Interactive Mobile Doctor (iMD) to Promote Patient-Provider Discussion on Tobacco Use among Asian American Patients in Primary Care: A Pilot Study

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Figure 1.
Sample bilingual summary (English/Vietnamese) printout generated by the Interactive Mobile Doctor (iMD) intervention.
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Figure 2.
Participant flow diagram. PCP, primary care provider.
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Figure 3.
Documented primary care providers' delivery of the 5As (Ask, Advise, Assess, Assist, and Arrange) to 47 study participants across 3 consecutive primary care visits at preintervention, intervention, and postintervention based on 141 progress notes extracted from electronic health records.

Table 1.

Coding Definitions of 5As to Quantify Primary Care Providers' Delivery of 5As as Documented on Electronic Health Record Progress Notes

Code	Definitions	Progress Note Examples
Ask	Any statement mentioned about patient's use of tobacco or smoking status. Examples: diagnosis codes, smoking status updates, mentions of tobacco use.	Tobacco abuse Still smoking 5 to 6 cigarettes per day
Advise	Statements advising patient to quit or to reduce.	Tobacco use: encouraged cessation
Access	Statements reflecting patient's readiness to quit; examples: patient's intent, motivation or effort at quitting.	Trying to cut down Precontemplative, does not want to set date, will try to decrease number of cigarettes for next visit by 1/2.
Assist	Statements addressing commitment to a method to achieve quitting (ordering, planning or provision of information relating to smoking cessation medications)	Plan quit date 3/8/15. 800-778-8440 call smoker's helpline Vietnamese. Use Nicotine 21 mg/24 hr daily × 6 weeks #42, then 14 mg/24 hr daily × 6 weeks, then 7 mg/24 hr daily × 6 weeks …
Arrange	Statements document specific plans for follow-up with a patient's effort to quit	Tobacco smoking cessation discussed … He is to schedule a follow-up visit 2 to 3 months

Table 2.

Sample Characteristics at Baseline (N = 47)^*

	Values^{^†}
Demographics
Male	47 (100)
Ethnicity
Vietnamese	29 (61.7)
Korean	18 (38.3)
Age, years
<50	9 (19.1)
50 to 59	17 (36.2)
>60	21 (44.7)
Married	31 (66.0)
Lived in United States <15 years	17 (36.2)
Education
< High school	21 (44.6)
Graduated high school or beyond	16 (55.3)
Income (% of federal poverty level)
100% to 200%	24 (51.1)
<100%	11 (23.4)
Unknown	12 (25.5)
Health status
Self-rated health
Fair to poor	34 (72.3)
Tobacco-related diseases^{^‡}
Hypertension	27 (57.4)
Diabetes	11 (23.4)
COPD	10 (21.3)
Others (CVD, stroke, or cancer)	6 (12.7)
Behavioral health conditions^{^‡}
Depression	13 (27.7)
Anxiety disorders (including PTSD)	9 (19.1)
Others (alcohol use or sleep disorders)	5 (10.6)
Smoking status and history
Number of cigarettes smoked per day, mean (SD)	9.3 (4.5)
Time to first cigarette after waking
Within 30 minutes	33 (70.2)
>30 minutes	14 (29.8)
Years smoked regularly
>10 years	3 (6.4)
11 to 20 years	3 (6.4)
>20 years	41 (87.2)
Intended to quit in the next 6 months	22 (46.8)
Had 24-hr quit attempt past year	18 (38.3)
Attempted to quit in the past year	28 (59.6)

COPD, chronic obstructive pulmonary disease; CVD, cardiovascular disease; PTSD, posttraumatic stress disorder; SD, standard deviation.
↵* Column percent for mutually exclusive categories may not be summed to 100% due to rounding.
↵† Values are n (%) except where indicated.
↵‡ Participants may endorse one or more categories for tobacco-related diseases, and behavioral conditions.

Table 3.

Feasibility and Acceptability Outcomes of Interactive Mobile Doctor Intervention (N = 47)^*

	Values^{^†}
Feasibility Measures
Length of iMD administration (minutes)
Mean (SD)	12.9 (3.7)
Range	10 to 25
Needed staff assistance during administration
No assistance needed	30 (63.8)
Once	17 (36.2)
More than once	0 (0.0)
Completion of iMD prior to seeing PCP
Yes	45 (95.8)
No	2 (4.2)
Acceptability Measures
Please tell us what you think of the length of the video intervention? Would you say the length was…
Too long	0 (0.0)
Just right	46 (97.9)
Too short	1 (2.1)
What did you think of the messages from the videos? Were they…
Too difficult to understand	0 (0.0)
Somewhat difficult to understand	1 (2.1)
Not too difficult to understand	6 (12.8)
Quite easy to understand	40 (85.1)
How helpful or not helpful do you think the video program was in your decision about quitting cigarettes?
Not at all helpful	1 (2.1)
Somewhat helpful	5 (10.6)
Moderately helpful	13 (27.7)
Very helpful	28 (59.6)
In terms of enhancing the quality of the communications between you and your doctor in the clinic visit you just had, how helpful or not helpful do you think the video program was…
Not at all helpful	1 (2.1)
Somewhat helpful	5 (10.6)
Moderately helpful	6 (12.8)
Very helpful	35 (74.5)

iMD, Interactive Mobile Doctor; PCP, primary care provider; SD, standard deviation.
↵* Feasibility data were obtained by research staff's observation. Acceptability data were obtained by participants' self-report from an in-person assessment immediately after the primary care visit after the iMD administration.
↵† Values are n (%) except where indicated.

Table 4.

Multivariable Logistic Model Results for Electronic Health Record-Documented Outcomes^*

EHR-Documented Outcomes	Time Points^†
EHR-Documented Outcomes	Intervention Visit AOR (95% CI), P Value	Postintervention Visit AOR (95% CI), P Value
Ask	2.26 (0.94–5.46), .07	1.49 (0.62–3.57), .37
Advise	1.44 (0.66–3.13), .36	1.44 (0.54–3.79), .47
Assess	4.49 (1.62–12.49), .004	3.34 (1.32–8.44), .01
Assist	17.63 (4.67–66.57), < .001	2.02 (0.54–7.56), .30
Arrange	10.28 (2.92–36.23), < .001	1.80 (0.44–7.39), .42

AOR, adjusted odds ratio; EHR, electronic health record; 95% CI, 95% Confidence Interval.
↵* All models used generalized estimating equations (GEE) to adjust PCP clusters. Multivariable logistic regression models included the following as covariates: ethnicity (Korean vs. Vietnamese), age (<60 vs 60 or older), education (<high school vs. high school or beyond), presence vs. absence of a tobacco-related disease condition (hypertension, diabetes, chronic obstructive pulmonary disease, cardiovascular diseases, stroke, or cancer), and number of cigarettes smoked per day (<10 vs 10 or more). Bold text denotes significant AOR, 95% CI, and P-value (P < 0.05).
↵† Referent is preintervention visit. Three time points were included in this study: (1) at preintervention, one primary care (PCP) visit prior to the intervention; (2) intervention visit with participants receiving the interactive Mobile Doctor (iMD) intervention; and (3) at postintervention, one PCP visit after the intervention visit.