Are you connected? On-line services take patient care to new horizons
Systems aim to improve outcomes, reduce health care costs
It’s 6 a.m., and as you reach to turn off the alarm, you glance over at the small, freestanding screen on your night table. "You have a session waiting," it says. If you touch it, it will come alive with questions.
"Hello, Michele. Have you checked your blood glucose in the past 24 hours?"
If you haven’t, it asks you to check it and enter the reading. Then it follows with a short series of health monitoring and patient education questions that vary day to day. Did you check your feet? Did you take your medicine? "Have a good day, Michele. I will be in touch with you again tomorrow. Bye-bye."
Welcome to the new world of outcomes management. Thanks to the Internet, touch screens, and other forms of computer technology, doctors and nurses can reach into the homes of their patients and monitor their care daily.
With the Health Hero Network system described above, patients can answer the preset questions any time during the day. The device, called the Health Buddy, automatically transmits the answers through a phone line in the middle of the night. Physicians or nurses can call up a list of patients they’re monitoring, with red flags for patients whose response (or non-response) suggests a problem in symptoms, behavior, or knowledge.
The Health Buddy, which costs about $20 per patient per month, is about the size of a hardback book and can be easily packed if patients travel. It transmits information through a toll-free number. Other similar systems of on-line care management have evolved using a direct Internet connection, which requires patients to have and be able to use a computer. From a password-protected Web site, they can e-mail their doctor, record key clinical indicators or symptoms, and chat with others who have the same condition.
"It’s a continuous process of documenting how the patient feels," says Steve Brown, chief executive officer of Health Hero Network in Mountain View, CA.
These systems encourage patients to become responsible for monitoring outcomes while allowing early identification of those patients whose symptoms are progressing or compliance is lagging. "People [usually] just slip between the cracks, and you don’t hear from them at all until they show up at the emergency room," says Brown. "That’s what we’re trying to avoid."
A better way of keeping tabs
Standard disease management is supposed to keep close tabs on patients. But the Santa Clara County Individual Practice Association (IPA) in San Mateo, CA, discovered failings. Nurses in the IPA’s disease management service, which was provided through a contract with an outside vendor, called congestive heart failure patients every day with a list of questions.
"It was the same set of questions standardized every day to all the patients," says Calvin Chao, MD, MBA, the IPA’s associate medical director. "There was no customization of the questions and no variation of the questions."
The IPA learned that of 120 patients in the program, about 40 were either improperly enrolled because their conditions didn’t meet the parameters of the service or were noncompliant with the disease management intervention.
"We felt there was no substitute for managing a program with our own nurses," says Chao, whose IPA includes 850 physicians in Santa Clara County and 125,000 members. "That would give us the oversight and ability to develop some key insights into the population we were managing."
The IPA chose the Health Buddy system with an eye toward the type of patient with congestive heart failure. Most are in their 70s and 80s and have multiple medical problems, often including use of a wheelchair or oxygen.
To join the program, both patients and their physicians had to agree to use the Health Buddy. The IPA staff assured patients that the device would be easy to set up and use, and provided orientation sessions. Fifty-nine patients are now on-line with Health Buddy.
"Whenever you present octogenarians with a piece of unfamiliar technology, you have to do some orientation and some hands-on selling of the device," he says. "We’re very pleased with how many people did hook up the device."
Initially, the Santa Clara County IPA asked each patient the same questions, although the questions would change from day to day. The IPA can easily change questions by accessing a password-protected Web site.
But based on responses, the IPA identified subgroups, such as smokers or diabetics, and targeted specific issues to them. For example, patients with weight problems or who admitted to adding salt to food might be targeted with dietary questions and information.
"You can program this [device in a way] that the patients feel each question is written with them in mind," says Chao. "It appears as if somebody is on the other end writing e-mail to this person.
Health Hero Network users can determine how they want the patients’ information flagged. Nurses or physicians might follow up with patients who are out of compliance with goals (for example, diabetics with high blood glucose readings) or suffering worsening symptoms (such as congestive heart failure patients with extreme shortness of breath).
The Santa Clara County IPA uses a red flag to indicate that a nurse should follow up that day. A yellow flag means the follow up should occur within two to three days, and a green flag suggests a follow-up at the nurse’s convenience. The Health Buddy responds to a report of seriously acute symptoms by telling the patient to call their physician immediately. (The Health Buddy doesn’t transmit information to the IPA until the next day.)
A cardiologist also works with nurses as a consultant and carries a beeper so he can be responsive to urgent questions about Health Buddy patients. Nurses also can refer a home health nurse to check on patients.
For those willing to venture fully into the Internet, the on-line potential for disease and outcomes management expands. Virtua Health, a health system based in Marlton, NJ, is conducting a pilot study of on-line diabetes self-management. Patients have access to every imaginable on-line amenity, including a personal diary to collect information, an education center with everything from medical information to recipes, and an algorithm-based "What If?" section that essentially helps patients know when to seek additional care. There are chat rooms, bulletin boards, and messaging centers.
The study, called Community Health Advancement Through Technology (CHATT), is jointly funded by Virtua Health, Communi-Health, an on-line health information company based in Chicago, and Intel Corp in Santa Clara, CA. It uses the Internet-based HealthAnswers software, developed by CommuniHealth, as its core module.
To participate, the 240 patients in the pilot test agreed to log in at least once a week. They could do whatever they chose within the Web site.
"They didn’t necessarily have to log in and record all their blood sugars," says Tracy Carlino, RN, CDE, director of community education for Virtua Health. Chat rooms have been the most popular areas, she notes. "The social support they’ve gained has been critical."
"The frequency [of connecting with the program] is variable," she says. "I have people who log on 20 times a day, and people who barely make their one time a week. It seems once they get started, they don’t get off. It’s a matter of motivating them."
Diabetes educators have full access to the site and receive copies of such things as e-mail messages to doctors. They can view a patient’s personal diary to see the blood glucose readings. So far, no emergency situations have emerged on-line, and patients understand that they should call their physicians with urgent medical problems, Carlino says. Physicians have been slower to embrace the technology, says Carlino. "They’re so used to their day-to-day routine that finding the time just to sit down and log on is an issue for them now."
Program directors expect cost savings
This summer, Virtua Health is beginning to collect and analyze information on the on-line program, with a comparison control group that did not receive access to the site. The health system conducted a pre-assessment and will follow up with a post-assessment that involves a medical exam, lab tests, and patient surveys. Outcomes measures include satisfaction, changes in health status, knowledge about self-care, hospitalization, and participation in at-risk behaviors.
Based on cost-savings through better control of chronic diseases, it may be economically feasible to provide computers to patients willing to use the program, says Carlino. Managed care organizations also have expressed interest in enrolling their patients in such a program, she says.
The Santa Clara County IPA is collecting data on hospital admissions, inpatient days, and emergency room admissions to determine the impact of the Health Buddy on congestive heart failure. So far, both physicians and patients seem pleased, says Chao.
In a survey conducted through the Health Buddy, the IPA found that patients felt more confident in handling their condition and had a better understanding of congestive heart failure. Meanwhile, the IPA is considering using the Health Buddy system with other conditions.
"We’re learning that this is a very powerful tool," says Chao. "It is useful for anyone who requires disease monitoring. It’s just a matter of plugging in the right questions to the right people and conducting your interventions."
Other Internet-related programs developing
Meanwhile, other disease management programs are adding on-line components. LifeMasters Supported SelfCare of Newport Beach, CA, is conducting a pilot test of a congestive heart failure program in conjunction with Intel Corp. and Physicians Medical Group of Santa Cruz, CA.
In that program, patients are expected to access a personalized Web page daily and answer a list of questions. Nurses monitor the responses and regularly call patients to check on them. LifeMasters offers the program and four others to medical groups or managed care organizations, allowing physicians to vary the expected patient response times from daily to less frequent based on a risk stratification.
The Health Coaching Network, developed by Boston-based HealthDialog, is creating a Web site for its disease management programs that allow patients to respond to questionnaires. Nurses then follow up with telephone calls. In yet another application of the technology, patients considering various treatment options will be able to access shared decision-making information that helps them understand how their personal values and preferences may affect their choice. Again, a nurse follows up and even helps patients frame questions they’d like to ask their doctor. "The purpose is to facilitate the patient’s communication with the physician," says George Bennett, PhD, chairman and CEO of HealthDialog. "If that communication is facilitated, the decision that is made is more consistent with the values of the patient."
Connecting patients with physicians and other clinicians is likely to accelerate as Internet access becomes faster, easier, and cheaper. "The percentage of people getting on the Web are increasing daily," says Carlino.
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