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Editor's Note: Commentary based on Forman DE, LaFond K, Panch T, Allsup K, Manning K, Sattelmair J. Utility and efficacy of a smartphone application to enhance the learning and behavior goals of traditional cardiac rehabilitation: a feasibility study. J Cardiopulm Rehabil Prev 2014;34:327-34.

Background

New mobile health technologies may offer ways to electronically link cardiac rehabilitation (CR) programming to patients in-between visits, especially in those with barriers to learning and adherence. In this study, the utility of a mobile smartphone application (app) for improving patient knowledge, behaviors and adherence, was tested as an adjunct to traditional CR programming.

Methods

The authors conducted an observational pilot study among 26 cardiac patients enrolled in Phase 2 or Phase 3 CR at a community hospital in southeastern MA. Patients had to be current users of an iPhone, iPad or iPod (Apple Inc., Cupertino, CA), English speaking, without communication barriers, and agreeable to use a mobile, e-health tool. The experimental Heart Coach® mobile software (Wellframe, Inc. Boston, MA) was downloaded by patients and used for a 30-day period. The mobile app was built around the hospital's established CR protocol and delivered a suite of tasks to patients each day, including to-do lists, medication reminders, educational content (via text and video), physical activity prompts, an exercise measurement tool (via the device's accelerometer), survey questions (to assess symptoms, barriers and overall status), and responses to staff messages. Task completions were tallied and cleared at the end of each day. For CR staff, a web-based dashboard allowed real-time monitoring of each participant's progress, connectivity to patients via one and two-way secure messaging, and the ability to individually tailor tasks depending on patient progress. Patient outcomes measured were: acceptability and use of the tool, engagement with the tool to complete daily tasks, and qualitative feedback. Staff outcomes were: use of the dashboard, perceived value and measured impact on patient adherence.

Results

Patient engagement with the mobile app was high. Patients received an average of 6.3 tasks per day and completed an average of 78%, including 88% of education tasks, 82% of survey questions, 79% of medication reminder tasks and 49% of exercise tasks. Ninety-percent completed at least one task. Qualitative assessment was also positive. Ninety-six percent of patients reported a clear understanding of how the app supported their CR experience, 93% indicated that it helped them maintain adherence, 83% had a positive experience with the app, and 71% felt it improved the quality of on-site session visits.

Staff engagement was also high. Staff sent a total of 825 messages (an average of 32 per patient) over the 30-day period, including 10 two-way messages (71% of which were answered). One nurse spent an average of 20 minutes per day reviewing patient progress and the electronic interactions of patients and staff. Qualitative feedback of the tool by staff was good.

Only one quality outcome was retrospectively measured. Among patients in Phase 2 CR, those using the mobile app had a 42% lower session cancellation rate than those not using the Heart Coach® app (1.9 vs. 1.1 cancellations per month). No other clinical outcomes were measured.

Conclusions

The authors concluded that integrating mobile e-health technologies into traditional CR programs is feasible and viewed positively by patients and staff. Moreover, they suggest that mobile care apps like Heart Coach® offer promise for extending the benefits of CR to more patients, perhaps at a lower cost, the principal goal of accountable care.

Perspective

There have been calls for implementing elements of the chronic care model, including 'health care delivery redesign,' to improve secondary prevention of coronary disease. This pilot study suggests that mobile care apps for CR and other secondary prevention programs might be one way to accomplish this task. The authors have shown that a downloadable, interactive, clinician-designed, nurse-led electronic program that delivers patient education, reminders, surveillance, monitoring and feedback via a mobile device is safe and feasible. Moreover, they demonstrated that this particular e-health care tool was widely used, possibly due to its user-friendly platform and the high degree of connectivity to caregivers that it provided to the patients. However, the small number of patients studied, and the short duration of the pilot, raise the question of how well the tool would perform, among patients and staff, in a larger group over an entire 12-18 week CR time-frame, and beyond. The findings also raise broader questions—is this mobile care app a tool for 'amplifying' the traditional CR care model, as the developer suggests? Or could it replace traditional CR, and usher in wide implementation of less costly, home-based programs by health care systems seeking to transition to value-based care? Likely, it could do both. However, before these applications can be considered, the ability of mobile care apps to improve exercise capacity, diet scores, risk factors, psychosocial, and other quality measures in broad subsets of CR patients, and be cost-saving (or cost-neutral), will need to be tested in randomized controlled trials.

Keywords: Caregivers, Cell Phone, Coronary Disease, Data Collection, Delivery of Health Care, Diet, Goals, Hospitals, Community, Mobile Applications, Malus, Motor Activity, Patient Compliance, Patient Participation, Pilot Projects, Risk Factors, Secondary Prevention, Telemedicine, Telephone, Retrospective Studies

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