Dialogue4Health

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Public Health Institute

Digital Health Solutions to Advance Health and Well-Being for Vulnerable Populations

Thursday, August 18, 2016

12:30 – 2:30 p.m. EST

Remote CART Captioning

Communication Access Realtime Translation (CART) captioning is provided in order to facilitate communication accessibility and may not be a totally verbatim record of the proceedings. This transcript is being provided in rough-draft format.

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>> Laura Burr: Welcome to today's Dialogue4Health forum on digital health solutions to advance health and well-being for vulnerable populations, brought to you by Public Health Institute, in partnership with the Center for Information Technology Research in the interest of Society, known as CITRIS, at the University of California. This event is sponsored by the Aetna Foundation. . My name is Laura Burr, and I will be your host for today's event.

Before we get started, there are a couple of things I'd like you to know about. First of all, realtime captioning is provided by Home Team Captions. The caption window is located on the panel on the right side of your screen. Click on the media viewer icon on the top right of your screen. If you're on a Mac, you'll see it on the bottom right of your screen.

If you would like to use captioning, you'll see a link in the captioning panel that says, "Show/hide header." If you click both of those links, you'll be able to see the captioning more easily. And if the captioning window ever disappears, click the media viewer icon to bring it back again.

Today's Web forum is listen-only. That means that you can hear us, but we can't hear you. That doesn't mean, though, that it won't be interactive. We'll take your questions during the Web forum, and you can type those questions at any time into the Q & A panel. The Q & A panel is located on the right side of your screen, and it can be toggled on and off by clicking the Q & A icon that you'll see at the top right of your screen. Again, if you're on a Mac, you'll see that icon on the bottom right of your screen. In the Q & A panel, it's very important that all panelists is selected. If it doesn't say "All panelists," please make sure to choose that option so that your question gets sent to the right place. You can also use the Q & A box to communicate with me if you're having audio issues. We're really interested in your thoughts and questions about today's presentation, so please be sure to submit them in the Q & A box, and we'll try to answer as many of them today as we possibly can.

Next, we'll conduct a quick poll. Just select your answer, and then click the "Submit" button. So here's today's poll. You can read it there on the screen. And now, we'll open the poll for you. You'll see it appear on the right of your screen, and you'll be able to select from one of the four choices, and then when you've made your selection, just click the "Submit" button. So please let us know, are you attending this alone? Are you attending maybe in a small group of two to five people? Are you in a larger group of six to ten? Or perhaps you're in a large room today with all of your colleagues? That would be more than ten. And we can see the responses coming in now. And just let us know who you're attending today's event with, and if you made a choice and didn't click the submit button, please click submit now, and I'm going to go ahead and close the poll. It will take a few moments for the results to tabulate. Once you're done answering the poll question, click on the media viewer icon to bring back closed captioning if you'd like to see that.

And we'll have to get back to that poll in just a second. Okay. And Valerie, if you can take the host role there for a moment, that will help us out. And then we'll be able to get to the next slide. Thank you, Valerie!

>> Valerie Steinmetz: No problem.

>> Laura Burr: So we're just having a little bit of a slowdown on my side. So thank you for your patience while we get things picked up again. And then we can move on to introducing all three of our presenters. I'll go ahead and tell you about who will be joining us today on this event.

In just a moment, you'll be able to see their pictures. I'll introduce them now.

So first, I'm very pleased to welcome Public Health Institute's Andrew Broderick. Andrew leads PHI's efforts to advance the design and planning, implementation and valuation of Mhealth programs. He has extensive experience evaluating mobile technology interventions among underserved populations, and in leading user experience research and conducting focus groups and interviews with all level of stakeholders in healthcare settings. He serves as co-principle investigator on this Aetna Foundation funded digital health solutions for vulnerable populations project.

Also joining the conversation today is Dan Gillette. Dan works at the intersection of design and culture with a special focus on education, public health, disability, civic life, accessibility and healthcare. Dan is a research scientist at CITRIS at UC Berkley, and an independent product, experience and curriculum designer at CITRIS. Dan focusses on design research with a special focus on developing inclusive and -- oh, Valerie, we can -- put you on hold, please. Valerie, can you go ahead and -- sorry.

>> Valerie Steinmetz: Sorry, everybody.

>> Laura Burr: Thank you for jumping in. Valerie was helping out with a technical difficulty. So now you're able to see everybody's picture there. And I was going to say, Dan focusses on design research with a special focus on developing inclusive and co-design methods that enable all stakeholders to equally govern and contribute to the design process.

And last, but not least is Valerie, along with Andrew and Dan, we'll hear from Valerie Steinmetz today. Valerie manages a portfolio of projects and programs at Public Health Institute, focused on accelerating innovative programs and the diffusion of technology-enabled chronic disease care that benefit older adults and those with advanced illness. So welcome! And now, over to our presenters, I'm very happy to have Andrew, Dan and Valerie with us.

>> Valerie Steinmetz: Thanks, Laura.

>> Laura Burr: Thank you!

>> Valerie Steinmetz: So before we start, we just wanted to show everyone what the registrants look like in terms of where the audience is from. So we have a very large distribution within the U.S., which is wonderful to see, and we also have additional countries like Australia, Canada, Colombia, Mexico. We have Puerto Rico, too, and UK.

And then when asked are you part of an organization that works directly with vulnerable populations, we have over 80% of registrants that said yes. And now I'd like to turn it over to Andrew Broderick.

>> Andrew Broderick: Good morning. Good afternoon. Thank you for joining us today for this webinar presentation on Digital Health Solutions to advance health and well-being for vulnerable populations. This is a project sponsored by Aetna Foundation through its innovation and underserved communities program and is a collaboration between PHI's Center for Innovation and Technology in Public Health and the Center for Information Technology Research in the Interest of Society, which is a program of the UC campuses at Berkeley, Davis, Merced and Santa Cruz.

So for today's program, we'd like to introduce focus group research that has been conducted in three communities in June and July of this year. To review the data and insights from focus group surveys and focus group discussions and highlight opportunities for improving digital health solutions for use by vulnerable populations. And finally, to identify some strategies for advancing research and promoting use of digital health solutions by vulnerable populations.

So to begin, just to give a definition of vulnerable populations, our definition includes individuals who span the age continuum, are low income, are foreign born, are persons with disabilities, as well as racial and ethnic minorities, formerly homeless, formerly incarcerated and refugee and immigrant populations. Many of these populations experience an increased burden of poor health and variations in access to and utilization of health services due to socioeconomic status, health, functional or developmental status, age and gender and cultural background. They also reflect broad diversity in terms of belief systems, religious or cultural values, life experiences and group identity that can impact their receptiveness to and the effectiveness of interventions designed to reduce their risks for health disparities.

Digital Health Solutions reflect the convergence of sensor, analytical and mobile technologies to offer an opportunity to realize new and potentially innovative forms of health services.

The project's core activities involve two main areas of work. The first were community engagement listening sessions to develop our core understanding of the actual and potential role for digital technology in reducing health disparities, as well as user-centered design requirements. And secondly, a national review of best practices for digital health solutions to try and identify those interventions that are most meaningful, appropriate and impactful for vulnerable populations.

Community listening session goals had, at its kind of core, the goal to develop understanding of the level of technology access and use among vulnerable population -- how do they use those devices, and what their experiences are when using those devices. The extent to which technology provides access to and effective use of health resources. So, for example, looking for health information, engaging or interacting with patient portals, using health apps and engaging in structured communication with healthcare providers.

And finally, our goal was to develop some user-centered design principles for effective technology use and sustainability that addressed some concerns around security and privacy and inter-operability.

The national best practice review goals were to identify some digital health solutions to apply to the prevention and be management of chronic conditions, as well as facilitating linkages for residents and communities to resources that would benefit their health. Methods involved interviews and key -- with key stakeholders and review of the national literature on the current state of practice, evidence of outcomes and best practices for deployment. Our primary goal through this best practice review is to select three best practices in design, implementation and sustainability, and we can talk further about that towards the end of this presentation.

Moving it to the community selection, I just want to review the methodology to the planning and implementation of focus groups. Our primary criteria were to focus on social and economic hardship as the kind of first kind of selection criteria for identifying communities. We pre-selected a number of cities in consultation with the foundation, and selected three of those. And using a tool from the community commons, we were then able to select communities within those three cities.

Those three cities that we identified were Louisville, New York City and Miami-Dade County. And within each of those communities, we identified -- at Louisville area, we identified the South -- sorry, the Miami-Dade kind of inner city metro area, Liberty City, Little Havana, Overtown, Winwood and communities like that, as well as in the New York City area, we focused on the South Bronx and specifically on the Morrisania and Criptona area. Each community was selected because they offer distinctiveness in terms of their geographic and demographic diversity, as well as experiences with health disparities for focus groups to be able to provide meaningful inputs to the community engagement listening sessions.

Our project goals also compliment local community health assessment and planning activities taking place in those communities, and align well with the local stakeholder organizations, as well as local funder strategic interests. And the local organizations that we partnered with in each community also expressed high levels of interest in our goals and mission, and a motivation to partner in the planning and implementation of our focus groups. We also conducted extensive background research on health challenges and indicators and needs in each community through review of county and neighborhood community need assessments and health improvement plans to identify at-risk communities, and we also conducted scans of digital health solutions available in those communities to inform the design of the focus groups. So just to give an overview of the focus group before we go into some of the findings, our design goal was to have ideally eight to ten participants age 18 years and older in each group. In some cases, we had more participants involved, and each participant did receive a token incentive for the time and commitment and contribution shared through their participation.

Our format for the focus groups was 30-minute consent and pre-focus group survey completion, followed by a 90-minute focus group discussion. In each of the three communities, in Miami-Dade, we partnered with the local government agencies and Linda Quick, who is past president of the South Florida Hospital And Healthcare association to conduct outreach to local service organizations to host seven focus groups. In the South Bronx, we also partnered with the local government agencies and ten local service organizations to host 14 focus group populations.

And in West Louisville, we also partnered with the local government agencies and nine local service organizations to convene and host 14 targeted focus group populations.

This slide just gives a representation of all of the organizations that were partner organizations in convening and hosting focus groups. Our populations, if we look at them in terms of distribution across the communities, we had in one community persons living with HIV AIDS. We had parents of children with behavioral healthcare needs. And we also had one workforce group of home health aides in New York City. Two communities had representation of physically disabled persons, faith-based organizations, immigrant and refugee populations, neighborhood center clients, formerly incarcerated populations and victims of domestic violence. And in all three communities, we had representation of residents of public housing, FQHC general patient populations, pregnant women and mothers, formerly homeless, in supportive housing, older adults, including, in Miami, a PACE Program, and finally, addiction treatment and recovery clients.

Our data collection methods, as I indicated earlier, included a baseline survey on demographics, technology use and health behaviors, and we also conducted a self assessment tool for digital health literacy, which is called the eHEALS survey. Our focus groups involved qualitative collection of data through the discussion, which we captured through notes and recordings, and in each focus group, we distributed three worksheets. First involved asking people about their online activities for health that they have done in the previous 12 months. The second worksheet was about the digital health technology usage and their current use for self management. And finally, future technology use for healthcare to ascertain the potential level of interest.

So on the baseline survey demographics, overall we had representation of 345 individuals in our focus groups. This just gives a kind of representation of distribution by gender. So two-thirds were female. There was quite even distribution across age cohorts, and by relationship status, we had nearly half of our participants being single. In terms of race and ethnicity, over half of our participants were black or African-American, followed by Hispanic, Latino and Latina, and participants, and the third major category were white, non-Hispanic origin.

In terms of educational attainment levels, 44% were our participants had a high school or lower attainment. Approximately 70% had some college or lower in terms of their educational attainment.

We asked people about their health behaviors and attitudes. We used five questions in terms of asking them about their agreements with the statement, I'm responsible for my own health. I should be in control of who has access to my health data. I am actively taking care of my health. I would share my data so I can have better care of my doctor. And finally, I am willing to pay for my healthcare expenses out of pocket. On the right-hand side, the figures indicate the weighted average for their responses, but as you can just see, overall, there was relatively strong agreement with the statement at the top in terms of majority agreement, and many people disagreed with the bottom statement in terms of their willingness to pay out of pocket. And this part of our kind of data collection just gave us an indication of motivation and engagement in healthcare and willingness to look at affordability in terms of access and willingness to pay.

We also, as part of the digital health literacy self assessment, the eHEALS tool I referred to earlier, we asked people how useful is the internet in helping you make decisions about your health? And overall, we had about two-thirds of our respondents who said that it was very useful or useful. In terms of the importance of being able to access health resources on the internet, again, over two-thirds of respondents told us that it was very important or important. When we looked at knowledge in terms of the majority of participants know what health resources are available online, and they know where to find helpful resources on the internet. In terms of their comfort using technology, the majority of respondents told us that they know how to find health resources on the internet and how to use the internet to answer questions they may have about their health. Where there was less, I think, reporting of their ability was in the area of skills and confidence. So there was still, I would say, moderate levels of people saying that they had skills and confidence, but at much lower levels than comfort using technology or the knowledge sections.

So on general technology use, what I'd like to just do is review the participants' general access to digital devices, what some of their attitudes are towards technology, some of the features that they use more frequently, some of the online activities that they participate in and enjoy. Some of the apps that they use. The user experiences that they have and reported to us, and issues around personal safety and security and attitudes towards technology and data.

>> Valerie Steinmetz: So I'll jump in with this. So we started off looking at digital technology access and we saw that the cell phone is the predominant technology used by over 90% of participants. And of those users, two-thirds of them indicated they owned smartphones.

Some of the respondents that said they do not own cell phones were older adults, and individuals within addiction, treatment and recovery programs, which often do not allow cell phone use or ownership while living in the facilities. In terms of cell phone plans, we saw that over a third have standard contract plans. Another third have these non-contract, more monthly pre-paid plans, and then close to 20% had indicated that they have government phones, and this is their primary cell phone. In terms of the operating platform, we saw Android was the predominant smartphone operating system, and we heard that visually impaired participants were mainly Apple users.

We saw that many participants use two or more phones. One is most often used for calling and texting, and we see that the other is used for wifi, to access the internet, and often the cellular service is turned off.

We're also seeing a rise in the use of government phones. So through the Federal Life Line Assistance Program, qualifying households can receive monthly discount on wireless or land line phone service. There are numerous companies out there like Safe Link and Assurance that offer free phones to individuals. These phones and plans can vary in terms of the free minutes they offer, but we heard from participants it can range from 250 to 500 voice minutes and unlimited texting. As we've seen plans and companies, they vary by state, and some companies within specific states are offering data for feature and/or smartphones.

Participants reported that these government phones were basic phones, often durable, but were good to have if their current phone broke or if they ran out of minutes. Other digital technology access, we saw that participants reported lower-level access to computer and other digital platforms, like laptops, tablets, eReaders, game consuls, and smart TVs. Those are actually very popular.

We saw varying attitudes toward technology. So we heard many had said they can't live without technology. It makes their life easier while others were challenged by barriers to use technologies, like costs of purchasing and maintaining regular services.

So we saw a widespread use of standard features, but this varied according to comfort level and the specific task being undertaken. So texting and voice were the top standard features used. Texting challenges overlap with technology challenges in general in terms of hardware use for typing with small keys. Frustration was expressed over auto correct features and misinterpretation of abbreviations and emojis. Use of speech input was reported as a key technology behavior for use with health and non-health behaviors. Participants reported ease of use for speech-to-text, for texting, and for verbal phone commands. I think a key area to point out here is use of voice to ask questions in search engines, or, like with Apple products, use of Siri. So participants would often search for medications and side effects, and preferred to use voice commands to ask these questions so not to have to try to spell out often long medication names. And I know Andrew will touch on this in the next section.

Looking at online activities, we surveyed focus participants and we found that 66% of the respondents primarily go online through their cell phone device. Most of these online activities were completed on cell phones versus other devices, and some of these activities are texting, E-mail, video chat, listening to music and playing games. Again, in the next section, Andrew is going to do a deeper dive into online health-related activities, but we did find that 77% of respondents that went online in the past 12 months searched for information on a health-related concern. We did see varying levels of reported social media usage, so many regarded social networks as personal and ways to connect and staying in touch with family and friends. We did hear a backlash and high levels of non-use of popular sites as stated tired of online drama and explicit content that can appear in users' feeds.

Apps are another popular online activity. Photo and video chat apps were listed as top communication apps, specifically which app is popular for staying in touch with those outside of the U.S., and then facetime, Tango and imo were popular. We also heard that participants like mapping and GPS apps and some even said this was their favorite online activity. We did speak to many immigrants and participants from other countries that reported using Google Maps and Google Earth to actually see locations in their countries where they could specifically look at their own homes even.

In terms of paying for apps, we saw there was an overwhelming agreement on the unwillingness to pay for apps. Participants did report that they would pay for some apps, specifically for entertainment, health and fitness, games and education. We also heard that visually impaired participants may pay more for apps, as many do cost a lot, but there are others that are free, like tap tap, and those were popular and free to use.

Looking at the user experience, participants reported many technology usability challenges, listed below, and I'll just highlight a couple of them. So one of them we heard repeatedly that data plans can be consumed quickly, especially when the plans are shared with families. And then we also heard difficulty remembering user name/password combinations, especially when switching between different phones or getting new phones.

We asked participants about their practices on sharing personal data online and their online security measures taken. I think one large take-away from these focus groups is just this pervasiveness of online scamming that participants are subject to. We heard many examples of identity theft and fraud, and just this constant online harassment and phishing with 20 to 40 texts a day from scammers. In hearing these stories, we saw potential explanations for such fraud were seen when opening -- or when using open wifi and online networks, and not using protective measures. When participants were willing to provide personal data in exchange for different coupons or discounts. And then when participants responded to surveys or E-mails from these fraudulent organizations and untrusted sources.

So looking at some of the personal data and security practices, we did hear some of the practices used online to keep personal information safe from participants. There was a reported use of password protected devices and apps and use of the biometric thumb print. Participants reported they felt safer using desk top computers for such things as online banking and shopping versus their cell phone. Online retail commerce using trusted brands was an important point. And I think we're going to see that as a theme throughout the webinar, just the trustworthiness of organizations and brands is what can connect participants to different technology solutions.

And then we saw many tried to protect themselves with use of pre-paid visa cards or Pay Pal to pay for online purchases which can help minimize risks to personal financial information being obtained. And then we did see high levels of comfort using online banking and online bill pay, as well as confidence that banks will call if there is any kind of suspicious activity.

So again we saw varying attitudes toward technology and data. So many participants have this general awareness of not to share personal information online, and they have a mistrust and a reluctance to provide personal information, when asked. But others see phones as the gateway to all of their personal information, and they equate losing your cell phone to losing your life.

So with that, I'll turn it back to Andrew, who will talk more about technology use, specifically for managing health and well-being.

>> Andrew Broderick: Thank you, Valerie. As part of this section, I just want to review, as Valerie indicated, online health-related activities, so this will involve looking at health information search, access to healthcare services, self management to health, some of the self management practices and attitudes around technology and health, as well as some future technology use that participants expressed levels of interest in.

As part of our worksheet collection on online-related activities to health, we asked participants about activities and about subjects or topics that they have looked up information on in the previous 12 months. So here we have a representation of those results, a specific disease or medical problem was ranked as the most popular topic or issue that people looked up information on, followed by a certain medical treatment or procedure. What came up in discussion frequently was weight loss and diet and nutrition. So how to lose weight or how to control your weight was a very common and popular topic. Mental health issues, particularly depression, and food safety and drug safety, as well as recalls, were also popular topics. Health insurance, drugs that people saw advertised, and also looking up information when caring for a family member or friend.

So when we focused our discussion in the groups on health information search, the most popular strategy for health information search is Google. Participants reported that they enter keywords into the search bar to ensure that they have the correct spelling of medical terms or drugs, because they would receive a prompt through the Google search bar, and they were also prompted with additional search terms to consider, which also helped refine their search. Many participants told us that Google can serve as a de facto 911 surrogate when they want to check symptoms or understand what is happening to them or a family member, but sometimes this can also offer a misleading diagnosis, but it gives them at least a preliminary indication about what may be taking place and whether they should go to an emergency department or seek more professional care. People also commonly reported to us that they enter the serial number on a medication into a search engine to get more detailed information about a drug, and they also mentioned that information that they find online can sometimes be a worst case scenario, and by that I mean that they would put in symptoms or certain kind of information about, say, a medical condition, or a symptom that they had, and it would give them a result that they may be having a heart attack, for example, when it wasn't necessarily that. So it could also lead to some misleading or erroneous kind of feedback in terms of the information that they get when it concerns a personal issue.

We also asked about other search engines that people use. and platforms such as Facebook were mentioned as search mechanisms, but less so than Google, while Yahoo and Bing were rarely mentioned by participants. People were generally mistrusting of Wikipedia or Yahoo platforms as sources of information because people thought it represented a person's opinion more than actual factual information. And, you know, I think Wikipedia was seen as a good way to get a description or explanation to something, but not to be used as a kind of verified, trustworthy source of information in more detail. A lot of people, when they got their Google search results, reported that they reviewed the top results for consistency, and that helps validate the information in the results, and potentially informs them of additional strategies for a more focused search.

Other search strategies that people reported to us include use of YouTube, especially for instructional or educational information, but in many instances, people had a limited ability to discern the credibility or the quality of that information.

YouTube was a useful reference for instructional aspects like fitness, dance, recipes, breast feeding and procedural issues. For example, what to expect when scheduled for a surgical procedure and other information of that kind.

So YouTube did serve a benefit for individuals who are potentially more visual learners by showing rather than telling people how to do something in many instances. People also refer to their online social networks to ask family members, friends or people with shared lived or life experiences for information on issues like detox plans or alternative treatments, nutrition and diet and breast feeding. People are also likely to share information on health and medical issues through Facebook that they believe other people will find helpful. And again, this deals with issues like weight loss, diet, detox plans and alternative therapies or treatments.

Personal testimonials and experiences that are shared online through social networking platforms, for example, are valued and serve to help people determine what is meaningful and appropriate for their personal needs. Certain types of information are best when personalized, such as advice and practices for breast feeding. But young mothers reported to us that they tend to private message rather than ask more generally or broadly, as they found that you can have too many people telling you what to do and many of those people will not have the pregnancy experience or the shared life experience that they have.

People generally reported to us awareness of medical Web sites, particularly Web M.D. and the Mayo clinic, and strategies that they used to verify Web sites as trusted sources of information include referring to the domain names, such as dot-org, or dot-edu were more trustworthy than dot-com and dot-gov. And they also looked at references that accompanied information as one way to verify the credibility of information. A number of less well-known or formal Web sites were reported, ask M.D. and Dr. Oz, and they often tended to be specific to the community. So, for example, in Louisville, we heard more people talk about Dr. Oz than we did in the two other communities.

People reported that information that they found online related to health and medical issues was later validated by a provider, as well as could serve as a second or third opinion to what a doctor may have previously told them. People are also likely to go directly to personal context to ask -- contact to ask questions, as well as share information that they may have found online. And many times, we had participants tell us that they go to a family member who works in a healthcare-relate another capacity, such as a pharmacist or a nurse. Older participants are more likely to ask a family member to help with searching specific information online about drugs, surgical procedures, et cetera.

In terms of access to healthcare services, overall, a lot of people reported to us that they preferred the high-touch personal connection that they have with their providers and care teams. In many instances, they see technology as more of an administrative support mechanism rather than a direct communication tool. So the technology-enabled interventions with healthcare providers are mainly through texting, particularly reminders that they receive for appointments, and only some participants reported use of patient portals. Those participants who do use patient portals found them to be convenient for the access that they provide, the ability to stay on top of appointments, test results, review medical records, and communicate directly with their providers. And those who preferred texting for receiving reminders or confirmation of appointments did so because the day, the time and the address were written down and easily referenced for confirmation when needed.

Pharmacies were frequently referenced for handling prescriptions electronically, so there's no need for paper prescriptions, as well as sending text reminders for when refills were due and when prescription orders were ready for pick-up. Pediatricians and dentists were also frequently reported as active in sending text reminders for appointments. And people who shared their experiences in focus groups on the use of patient portals through apps or Web sites served a benefit in the focus groups through creating greater awareness among other participants of the availability of patient portals, the function that they provide and the benefits that can be realized. As a result, there was strong interest in those participants in wanting to learn more about patient portals and how to use them. And one young adult, for example, in New York told us that it would be good to have a medical record access through a patient portal very much like they do for a school record.

In terms of self-management to health, this was the second worksheet that we distributed in the focus group. We asked people about what technologies do they currently use that do not necessarily require interaction with the provider, but that can be used in the self-management of their healthcare. We found that current use of digital technology, what came out were wearables for physical fitness more than chronic diseases. Then apps and social networks. Lots of people downloaded apps for diet and food and nutrition, as well as used social networks for the same end goal. Health devices that were used by people were primarily for blood glucose monitoring and blood pressure monitoring. People referred to health Web sites for information on depression, stress and pain. And also for information on medication management.

So as I mentioned, a lot of the devices that people use in their own care include very standard devices such as the blood pressure monitors, glucometers as well as sleep apnea devices. The data that people collect from these devices is more likely to be written in a journal that the patient then takes to their next appointment, although some do take their glucometers to the office where the data can be downloaded during the visit. People are not using wearables, dedicated health apps or social networks such as patients like me for health self-management. Only several individuals reported to us that they actually had a smart watch, such as the Apple or Samsung brands, and that they paid several hundred dollars for these devices, or they either received them as a gift. And those who paid money for these devices tended to be younger people rather than those who are middle-aged or older.

I think a major inhibitor to the adoption of wearables and apps is the cost barrier to the purchase of the device, and then the service, as well as the upselling that they frequently experience once they start to use an app. People did report to us that opportunities using technology for wellness can be beneficial. So, for example, some people used yoga apps for physical kind of exercise, because it was cheaper than going to a class, and therefore it was more affordable while they could still get the instructional benefit through the app.

Younger mothers reported to us that local Medicaid health plans offer financial incentives for using apps during the pregnancy, and gift cards to adhere to their kind of baby check-up visits.

A lot of apps is that we did hear in use for kind of health purposes did come from pregnant women, particularly the most common apps that we heard for use during pregnancy were Baby Center and What to Expect. We had one employee in Louisville who worked as Humana who mentioned that their company was helpful in learning about and recommending apps for personal use, and that the employer offered incentives for those use to stay fit and to stay well. People are more likely to use more traditional technologies for tracking their physical activities, such as pedometers or stop watches to time distances. Smartphone users are more likely to use the bundled apps that come on the phone for activity monitoring, such as step counts and calories burned. A popular app that we heard from participants for physical activity was one called My Fitness Pal, which allows users to enter in personal biometric values and goals, as well as scan food bar codes, and all of that information can be integrated to provide more personal customized feedback to the user.

People also reported to us that they used basic features on the phone, such as calendars and alarms, or more conventional strategies like pill boxes for health management practices around medication. Games were also popular kind of applications that were used for stress relief, but also some people reported that games can also make them more agitated, such as the gauge Angry Birds.

Elderly patients or participants reported using games for cognitive fitness, but more specialized games such as Fit Brain were used less so because of the requirement to pay after a limited free trial period. YouTube was useful in many ways because people could access videos for meditation, such as hearing sounds of the ocean waves and images of the water, and people refer to YouTube for spiritual and coaching videos that were helpful to their life situations.

In New York, with our HIV positive focus group population, they gave very high marks to an app called that connects them to medical information, helps manage their medications, connects them to peer mentors, creates avatars for virtual group support and they would receive incentives for the first year of use of that app. And after the first year of use and the incentive that they would receive, they would then have to pay out of pocket. But many people found that during that trial period, the benefits were considerable enough to have them to want to continue to use the app thereafter.

And in Louisville, we had one participant who gave us an example of taking photos of their medication bottles instead of bringing those bottles or writing out lists to bring to their appointments. In terms of their medical information, one participant also told us that they used the 16 gigabyte memory stick to store and port all of their medical information as they went to see different providers.

A pill management app that people used was Physicians Desk Reference, PDR Pill Identifier, and that helps participants get pictures and descriptions when they entered pill numbers.

So technology and health attitudes were varied, but I think overall, we had a lot of positive aspects to the use of technology, as I've described, such as text reminders from healthcare providers, for appointments and prescription refills, and those are helpful and valued by many participants. And individuals also have very strong loyalty to the organizations that they received services from, and therefore, you know, I think value a lot of the interaction that technology can provide. But in many ways, there was a lack of awareness in many situations, about patient portals, and if there was awareness, there was a lack of knowledge about the benefits and therefore a limited motivation on the part to pant to activate the patient portal for their own personal use.

Finally in the discussion group, we asked people about what technologies would they be interested in in the future if they could have it in a way it supported the way that they live their life today. And so these were the top kind of results that we had from the self rating as very or extremely interested in. So first we had text reminders, online scheduling and online access to a repository of all health-related data. So again, a lot of these, I think kind of -- a lot of these are already available to many participants. A lot of participants are using the text reminders, but the online scheduling and online access aspect is something I think through more patient education and training could be realized in the future. A lot of people told us that listings of relevant to you local activities, support groups and services would be very beneficial to them, not just only around kind of health-related services and resources, but also those that are more kind of labels as social determinants to health. So everything from food pantries, housing, education, schools, libraries, et cetera.

The third most popular choice was online reviews of healthcare providers and online reviews of medical treatments. So this is an area where we found a lot of people were searching for information about the providers that they're seeing to know about aspects related to their personal communications file and how other patients report on that, as well as some of their kind of background in terms of having medical malpractice issues and other concerns that might affect the quality of their care. As Valerie indicated, Google Maps and GPS were very popular in their everyday life, and people found that local community resource mapping services would be very practical to them in the communities that they live. And particularly in a larger city like New York, where there's many diverse populations who were not local to that community, and are kind of climatizing to living in New York and getting to become familiar with the neighborhoods and communities that they're living in.

In terms of apps, we had a lot of interest in behavior-change apps, so particularly in areas such as diets, exercise and addiction, and we also had interest in kind of technological solutions that would help keep track of the health and care plan of someone for whom they care for. And then online social health and well-being networks were of great interest to people, so they could be connected to other people who are local to them in ways that they share their life experience, and that they could engage with in sharing resources, advice and engaging in activities together.

So moving forward, you know, thinking about ways that we can build on this research, there are several ways that we'd like to propose to participants on this call today is one, thinking about ways we can expand research on digital health solutions for vulnerable populations. There's ways to look at it by geography. We focused on three communities, but there are many other urban environments that we could look at, as well as rural areas that we could go into and find out about very similar experiences that people have with technology, and ways that they're using technology today as it relates to their health and ways they think it could benefit them in the future.

Some populations, there are many populations where we think there's a greater need for deeper dives, especially people in addiction treatment and recovery programs. I think there's definitely a way to look at how technology can better serve them in many ways. People with disabilities, I think we got a lot of interest from the groups that we had there about lack of apps that exist, the affordability of apps to those populations, and ways that technology can just better serve them. And then by thematic issue, as Valerie said, there are aspects around scamming and fraud that are pervasive throughout many kind of low socioeconomic status populations, but linking that to healthcare, there are issues around medical I.D. theft and other aspects of fraud related to the quality of care that people may receive that could be explored much more deeply through further research.

On technology training and education, we find that online privacy and safety is an area I think where people do need support as it relates to participating in online activities when it comes to sharing personal information, when it comes to managing apps. We found very few people indicated that they actually reviewed the terms and conditions of apps that they download, and are not very aware of how the data that's being collected through that app is being shared with third parties or is being used outside of their knowledge. And health literacy and patient portals are other areas where I think there's great need for populations to have support when it comes to education and training.

And finally, you know, there are many opportunities to think about ways that technology could be improved, or ways that technology could be developed to support individuals when it comes to managing health and well-being, and there are opportunities to work with people on this call, as well as other organizations where we look at co-development of interventions in that regard. And some interventions that we had kind of mentioned by participants were apps for navigation, particularly of the health system, and insurance. A lot of people feel overwhelmed by aspects of care and not knowing, you know, how to navigate, you know, the care resources and services available to them, as well as to understand the insurance benefits that they have and ways to kind of optimize those for their needs.

There were other aspects that we had in terms of video chat. A lot of people, as we mentioned, you know, are using video chat in their personal life, but found that it could be useful to them in a kind of healthcare context, where they could have video interaction in situations where they could talk with a therapist, or they could have some preliminary discussion with a provider that might obviate the need for them to go to a medical appointment, or kind of be directed to go and seek more professional care or immediate care in a kind of healthcare setting. So that was another opportunity area that people kind of expressed a lot of interest to us. And overall we did have another good example of an app that we had was from pregnant women who, in Louisville in particular, who talked about a Siri-like tool, Siri being the kind of speech/voice function on the Apple devices that mirrors a program that they participate in called "Mommy and Me," that pairs them with a human expert as they go -- as their go-to resource during pregnancy. So thinking about how technology can duplicate, if not parallel, or in some way be a hybrid to that human role where there's a blend between the technology and the human element, and people can use technology to benefit them in that way by being able to speak into devices and get spoken-back responses in terms of, you know, resources and other advice that may be helpful to them during their pregnancy.

So at this point I'm going to hand over to Dan Gillette, who's our partner at CITRIS, who has been conducting the best practice review and he will talk more specifically about strategies from a technology, design and development perspective for advancing research and promoting use of digital health solutions. Over to you, Dan.

>> Dan Gillette: Thank you, Andrew. So we've been also looking at the general landscape around digital health solutions, both in the broad population, as well as specifically more vulnerable populations where there actually isn't that much information, but we were able to do some discovery there, and one of the important things that I think has been coming out is how this piece of the research has echoed a lot of what Andrew and Val have found in their listening sessions, and also that those listening sessions have illuminated holes in what we might find in the academic research or in the market space as well, and so there is a correlation, but also perhaps not enough awareness on industry. And one of the things that is clear is when people talk about E-health, or internet-based health or digital health, most time we are now talking about mobile. And a lot of these technologies require specialized hardware for certain sensing, or sophisticated back-end systems for managing information and processing that information, but the reality is that where we live today is through our mobile devices. So the interaction with users, both patients and clinicians and other service providers is going to be mostly through mobile. So we ended up looking at primarily mobile health solutions or M-health solutions.

And there's a lot going on right now. A lot of different categories. The most significant category tends to be single-use M-health apps, and these apps tend to be primarily informational, as well. Or they do something very specific in tracking or assisting you in minding your medications or tracking calories or your steps or things like that.

Another area that is showing a lot of activity is in the social side of things, and that would be bringing people together to support each other, to learn, and to motivate each other. And then we get into the more integrated aspects. And this is where things tend to be more around a few larger organizations, through their electronic health records, trying to unify the experience for their constituency, or where we're looking at chronic conditions, where we're bringing together a lot of different technologies and information and services. But integrated M-health is still a complicated thing. From a policy perspective, how do things inter-operate, from a business perspective, a lot of times there's a desire to keep things siloed so that you can retain more of the activity that a patient may be doing, and not straying from your services. And it's sort of early days for that. And perhaps, as we'll see, one of the reasons why we're not seeing a huge uptick in the use of these technologies.

And that fits into the complex apps.

All right. So moving on, significant apps development. So one of the things that we're seeing an explosion of apps development going on, and we are now exceeding the most common app stores, exceeding 165,000 applications. There are also an incredible number of mHealth clinical trials underway. 300 seem to be going on right now. Many are targeting senior populations, which, in ways, fit in with our current, you know, focus on vulnerable, not all senior populations would fit into our categories, but clearly part of that.

But what's interesting is that these clinical trials are showing, one thing they're showing is that this is a huge jump in the numbers over the past few years and I think that one of the things this is showing is that there hasn't been a lot of traction. There hasn't been a lot of understanding of the value of these technologies, and that we need to better understand how they work and what their value is.

Also, pharmaceutical companies are extremely interested in mHealth, and continue to turn out very large amounts of apps, but they are not finding much success at all. So also one of the things you have to think about is who's going to pay for these apps and these services, and pharmaceuticals are a likely contributor. We're seeing the need for things to be kept low-cost, to be kept free, who's going to provide that, especially for organizations that have low budgets that are serving vulnerable populations. The pharmaceutical companies are interested but they have not really found traction yet in what they're providing or found their role, and so traction is elusive.

Many reports say that mHealth apps, after 30, 60 days, most people don't use them. So people may try them, but they're not turning the use of these apps into habit. There are some numbers that show, in certain populations, for instance, fitness apps may have better traction with people who already identify as athletes, but we still don't seem to be seeing good numbers on adoption for individuals who are coming to things like fitness and health apps to manage diabetes or to make a life change. And that pretty much goes also for care management apps, around medication management and service management, VHRs, other things like that.

And what is interesting is that if you took a scan four or five years ago of the marketplace and you were to look again today, which is really what we're doing, you're not going to see much change in what's going on. And there seems to be still very little clarity on how to best provide solutions. What's interesting is that we are finally starting to see responses to that one, is the clinical research studies that are being conducted, and the other is that we're seeing a lot of the big players start to look for different methods of being involved in the space and creating useful technologies. One of the most interesting things was that just this spring, Ginger Io, which some of you may know, a maker of many apps and an innovator in the use of culling the data that's collected by the patients using their apps to better understand needs and what's going on in the lives of those patients and their care, has decided to not be so much an app developer anymore, and to become more of a provider in its own right. And so they are becoming essentially an online mental health care provider, providing certain services directly to individuals. And this is a very interesting shift in that they are, in many ways, identifying that the apps alone are not going to get us there, but that we need more of a holistic approach.

Another interesting thing is that even though you could -- we're nine years into the iPhone, we're going on 20 years of moderately widespread use of the internet, usability of all of these things is still quite low. There have been very few studies where there's actually a look at real people using these apps and observing them directly. This study by Sarkar and others on using commercially available mobile applications did look at one of the problems with these types of studies is they're very time intensive to bring people in and try different apps with them and as a result they didn't look at too many apps but they did do a good job of selecting what would be considered standard apps for different purposes. And they found that pretty much everything was very hard to use if it was beyond a single-use app. And so while Andrew and Val have noted, in our listening sessions we heard people talk about an understanding of the potential of usefulness of the technologies that they've tried, in reality, they're just not -- that doesn't supersede how much training and work is required to use these apps. Also, the lack that you're on your own often figuring this out. So that's a big problem.

And as a result, as we saw in our listening sessions, and what we're seeing in reality across the board, is most patients just end up repurposing their default apps that come on their phones or that they're using for fun. And so they'll use their task managers, they'll use video chat and regular chat. They'll use Google, Facebook. Facebook continues to be probably the largest by a very wide margin, place to find patients meeting other patients in support groups, in information-gathering, and other things, even though there are numerous platforms that are more secure, safer, more purpose-built to that need. And one of the big reasons is people know that Facebook is there.

The other thing is that when I think about how the medication impacting how I feel today, there are apps that I can look up, but in that moment, just like everything else, I'm going to go to Google. So there's a bit of a disconnect in that we continue to try and pull these consumers, these patients, away from the places where they go for information, where they go to manage what they're doing, into the clinical world, into the -- that provides safety, that might resolve some policy issues around information, things like that. But the dilemma is that people just aren't there in the clinical -- using these clinical apps. They are there living their lives in the apps that come on their phones or that they use for other purposes.

Now, there are few success stories. It's very hard to find right now, where we see a broad success story. We will find people who have apps that have been transformative in their care, in their health as individuals, but we don't often see that happening in larger groups. Areas where that is actually happening in broader populations primarily is in a care of acute and chronic conditions. So, for instance, in cardiac care, companies like a Alivecor that provide apps to look at your heart health, to understand does my racing heart right now require that I go to the emergency room, or am I okay to wait a while, these sort of apps around diabetes, around heart conditions, things like that, are popular, but in many cases, it's because there's no other choice. This is critical to it's a life and death situation or a very significant quality of life situation, and it's worth the investment of time, of resources, and that there's clear support for these types of apps. And people pay for these, and it's a large portion of where we do see adoption.

Other examples would be, you know, Rango was mentioned before, and it's probably our best example right now, of a more general healthcare application, care management interacting with your healthcare services, managing your own care, and that's Rango, and what's interesting about Rango is it was created by Village Care of New York, which is a service provider and connects people with services, and yet went and worked with technology providers for specific components such as text messaging, video chat, other areas. And so Rango is introduced as part of the Village Care suite of services. And if you go to Village Care's Web site, you don't even see much. You have to kind of go fishing to find information on Rango. So it's not led by here's a technology that's going to transform how you receive your care or manage your care. It is much more, this is one of the tools in our suite, and it's coming from the community, coming from the organizations that are working with these populations. And I don't think it's much of a surprise that we see that that's more successful when it's a 360 sort of integration.

So why default apps? You know, some of the reasons have been discussed. But some other things to think about is there is just that inertia, it's where everyone is, but another big thing is that there's critical mass, everyone else is using these apps as well, and so if it's a social app of some sort, then I'm going to find a lot of other people there, and I know that. If it's just something that I'm using personally, I also know that other people will be able to help me with it, either online or in my family, or people I know. I can just ask someone and they probably can help me figure it out. So there's that critical mass. Also the amount of use leads to more refined interactions, which is critical to helping someone figure something out on their own.

The other is that in general, these consumer apps are mostly intended for agnostic purposes, to manage information like your tasks and your calendar, or they're for fun and they're enjoyable, and so there's primarily positive associations with these default apps or these consumer-driven apps, where a lot of the way that we introduce technologies around things like diet, health, wellness, is you're constantly being reminded that you need to change, and I don't think that we can discount that every time you see that app you're kind of reminded and feel in the pit of your stomach that change is necessary, or something's wrong, where with these default apps, it's a different association.

The other is the getting into the habit. It's just hard to form habits. We all know that. And the apps you're already using allow you to -- you already have the habits of that use. To hack on another purpose to that app means that you will -- that's a lot easier than starting from scratch. And I think that's the other reason why we see these 30-day rates as being not that great for adoptions after 60 days and it proves that people are not forming habits with these apps.

So how can we change the situation or at least take advantage of digital health? And that's really to connect the tools to the patients they're already using. And before, there were a lot of electronic health apps, we used to send things like templates that you would load on to your personal digital assistant or your computer and would work with your task program instead of asking for a brand new task management app around your healthcare. We would connect to your calendar in more direct ways. And we've stopped doing that. And there is a lot of fear in connecting directly with these services that aren't as well-protected, or under control of the service providers, but I think we have to realize that we have to solve these problems. We have to figure out how to do this much more than we already have because the siloed technique has been given enough time, and it's just not working, especially for vulnerable populations. I think that we need specialized applications and technologies for certain things, but that we have to lead and mostly interact through the more standard, open environment and we have to take the steps to do that.

Also take examples from other industries. The bank is not more secure than most DHRs, but they're perceived as more secure and a lot of that has to do with just being more polished with a lot of advertising to say they're secure, with clarification on what happens when something goes wrong. You know, you don't have to pay if your account gets hacked, things like that. And we have to look at treating our clinical apps as more like consumers apps so that people are comfortable with them so they understand what they can do, so that they are easier to use.

Another interesting thing is when we saw how many people had cell phones to use just with wifi, and that is startling from a economic perspective because for a lot less, we could be giving these same people tablet computers that are better suited to help them. Small tablets that cost half as much as phones that would allow for bigger text, easier interaction in editing text, and just a better experience. Another thing that we're not seeing that would be an interesting thing to try is that we now have the capability to provide data subsidies through cellular providers on an app-specific basis. So perhaps instead of saying you only have, from a service provider, X number of minutes available to every -- for all your use, be that for the purpose of your health or for fun, provided by the state or the county, we could say, here specifically, you have unlimited use when you're using these apps.

And the most important thing is let tech play a supporting role. And this is complicated by people needing to have business plans in the tech companies are developing these tools for service providers to differentiate themselves, and you can check to do so, but what we see is the only time this works is when there's social engineering of bringing a community together, and then providing that technology to that community where they can utilize those tools. Something we see a lot with the fitness apps where they really only see adoption in a workplace, or in a -- or in let's say a religious organization setting. Where you have a community using them and interacting with each other. The other things that they need to play a supporting role in what the services are available. So how do we get there? And we need to develop community-based pilot programs, and we need to work with all of you to do that. Is that something we really want to do is develop programs where we're using the -- all the members and stakeholders that would be involved in the end results of bringing a technology or service to market, and they're involved in piloting. They're also involved in figuring out how these things will be integrated into services, and ultimately involved in the creation of these tools. And we would like to work with organizations to do that, it's something that we are working on right now in methodologies and other projects and very interested in and we also need to share with each other. So we're running low on time, and I'll open it now up to give back to Laura and open it up to questions.

>> Andrew Broderick: Thank you, Dan.

>> Valerie Steinmetz: Great. So again, if you guys have questions, please go to the panel on the right side and click the Q & A tab and then type in your questions and send them directly to the hosts and the panelists.

So let's start off. I'll put the first question out there. And Andrew, Dan, you guys jump in, as will I.

So one of the questions we received is, what are some of the ways in which CHWs, community health workers, are co-designing digital health solutions?

>> Andrew Broderick: I can take that. This is Andrew. Community health work is an area of work that I've been involved with here at PHI. I would say in the United States, there's not a lot of work currently going on in terms of co-design. There are some organizations, one being migrant health promotion that I do know that works with migrant health workers, farm workers. It has been co-designing some tools around data collection. Here at PHI, we have been interested in looking at the design of some tools that might help with collecting data on community health indicators and social determinants to help and having that more formally integrated with electronic health records in a way that healthcare providers have a broader context of health when they're seeing patients and are able to address a lot of those issues. So I think it's an area that's emerging, and one of great opportunity, and definitely needs more focus, and it's something that we would be interested in talking with any interested partners on further about that. And just finally, you know, there has been a lot of tool development with community health workers using mobile platforms outside the U.S. So there really is an opportunity to look at some reverse innovation, bringing back lessons learned from overseas in low, middle resource country settings and applying those within the safety net context in the United States.

>> Valerie Steinmetz: So we have another question.

>> Dan Gillette: Okay. Go ahead.

>> Valerie Steinmetz: Oh, go ahead, Dan.

>> Dan Gillette: I would just say also that we see these sort of innovations happen informally when it's a malleable technology. So, for instance, when text messages are being used to help someone find services or to work through an addiction program, and it's a component of that, where it's high touch between counselor and the individual, and they're texting back and forth, that develops a knowledge base with a digital record that often leads to improved ways of doing those types of technologies. The more complex the technology, the harder that is. But where we have high touch between the community health workers using these tools to interact with their clients, we do see that innovation happening somewhat quickly.

>> Valerie Steinmetz: Thanks, Dan. We have another question. What are some organizations developing HIT solutions for the East Bay area in California?

>> Andrew Broderick: This is Andrew again. Here in the Bay Area, there is an organization we work closely with called YTH, Youth Technology and Health and they're very active in developing solutions for young adult populations and adolescent populations using mobile technology and social media, so that is one partner organization to look at.

There are a number of start-ups that are focusing on underserved populations that are local to the bay area, given our proximity to major academic compasses, as well as Silicon valley. One in particular is an organization called Care Message. And here at PHI with CITRIS, we have a collaboration currently with the Wallace Center at the School of Public Health focusing on the maternal child health trying to extend our research that we've just presented here, looking at women who are pregnant, and young mothers in the bay area, again at what their current use of technology is and how it serves them today when it comes to health and access to services and resources, and that output that we're looking from that is to look at some co-design strategies and ways we can work with some of the partner organizations that we're working with there.

So Dan, I don't know if you have any comments on local resources in terms of --

>> Dan Gillette: Well, there are a lot of organizations that will improve Web sites, things like that, as part of community training programs. Act hood is one example. One area that we are working on is better ways to connect community with, say, college students who are working, so there's been a lot of work in the UC and at other campuses to develop challenges and classes that focus on these needs, but they tend to happen a little bit more in a vacuum, so we see some good ideas come up, but they need more contact, they need more interaction. It's one of the areas at CITRIS that we're working on is how do we involve the community more in all aspects of that. How do we develop new classes, for instance we taught a class last semester where we had half of the class with elders from the community and half the class with college students, and where that might lead to better solutions that then might be put into an entrepreneurial pipeline to get them to people, get them out to market faster.

>> Valerie Steinmetz: Thanks, Dan. Here's another question. How can digital health tools be best linked to help disparities? What tools are both effective and budget friendly?

>> Andrew Broderick: Well, I think, again, just through our presentation, the tool that was specific for the subpopulation, HIV positive population, where it was very integrated in terms of addressing a lot of the needs that they have around both kind of management to care of medications, as well as communication through kind of social kind of platforms to connect with people with shared lived experience. Fitness was an area where we heard a lot of apps, just around general physical activity, nutrition and wellness, and pregnancy was another area where we saw a lot of apps being used by vulnerable populations/underserved populations. So again, a lot of people are looking for solutions that are affordable and do not cost money, and in many ways, the My Fitness Pal, the and the Baby Center are kind of three solutions that were highlighted to us by participants in the focus group that are very usable and very effective in addressing a lot of the information needs that they have and helping them to better support their care management.

>> Dan Gillette: And I think I'll just add to that as one of the things that we need to do is just start to add more when we are working with our clients, is how do you use what you have? So to be more discrete in training around the tools that are available, and to present strategies. So you may talk to someone who's dealing with a complex medication management plan, for instance, on how they might use tool boxes to organize things but I don't think that we go far enough, and we do see people talking about how do you use the task managers or the alarms that are available to them for free in their apps, but -- on their phones, but I don't know if we go far enough into how could you start to methodically track your symptoms without going to a purpose bill paid app that may or may not be -- you know, probably isn't necessary if there is a little bit of training. So I think one of the things that we've seen across the board in these listening sessions is the need to expand the education around using digital technologies in general. And then whether or not a specific app is necessary would fall into that category as we're dealing with individuals.

>> Valerie Steinmetz: Thanks, Dan. And just to end, we have one last question we wanted to review, but to also know that thanks to all of you who have submitted questions, we'll try to get back to you based off of your registration information to answer what you've asked.

But maybe for our last question, we can end with what are procedures involved if one wants to conduct focus groups? How do you do this? Do you provide resources for this?

And then we also received a question around just what was your approach for engaging so many community stakeholder organizations?

>> Andrew Broderick: It's a good question, and one that, you know, I cannot speak more highly of the kind of collaboration that we had from all our local partners. Our initial approach was to go to local health foundations in each community, talk with them about the stakeholders that we should be engaging in this process. The key stakeholder in many instances and across all three communities were local health departments. They were very bought into the process and were very effective in making sure that we got connected to community-based organizations that could facilitate our ability to promote outreach, convene groups and then host those groups. We had a modest incentive to those organizations that we provided for the time and effort. And for the participants who were in the focus groups, they also received a modest incentive in the form of a gift card. Overall, also, I think another major benefit that we tried to offer to all organizations that collaborated with us was that we would go back and share our findings specific to each community and look at ways that we could work moving forward in improving upon some of the technology aspects that we learned about in those communities, as well as some of the co-design opportunities to bring new technology solutions into those communities. And that's something that we'll be working on, you know, at a future date, meaning after this presentation. But at this time, we've just kind of concluded the focus groups, done the analysis of the data, presented a very high-level view here of what we've learned through that, and we'll continue to work, as I say, with those communities and sharing specific findings and identify opportunities to work more collaboratively together.

>> Valerie Steinmetz: Thanks. So I think Laura, we'll turn it back over to you.

>> Laura Burr: Great. Thank you. And thanks so much, Valerie, Andrew and Dan, for sharing your insights today, and to digital health solutions for vulnerable populations. It was a great presentation. And thanks also to our sponsor today, Aetna Foundation.

And I want to thank all of you in our audience, and we appreciate your participation. A recording of today's presentation and the slides will be available by next week at . You will receive an E-mail from us with a link to a brief survey we hope you'll take. We really want to know your thoughts concerning this Web forum today and especially what topics you would be interested in for future Dialogue4Health forums. Please be sure to take a couple of moments to complete the survey. We would like to hear from you. And also, if you didn't have a question answered today, you are welcome to submit that question with your E-mail address in the survey, and you'll get a response from our presenters. So thanks so much for being with us today, and that concludes today's Web forum. Have a great day!

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