Nearly 20 years ago, David Miller, MD, MS, a physician with a background in computing and economics, envisioned a need to create digital health education materials. He and his colleague and friend, Ajay Dharod, MD, FACP, teamed up to create the system that today is known as mPATH™, or Mobile Patient Technology for Health. They perceived a growing need for preventive health screening along with a blossoming opportunity presented by burgeoning digital and computing technologies.
Miller is now the associate director of the Clinical and Translational Science Institute, director of the Center for Healthcare Innovation's Digital Communication Core, and professor of Internal Medicine. Dharod is assistant professor of General Internal Medicine and Implementation Science, and vice chair of the Department of Internal Medicine’s Informatics and Analytics group. Their brainchild, mPATH, gives patients expanded access to screening and was perfectly poised to fill a virtual health tool need during the pandemic. mPATH allows clinical providers an option for capturing information digitally, engaging patients in their own health care and reconnecting with patients after they may have skipped their annual appointments.The platform currently consists of mPATH-CRC, which is designed to increase screening for colorectal cancer (CRC), the second-leading cause of cancer deaths in the United States, and mPATH-Lung, which is designed to boost screening for lung cancer. mPATH is one of the many research projects supported by the Center for Healthcare Innovation.
mPATH for Colorectal Cancer Screening
mPATH-CRC for colorectal cancer screening is currently delivered in the primary care setting. Upon arrival at the doctor’s office, all patients received an iPad for routine screening. Those who have been identified via their electronic health records as potential candidates for colorectal cancer screening are presented with a pre-programmed colorectal cancer screening module on the iPad with a series of health-related questions and decision aids designed to educate them about colorectal cancer risks and the benefits of screening. Patients are then presented an opportunity to opt in for screening, essentially “ordering” their own tests.
As of September 2021, over 30,000 patients have used the program, and studies have shown that it leads to a dramatic increase in colorectal cancer screening, typically by people who are long overdue for or have never undergone the screening. “The program has already identified over 2,000 patients who are overdue for colorectal cancer screening, with 79% of those patients never having been screened for colorectal cancer before. “We’re clearly reaching patients that we traditionally have not been reaching,” says Miller.
“The fundamental concept helps patients drive their own care, through informed and shared decision making,” Dharod says. “The current version of the program is novel – instead of simply asking patients about colon cancer screening, the program offers patients the ability to request a screening test and tell your doctor you want it. We’ve found that the ability to let patients select and “request” their own test is one of the more powerful features of the program,” Miller adds.
With the inclusion of the several routine check-in questions, the program also benefits the clinic staff and optimizes the patient’s time with staff and physicians. “Our goal is to empower patients to manage their care and offload common, routine tasks from busy health care professionals, freeing up the professionals’ time to focus on those things that really only they are uniquely qualified to do,” says Miller.
mPATH-CRC is currently being used in clinics throughout the Atrium Health Wake Forest Baptist system. A cloud-based asynchronous version is under development.
"The concept helps patients drive their own care, through informed and shared decision making” - Ajay Dharod, MD, FACP
mPATH for Lung Cancer ScreeningThe next mPATH module under development is mPATH-Lung, a web-based application accessible by patients on their home computers, tablets, or smartphones. The program educates patients on the risks and benefits of lung cancer screenings and determines if they qualify.
The mPATH team is currently conducting a randomized pragmatic clinical trial (see sidebar) to assess the effectiveness of the intervention. Miller explains: “We are reaching out to randomly selected patients across Atrium Health Wake Forest Baptist and UNC Health, the two participating academic centers. We have an automated algorithm that runs against the electronic health records of both systems every week. It identifies patients who may qualify for lung cancer screening, who may not even realize it. Then, we send them either a text message or a patient portal message inviting them to visit mPATH and learn more about some information that could improve their health.”
Approximately 1,320 patients will be enrolled in the study. The trial is designed to tell the researchers how effective the strategy of reaching out to patients digitally is in terms of getting more people screened for lung cancer, and whether the outreach is effective in reaching all different patient groups equitably across the health system. Preliminary results are expected by mid-2023.
“With the pragmatic study, because our program delivers guideline-recommended care, none of the care we’re giving is experimental,” says Miller. “For that reason, there’s no additional risk to patients. Our program does exactly what best care principles say we should be doing,” he adds.
Dharod elaborates: “There are many elements in medicine where the risk-benefit ratio is unclear or the benefits only slightly outweigh the risks, but there are a few things like vaccinations, preventive cancer screenings, or other preventive care, where the benefits are incredibly high, and the risks are low. Those are the services we think are valuable as asynchronous from a clinical visit while ensuring that the patient and the provider are still tied into the care paradigm.”
The primary care physicians are sent summary letters of program usage to keep them in the loop.
mPATH: an academic learning health system in practiceOne of the core concepts of an academic learning health system is the inherent ability to accelerate the process of adoption of new knowledge into clinical practice. mPATH embodies that idea.
Miller agrees. “We are able to leverage the value of an academic learning health system, where we have all of the tools already in place for us to learn from the incredible amount of data that our health system generates every day just in the process of giving usual care. That’s how we can learn how to make that care even better and more impactful for our patients.”
Benefits to Taking the mPATH
Since mPATH has been in use in the real world, the team has already learned that it contains several distinct advantages over previous approaches.
- Privacy: Patients are often more comfortable answering health-related questions on a digital device than they are discussing such matters with people.
- Consistency: The questions and screening education are presented exactly the same way every time, eliminating potential variations when people ask the questions or present the information.
- Reduced bias: When people ask the questions and record the answers, they may consciously or unconsciously introduce bias.
- Access: Leverages widespread smartphone ownership and internet access.
- Overcoming literacy barriers: All material is presented in lay language, and the use of graphics, animations, and narration helps comprehension. In testing with 166 low literacy patients, over 93% reported the program was easy to use and that they felt very confident using it.
- Patient Engagement: Empowers patients to become active participants in their own health care, while maintaining doctor-patient and nursing staff-patient relationships.
The mPATH Forward
As is the case with so many digital innovations, the next step in the evolution of mPATH is clearly going to involve making it widely available in the commercial marketplace and extending it’s impact.
They say there is great interest in the technology. “As we publish more data on the effectiveness, accuracy, usability and reach of the software, we are receiving more attention from other institutions,” says Dharod.
The colorectal and lung cancer screening modules may be only the beginning for mPATH. Dharod notes that any care paradigm that can be “algorithmized” could be a candidate for addition to the mPATH platform.
“We purposely created mPATH to be a digital health navigation platform that we can use with any chronic care or preventive care need,” says Miller. “There are so many potential use cases. One of our biggest challenges is prioritizing what we do next, because there are so many people coming to us with great ideas.”
From Individual to Population
One of the beauties of mPATH is its unique position to specifically address the wants and needs of individual patients while also yielding benefits on a population level.
“This is personalized medicine at its best,” says Dharod. “We take a population that we think is eligible and ask, ‘Are you truly eligible?’ Then we say, ‘OK, let’s do some informed decision making. Here are the risks, here are the benefits of the potential screening test. Then we do a personalized risk assessment based on your individual risk factors, your age, we ask a few more questions about your race, your ethnicity, your smoking history, and other detailed questions. We come up with a personalized risk assessment, and then the most key component is the patient indicating ‘Yes, I do want that service’ or ‘No, I don’t’ or ‘I’m not sure.’ And then you can triage. Those that want the service should be able to immediately get referred to a health system, get that service, and send a summary to the primary care clinicians. Those who say no or are unsure, maybe they need a follow-up touch point to understand their values and perspectives to make the right decision for that patient - personalized medicine.”
“We see mPATH as a great tool for population health,” says Miller. “That’s really the goal with where we want to scale it, being able to deploy it across a population of patients, giving them the power to help manage their care.
"The valuable lessons we’ve learned through our academic learning health system clinical partners have been crucial to our success." - David Miller, MD, MS
The mPATH to SuccessMiller and Dharod emphasize that over the years, mPATH has been very much a team effort. “Dave and I are the faces, but there have been so many people involved who made key contributions. We are filled with gratitude for all the hard work” says Dharod. He specifically identified the collaboration with the Center for Healthcare Innovation, Information Technology Services and the Department of Internal Medicine’s Informatics and Analytics team as being crucial to mPATH’s development and success.
Miller cites the critical role played by the ongoing partnership between the research side and the clinical arm. “You have the academic researchers like me and others who are developing the study protocol,” he says. “We’re using implementation science to deploy the program in a way that supports sustainability over time. And of course, we cannot do our work without our clinical partners who are on the front lines graciously willing to try the program with their patients. The valuable lessons we’ve learned through our academic learning health system clinical partners have been crucial to our success.”