Going mobile with primary care: smartphone-telemedicine for asthma management in young urban adults (TEAMS)

Figures & data

Table 1. Patient demographics and baseline asthma characteristics.

Patient Demographics (N = 30)	N (%)
Sex (Female)	19 (63.3%)
Race/Ethnicity
Black	15 (50.0%)
White	6 (20.0%)
Hispanic/Latino	4 (13.3%)
Multiracial	4 (13.3%)
Asian	1 (3.3%)
Insurance (public)	23 (76.7%)
Education (Highschool or less)	16 (53.3%)
Marital status (Single)	19 (66.3%)
Transportation (public, no car)	16 (53.3%)
Employed full or part time	19 (63.4%)
Current smoker	11 (36.7%)
Comorbid mental illness	17 (56.7%)
Comorbid substance use disorder	4 (13.3%)
Had asthma related emergency visit past 12 months	15 (37.5%)
Satisfied with current asthma care	17 (51.5%)
Average age (years)	32.97 (SD 6.33)
Body Mass Index (chart review)	34.36 (SD 11.29)
Average years with asthma (years)	19.55 (SD 10.17)
Average household Income (in $1,000 USD)	27.53 (SD 13.97)
Patient Smartphone usage
Has cell phone with unlimited data	24 (80.0%)
Uses phone to make video calls	25 (83.3%)
Uses phone to access health information	19 (63.3%)
Uses phone to set health reminders	17 (56.7%)
Ever had trouble keeping phone plan active	9 (30.0%)
Has smartphone available most or all the time	30 (100%)
Ever used phone to access patient portal	22 (73.3%)
Owns a computer	7 (23.3%)
Patient Asthma Severity^a
Intermittent	2 (6.7%)
Mild	1 (3.3%)
Moderate	11 (36.7)
Severe	16 (53.3%)
Patient Asthma Control^a
Well controlled	2 (6.7%)
Not well controlled	12 (40%)
Very poorly controlled	16 (53.3%)

Notes. ^aExpert Panel Report 3, guidelines from the National Heart Lung and Blood Institute (2007).

Table 2. Provider characteristics.

Provider Demographics (N = 4)
Sex (female)	4 (100%)
Race/Ethnicity, White	3 (75%)
Race/Ethnicity, Asian	1 (25%)
Role, MD	1 (25%)
Role, NP	2 (50%)
Role, PA	1 (25%)
Average age (years (SD))	36.50 (SD 15.33)
Average years in current professional role (SD)	3.63 (SD 3.59)

Table 3. Primary and secondary patient outcomes for TEAMS intervention.

	Mean (SD)	Mean (SD)	(d)	(p)
Primary Outcomes	Baseline(0m)	End (6 m)	Effect	Significance
Asthma control (ACQ)	2.157 (0.848)	0.975 (0.111)	1.955	<0.001
Asthma quality-of-life (AQLQ)	4.418 (1.121)	6.019 (0.894)	1.579	<0.001
FEV1 % predicted	81.17% (2.273)	85.37% (2.689)	1.687	0.046
Secondary Outcomes	0 months	6 months	Effect	Significance
PCP prescribed therapy aligns with EPR3^a	43.3% (50.400)	86.7% (34.574)	1.004	<0.001
PCP prescribed Stepwise level of therapy^c	2.23 (1.478)	3.60 (1.423)	0.944	<0.001
Adherence to prescribed controller medication^d	45.58% (41.678)	85.29% (25.091)	1.154	0.004
Mean stepwise level actually taken by patient^b	1.90 (1.423)	3.10 (1.348)	0.866	<0.001
Secondary Outcomes	Year prior	Year following	Effect	Significance
Prescriptions for controller medication (ICS, LTRA)^e	3.39 (4.565)	7.89 (4.254)	1.020	<0.001
Preventive office visits for asthma	0.62(1.115)	1.76 (2.459)	0.597	0.004
Prescriptions for SABA^e	4.0(4.329)	6.36 (4.961)	0.507	0.022
Treatment of related comorbidities^f	0.64 (0.951)	1.18 (1.188)	0.502	0.022
Asthma related emergency visit (chart review)	0.70 (1.236)	0.33 (0.922)	0.339	0.054
Asthma related emergency visit (self-report)	1.36 (2.959)	0.71 (1.384)	0.281	0.288
Systemic corticosteroid use	0.54(0.838)	0.68(2.001)	0.091	0.641

Notes: ^aTherapy prescribed by PCP is appropriate for level of asthma severity based on EPR3 stepwise treatment recommendations (binary). ^bStepwise level of therapy actually used by the patient accounting for medication adherence; ^cStepwise level according the EPR3 guidelines. ^eShort acting beta agonist (SABA) and controller therapy (ICS = Inhaled corticosteroids, LTRA = Leukotriene receptor agonists) measured as months of coverage; ^fPCP initiated treatment of related comorbidities : rhinitis, allergies, obesity, esophageal reflux, tobacco dependence, counted once per diagnosis.

Table 4. Feasibility and intervention dose.

Scheduling and Technical data	N (%)
Visits kept as originally scheduled	148/277 (53.4%)
Rescheduled by text message	81/277 (29.2%)
No show	47/277 (17.0%)
Visits occurred on weekend	26/148 (12.8%)
Visits occurred after 5 PM	39/148 (25.7%)
Visits without any Audio/Visual problems	109/148 (73.6%)
Visits with major Audio/visual problems	10/148 (6.8%)
Smartphone telemedicine visits dose	Mean (SD)
Total smartphone visits per patient	5 (2.04)
Minutes late to smartphone visit	6.37 (10.68)
Visit duration (minutes)	26 (11.39)
Documentation and follow up time per visit (minutes)	12.05 (13.28)
Total nursing time per visit (minutes)	44.47 (21.67)
CDSS recommended asthma follow up interval (weeks)	3.67 (2.49)
Self-management training (SMT) dose	Mean (SD)
Total minutes of SMT (range 33-177)	80.50(42.467)
Specific SMT modules^a
Module 3: Is your asthma controlled?	4.10 (1.626)
Module 4: Different types of asthma medications	3.40 (1.276)
Module 8: How to take puffer and powder inhalers	3.37 (1.608)
Module 9: Why you should use a spacer	2.90 (1.242)
Module 10: Measure your lung function (PFM)	2.73 (1.015)
Module 15: Smoking cessation strategies (smokers)	2.45 (1.572)
Module 2: Uncontrolled asthma can scar your lungs	2.30 (0.988)
Module 11: Asthma triggers and what to do	2.13 (1.655)
Module 5: Know the symptoms of asthma	2.07 (1.230)
Module 1: What is asthma?	1.93 (0.82)
Module 6: Guidelines for treating an asthma attack	1.73 (1.337)
Module 7: Life threatening symptoms	1.67 (1.322)
Module 13: Keeping track of symptoms	1.60 (1.429)
Module 12: Managing exercise asthma	1.27 (1.437)
Module 14: Action plans	0.10 (0.409)
Smartphone symptom monitoring dose	Mean (SD)
Symptom/PEF tracking (# of days recorded over 6 months)	23.73 (38.403)

Notes. ^aAverage number of times each module was delivered to each patient.

Table 5. Key themes and quotes from end of study interviews with Healthcare Providers (N = 4) exploring perceptions of the TEAMS smartphone-telemedicine program for adults with asthma.

PERCPETION OF TEAMS TELEMEDICINE PROGRAM More efficient process Reduced barriers to care for vulnerable population Better educated HCP Better educated patient Better patient outcomes	MD: it's all been positive… one patient I had never met before but her pulmonary function testing was really poor and TEAMS was working on escalating her step wise treatment… so when she came to see me she was already doing a lot better…. we were able to work behind the scenes to figure out what worked … so, I didn’t have to see her in clinic, change her meds, send her out, and then have her come back in—that can be really hard for patients to come in repeatedly. it’s hard for our patient population to make it to appointments with social determinants of health causing barriers…so I really appreciate the TEAMS program NP1: It's a great program – I’d get a message in my inbox with the record that told me that a patient was enrolled and their level of asthma control. And it was pretty easy to read and assess how the patient was doing, even if I hadn’t met them before. NP2: The patients that went through the program that I touched, they all got better…and they showed up to their appointments. One patient, he was very excited. Now, he can tell me what his pulmonary functions test, and he can tell me the impact of his smoking, and how it changed his asthma when he stopped and when he started again – he really understood what was going on. PA: I loved it. [The telemedicine nurse] would send me an encounter describing what she did, and follow up, and she would ask, “Can you prescribe meds if you agree?” So, we would get things moving, and then the patient would come and see me [in the office], and we would kind of go through with how the changes are helping or not helping. It actually taught me a lot about titration and protocols for asthma. It not only helped the patient, but it helped my education as well.
IMPACT ON PATIENT CARE Increased adherence to controller medication Better symptom control Happy patients Empowered patients Educated patients More engaged in healthcare	MD: I really appreciate that the program teaches compliance and proper usage of inhalers… usually I don’t have time to do that at clinic… I’m trying to cover a lot of things at once [and] I only see these patients once in a blue moon NP1: There was a significant benefit to the patient. Two patients I’m thinking of specifically were just so happy - they just didn’t know that they could get control, because they hadn’t been involved in care previously. I think people just accept that they have asthma and don’t realize they can get control. NP2: Often times our patients end up in the emergency room. We talk to them, they don’t understand what controller medications are, and that they have to take to keep them out of the emergency room. They always told me tell me, “these don’t work.” I’m like, “well, they don’t work because you don’t take them every day.” Somehow, TEAMS was able to get through to them that this was very important stuff. Part of the problem with controlling asthma is that people don’t have the education and with [this program] they got the education and understood why they needed to take their inhalers and started to feel better. That was amazing. PA: A lot of patients I normally don’t see actually came more because they were feeling better and they had a connection, so they actually came to their appointments. [We]would talk about their asthma, and they’d be so happy about it. Like, “I never knew that I wasn't controlled…now I feel amazing.” And I’m like, “that is how you’re supposed to feel!” The patients really turned around … I don’t know, they were just different people. It ties into everything, like their attitude toward medical care. And they want to learn more now, they want to connect with their health and be more in tune, because they feel better.
IMPACT ON WORKFLOW Saves time for HCP Saves follow up visits Makes job easier	MD: It saved me a lot of time because I wouldn’t have to make an extended visit or 2 appointments… the population we work with transportation is a big limiting factor, they have to take off work and they can’t afford to miss a day’s pay, or they have children they need child care for, [so] they miss their appointments. NP1: it made [my job] really easy. So sometimes we would increase the stepwise therapy before they came back in, so when you saw the patient, you get like two for one—you see the patient and they’ve already done what you wanted to do, so they don’t have to then come in for a second visit to reassess. So, it made it a lot easier, for the patient, but also for me… it saves office visits NP2: it didn’t really increase my workload at all…the information would be documented in the TEAMS note, and the patients were actually able to tell me the information, which is huge… I got more information, what their peak flow was, objective information. PA: It made it easier. Way less work. The education was the best. Education is the part that takes longest…understanding how to use their inhaler takes a long time, understanding what asthma is, what triggers asthma, or what inhaler to use at what times, that takes a long time. And when we’re in a visit, we’re not just focusing on one thing. Patients are complex and have multiple things…If their diabetes is uncontrolled [or] they feel bad, they’re going to put asthma to the wayside.
ADVANTAGES, DISADVANTAGES Improved access to care 1:1 education Focused on asthma Better communication	MD: It’s important to have one-on-one communication [like this] where they’re only focusing on one chronic medical condition—[patients] need someone monitoring them more carefully than the PCP can. Even in a private setting, I would see patient 3 or 4 times a year, which is not enough, because asthma changes. NP1: I found [the telemedicine visit notes] helpful – It’s a lot easier to read it than it is to try to get all that information out of a patient… it was like somebody did a pre-assessment, and you could just confirm it with the patient. It made the visit easier, because all the education was done, and education can be the hardest part, especially in an office setting. I didn’t really see any disadvantages. But, if every single patient had asthma, I could see it being a little bit more cumbersome. NP2: I've been in practice over 30 years, and asthma has been one of the things that is hardest for the working poor to control because of their barriers… They can’t get to the doctor, can’t get off work, don’t have extra time, but they have smart phone… I think it benefits those. This would help reduce admissions and ED visits. PA: This was just so helpful - I mean, it would be awesome if we could implement that into primary care. I wish we could do more telemedicine like this.

Figure 1. Thematic map of key findings from exit interviews with patient participants regarding the impact of the TEAMS smartphone telemedicine.

Table 6. Quotes from Patient exit interviews (N = 30) exploring personal experiences and impact of the TEAMS smartphone-telemedicine program for adults with asthma.

P1 (M, AA): it’s a dramatic change …. I went from having [symptoms] three to four times a day to once or twice a week…. I haven’t felt this good in a long time. I feel like, okay I can do this… before I just postponed taking the medicine and just tried to not do much … now, I take my medicine like clockwork…. Life has been a lot better.

P3 (M, C): I’ve learned I can control my asthma…[Before] I'd have gone to the doctor to get treated for an infection. [Now] I’ve been telling other people that have asthma to get on control medicine. My buddy at work has way worse asthma… I talked him into getting control medicine. I'm coaching my nephew, and my grandmother with COPD how to use her inhalers properly.

P4 (F, AA): I couldn’t run around and play with the kids—now I can. It changed my life, for sure. I went from [having] asthma, terrible, can’t do nothing, to now my asthma is well-controlled. I don’t have to use my rescue inhaler, I don’t have to worry when I go outside, I really don’t have any symptoms…. I got a regimen and a reminder in my phone, and I was able to stick with it.

P5 (F, AA): it feels like a doctor visit, but at your leisure, on your own schedule. That was important, otherwise I wouldn’t have had a visit at all. I haven't been to a doctor’s office in a long time.

P6 (F, AA): I know how to keep it under control now—that’s a big improvement. Before I was using it [albuterol] every 2 h. [The ICS] helped me a lot, it’s keeping me from using my rescue inhaler. Even though it irks my nerves and stresses me out keeping track of it, I got myself better. My mom she wanna join this too.

P7 (M, C): It was a blessing that it was the same person [every time]—It was actually like she was sitting in front of me. The phone reminders were a very, very big help. [Now] I’m able to actually take a deep breath without freaking choking…[We've] gotten my breathing under control. Everybody who has asthma should be in this program.

P9 (F, AA): What makes a difference with me is doing the peak flow, being able to see how my breathing is … Soon as I see the numbers start to rise, I felt that I was doing it right. if I see my numbers are up above 430, I’m taking my control medications right, I’m taking everything right. It helps me keep track… [Before} I was guessing.

P10 (F, AA): [Before] I was not controlled. I wasn't taking my asthma medicine … I just be brushing it off, like hit and miss…Now I take them regularly I don’t wake up with barely any symptoms

P11 (M, AA): I’m more of a hands-on person, [I'd rather] go to a building. If I’m not face-to-face, I’m distracted, [and] I didn’t like [doing] the PFM - It kind of hurts when you blow into it.

P12 (F, AA): I was not good at taking my meds before this program at all …I be thinking I’m fine, but when my doctor listens to me, she be like,“Oh you’re wheezing pretty bad”, and like, I don’t be really hearing it. I have an alarm now for my meds, and I’ll take it because I got it on the clock…the [control medicine] really helps.

P13 (F, MR): [Before] I was feeling like I might just die because I couldn’t breathe. I don’t feel like that anymore …. I feel way more confident. [Now] I walk either in the morning or at night… I couldn’t do that before. Being face to face with somebody [on the smartphone], there’s more of a connection. You feel like the person’s listening when they’re actually looking at you.

P14 (F, AA): it’s a life changing experience…I've never been in control of my asthma like I am now… Before I used to panic, because I have so many problems breathing, and the pumps didn’t work…. then they showed me the proper way of using the pump and the spacer [and] It works! [Now] I walk everyday, I play with kids… before it was ‘I can’t play with you, I can’t breathe if I do.’

P15 (M, C): I don’t like going to the doctors [because of] social anxiety and PTSD. [This works] because …it’s through the phone. If I want to, I can set the phone down and she can’t see me I can’t see her. I think that’s the biggest problem why people don’t have controlled asthma,… no one is educated. I didn’t know half the shit that [[She]] told me until afterwards.

P16 (F, HL): I learned it was actually asthma symptoms that I was having… I feel more confident knowing more about it…I know what what can happen if you don’t get any treatments

P17 (M, HL): I’m able to pick up on things that are triggering [symptoms] symptoms I didn’t think were attributed to asthma I come to learn are. … It causes me to change the way I take my medications… I used to see asthma as a burden and something that would always limit me in some way. It’s not the case anymore, really.

P18 (F, AA): I was taking the inhaler wrong, using so much clean up products and scented candles…[they] showed me something different that I should've been doing, using the [spacer]so all of it [medication] goes into your lungs…that improved me a whole lot… now I could walk up and down the stairs, without huffing and puffing! It taught me a whole different route for treating my asthma. That little spacer thing, that little peak thing… it was very useful. It showed me different numbers of how I was breathing, [if] your lungs wasn’t functioning right

P20 (M, AA): I feel amazing, now… [before] I was all horrible, I was having bad-bad symptoms, and now I feel like I can run around, and do everything that I really, really want to do.

P21 (F, HL): I can do stuff that I wouldn’t do before. Like, I can go upstairs, downstairs, through the whole house. When I used to do that, I breathed so hard, sweat so hard, my asthma be bothering me [so] I don’t do them. Now I don’t have the symptoms anymore, It’s amazing. [It's] a big change in my life….I can be happy with myself, instead of being always down.

P22: (F, HL): I didn’t know about the scarring and the swelling. I didn’t know that asthma can do that to your lungs … I’ve been talking to my little brother and sister about it, because they have asthma [and] they have no idea. I feel like now-since I know how to use [control medication] better that I am able to take care of my asthma by myself now.

P23 (F, As): I didn’t know untreated asthma can like, really damage your lungs, like really badly. This taught me like, I don’t have to live life miserably every day. [Before] I thought it was normal. This was perfect, I don’t have time to go to an office to talk to somebody… [with this] I can just video call [the nurse], it was super easy, and it was really good quality video too

P24 (F, MR): I feel in control, and I actually bragged about this. It makes me feel safe. I actually feel confident. I can pace myself and walk to the pharmacy, and I don’t feel labored. I don't feel like my lungs are bleeding, I’m not coughing, throwing up and dizzy. This gave me a blanket of security.” [Now] I’m not worried if I don’t have my [albuterol] on me…I’m not so scared or worried.

P25 (F, HL): I learned a whole lot from this, and I even taught my husband. He didn’t know things either and he’s asthmatic. Like, I didn’t that the lungs get swelled up… I’m like “Whoa!.. I need to control my asthma!"… now I'm taking my medication. Before I wasn’t because I feel like it wasn’t useful, like, “Eh, don’t need it, that’s not doing anything for me.”

P26 (F, AA): [This] changed my outlook on everything. It changed my life. it showed me how to control my asthma and keep me from getting sick and almost dying. [Now] I can be active more and play with my son and do the things I want to do. It helps you stay focused… [like] how to keep up with my meds and how to know when [the inhaler] is getting low.

P27 (M, AA): It improved the way I breathe, the way I live. I don’t struggle as much as before. [Asthma] was restricting my life, [this] pushed me to do better with my own health, give me tools that no one else has given me. [And] it was convenient. I don’t have to get up and drive during snowing weather. It was personable, I really liked that, and it was the same doctor all the time.

P28 (M, MR): My awareness is different. how I approach my health [is] a more active as opposed to just going with the flow and hoping that you know my symptoms get better.

P29 (M, C): It is so comfortable…I didn’t have to go somewhere for a visit. Like it doesn’t matter if you had pants or shoes on, you didn’t have to be dressed up to go out…It's less stress.

P30 (F, MR): I had asthma for 25 years and no one gave me a control inhaler, only albuterol. I was walking around like an 80-year old, exhausted every day. [Now] I keep up with the control inhaler. I have no symptoms, I feel wonderful, I can run around with my kids. I control my life now, participate in things, not be sick everyday. I don’t have problems with my asthma anymore.

P31 (M, C): Video chats made all the difference…. I did all my visits on the road. If I have to take a day off work or go without [healthcare], I’ll go without. [Now] I’m doin’ stuff I didn’t use to [be able] do; movin’ around quicker. I used to ignore my asthma…now, I take the meds and I actually see a difference…so now it’s worth doin’….

P32 (F, AA): I feel like my asthma’s under control. [Now] I gotta work with my brother to get his asthma under control. I told him about the inhalers, how to properly use them. I got him using his because he takes a controlled inhaler so I’ve been helping monitoring him, reminding him to take that every day [and] use a spacer.

P33 (F, AA): Before, I was scared …I would be taking medicines just to take it…now I know how to take it and what to do…I have asthma but it doesn’t have me. It doesn’t control my life anymore. I can kick asthma’s butt, but asthma can’t kick mine. I feel so good about myself…This helped save my life, cause asthma was getting the better of me.

Notes. Quotes are presented sequentially by Participant# (sex, race), excluding non-completers #2, 8, 19 (n = 3). F = female; M = male; AA = African American; C = Caucasian; HL = Hispanic/Latino.