intended audience for Health Communication: Strategies for Developing Global Health programs?

A: The book is written for researchers and clinicians, but is really for anyone involved in or interested in the field of health communications. Health communication technology is exploding right now, and there’s a lot of hype, both positive and negative, about its possible impact on behavioral health. Some think that mHealth is the answer to many issues in behavioral health, from the treatment gap to treatment modalities. Others perceive mHealth as a passing fad, or worse, a threat to quality treatment. This book offers a balanced view that I think puts a check on the hype and addresses the concerns of those who are not entirely convinced of the potential benefits of mHealth.

Q: The chapter that you wrote with Dr. Shaw covers mobile health or "mHealth" applications. What is the definition of an  mHealth application? 

A:  Right now, most mHealth applications are software programs delivered through a mobile device such as a smartphone. These applications are being developed at an amazing rate, and the app stores (Apple’s iOS App Store, Google Play Store, the Amazon Appstore) offer thousands for people to purchase. These apps help people manage health issues ranging from diabetes and obesity to smoking cessation and medication adherence. 
While smartphones are currently offering the majority of mHealth applications, other devices on the market now or expected to be in the near future include wearable devices such as fitness trackers, smartwatches, and GoogleGlass. It won’t be long before we see a proliferation of other less conspicuous mHealth applications such as clothing that monitors vital signs, or algorithms for early diagnosis of mental health disorders using data that is already in the cloud.

Q: What are some of the benefits that mHealth offers the field of behavioral health?

A: The ability to unobtrusively capture lots of data that may be used to create individual behavioral models that predict key behavioral moments and provide custom intervention in real time. In this way, mHealth can help diagnosis and intervention to move from the clinic to the patient’s “in vivo” environment. In the current model, people receive treatment primarily in a clinic setting—but they recover out in the community. Mobile health gives people access to their treatment at all times. In a sense, they can carry their treatment with them. Or better yet, their treatment is with them at all times without them having to think about it. For example, A-CHESS, the application that I’m working on as part of the study team at CHESS (the Center for Health Enhancement Systems Studies at the UW-Madison) has a feature that allows a patient who is struggling with a trigger to access a peer support network or a counselor at any time. This aspect of mHealth can give clinicians more information—or perhaps more useful information—in a more timely fashion about what’s working and what’s not working in a patient’s treatment plan. It changes the definition of “in treatment” and allows clinicians to make adjustments tailored to the patient’s needs more quickly.

The data available from mHealth applications also allows for proactive rather than reactive treatment. A-CHESS, for example, has a weekly check-in feature that people use to make an inventory of their thoughts, feelings, and potential triggers, and how they react to them. In our first study of A-CHESS, this was a tool clinicians could use to react to a patient’s relapse. Now, it’s become a tool that alerts both the patient and the clinician to a possible relapse, and can prevent it: either A-CHESS will offer the patient a strategy for preventing relapse, something that’s proven effective for that patient in the past, or A-CHESS will engage a counselor to intervene. Mobile health also has the ability to promote integration of behavioral healthcare with primary care, or a movement from silo-ed to integrated care. We know that many people with substance use disorders also suffer medical problems related to their substance use—but care for the multiple issues is not connected. mHealth data may eventually lead to a deeper understanding of how behavioral health and primary care issues are interrelated, as well as provide opportunities to intervene in a manner that honors this systemic nature.

Q: What do you consider to be some of the drawbacks of mHealth applications?

A:  One of its great advantages—the access to timely data—also presents greater potential for abuse by payers, employers, and anyone who has a financial stake in healthcare.

All the hype surrounding mHealth right now presents a drawback, as it’s creating a polarization between those with opposing views about its benefits. Some techies consider mHealth an inevitable panacea, and some traditional practitioners consider it a threat to what really works. I think both are misguided. This polarization could slow down adoption of really useful applications.

Privacy is a big concern that is being addressed at research institutions that are developing mHealth apps, as well as government agencies such as the FDA. Again, all that data could be abused.

Another issue is quality. There are a lot of ways for an mHealth application to fail. A good idea could be crippled by a sloppy user interface. A well-designed and useful application might become obsolete if it’s not updated to keep up with improving operating systems. And no mHealth application is going to have long term effect unless the users (patients or clinicians) believe in it and are not burdened using it. Consumers and clinicians will need assistance in selecting quality applications that cover all the bases.

Q: In addition to the book, what are some other resources available now that people can turn to for more information on mHealth? 

In the ATTC Network, the National Frontier and Rural ATTC is doing a lot of work on telehealth to improve access to treatment.

To keep up with the latest in mHealth, check out mHealth News ( For a thought-provoking and balanced take on the future of mobile technologies, read Jaron Lanier’s books, You are Not a Gadget  and Who Owns the Future?

Andrew Isham, M.S., is a researcher at the Center for Health Enhancement Systems Studies, University of Wisconsin - Madison. Isham has a BS in mechanical engineering, a minor in psychology, and an M.S. in industrial engineering, with a specialization in health systems engineering. Isham is the director of development for the randomized clinical trial for Addiction-CHESS (A-CHESS), a smartphone application designed to help patients leaving inpatient addiction treatment avoid relapse. 

What happens if they say "Yes"?

November 21, 2013

Catherine Ulrich Milliken, M.S.W., LICSW, MLADC, LCS 
Program Director,The Dartmouth Hitchcock Medical Center Addiction Treatment Program 
Instructor, Psychiatry 
Geisel School of Medicine at Dartmouth.

In my last blog post, “Start with the Why,” I wrote about how the Addiction Treatment Program at Dartmouth Hitchcock Medical Center is using the NIATx process to implement SBIRT across settings—in our case, in the Medical Center’s OB-GYN clinics.

Since then, our change team has made some exciting discoveries, and I attended the SBIRT Training of Trainers (or TOT-October 14–16, Kansas City) offered by the National Screening Brief Intervention and Referral to Treatment ATTC. Many thanks to Laurie Krom, director of the ATTC for sponsoring me, and to the fabulous trainers, Holly Hagle and Jim Aiello of the National SBIRT ATTC.

The overall goal for the training was to help trainers develop the knowledge, skills and abilities needed to effectively train others on the various tasks involved in providing SBIRT services. We learned about the conceptual framework of SBIRT as a public health model and its impact as a system change initiative. We reviewed and practiced the skills necessary to provide, and train others to provide, screenings, brief interventions, and extended brief interventions. We also discussed the business of SBIRT including information on reimbursement for services. Thanks to the training, I feel ready for the challenge of training my team members and others on SBIRT—but more about that later.

Our change team tackled our first barrier with a month-long PDSA Cycle in October focused on the question: How do we ask? Specifically, how do we ask pregnant women about their alcohol and substance abuse use?

Concerns had been raised about pre-screening women for substance use with their families and partners present. The change team suggested a change in practice that some thought would be impossible: separating the patient from family members to conduct the pre-screen about substance use and to ask questions about domestic violence. The team anticipated push back from the patients and their families and had concerns about offending them. What we discovered, much to our surprise, was that no one was offended or refused.

With this success, it was clear that the change team was gaining confidence and ready to move forward with creating a workflow diagram to map the flow of SBIRT in the clinics. They were also eager to learn how to administer the screening tools and conduct brief interventions, so the timing of the SBIRT Training of Trainers could not have been better.

The team recognized several areas of need regarding training. They identified the need to provide a department-wide training on the SBIRT initiative and the change team’s progress to date. They also expressed concerns regarding training on administering screening tools, conducting brief interventions and treatment and an overall refresher on current drugs of abuse.

After we reached consensus on our SBIRT Process Map for clinic flow, we agreed to explore dates for a grand rounds training on SBIRT and the change team’s progress. We also selected dates for me to conduct an implementation training for the change team to allay their fears about “What happens if they say yes!” As a trainer, my challenge will be to condense a two-day training into an hour long grand round presentation and a series of 1.5-hour provider trainings. Having attended the TOT, I feel ready for the challenge and confident that I have the resources and the network I need to move forward.

The Specialty Clinic for Pregnant Women (the “T” in our SBIRT adventure) that I wrote about in my previous blog post is getting a lot of attention, and we are working to enhance the program by partnering with various experts in the field of pediatrics and early intervention. Bonny Whalen, MD (medical director of the Newborn Nursery at Dartmouth-Hitchcock Medical Center assistant professor, Department of Pediatrics, Geisel School of Medicine at Dartmouth) came and spoke to our clinicians and our patients about Neonatal Abstinence Syndrome (NAS). She was so warm and reassuring, answering all of the questions and concerns raised. Dr. Whalen is working on a pilot program with our women so that they will be able to room in with their babies if they need treatment for NAS.

What has become clear to us is that this partnership of integrated care is benefiting all involved. As we continue to share our experience, new champions come forward, and our vision becomes clearer and more comprehensive, despite the perceived barriers. Our change team invites you along for our next challenge: training and implementing SBI. We welcome your feedback, experience and wisdom!

We hope you find this blog helpful as you consider implementing SBIRT across settings. Below are some useful resources on SBIRT and SBIRT Trainings:

Catherine Ulrich Milliken, M.S.W., LICSW, MLADC, LCS, is the Program Director for The Dartmouth Hitchcock Medical Center Addiction Treatment Program and an instructor in Psychiatry at the Geisel School of Medicine at Dartmouth. Previous academic appointments included University of Southern Maine, University of New England, and University of New Hampshire. She has worked passionately to improve the care and treatment of women's mental health and substance issues for the last 15 years. Before working at Dartmouth, she was the Director of Outpatient Services at Crossroads for Women, which provides gender‐specific and trauma‐informed outpatient programs and services for substance abuse and mental health, as well as residential rehabilitation and halfway house services for substance abuse in Portland, Maine. During that time, she also saw clients in private practice, specializing in adult psychotherapy, substance use and women's issues and worked with clients struggling with HIV and AIDS diagnoses. She conducts training on the basics of chemical addiction, tools for leading groups, exploring the relationship between substance abuse and child maltreatment, and women's treatment concerns, among other areas. 

Happy Birthday, ATTC Network!

November 15, 2013

Maureen Fitzgerald
Communications Coordinator, ATTC Network
Editor, NIATx

2013 is a big year for the ATTC Network: this year, the Network celebrates 20 years of helping the addiction treatment and recovery services field adopt and implement evidence-based practices. Over the past two decades, the Network has worked to build the knowledge and skills of the workforce that addresses the needs of people with substance use or other behavioral health disorders.

The continuing support from SAMHSA’s Center for Substance Abuse Treatment has allowed the Network to evolve and grow into a vital resource for the field, bringing researchers and clinicians together to address the ongoing need for effective treatment. Thousands of clinicians have been trained in evidence-based practices. And because of the work of the ATTCs, the concept of technology transfer as a process that extends from research design through implementation in treatment programs has become standard knowledge.

How much do you know about the ATTC Network and all that it has accomplished in the past two decades? Test your knowledge with the 20 Questions Challenge!  Be the first to answer all the questions and you’ll win an ATTC messenger bag filled with 20 ATTC products and other goodies. 

(Hint: You can find answers to all 20 questions on the ATTC website.)

The ATTC 20 Questions About 20 Years Challenge

1.   In what year was the ATTC Network founded?  (Yes, that’s a giveaway….)
2.   How many states does the ATTC Network cover today?
3.   What are the ATTC Network’s priority areas?
4.   When did the ATTC publish The Change Book: A Blueprint for Technology Transfer?
5.   When did the NIDA/SAMSHA Blending Initiative begin?
6.   The ATTC Network also covers the Pacific Jurisdictions. What locations do they include?
7.    Where is the first international ATTC and in what year was it created?
8.    When did the Network complete the national workforce study, Vital Signs?
9.    How many Regional Centers comprise the ATTC Network in 2013?
10. What are the names of the National Focus Area ATTCs?
11.  Where are the offices of the Network Coordinating Office located?
12. When did the ATTC and NIATx launch the Service Improvement Blog?
13.  What is the name of the Network’s monthly electronic newsletter?
14.  How many courses does the ATTC eLearn currently offer?
15.  Which monthly webinar series hosted by the Network offers the opportunity to earn continuing education credits?
16. How many video views are there on the ATTC YouTube account?
17. Which ATTC Network website resource serves as a term and definition resource for the field?
18. What is the name of the ATTC Twitter account? (Hint: @......)
19. Which ATTC electronic publication features views on technology transfer from leading researchers?
20. Which ATTC web resource provides information on institutions that offer degrees in addiction studies?

Submit your answers to: by 5pm on Tuesday, December 31,  2013. We’ll announce the winner and provide the answers in an upcoming blot post. Good luck!