We implement innovative biomedical informatics methods, create research tools, and follow the principals of community-based participatory research to address health disparities among underserved communities (e.g., African American, LGBT, youth) and to create a Learning Health System that is responsive to vulnerable populations, particularly those at risk for acquiring HIV/AIDS, Drug Use Disorders, and Diabetes.


Using Smartphones for Early Detection of Opioid Misuse to Inform and Improve Physician Drug Screenings with Patients

(PI: Dr. William Brown III)

Chronic pain occurs in as many as 85% of patients living with HIV (PLWH-patients) and a significant proportion (53%) of those use prescription opioids to manage their pain. One study of PLWH using prescribed opioids found that 62% of them experienced misuse. For PLWH opioid misuse can lead to high risk behavior and poor retention in care, and can negatively impact antiretroviral therapy (ART) adherence and viral suppression. Studies have found that early detection and treatment of opioid misuse resulted in 20-60% reduction in clinical costs, reduced mortality risk by 2.4 times or more, and significantly better retention in care. Thus, developing a mobile intervention using sensors that detects opioid misuse and improve physician opioid screening could greatly improve healthcare outcomes of patients at risk of substance misuse, and contributes to a learning health system. UCSF researchers have developed “Eureka” (U2CEB021881; Marcus, Olgin, Pletcher), a first of its kind customizable, device-universal, HIPAA compliant, and EHR integrated, mHealth development platform. Eureka, provides an opportunity to design, build, and pilot an innovative, scalable and extensible mobile app for the “Intelligent Detection of Opioid misuse to improve Care” (iDoc). The iDoc app would algorithmically assess potential opioid misuse in real time and alert the patients’ primary care physician (PCP) via their electronic health record (EHR) if there are indicators of opioid misuse. The goal is to influence PCP’s to follow-up with patients to conduct an assessment for opioid misuse and intervene as necessary. The iDoc app could potentially improve early substance misuse screening and lead to timely intervention, reduced risk of drug addiction, and improved patient health outcomes. With a committed mentorship team and additional training, the principal investigator will pursue three specific aims:

Aim 1: Identify opioid misuse indicators, desired app features, and concern for both patient and physician. Using mixed methods, we will conduct five focus groups each consisting of eight PLWH-patients who use opioids (N=40). We will also interview 10 physicians providing care to PLWH.

Aim 2: Translate aim 1 findings into iDoc app features; build and refine iDoc; link iDoc to EHR. We will use findings from aim 1 to develop iDoc’s opioid misuse detection algorithm and logic models. iDoc’s EHR integration will be developed using the Eureka platform.

Aim 3: Test the feasibility and acceptability of implementing iDoc; pilot pragmatic clinical trial. We will recruit at five PCPs and at 40 of their opioid-prescribed PLWH-patients (e.g., 8-patients:1-PCP). The primary outcome is whether PCP opioid assessment increases (indicated in EHR data).

To assess feasibility, we will examine recruitment, retention, patient and PCP feedback and iDoc metadata. We will assess acceptability using Technology Acceptance Model v2-based survey items and a final interview. This K12 study will build the foundation for the PI’s career as an independent researcher by providing: a) skills to develop and implement patient-centered clinical interventions; b) statistical and methodological skills to conduct pragmatic clinical trials; c) an innovative trial-ready, scalable intervention; and d) pilot data supporting an R01 trial of the iDoc intervention.

Creating Community Driven, Personalized Health Maps for Patients with Diabetes

(PI: Dr. Courtney Lyles; Co-I: Dr. William Brown III, ...)

This NLM R01 proposal aims to develop and test a personal health library platform for patients with diabetes and prediabetes, harnessing both personal health and healthcare data (e.g., medication lists, upcoming appointments, self-tracking of diet and blood sugars) and location-based mapped data about neighborhood health resources (e.g., community reviews about the quality of grocery stores and parks). Diabetes and prediabetes patients have substantial needs for tracking and accessing health and healthcare information that are poorly met by existing platforms that largely operate in silos. Furthermore, existing digital health tools have not utilized participatory design approaches and have low uptake among specific subgroups, such as racial/ethnic minority and lower income populations. In this project, we will use design science to create and evaluate a new personal health library platform to strengthen and improve the ways in which low-income individuals and communities of color access and interact with personal health data that better reflect their needs and interests. Specifically, we propose to create a new platform that enables patients with diabetes or prediabetes to import their personal health data to a mapping platform, in order to have access to the store and view both private and public views of health- promoting and health-inhibiting community factors in their own neighborhood. This new platform will be titled: Mapping to Amplify the Vitality of Engaged Neighborhoods,? or MAVEN.

In Aim 1, we will use inductive observational methods to follow community leaders/health advocates and patients with either diabetes or prediabetes to understand existing health and healthcare journeys and map existing resources in their neighborhoods. We will recruit patients and community-based organization leaders from 3 San Francisco neighborhoods with the highest prevalence of diabetes and pre-diabetes, which also correspond with existing San Francisco Health Network clinics in our healthcare system.

In Aim 2, we will recruit a second sample of individuals to complete user-centered design methods (e.g., card-sorting and think-aloud interviews) to prioritize and test prototypes of data elements within the new MAVEN personal health library platform.

In Aim 3, we will conduct real-world usability testing of a functional version of the MAVEN platform to explore its acceptability and usability in everyday life. Because we will engage racially/ethnically and socioeconomically diverse patients in this project, we will ensure that the MAVEN personal health library platform is relevant for patients with varying levels of health literacy and technology proficiency. In addition, because we will engage community health advocates and public healthcare system leaders, our findings will have more direct implications for implementation and dissemination.

Public Health Relevance

This goal of this study is to develop and evaluate an online platform that patients with diabetes or prediabetes can use to combine important information relevant to their health and healthcare ? such as medical information, personal data on diet or blood sugar levels, and community data on health resources in their neighborhood. We will first design the platform with community member and community health advocate input, and then we will test the platform to see how individuals use it in everyday life. We will recruit racially/ethnically and socioeconomically diverse individuals in this study to ensure that the final product is relevant for the broader public, even those without extensive experience using technology.

The Next Frontier in Diabetes Communication: Promoting Health Literacy in the Era of Secure Messaging

(PI: Dr. Dean Schillinger; Co-I: Dr. William Brown III, ...)

Limited health literacy (HL) places individuals at greater risk of type 2 diabetes (DM2) and its complications, is a marker of vulnerability, and presents a critical clinical and public health problem. To be health literate in the 21st century, patients will need a certain level of linguistic facility, in combination with technical skills, to access services via online patient portals. Our research has shown that DM2 patients with limited HL are actively using patient portals. However, as healthcare becomes increasingly dependent on electronic communications (e.g., secure messages via internet-based patient portals), patients with limited HL may have difficulty communicating electronically with their clinician or understanding their clinician's secure message responses or instructions. For clinicians to electronically provide meaningful and actionable information and support, their secure messages must be written in an easily comprehended style. Few studies have examined how patients with limited HL interact with their healthcare providers via patient portals. This trans-disciplinary proposal, involving a team of health services researchers, health communication scientists, and computational linguists, will focus on a population of ethnically diverse DM2 patients and their primary care providers from 1) a large, integrated group model HMO with a well-developed patient portal and 2) a county-run, integrated public (safety net) delivery system with a newly launched electronic health record and patient portal. Our study is designed around a conceptual framework promoted most recently by the Institute of Medicine: overcoming the challenges LHL patients face in managing DM2 requires that healthcare systems, and their clinicians, make accommodations to meet patients' communication needs. The degree of linguistic mismatch observed in secure message exchanges between DM2 patients and their providers, measured using computational linguistics, will serve as one indicator of the extent to which providers are, or are not, making such accommodations. 

Our specific aims are to (Aim 1) develop and validate a novel, automated linguistic complexity profile (LCP) to assess secure message content generated by DM2 patients and their providers via patient portals. We will employ natural language processing (NLP) to develop and validate the LCP, based on secure messages and data from >200,000 DM2 patients. The LCP will demonstrate construct validity with patient HL and patient reports of provider communication, and will be associated with DM2 outcomes; 

(Aim 2) examine whether concordance between provider and patient LCP is associated with adherence among DM2 patients newly prescribed insulin or antidepressants; 

(Aim 3) characterize the collaborative nature of exchanges between providers and low LCP patients, using mixed methods, to enhance our understanding of communication in the critical period surrounding initiation of insulin or antidepressants; 

(Aim 4) create an automated, LCP-based prototype to provide real-time feedback to providers while writing secure messages to reduce linguistic complexity and better accommodate DM2 patients' linguistic skills and HL.

Public Health Relevance

Limited health literacy places individuals at greater risk of type 2 diabetes and its complications, making limited health literacy a critical clinical and publi health problem. As healthcare becomes increasingly dependent on electronic communications, patients with limited health literacy may have difficulty communicating by email with their clinician or understanding the clinician's emailed replies or instructions. This proposal will use computational linguistics to examine how diabetes patients with a variety of health literacy levels interact with their clinicians via patient portals, will explore whether linguistic gaps between patients and clinicians are associated with diabetes outcomes, and will create a feedback tool to assist clinicians to better accommodate diabetes patients' communication needs.

Rapid Home Test to Reduce Sexual Risk Behavior in MSM and Transgender Women

(PI: Dr. Alex Carballo-Diéguez; Co-I: Dr. William Brown III, ...)

More than 30 years into the AIDS epidemic, men who have sex with men (MSM) continue to engage in unprotected anal intercourse (UAI) in circumstances in which there is risk of HIV transmission. MSM are the only CDC-defined risk group in the US in which new HIV infections have been increasing steadily since the 1990s. Statistics about HIV among male-to-female transgender women (TGW) are often unavailable but it is known that HIV prevalence in this population is high, and the 2011 Institute of Medicine Consensus Report called for much needed research among transgender populations. Alternatives to condom use are needed for individuals who cannot or will not use condoms. Use of a rapid HIV-home test (HT) to screen potential sexual partners could be an important risk-reduction tool for such population.

The primary aim of our study is to determine if high-risk MSM and TGW who have access to HT and learn how to use it with potential sexual partners engage in less sexual risk behavior than MSM and TGW who do not use HT.

The secondary aim of the study is to determine if ease of access to HT affects its use to reduce occasions of UAI.

This 5-year randomized controlled trial will target mainly, but not exclusively, ethnic minority men and TGW who have sex with men, are HIV-uninfected and non-monogamous, never or seldom use condoms, and have a history of serodiscordant UAI. We will recruit and pre-screen approximately 600 participants in two cities with high HIV prevalence: New York, NY, and San Juan, PR. Given the stringent eligibility criteria of the study, we expect that only 300 participants will be eligible to enroll in the trial after screening at Visit 1. At Visit 2, they will be randomized in equal numbers to one of two groups: Group A participants will receive an HT intervention orientating them to effective ways of using HT to screen sexual partners and will be supplied with HT kits to use with sexual partners over 6 months; Group B participants will receive neither the HT intervention nor supply of kits, and we will monitor whether they avail themselves of HT kits through purchase or other means. Both groups will receive risk-reduction counseling. All participants' behavior will be monitored for 6 months through daily brief SMS reports. At Visit 3 (6-month evaluation), we will test our primary hypothesis; also, we will discontinue the provision of HT to Group A. Group A will be monitored for three additional months. At Visit 4 (9-month evaluation), we will test our secondary hypothesis. Demonstrating that use of HT is an effective risk-reduction tool can have a high, transformative impact in the HIV prevention field. Additionally, demonstrating the crucial nature of easy access to HT to realizing the potential of HT as a risk-reduction tool may spur action to make HT more accessible to populations most likely to benefit from its use. It will give evidence that use of biotechnology that is already available and less costly than others (e.g., PrEP) can potentially result in fewer new infections and reduce public health expenditures.

Public Health Relevance

This study focuses on HIV-uninfected men and transgender women who have sex with men, with special emphasis on ethnic minority individuals, who have more than one sexual partner and never or seldom use condoms. It seeks to demonstrate that these individuals will have fewer occasions of risky sex if they use a rapid HIV home test (HT) to determine if their sexual partners are infected with HIV (although the test does not detect very recent infections). The study also seeks to show that having easy access to HT, including an affordable price, is crucial so that people can use it to test potential sexual partners; this is important because this procedure may become a brand new approach to HIV-prevention, leading to fewer new infections and a decrease in healthcare costs.