Online Disease Management May Prompt Patients to Meet Goals

Though the concept behind them is relatively new, online chronic disease–management programs can help patients attain measurable health goals and improve outcomes, preliminary results show. Plus, the programs may enhance continuity of care, allow for greater patient involvement in disease management, and improve efficiency of care delivery.

“In our current [health care delivery] system, most people experience a fragmentation of care,” says James D. Ralston, MD, MPH, assistant investigator for the Center for Health Studies (CHS), which conducts research that supports Group Health Cooperative, a nonprofit health care system based in Seattle. “Our system is well set up for acute problems.... But now we're seeing so many patients with chronic conditions, and yet the system is the same as it was a hundred years ago. People with chronic conditions are the ones at home managing the disease.”

Ralston says patients with greater access to their health records and a means to contact their physicians whenever questions arise are better able to manage chronic illness. He and colleagues at CHS designed and evaluated an online diabetes-management program to test this assertion at an internal medicine clinic affiliated with the University of Washington.¹

Nine subjects, ages 43–65 years, with type 2 diabetes, received care on a routine basis from one of eight internists. A case manager (a nurse practitioner with the clinic) oversaw the program—encouraging patients to review medical records online, upload blood glucose readings weekly, and send inquiries as needed to providers via electronic mail. Online care providers responded to electronic inquiries during the workweek and reviewed posted glucose levels at least weekly.

A qualitative analysis revealed both potential and problems. Participants reported an enhanced sense of security about their health and health care in general and increased confidence in their ability to manage their diabetes. They said they valued the feedback from clinicians. But some expressed frustration with unmet expectations—when they did not receive timely responses to their electronic messages, for example—and difficulty incorporating the program into daily life.

To be most successful and effective in the long term, the patients ought to have some framework for established “real” relationships with the provider team they are communicating with electronically, says Elizabeth Venditti, PhD, director of the Lifestyle Resource Core for the Diabetes Prevention Program Outcomes Study at the University of Pittsburgh Medical Center.

“Ideally if a patient were to participate in such a program they would be an established patient at the practice and undergo some type of orientation that clearly laid out the limits of the communication so as not to foster unrealistic expectations,” Venditti says.

Although this study was conducted specifically to evaluate patients' experience with online communication with care providers and did not measure changes in health outcomes, other studies of online programs have demonstrated positive health outcomes.

PATIENTS TAKE CONTROL

Australian researchers, led by exercise physiologist Michael McCoy, PhD, developed a 10-week online weight-loss program intended to serve as a diabetes-prevention program that encouraged participants to create their own health goals.²

The program emphasized physical activity and dietary modifications for 464 adults aged 19–71 years. Program components included an initial online health-risk appraisal to determine appropriate goals such as reducing body mass index (BMI), blood glucose levels, and blood pressure. Participants were supported by interactive software applications (diet and exercise planners), related readings, and daily program schedules.

Fifty-three percent of participants reported an average weight loss of 3.8 kg (8.37 lb), and 56% agreed the program helped them achieve their weight-loss goals.

“Over the last 5 years, the program has been progressively enhanced and delivered widely to private health insurers, where its use is associated with lower insurance claims,” says principal investigator McCoy, managing director of fitness2live, a computer-based health-management service.

DOCTOR ON BOARD

Some online disease-management programs require legwork on the part of patients, but others are designed for providers to take a more proactive role. Such is the case with a diabetes-management initiative at Geisinger Health System in Pennsylvania.

“We search through our electronic information, find patients who haven't had an appointment in 6 months, and contact them,” says Frederick H. Bloom, MD, Geisinger's director of quality and performance improvement. Although the program is too new to have recorded any outcomes data, Bloom says physicians have noted increased volume in certain laboratory tests, such as glycated hemoglobin (A1C).

All Geisinger patients, regardless of their health status, can enroll in a separate program called MyGeisinger.com, an online health management tool. Via a secure Internet-based portal, the program permits patients to gain electronic access to their health records, engage in electronic communication with their providers, receive certain lab results, and schedule appointments.

“It allows patients to become more actively involved in their care,” Bloom says. Thus far, about 10%, or 250,000, of the system's patients have enrolled, and about 30% of users are >55 years of age.

Though online disease-management programs remain a niche offering, demand is increasing. Their future success, however, depends on how well they keep doctors in the loop and how well patients are oriented to their use and context with in-person visits. In addition, electronic communication is not a reimbursable visit, Venditti notes, “so costs must also be examined as such programs are being studied.”

“For online DM [disease management] to take over the market and engage a lot of patients, it's got to be integrated,” says Bruce Bagley, MD, medical director for quality improvement at the American Academy of Family Physicians. “They can't operate independently of the family physician.”

Conversely, physicians need to accept help with managing their chronically ill patients, something Bagley says they're prepared to do.

Currently, most online disease-management programs are either self-created by health systems or mass-produced by companies that market to insurers. “We're not marketing directly to doctors,” says Ted Dacko, president and CEO of HealthMedia, Inc., a behavioral health company that designs online disease-management and wellness programs. But his company's programs do seek to involve physicians, he says. “Doctors can log in and check on their patient's progress, or a summary can be sent to them.”

Clinicians involved in online programs say patient-provider interaction resonates for patients. “It seems that the patients who benefit most were either recently diagnosed or moving through a phase change in their disease,” Ralston says. “They're really hungry to understand more about how to manage their care and want to interact with a physician and health care team.” ▪