Managing Patient Care Through mHealth

Rebecca Schnall’s research focuses on informatics strategies for people from underserved communities, primarily people living with and at risk for HIV. She has conducted research on the use of an electronic reminder for HIV screening in the Emergency Department that provided significant insights to policy makers and clinicians, demonstrated the usefulness of a web-based tool for improving symptom status, and led studies that provided the foundation for the CDC’s development of mobile applications for HIV prevention and care. She was recently installed as the Mary Dickey Lindsay professor of Disease Prevention and Health Promotion at Columbia Nursing. Schnall earned a BS in history from Northwestern University, an MPH from University of Illinois at Chicago, a BSN from Pace University and a PHD in Nursing Informatics at Columbia Nursing. Schnall teaches informatics and qualitative methods courses to DNP and PhD students. She also advises PhD students and postdoctoral research scientists. Schnall is a fellow of the New York Academy of Medicine.  

You are the co-principal investigator on a $7.9 million NIH grant that will test an HIV prevention mobile app developed specifically for high risk young men. You’ve developed additional informatics tools that help patients manage HIV and other symptoms and make decisions about their own healthcare. How are mobile innovations improving health outcomes and helping to overcome societal health disparities?

There is a shortage of health care providers, particularly in primary care, and we have a fragmented health care system. mHealth is a promising field that allows patients to engage with their own care by managing some of their health information and, as appropriate, their conditions when they are unable to see a provider.

Studies have shown short-term improvements in health outcomes when mobile apps were used for smoking cession, glucose management for diabetes and treatment for schizophrenia. This technology can also potentially reduce the duplication of services like blood draws and immunizations by serving as a hub that collects health data from multiple sources that patients can access in one place.

For the NIH grant, our research team is designing a mobile health app that will deliver HIV prevention information to diverse, 13-18-year-old men at risk for HIV. Our research has revealed that this population is the least likely to visit a healthcare provider and that mobile apps can be an effective way to reach them. We have also found that mobile apps can provide a safe place to access health information for teenagers who may feel stigmatized about their sexual health and behaviors.

What inspired you to become a nurse and nurse researcher?

I always knew I wanted to work in healthcare, but I thought I needed to gain an understanding of people outside of the basic sciences. I studied history as an undergraduate to explore the connection between circumstances and human character. After earning a BSN and a Master’s in Public Health, I worked as a pediatric nurse. It was a rewarding experience, but I felt inspired to enact change on a systems level and improve healthcare at the population level. When I worked as a nurse on a sub-acute pediatrics floor, all of the patient records and medication orders were paper-based. This was an error-prone and inefficient system. But implementing an electronic system that automatically checked for errors when conducting dose calculations based on patients’ weight could have saved time and potentially lives. I wanted to become a nurse researcher so that I could work on creating solutions for nurses and other healthcare providers to make their work more efficient, and allow them to provide better patient care.

Why did you decide to pursue your research subject area of underserved populations, including those at risk and living with HIV?

As a Masters of Public Health student, I had a formative experience. I shadowed the attending physician in a large, Chicago Emergency Department (ED) for a practicum I took on improving the patient intake procedure. I saw many patients wait in the ED for hours to be cared for asthma symptoms that could have been controlled through the use of self-management strategies. They often missed work which meant their children could not go to school. This is also inefficient and expensive from the provider perspective. If those patients had primary care providers and were educated about self-care, they might have been able to avoid the trip to the ED as well as avoiding a loss of productivity for themselves and their families. This experience inspired a later research study I conducted on the impact of mandatory HIV testing in New York State EDs. Through our work, we found that clinical decision support systems increase HIV testing rates in the ED and also make it more likely to test those persons who are affected by the illness. The use of technology can therefore improve efficiencies in care, reduce duplication of services and ultimately decrease overall healthcare costs.

We have efficient ways to link HIV patients to care and help them manage their disease.  No one wants to wind up being an AIDS patient, at risk for opportunistic infections and unable to work. In the US and the developed world, HIV is a chronic illness where many people could take a pill once a day and enjoy a high quality of life. If someone is diagnosed with HIV at 18, they can anticipate living to 65 years old with very few comorbid conditions. This is an amazing statistic, but we have to think about the efficiencies we need to test people and link them to care and make it accessible for more people. These findings are true across many chronic illnesses in which we can allow people to access care, self-manage their illness and then go on to live productive lives with a high quality of life.

There are hundreds of thousands of health apps available which can make it overwhelming for health professionals to find those that are the most appropriate for their patients. What are some tips on how nurses and nurse practitioners can use mHealth tools to support their patients?

Unfortunately, no central clearing house exists where all healthcare apps are vetted. However, healthcare providers can do two things.

First, nurses and NPs need to vet who built the app. They should find out if it was produced by a healthcare organization, the government or a pharmaceutical company and then determine if it is something that will enhance their work and benefit the patient.

Second, they need to have a conversation with their patient. Ask them if the app is something they are willing to use to track their medications or perform other tasks. Apps cannot replace providers, but can be used as an adjunct to the care we deliver.