1. Practicing in a
Connected World:
Tech-Use Guidelines
Robert Ciulla, Ph.D.
Joint Base Lewis-McChord/ Tacoma, WA
10 April 2013

2. Technology to Make People Healthy
Aligned with USAMRMC: DCoE Component
Located at JBLM
Lead the innovation of health technology solutions. Deliver
MISSION tested, valued health solutions that improve the lives of our
Nation‟s Warriors, Veterans, and their families.
• Telehealth • Emerging Technology
FOCUS AREAS • Mobile Health • Suicide Surveillance
Services, Academia, Federal (VA and others)
PARTNERSHIPS and civilian agencies
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3. T2Health.org

4. Scope of Behavioral
Health Challenge
INSTITUTE OF MEDICINE IOM RECOMMENDATIONS
• 13-20% of 2.6 million • "...the DoD and the VA also
service members deployed should support research
to Iraq or Afghanistan since that investigates
2001 may suffer from PTSD emerging techniques and
• Only slightly more than half technology, including
of those diagnosed with telemedicine, Internet-
PTSD actually received based approaches, and
treatment virtual reality, that may
• “Treatment gap”: stigma; help to overcome barriers
difficulty accessing care; to awareness, accessibility,
health care workers not availability, and adherence
suitably trained to treat to evidence-based
PTSD treatments.”

5. Mobile Health
• A mobile app is a type of application software
designed to run on a mobile device, such as a
smartphone or tablet computer.
• A mobile device is a portable computing device
such as a phone or tablet, typically having a
display screen with touch interface and/or a
miniature keyboard.
• The MHS Mobile Application Framework defines
mobile health as the use of mobile devices to
deliver health care services wirelessly.

6. Mobile Operating Systems
• iPhone (iOS) system (Apple‟s AppStore)
• Android (Google Play; Amazon appstore)
• Windows Mobile (Windows Phone market)
• Symbian operating system (Ovi)
• Blackberry (BlackBerry World)
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7. Mobile Applications
• In 2009, the University of Pennsylvania‟s Wharton
School named the biggest “life changers” of the past 30
years. They cited, in rank order, the Internet, broadband;
PC and laptop; mobile phones; email; and DNA testing
and sequencing. Today, approximately 40 years after Dr.
Martin Cooper conceived the first portable cellular
phone, a typical smart phone can do all the above, with
(at this writing) DNA sequencing being the possible
exception.
Eric Topol, MD. The Creative Destruction of Medicine: How
the Digital Revolution will Create Better Health Care, 2012, p.7
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8. Perspective
• 2007: the iPhone
• 2008: Apple‟s AppStore
• MAR 2012: 25 billionth AppStore download
• Mobile apps are the single-biggest digital
channel since the ’90s and the Web.
Industry Analyst Frost & Sullivan
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9. Health-Related Apps
• MobiHealthNews (July 2012): 13,600 health-related apps. Top Five
Categories:
– Cardio Fitness; Diet; Stress; Strength Training; Women‟s Health
– Over 1,400 stress apps
• 700+ mental health apps; overall represent about 5% of health apps
• 8.7% mood tracking
• 500 sleep apps (3.6% of health apps)
• Affirmation apps are particularly prevalent
• Number of substance abuse apps is increasing
• Chronic condition apps
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10. Mobile Technology in
Behavioral Healthcare
• Various disorders (developmental, cognitive,
substances, mood, eating, sleep)
• Informational, assessment, track/graph, interactive
tools, self-monitoring prompts
• Mobile apps‟ many other capabilities:
– Contact Lists
– Phone, email, and texting
– Videoconferencing
– Calendars, file-sharing, therapist audio-recordings, date-stamp
homework assignments
– Real-time audio/ video coaches (telehealth)
– Global positioning system (GPS)
– Wearable sensors (biofeedback)
Luxton et al. – mHealth for Mental Health: Integrating Smartphone Technology in Behavioral Healthcare.
Professional Psychology: Research and Practice. 2011, Vol.42, No. 6, 505-512.
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11. Technology Adoption:
Some Challenges
• “I can‟t do my job unless the patient is in the same room.”
• “If this is anything like programming my DVD player, forget about it.”
• “I don‟t own a smartphone.”
• “I‟m not a supporter of technology – it‟s making us more isolated.”
• “This will involve more work on top of my already busy schedule.”
• “Is there any evidence that these „apps‟ work?”
• “Do these devices „talk‟ to other systems?”
• “The IT department says they have to do system upgrades first.”
• “Does this mean that patients can email me 24/7?”
• “I don‟t know how to „chart‟ electronic communications.”
• “How do I establish a therapeutic alliance using a mobile app?”
• “What about: security; privacy; FDA; HIPAA?”
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12. Early Adopters
“I’m ready, willing
and able – Where
do I start?”
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13. Mobile Application Development
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14. PTSD
PTSD Coach
T2 collaborated with the VA's National
Center for PTSD to develop this app to
assist veterans and active duty
personnel (and civilians) who are
experiencing symptoms of PTSD. It is
intended to be used as an adjunct to
psychological treatment but can also
serve as a stand-alone education tool.
Features:
• Self-assessment of PTSD Symptoms
• Tracking of changes in symptoms
• Manage symptoms with coping tools
• Assistance in finding immediate support
• Customized support information
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15. PTSD (2)
PTSD Family Coach
T2 collaborated with the VA's National
Center for PTSD to create the PTSD
Family Coach. This app provides
support to families of Veterans and
Active Duty personnel (and civilians)
who are experiencing symptoms of
PTSD.
Features:
• Education about PTSD
• Coping tools to help manage stress
• Guided deep breathing and progressive
muscle relaxation
• Assistance in finding immediate support
and resources
• Customized support information
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16. PTSD (3)
PE Coach
The first mobile application that
supports the elements of an
evidence-based psychotherapy for
PTSD
Features:
• Session homework
• Confidential and convenient
• Therapist guide
• Session audio recording
• Assessment result tracking
• Disabled veteran accessible
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17. Stress Management
Breathe2Relax
A portable stress management tool
utilizing hands-on diaphragmatic
breathing exercise. Breathe2Relax
uses state-of-the-art
graphics, animation, narration, and
videos to deliver a
sophisticated, immersive experience
for the user.
Features:
• Setup guide to assist with tailoring app
• Customizable backgrounds and music
• Immersive tutorial videos
• Body scanner to display effects of stress
• Graphing to track effectiveness
17 • Audio narration

18. AfterDeployment.org/ Mobile Version
Life Armor
A multi-topic application derived from
AfterDeployment.org to provide the
user with knowledge and tools to cope
with the many challenges faced by
today‟s service members.
Features:
• 17 Self-assessments
• Multi-topic resource guide
• Ease to manage, customizable views and
favorites
• Manage symptoms with coping tools
• Video resources on topics
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19. Behavioral Activation
Positive Activities Jackpot
Provides suggestions for daily positive
activities. Based on positive event
scheduling, the active component of
Behavior Activation. Helps with
depression, self-harming behaviors, and
individuals without any mental health
difficulties.
Features:
• “Jackpot” suggests random activities
• Users select from 376+ possible activities
• Augmented reality technology to identify
activities in immediate surroundings
• Ability to invite friends or post chosen
activity to social media
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20. Mood Enhancement
Virtual Hope Box
Self-care tool for patients. Helps the user
cope with suicidal ideation and other
symptoms of depression by providing a
customizable, virtual “hope box”
containing reminders for living, distraction
tools, relaxation tools, coping cards, and
other symptom management tools.
Features:
• Customizable pictures, video, and music
to remind user of reasons for living
• Word games, photo puzzles, and other
distraction tools
• Guides user in controlled breathing and
progressive muscle relaxation
• Inspiring quotes
• Crisis lines and customizable contact
information for immediate support
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21. “Wearable” Sensors
BioZen
Monitor, track and view biometric data
from Bluetooth enabled devices to
assist with biofeedback therapies.
Features
• Real-time tracking
• User tutorials for setup and learning
• Customizable graphical feedback
• Supports broad range of signal data
including:
EEG, EMG, GSR, EKG, respiratory
rate, and temp
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22. Provider Support
Provider Resilience
Self-care tool for healthcare
providers who work with service
members and who may need
support in coping with burnout or
compassion fatigue
Features:
• Quick dashboard view
• Graphing to track resilience
progress
• Tools to assist increasing
resilience
• Inspirational value cards
• User sets reminders
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23. Practice Guidelines (1)
mTBI Pocket Guide
Clinical Practice Guidelines
for treatment of mTBI
Features:
• Quick results with coding guidance
• Symptom management lists
• Summary of clinical recommendations
• Patient education resources
• Clinical tools and resources
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24. Practice Guidelines (2)
mTBI Co-Occurring Conditions
Toolkit
Co-occurring Conditions Toolkit:
Mild Traumatic Brain Injury and
Psychological Health
(Co-occurring Conditions Toolkit)
Features:
• Guidance to primary care providers on
the assessment and management of
patients
• Synthesizes information from the
following VA/DoD CPGS: mTBI,
• PTSD, depression, chronic opioid
therapy and substance use disorder
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25. Early Adopters
“O.k. Now I have an idea
what’s out there. So how do I
bring mobile health into my
practice? Is there a
Technology Clinical Practice
Guideline?”
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26. Mobile Health Guide for Clinicians
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27. Early Adopters
“A how-to manual!
What will it teach me?”
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28. The First Mobile Health Session:
What You Need to Know
• The benefits of mobile health.
• Basic information/ how-to‟s.
• Anticipate frequently asked questions.
• Know the range of available apps.
• A treatment plan that includes mobility.
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29. The First Mobile Health Session:
What You Need to Ask
• “Do you own a smartphone or a tablet?”
• “Are you familiar with smartphone “apps”
and how to download an app?”
• “Have you ever used a health-related app
to help with (nutrition, sleep problems,
exercise tracking, depression, etc.)”
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31. Customizable Self-Rating Tool
T2 Mood Tracker
Self-monitor, track and reference
emotional experiences over a period of
days, weeks and months.
Features:
• Self-rating on pre-populated categories
• Full note adding
• Graphed results
• Fully customizable categories
• User-set reminders for self-rating
• Send results to providers
Advantages:
• Smart phones are always with us
• Minimizes stigma
• Fills the white space between visits
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32. Health Technologies:
Paradigm Shift
• Educated/ integrated consumer
• Social networks/ crowdsourcing
• Wearable sensors/ the “measured life”
• Patient-centered/ participatory model
• Advancements in user interface
• Files uploaded directly to health records
• Barriers overcome by „virtual‟ clinics
• Clinical practice in „the age of connectivity‟
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33. 21st Century Healthcare:
“Anywhere, Anytime, Any Device”
• Making Connections
• Enabling Access
• Working in the “White
Spaces”
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34. Communication Opportunities
LinkedIn AfterDeployment.org
• For behavioral health providers • AD.org Community of
who treat Service members and
Veterans Practice
• Share ideas and best practices
• Next meeting July 10
• http://www.linkedin.com/groups/
Psychological-Health-Providers- POC:
Military-Community- robert.b.miller321.ctr@mail.mil
4135318/about
• T2 moderators screen group
applicants to ensure they hold
the necessary credentials
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36. Technology to Make People Healthy
“I want us to ask ourselves every
day, how are we using
technology to make a real
difference in people’s lives.”
- President Barack Obama
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37. Contact Information
Robert Ciulla, Ph.D.
Director, Mobile Health Program
National Center for Telehealth and
Technology |T2|
Joint Base Lewis-McChord, Tacoma, WA
robert.p.ciulla.civ@mail.mil
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