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november 26 :: vol 23 no 12 :: 2008 43
NURSING STANDARD
THE CAPABILITIES AND ACCESSIBILITY of
new technologies have been recognised in
preventing, diagnosing, monitoring and treating
disease, and in the development and delivery of
preventive measures and proactive health
promotion programmes. These technologies
include internet, email and mobile phone
applications, and are often referred to in health
care as ‘electronic health’ or ‘eHealth’ (Pagliari et
al 2005). While eHealth incorporates a range of
electronic communication technologies, this
article focuses on the application of mobile
phones for capturing nursing documentation,
monitoring health values and collecting data to
demonstrate health promotion outcomes in
patient care and research.
Applications of mobile phones
Mobile phones are an integral part of everyday life,
although mobile phone technology is a relatively
new and innovative eHealth methodology. A
significant proportion of the UK population owns
or has access to a mobile phone, and this form of
technology is generally well accepted by most age
groups (Office for National Statistics (ONS) 2007).
Some nurses and medical staff use mobile phones
during home visits to improve communication with
hospital or community services.
Health informatics and information technology
in nursing practice are increasingly recognised in
government policy, such as the Department of
Health’s Connecting for Health Programme,
which delivers the National Programme for IT
(NPfIT) (House of Commons Committee of Public
Accounts 2007). Text messages are used in the
NHS in a combined email and text directory
service called ‘contact’, approved for the
transmission of patient data. Short message service
(SMS) texts can be used to maximise the efficiency,
effectiveness and equity of health delivery through
improved health communication.
Mobile phone technology is used in a wide
variety of settings although few research studies
have formally evaluated its impact in monitoring
chronic disease. An overview of the application of
mobile phones for wireless monitoring of health
outcomes and the delivery of health promotion
interventions has been presented (Blake 2008a).
There is emerging literature on the application of
mobile phones in healthcare delivery, although
published evidence is limited. As technology
continues to develop, mobile phones will become
increasingly important in the strategic
implementation of health monitoring schemes.
It is therefore important that nurses are aware of
innovations in this field.
Using mobile technology in health promotion
programmes has advanced their delivery by
providing personalised messaging to participants
and efficient data collection. Research evidence
suggests that mobile technology may be an option
for intervention in diet or weight management
(Kubota et al 2004, Wang et al 2006), physical
activity (Consolvo et al 2006, Hurling et al 2007),
smoking (Lazev et al 2004, Obermayer et al 2004,
Bramley et al 2005, Rodgers et al 2005, Vidrine et al
2006a, 2006b), and drug and alcohol consumption
(Collins et al 2003, Wilkins et al 2003, Freedman et
al 2006). Patients are offered mobile phone services
Mobile phone technology in
chronic disease management
Blake H (2008) Mobile phone technology in chronic disease management. Nursing Standard. 23, 12, 43-46.
Date of acceptance: July 9 2008.
&
art &science health communication
Summary
Mobile phones are being used to improve nurse-patient
communication and monitor health outcomes in chronic disease.
Innovative applications of mobile technology are expected to
increase over time in community management of cancer, heart
disease, asthma and diabetes. This article focuses on mobile phone
technology and its contribution to health care.
Author
Holly Blake is lecturer, School of Nursing, Faculty of Medicine and
Health Sciences, University of Nottingham, Nottingham. Email:
Holly.Blake@nottingham.ac.uk
Keywords
Health communication; Information technology; Mobile phones
These keywords are based on the subject headings from the British
Nursing Index. This article has been subject to double-blind review.
For author and research article guidelines visit the Nursing Standard
home page at nursingstandard.rcnpublishing.co.uk. For related
articles visit our online archive and search using the keywords.
p43-46w12 21/11/08 12:37 pm Page 43
that use the SMS text messaging or voice response
function to help them manage their disease.
This can include: accessing test results;
self-monitoring of health and providing objective
data to nursing and medical teams, such as
their blood pressure, cardiac pulsation and
electrocardiogram, weight and step counts; and
subjective data, such as self-reported quality of
life questionnaires.
There are few published studies that focus on
mobile phone technology for disease
management and health monitoring. However,
the technology is highly topical and the literature
reports rapid advancement in the field, for
example in the management of cancer (Bielli et al
2004, Maguire et al 2008), asthma (Anhøj and
Møldrup 2004), diabetes (Giménez-Pérez et al
2002, Farmer et al 2005, Gammon et al 2005,
Carroll et al 2007, Kim and Jeong 2007), and the
care of older people (Miskelly 2005). A review
identified that studies have been conducted
predominantly in Europe (Italy, Denmark,
Norway, Spain and the UK), Korea and the
United States (US) (Blake 2008b). These are
largely descriptive with few controlled trials.
Monitoring health status It is often difficult for
nursing and medical staff to obtain information
about patients’ health status once they have
returned home. In Italy Bielli et al (2004)
developed a wireless health outcomes
monitoring system (WHOMS) to improve
communication between medical teams and
patients about symptoms and quality of life. The
WHOMS system allowed structured
questionnaires to be sent directly to a patient’s
mobile phone by the medical team. Patients
could use the phone keypad to transfer their
responses automatically to an authorised
website. This information was then accessed by
the medical team and provided graphical
representation of the patient’s health status.
Bielli et al (2004) tested the WHOMS with 97
cancer inpatients and found that more than half
successfully completed a health-related quality
of life questionnaire with minimal missing data.
However, 42% of the patients refused to use the
system, which suggests that compliance could be
an issue, particularly for those individuals who
may be less familiar with the technology. This has
implications for health education.
Bielli et al (2004) suggest that using mobile
technology might be feasible for accessing cancer
patients in the community. The proportion of
users might also increase in practice as patients
who are not familiar with use of the technology
may be able to access help from family or friends to
transfer data. The study highlights some issues
with acceptability of technology, particularly for
older individuals who may be less familiar with
mobile phones in everyday life (Bielli et al 2004).
However, data suggest that older adults are more
likely to use mobile phones than the internet
(ONS 2007), and, as technology infiltrates more
aspects of daily living, generational differences in
use are likely to decline.
A randomised controlled trial reported on the
perceptions of nurses (n=35) towards a mobile
phone-based system (Advanced Symptom
Management System (ASyMS©) in managing
chemotherapy-related toxicity in patients with
breast, lung and colorectal cancer (Maguire et al
2008). Many patients receive chemotherapy as
outpatients without direct support from
oncology professionals. Information and
communication technology can be used to
support these patients at home. The nurses’
overall perceptions of this system were positive
and they recognised the benefits of using mobile
phones in early intervention and in the
management of symptoms.
Although the use of mobile phones in health
care is increasing, they are not extensively used as
many practitioners may still favour more
traditional methods of monitoring and data
collection. Advances in mobile phone functionality
and application therefore need to be matched by
advances in nursing education, with identification
and discussion of unresolved issues in practice.
Electronic tracking In the UK, Miskelly (2005)
reported the use of mobile phone alerts for the
electronic tracking of patients with dementia and
wandering. Findings were promising and showed
that it was possible to locate patients with accuracy
and reliability using a global positioning system
(GPS) enabled mobile phone. However, this system
failed when the relative or carer did not understand
how to set up the phone correctly and it showed
that there could be training issues related to user
compliance. The use of electronic tracking in this
way is controversial (O’Neill 2003). While it may
provide older people with increased independence,
and provide peace of mind for carers, it may also
restrict privacy and imply that technology is a
substitute for genuine care. Although there is still a
paucity of published research in this field, this work
highlights that there is potential for mobile phone
tracking systems to supplement patient care.
Self-management The internet has been proposed
as a tool to assist in the self-management of asthma,
although web-based asthma diaries, like any
web-based programme, are often susceptible to
high rates of attrition. Asthma diary data can be
collected efficiently by mobile phone. In a small
Danish study, Anhøj and Møldrup (2004) used
SMS to send 12 patients four text messages each
day and encouraged them to respond to at least
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three on a daily basis. The messages reminded
patients to take medication and requested peak
flow, sleep loss and medication dosage data. The
system was used during the two-month study
period and did not decrease over time, as is often
observed with web-based tools. More than half of
the patients reported two thirds of requested data,
although in subsequent focus groups patients
suggested that a lower number of daily messages
and graphical display of results could improve the
system (Anhøj and Møldrup 2004). The system
appeared efficient for many patients but the
outcomes need to be tested in a controlled trial
with a larger sample.
Mobile phone technology has most often been
applied to the distance monitoring of blood glucose
in child and adult diabetes. In interviews with 244
adults with type 1 diabetes in Spain, Giménez-Pérez
et al (2002) found that while there was a low rate of
internet use for health-related purposes, three
quarters of the sample owned a mobile phone, with
almost all patients using them more than once a
week. The authors concluded that mobile phones
therefore have potential for managing diabetes in
the community.
Anhøj and Møldrup’s (2004) work with
asthma patients suggests that graphics may
improve mobile phone monitoring systems.
Farmer et al (2005) described the development
and implementation of a real-time telemedicine
system, which was able to transmit blood glucose
data from a blood glucose monitor using a mobile
phone and collect data on physical activity levels,
eating patterns and insulin dosage. In this UK
study patients received detailed feedback on their
phones including colourful histograms charting
glycaemic control over the previous two weeks.
This information was accessible to medical staff
who could monitor patients’ blood glucose levels,
identify individuals who were not testing and
access charts showing insulin dose patterns and
how they can be modified by diet and exercise
behaviours (Farmer et al 2005). This system has
been formally tested in primary and secondary
care environments, which suggests it has potential
for wide-scale implementation.
Patients with type 2 diabetes have been
monitored using mobile phone technology in
nurse-led services. In a controlled study,
intervention participants (n=25) were requested
by nurses to enter into a website their blood
glucose level, and diet and exercise behaviours
each day using a mobile phone or wireless
internet source (Kim and Jeong 2007). Mobile
phone text messages were used weekly by a nurse
researcher to send optimal recommendations to
each patient over a six-month period. Control
participants received usual care without the
mobile phone intervention. Results were
promising as glycosylated haemoglobin (HbA1c)
decreased 1.15% points at three months and
1.05% points at six months compared with
baseline in the intervention group. Patients in the
intervention group had a decrease of two hours
post-meal glucose of 85.1mg/dl at three months
and 63.1mg/dl at six months compared with
baseline (Kim and Jeong 2007). The study shows
the potential of nurse-led mobile phone
messaging services in managing patients with
diabetes, although the sample was small and
more work needs to be done to assess compliance
in the long term.
Improving health communication Mobile
telecommunication systems have been tested
with children who have type 1 diabetes. As well as
improving communication between patients and
healthcare professionals, there is potential for this
form of technology to improve communication
between parents and their children. A Norwegian
study (Gammon et al 2005) reported the findings
of a mobile and wireless system, which was used
in the self-management of children with type 1
diabetes to improve communication with parents.
The system automatically transferred readings
from the child’s blood glucose monitor directly to
the parent’s mobile phone. Parent and child
experiences were evaluated using questionnaires
and interviews.
Given the acceptability of mobile phones as part
of everyday life, the system was effective and well
received when the child regularly measured his or
her blood glucose level, as it was perceived as a
method by which parents could maintain control
of monitoring while allowing their child some
independence. Difficulties were observed when the
child was irregular in his or her self-monitoring, as
this resulted in parents having to increase their
reminders, which could be negatively viewed by the
child (Gammon et al 2005).
Parents had concerns about the
appropriateness of the system for adolescents
(Gammon et al 2005). However, work in the US
by Carroll et al (2007) demonstrated that mobile
phone interventions can be effective in
adolescents with diabetes. Carroll et al’s (2007)
prototype diabetes monitoring system integrated
a blood glucose monitoring device into the
battery pack of a mobile phone. The small-scale
evaluation showed that the device had potential
for transmitting self-monitoring data directly
from the phone to a website where it could be
reviewed by medical teams, parents and patients.
Furthermore, the adolescents found the system
useful and easy to use (Carroll et al 2007).
Discussion
The benefits of mobile phones to assist nurses
with the distance monitoring of patients with
chronic disease are evident. In practice mobile
november 26 :: vol 23 no 12 :: 2008 45
NURSING STANDARD
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technology is beginning to play an important role
in improving the provision and transfer of
patient records, and in enhancing appointment
booking systems by SMS text message reminders
to reduce the rates of patients failing to attend
appointments, and to inform practitioners of
cancelled or rearranged appointments. Mobile
phone technology enables practitioners to
observe patients’ vital signs and activity levels,
track health status and detect problems by
identifying early warning signs.
Mobile phones can be used to collect small
amounts of data frequently and efficiently, and
require no manual data entry on receipt, therefore
reducing the possibility of record errors.
It is clear that there is a consumer market for
such systems and further work is under way to
enhance the interface and improve accessibility
and choice, including the integration of mobile
phones with palm computers, speech recognition
and interactive voice responders to provide more
individual choice in methods for response.
Conclusion
While mobile phones are widely accessible and
appear to be an efficient method of health
communication, opinions are mixed on the
success, cost benefit and practicality of such
interventions. More research is needed to
assess the impact of education programmes in
eHealth and to evaluate the clinical
effectiveness and cost effectiveness of nurse-led
mobile phone interventions NS
46 november 26 :: vol 23 no 12 :: 2008 NURSING STANDARD
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