1. “Creating Smart Health Decision Opportunities through M-
health for Health Literacy Challenged Diabetes Patients”
 Customized diabetes education & communication
interventions according to health literacy level and survey data
 Track longitudinal patient behavior over time by
qualitative/quantitative methodology (SPSS, R-Method)
 Increase patient knowledge, ownership of disease,
engagement, resulting in cutting health costs 8%
Stanford University, School of Medicine, “Mobile Health without Borders Project, “ March
2014
Dolores Richards, MBA, RN, Kamalpreet Hara, Vanessa Simic, Tejaswi Tamminedi, BsEE,
David R Donohue, M.A. , Team Leader

2. Problems
• Diabetes patients lack
– Medical health literacy
– Knowledge of their disease process
– Ability to assist in their own disease management
– Proactive ownership of their wellness
– Dealing with fear, pain, health system confusion
and lack of self management
– Medication and treatment compliance

3. Benefits of Patient Self-Management
• Increased knowledge of health condition
leading to
– Increase / Maintenance of Quality of Life
– Savings in Cost of Health Care, Goal of 8% HC
Savings
– Patient Engagement, Disease Ownership
• Increased MD and Clinician effectiveness
– Time devoted to “health solutions” rather than
emergencies

4. Interactive Media
• Interactive tools/games (NVS Literacy and Q-Method
Survey)
• Data Warehouse
• Data Mining
• Data Analysis
• Decision Support
• Interactive Learning Environment
• SMS, E-Mail, IVR, Web, Cell, Social Media
• Tools that sell wellness to patients and care givers

5. Powerful Clustering Methods and
Algorithms
• Create interactive attitudinal profiles of patients for
– Assessing patient medical literacy
– Tracking patient health status over time
– Monitoring patients for health status change “triggers”
– Creating/choosing health interventions
– Identifying user learning types
– Creating custom incentive packages for patient attitudinal
type, follow behavior patterns over time.

6. Our MHealth system isn't just another app. Rather, it engages patients via their own phones with their primary-
care providers on a daily basis, sending reminders and reinforcing self-care behaviors that match a diabetic
patients specific literacy level and factor group traits. Such approaches work best in systems where financial
incentives are aligned and where the technology can synch with electronic health records (EHRs), neither of
which is the norm as yet. Measure patient Health Literacy Level using Newest Vital Sign instrument
 Measure patient knowledge of their HbA1c, BP and Cholesterol condition and medical care experiences by
qualitative/quantitative methologies
 Identify and understand patient factor-group traits (opinions feelings and attitudes) influencing health education
and disease management experiences by subjective survey methods
 Create new M health educational interventions based on literacy level and factor group traits using SMS, E-
mail, IVR, Laptop, Kiosk as communication channels
 Monitor HbA1c, BP and Cholesterol levels and patient self management variables by SPSS,R-Method analysis
 implement HIPAA data security and patient privacy protocols, encrypted technology. Database security on all
provider/patient information and data
PROJECT TECHNICAL APPROACH

7. Partners
• Patient Primary and Physician Groups
• Health Care Delivery Systems
• Managed Care Companies (ACO’s)
• Insurance, Other Health Payors
• Phone/Internet/Digital Service Providers
• “Premium” Partners: Federal/State govt.
• Technology Companies, AT&T, Google

8. A Pilot SMS M-Health Research
Model: Financial Costs
March 2014
Even with the best health care available, patients with chronic
illnesses (diabetes) typically spend no more than a few hours a year in a
health care setting, while their outcomes are largely determined by their
activities during the remaining 5,000 waking hours of the year. As a
widely available, low-cost technology, mobile phones are a promising tool
to use in engaging patients in behavior change and facilitating self-care
between visits.
Cost Model Estimate per 6-month Daily Cell
Phone SMS diabetes Education Program
Base cost per diabetic patient $575 p/p
Breakout is $150.00 for technology;
$225.00 for staff; $200 facility/resources
COSTS OF TRADITIONAL DSME EDUCATION: Individual Diabetes Self Management Education (DSME) Initial
Visit, $158.00 Per One-Hr Visit:* Individual DSME, Follow Up, $79.00 Per 30 Minutes:* Group Diabetes
Management – Four Two-Hour Class Sessions,$120.00 per Two-Hr.;* Continuous Glucose Monitoring,$380.00;
General Nutrition Therapy – One-on-One, Initial Visit, $117.00 Per One-Hr Visit; Nutrition Therapy – One-on-One,
Follow Up, $69.00 Per 30-Minutes; Medical Nutrition Therapy, Initial, visit $132.00,Per 60 Minutes; Medical
Nutrition Therapy, Follow Up, $80.00 Per 30 Minutes; Pre-Diabetes – Four One-Hour Class Sessions,$26/ Each
One-Hour; Medical Nutrition Therapy Group, $30 Per 30 Minutes session; Medical Nutrition Therapy Reassess ,
$30 Per 15-Minutes: (source ICD codes) *First Ten Hours of Diabetes Education Per Year/PP
APPROXIMATE COST $1,247.00. NOTE: 37% of U.S. Type-2 diabetes patients need to repeat the initial
diabetes educational instruction series of classes.

9. Face to Face Interviews
M.D. Gastroenterology, Clement J Zablocki VA Medical Center,
Milwaukee, WI, March 2014
We would consider testing as a pilot Research Project
Literacy and provider/patient communications are critical to all
HC encounters and outcomes, benefiting all stakeholders
Project need refinement and focus as to actual outcomes
Overall a good beginning in developing solutions to a complex
ongoing challenge
What People are saying about “Creating Smart Health Decision
Opportunities through M-health for Health Literacy Challenged
Diabetes Patients.” March, 2014

10. Face to Face Interviews
What People are saying about “Creating Smart Health Decision Opportunities through M-health
for Health Literacy Challenged Diabetes Patients.” Interview conducted, Monday, March 3rd
, 2014
Marketing Communications VP, March 2014
The project needs metrics (ROI) before we consider
Overall has a good premise, lacking details
Needs links to strong partnerships
Continue developing the data and information security
element; that’s the #1 priority

11. Face to Face Interviews
What People are saying about “Creating Smart Health Decision Opportunities through M-health for Health
Literacy Challenged Diabetes Patients.” Interview conducted, Froedtert Hospital, Wauwatosa WI cafeteria
Sunday, March 2nd
, 2014
Diabetes Clinician/RN Summary
• Patients hide their literacy level
• They need simple wording/layman terms
•They have poor understanding of meds and treatment routines
•HIPAA data and security are key to success
Diabetes Patients Summary
• Want simple explanations/instructions
• Want information in layman terms
• Want friends/relatives as support
• Want additional information available
• Communication is a two way street
•Privacy and Information security very important

12. Interviews conducted New York City, NY- March 2014
Face to Face Interviews: Asked to 10 Medicare Advantage Members telephonically
Questions: telephonically for face to face 10 Medicare Advantage Members:
1. Do you have a cell phone?
2. Do you use it for telephone calls only?
3. Do you text?
4. Would you like to get a daily text reminder to do your finger sticks/weigh yourself?
5. Do you get on the internet to look up information about your diabetes/heart condition/hypertension?
Responses:
1. Do you have a cell phone? 10/10 said yes they have a cell phone.
2. Do you use it for telephone calls only?7/10 7 stated clearly that they only use cell to make calls.
3. Do you text? 0 none of the 10 use text.
4. Would you like to get a daily text reminder to do your finger sticks/weigh yourself?0 All 10 said they would not like text
reminders.
5. Do you get on the internet to look up information about your 5/10 diabetes/heart condition/hypertension? 5/10 50%
Medicare Advantage Members do use the internet to look up information pertaining to their diseases diabetes/heart
condition and or hypertension.
What People are saying about “Creating
Smart Health Decision Opportunities
through M-health for Health Literacy
Challenged Diabetes Patients.”

13. What People are saying about “Creating
Smart Health Decision Opportunities
through M-health for Health Literacy
Challenged Diabetes Patients.”
INTERVIEW: March 2014
Retired-2013, United Healthcare Insurance Executive , Chief Medical Office, M.D.
David-Here are my thoughts. Very nice 4-blocker (quad chart). Concise, easy to read. Good concept. Here are some
thoughts--to take or leave:
--I really like the tie in/sync with the Primary Care Provider and EHRs. So many projects leave this essential team member
out.
--You set a goal of 8% cost reduction. There are so many variables that can contribute to that and sometimes it takes a long
period of time to demonstrate cost savings. Sometimes initial costs go up when people realize they need additional
services--e.g. a comprehensive eye exam. Wonder if some shorter term measurable goals might be better--e.g. 10% drop in
HgA1c within six months, 10% drop in LDL, increased activity measured through a smart phone pedometer.
-- Is there a way to demonstrate interactivity and participant engagement? E.g something participants must do. Social
psych studies show stronger adoption and commitment when a participant performs some action however small.
Good luck with this -- sounds like an excellent opportunity!

14. Health Literacy:
The Life Blood of Provider/Patient
Communication & Understanding

15. Advancing Clear
Health
Communication to
Positively
Impact Health
Outcomes

16. How Big Is the Problem?
More Than 90 Million People in the US Have
Difficulty Reading and Writing
Approximately 40 to 48 Million
Adults in the US Are
Functionally Illiterate
Approximately 54 Million
Are Marginally Illiterate
Average Reading Skills of
Adults in the US Are Between
the 8th
and 9th
Grade Levels
Cannot Perform
Basic Reading
Tasks Required to
Function in Society
Have Trouble
Reading Maps and
Completing
Standard Forms

17. Low Health Literacy Impacts a Patient’s Ability to Fully
Engage in the Healthcare System
The Largest U.S. Study Conducted to Date
on Health Literacy Found That…
33% Were unable to read basic health
care materials
42% Could not comprehend directions
for taking medication on an empty
stomach
26% Were unable to understand
information on an appointment slip
43% Did not understand the rights and
responsibilities section of a
Medicare/Medicaid application
60% Did not understand a standard
informed consent

18. Who Is at Health Risk for Low Health Literacy?
 Anyone in the US – regardless of age, race,
education, income or social class – can be at risk for
low health literacy
– Ethnic minority groups are disproportionately affected
by low health literacy
– The majority of people with low literacy skills in the US
are white, native-born Americans, with H.S. diploma
– Older patients, recent immigrants, people with chronic
diseases and those with low socioeconomic status are
especially vulnerable to low health literacy
– 2014, new research has pointed to 15-35 year olds as
literacy challenged. PISA research study, 18% of 15 year
olds are only reading at a class 2 level (solving basic
reading tasks)

19. Finding a
Solution

20. Solutions:
Focus on Care Providers/Patient’s Educational
and Communication Materials and Harness ALL
Channels in One Voice
Healthcare Thought Leaders:
Agree that focusing on the patient-provider relationship
would provide the most immediate and impactful
solution to the issue of low HL
2/3 feel that low HL is driven by poor patient/doctor
communication and comprehension levels
Believe that providing easy-to-understand health
information is key, and understanding the needs of
each patient, as an individual from their viewpoint

21. A Picture of One American
City’s Reading Culture in
2014
“The New American Global
Standard?”
America’s least literate city
1. Bakersfield, CA
> Weekday newspaper circulation per 100: 10.1 (14th lowest)
> Pct. adults with college degree: 20.5% (9th lowest)
> Retail bookstores per 10,000: 0.84 (6th least)
> Median income: $53,693 (12th highest)
Bakersfield ,CA was in 2014 the worst city in the U.S. for its overall reading culture. The city was
among the worst in the nation for access to bookstores, as well as subscriptions to magazines and
scholarly journals. There were just two magazines with at least 2,500 subscriptions in the city in
2013 and no journal publications at all. There was just one independent bookstore in the city last
year and just 30 retail book outlets for the city’s more than 350,000 residents. The city’s library
system was also poor rated, with low circulation rates and understaffing. Low demand for reading
materials could reflect low educational attainment rates — just 77% of adults had a high school
diploma in 2012, among the worst nationally. The trend is a continual downward spiral.

22. “Creating Smart Health Decision Opportunities through M-health for Health
Literacy Challenged Diabetes Patients”
Creating Health Literacy in Primary Care Team, Stanford University, March 2014
Kamalprett Hara, Dolores Richards, MBA, RN, Vanessa Simic, Tejaswi Tamminedi, BsEE, David Donohue, M.A, Team Leader
SYSTEM ARCHITECTURE
TECHNICAL APPROACH
Technology involved, cell phones, SMS, IVR, E-mail , Video, digital
communications.
1. Determine patient parameters
2. Determine digital instrument protocols
3. Identify patient levels of literacy and comprehension and design
customized health education messages
4. Breakdown patient population into medical literacy groups
5. Analyze patient outcome data using SPSS, R-Method for monitoring
A1C, BP, and cholesterol levels, adjust communication as needed
6. Integrate results into treatment planning, address changes in
patient needs over time.
7. Adaptation to wireless technology (cell, PC, smart phone etc.)
8. Set a goal of reducing patient health care costs by 8%
PROJECTI OBJECTIVES AND DELIIVERABLES
The goal of this project is to develop an innovative diabetes digital
communication device and communicate customized educational
messages using cell phones based on the patient literacy level (1) Literate
(2) Literate Likely (3) Literate Unlikely. This is done by using NVS Newest
Vital Sign health literacy instrument. In addition, each diabetics patient ‘s
opinions, feelings and attitudes will be measured by a
qualitative/quantitative instrument, (Q-Method) resulting in disease literate
factor groups with similar traits.
 Establish new levels of understanding and communications between
patient and provider
 Increase patient’s knowledge and ownership of the disease and treatment
 Increase patient safety and quality of life
 Every diabetes patients now classified into a factor group with individuals
of similar traits (feeling, attitudes and opinions)
SURVEY OBJECTIVES AND DELIVERABLES
 Survey methodology is an objective way of analyzing subjective patient
data which allows assessment of reliability and validity
 Uses qualitative /quantitative methods to allow respondents to say
something about their own subjective attitudes that can be tested,
measured and compared
 Uses quantitative factor analysis (SPSS ,R-Method), data reduction and
induction to generate testable hypotheses
 Generating customized communication interventions based on data and
tested information
 Determine each factor groups specific medical education interventions
 Longitudinal , historic record of chronic disease patients progress and
status trends over time.
 Meet HIPAA data and patient security and privacy requirements