Learn by Doing: Maurice Hajjar

How can smartphones address public health problems?

As students filter out of the main doors of the School of Public Health after class, hands plunge into pockets and eyes glue to phone screens. Smartphone use has become nearly ubiquitous in the age cohort commonly referred to as millennials; 92% of Americans aged 18 to 34 owned a smartphone in 2015.

Mobily-optimized platforms such as Facebook, Snapchat, Whatsapp, and Instagram have bled into the social consciousness of America’s young people, and ‘digital literacy’ has entered the global lexicon, a must have in the 21st century economy.

The School of Public Health is now challenging students to view their phones, and other ubiquitous technologies, as tools that can be used to address some of today’s most pressing public health problems. Instructors are incorporating technology into their classes, and the school is working hard to offer internships and experiential learning opportunities for students excited to learn more about the growing field of mobile health.

For Maurice Hajjar, a student in the combined MD/MPH program, an opportunity to gain experience in this field represented a way to supplement the existing MPH curriculum with some hands-on field work. He secured an internship with Dr. Megan Ranney, an emergency physician and Director of the Brown Emergency Digital Health Innovation Program, on a project called ER-TLC, or “Emergency Room Texting Lifespan with Care.” ER-TLC is a text message-based intervention that aims to improve patient adherence to treatment plans upon discharge from the emergency department, and reduce the rate at which patients return to the emergency department for the same problem. Hajjar realizes the importance of this work based on the trends in treatment plan adherence he sees today.

“In today’s emergency departments, patients are sent home with written discharge instructions on how to manage their health problem, which often includes completing a course of medication, following up with an outpatient provider, or both,” he said. “For a variety of reasons, a large subset of these discharged patients don’t fill their prescriptions, or don’t make or keep their follow-up appointments with outpatient providers.”

This has huge implications for patients and providers alike. “Patients suffer because their acute health issues are treated sub-optimally, which often leads to patients returning to the emergency department for the same issue (termed emergency department recidivism) and lower overall patient satisfaction,” he said. “As public health problems, patient non-adherence and recidivism have far-reaching effects: It places a burden on the healthcare system because patients seek further care for unresolved health issues, it increases the cost of care since diseases may progress to more advanced stages, and it decreases patients’ quality of life overall.”

The omnipresent nature of the cellphone presents a new opportunity to tackle this problem. “What we know is that patients are more likely to adhere to discharge instructions if they are contacted after their visit,” Hajjar said. “But, contact via telephone is often unfeasible for high-volume emergency departments because they are very time- and resource-intensive. We also know that the vast majority of patients presenting to the emergency department have access to a text message-capable cellphone. This presents a unique opportunity to reach patients in a way that is both acceptable to them and that places a minimal burden on providers. Through an automated text message program developed by the start-up SenseHealth, ER-TLC leverages the ubiquity of cellphones and the acceptability of text messaging to reach patients in a series of post-discharge texts that remind them to fill any discharge prescriptions and make a follow-up appointment with an outpatient provider.”

This complex project, although challenging at times, has given Hajjar an opportunity to apply skills he’s learned in the MPH program. “Working with Dr. Ranney during this internship experience has allowed me to really hone the skills I’m learning through my MPH coursework, especially those pertaining to research methods and data analysis,” Hajjar said. “It’s also providing extremely valuable insight into the extraordinarily complex logistics of successfully managing a project of this nature, a ‘hidden curriculum’ that I wouldn’t have been able to learn from without this internship opportunity. Taken together, when confronted with future public health problems in the emergency setting, I’ll have a solid foundation to approach them systematically. For that, I believe I’ll have this internship experience with Dr. Ranney to thank.”

Hajjar has also reflected on the knowledge he’s gained on the use of technology to solve public health problems. “Working on ER-TLC with Dr. Ranney has really opened my eyes to the notion that technology doesn’t have to be complex or cutting-edge to have a meaningful impact. A researcher doesn’t necessarily have to develop a complicated proprietary algorithm or design a groundbreaking new device to improve the health of a population. Rather, I think some of the most meaningful research in this area will come from creative individuals leveraging existing technology in new and interesting ways. Consumer technology is an abundant untapped resource in public health and ultimately, using the technology that already exists in everyone’s pocket is going to foster the greatest level of access. It will be really exciting to see how collaborations between tech startups and public health organizations develop in the future.”

For Maurice Hajjar and many others, Brown is providing stimulating, challenging opportunities to explore the innovative space that exists at the intersection of technology and health. “One of the fantastic aspects of public health research involving technology is that it’s an exceedingly broad field and is only getting broader. Technology, especially consumer technology, can intersect with so many different areas of public health that anyone can carve out a niche of interest. For example, faculty at the School of Public Health are also utilizing a text message-based intervention to improve medication adherence for persons living with HIV in South Africa. Brown is a highly supportive environment to create opportunities for yourself in whatever area you’re passionate about, and there are always faculty who will be willing to help you realize those ideas.”