| Written by Kelly Close |
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SELF-MANAGEMENT SUPPORT: INTERNET & CELLPHONES MAKE DIABETES PREVENTION AND TREATMENT AFFORDABLE AND SCALABLE Executive Highlights Hello from Day #4 of AADE! Day #4 was very much focused on the future of diabetes care in all aspects– healthcare systems, mobile technology, social media, CGM, and teaching strategies. Enthusiasm was high among educators and sessions were generally packed all day. Dr. Paul Tang led off the day in a great General Session presentation. He highlighted how the use of electronic health records and the adoption of a patient-centered model of care could dramatically improve our health system. He emphasized again and again that patient engagement and personalization will be key to transforming healthcare, and the more we can do those things right, the better off our country will be.
Neal Kaufman, MD, MPH (DPS Health, Los Angeles, CA) In this presentation, Dr. Kaufman enthusiastically discussed the value for patients and healthcare providers of internet- and mobile-based technologies. To start, he discussed the qualities of the ideal technological intervention, which should work within the confines of the healthcare system, support patients, improve outcomes, and be efficiently scalable to deal with a large population. We definitely enjoyed his discussion of DPS Health’s VLM system, a highly regarded online-based lifestyle intervention program developed in conjunction with the University of Pittsburgh. The system has helped patients achieve an average sustained weight loss (on average 10.5 lbs.) over the course of a year. Most notably, it is cheaper and more efficient than the Diabetes Prevention Program – a serious plus as cashstrapped payers and overburdened providers look for effective tools to manage their patients. According to Dr. Kaufman, mobile health will create jobs, not eliminate them as many educators fear. During Q&A, audience members were notably skeptical of these technologies in terms of the required time commitment, expectations from patients, and reimbursement concerns. Going forward, there’s no doubt that all of these topics will need to be addressed more broadly to successfully implement mobile and internet-based interventions – we certainly believe that the leaders in the field have been thinking about them from the start. · High quality, technology-enabled interventions should support the chronic care model. Such systems will mimic the master clinician, maintain a patient support network, and leverage the administration staff. These optimal interventions typically engage a panel of patients, are evidence-based, are integrated into the medical care system, can scale to a large number of patients efficiently, and can improve healthcare quality and outcomes. · Internet and mobile-based technologies offer numerous benefits to the clinician and the healthcare system. These systems can extend a clinician’s reach (especially to rural areas), provide content and personalized learning and doing to patients, monitor performance, link to providers, family, and friends, and integrate into patients’ everyday lives. For the healthcare system, these systems can save money, improve outcomes, efficiently manage a large number of patients, and integrate health information technology into the healthcare ecosystem. · Adoption of mobile/internet technology faces challenges, especially with regards to the lengthy current clinical trial requirements. According to Dr. Kaufman, an intervention that starts today, ends in a year, and is published six months later used technology that was obsolete when the intervention began. These long trial cycles cannot keep up with the pace of innovation. Additionally, mobile- and internet-based technology may be difficult to apply to certain healthcare settings, mainly because every healthcare setting is different. According to Dr. Kaufman, “If you’ve seen one healthcare system, you’ve seen one healthcare system.” · The Virtual Lifestyle Management (VLM) is an online lifestyle intervention program based on the Diabetes Prevention Program (DPP). DPS Health (Los Angeles, CA) and the University of Pittsburgh jointly developed the system from 2006-2008. Essentially, it takes the diabetes prevention program and puts it online. The one-year program consists of 16 weekly and eight monthly online sessions (about thirty minutes each) with streaming audio and interactive workbooks. The sessions are very interactive, with a narrator guiding patients through the lessons with stimulating questions. Patients can also securely message a coach (response within three days) and can participate in moderated chats. Coaches also monitor patients and check on their progress over time. · A 2009 study showed that the VLM helped patients lose on average 4.79 kg (~10.5 lbs.) over one year; this benefit comes at vastly reduced cost and time requirements compared to the DPP. Using the VLM, the average coach can handle 400 patients because 95% of the program is automated and coaches only spend 5-10 minutes per user per week. By comparison, coaches in the DPP could only handle 25-40 (35 on average) patients each. During Q&A, he mentioned that access to the VLM program costs about $300 per patient per year vs. >$3,000 per patient in the DPP. Dr. Kaufman noted that not everyone got engaged, but that’s to be expected in studies of this nature. Linda Siminerio, RN, PhD, CDE (University of Pittsburgh, Pittsburgh, PA) Dr. Siminerio gave a broad overview of some of telemedicine’s newest advances. She first characterized the benefits of these technologies, which allow healthcare providers to interact with the community; more easily monitor the health of their patient populations; and collect the type of data that payers are gradually beginning to demand. Turning to some of the most exciting technologies more specifically, Dr. Siminerio discussed the TREAT and IDEATel projects – both have been quite successful at offering patients a more convenient, engaging, and personal healthcare experience. Finally, she closed by discussing the importance of patient access to electronic medical records, which in her view, will be increasingly demanded in the coming years. Nevertheless, it’s clear that patients don’t want to pay for these benefits, and reimbursement for providers is still a challenge. Going forward, Dr. Siminerio believes both will need to be addressed to ensure the success of these programs. · Technology can help the healthcare system better interact with the community. First and foremost, providers can use technology to better inform consumers and teach them self-care strategies. In Dr. Siminerio’s practice, the electronic programs help get messages out to patients in the healthcare system. Additionally, such systems can help engage patients to make wise healthcare decisions. She spoke highly of the benefits of social networking (e.g., chat rooms, Facebook, Twitter), calling these sites especially important healthcare information venues for the next generation of patients. Finally, innovative technology can help assure that healthcare services are of high quality. · Better computer and Internet systems can help monitor population-based health, an area of increased scrutiny from payers, organizations, and the government. According to Dr. Siminerio, educators and providers are going to be responsible for tracking population health and reporting to administrators and payers. Notably, AADE and ADA are building systems to help providers better collect data, track patients, and computerize information. She encouraged all audience members to visit the exhibit hall booths of both organizations. · TREAT (Telemedicine for Reach, Access, Education, and Treatment) a University of Pittsburgh project, is helping bring medical specialists to rural communities via telemedicine. In this system, an endocrinologist works remotely from an academic hub to provide services via videoconferencing to patients in remote areas. A nurse educator in the community supports the doctor. Dr. Siminerio said that primary care physicians love the program, as they simply don’t have the expertise to deal with such poorly controlled patients with diabetes (A1cs ~10%). Dr. Siminerio believes the program has been a win-win for everyone involved, and has saved significant time and money on transportation costs. · At Syracuse, IDEATel (Informatics for Diabetes Education and Telemedicine) has shown that telemedicine is equally as effective as in-person healthcare delivery. The project is one of the largest civilian telemedicine projects in the country. It incorporates a variety of home telemedicine and remote monitoring technologies, including physiologic monitoring, videoconferencing, secure messaging, and web-based resources. Patient satisfaction with the system was high, although costs were as well. Notably, Hispanic and rural populations did very well with this telemedicine program. · Patient access to their own electronic medical records will be an increasing trend, especially in the younger generations; at UPMC, the HealthTrak patient portal, an online EMR system, has been very successful. The system also features secure communication, self-management tools, electronic reminders, lab results, email access to the healthcare team, and online scheduling of appointments. Seventy-six percent of patients are very satisfied with the system, while 78% found it easy to use. According to Dr. Siminerio, the system is blossoming and patients love it, although focus groups indicate that patients are reluctant to pay for it. Malinda Peeples, RN, MS, CDE (VP, Clinical Advocacy, WellDoc, Baltimore, MD) Ms. Malinda Peeples, former president of AADE, spoke highly of the potential for mobile phones to change the landscape of healthcare. To start, she used recent data to establish the incredible ubiquity of mobile phones around the world, stressing that the capability for outreach with cell phones is something that has never happened with a technology before. She transitioned to a detailed description of the WellDoc DiabetesManager, although the slides were unbranded and the company and product were never mentioned by name. To lend greater credibility to the system, she mentioned the recent trial results published in Diabetes Care and emphasized that diabetes educators helped design the system. Ms. Peeples closed with a case study of a patient using the DiabetesManager to explain how educators would specifically engage with the program. Notably, WellDoc is working with George Washington University and the Air Force to pre-populate the system with data from electronic medical records. We found this very encouraging, as any required patient or provider data input will present a challenge to the system’s adoption. We also took note of her forecast that over the next five years, significantly more mobile phone-related behavioral research will be published. · Due to their ubiquity across all ages, socioeconomic classes, and geographic areas, mobile phones have the potential to democratize healthcare. Interestingly, US cell phone ownership is highest among English-speaking Hispanics (87%), followed by blacks (87%), and whites (80%). Globally, ownership of cell phones stands at four billion, with 50% of the world’s population owning at least one cell phone. In the developing world, Ms. Peeples emphasized that smart phones are often the first computer. · Text messaging is growing significantly, with the average user sending about ten texts per day. In an informal poll of the room, about half of audience said they sent around ten texts per day. Intriguingly, voice calls have decreased by 25%, while texting in the 45-54 year old segment has increased 75%. Questions and Answers Q: I’m a CDE from a rural area in Missouri. I think this is awesome that we’re going in this direction. My question is about vulnerability. Patients tend to hear what they want to hear in terms of contacting us. Although they’re sending us information, is there going to be a waiver or caveat that says we’re not available 24 hours per day? Ms. Peeples: When patients log on to our system, there is a disclaimer. And for the clinician there is one embedded in the software. It has to do with your communication with them. That’s the way we’re approaching it. Dr. Siminerio: With our patient portal, HealthTrack, we have a disclaimer as well. Patients have that understanding. Dr. Kaufman: We have a disclaimer too. Over 2,000 patients have a coach. Patients realize when you set the rules and expectations and explain. Our coaches are expected to answer a question every three working days. So basically twice a week you touch the system. Of course, they’re not worrying about glucose control so it’s different. It depends on the condition. Q: You mentioned at the beginning that 18 states’ Medicaid programs recognize telemedicine. Is California one of them? Dr. Siminerio: Yes, I think California is one. Send me an email and I can get you the list. Q: What were the credentials of coaches? I’m assuming they were non-clinicians? Dr. Kaufman: In our setting, coaches are chosen by the host organization and they’ve always been clinicians. Most have had experience counseling in weight management. Whether that is necessary is a researchable question. We’ve selected clinicians with advanced degrees as coaches so that they know how to respond to patients. Q: How do you keep patients motivated to continue inputting data into the system? Dr. Kaufman: Great question. In our setting there are no incentive systems. A couple of employers have talked about incentives and we’re happy to do that. Remember that 25% of patients drop out of our program in the first month. But that’s not unusual in a weight management program. These are all overweight sedentary people who need to lose 50 lbs. We have structured flexibility in our program. Patients can choose when to log on and the order to complete the lessons. The average patient touches the website 2.5 days a week and tracks their eating four out of seven days. You must give people structured flexibility and allow them to find the balance that makes the best sense. If they’re doing well, you leave them alone. If not, you reach out to motivate them. Dr. Siminerio: If there is a coach and an expectation knowing that the coach will contact you, they are a little more adherent to program. And in this case, the coach can do more because much of the work is done online. Q: After a while, you have thousands of patients demanding something from you. Who will pay for this? And how do you manage the larger volume of patients? Dr. Siminerio: We’re not at the thousands of patients. You’re right, we haven’t figured out payer systems on this. We’ve got to start using systems like this and figuring it out. These patients are still going to be there and we need to engage them. Ms. Peeples: We’re finalizing the data analysis on the clinical trial. We didn’t have people drop out. We did have people engage steadily and they would respond to the messaging that came from educators. Other folks were episodic, and an educator might reach out, and they’d say I have had a life event. I’m now ready to re-engage. I think back to the structured flexibility and personalization. What we’re doing with our expert system is figuring out algorithms for the most common events. This allows scaling up. We’re deploying in a couple of pilot sites. The technology allows you to manage that in a way you can’t right now. Dr. Kaufman: In the original Diabetes Prevention Program, the average coach managed 25-35 patients on average I think. Now, we’re up to 400 patients per coach with our program. We’ve come to public health scale at a personal level. Q: I’m from Joslin and my passion is pediatrics. I didn’t hear of anything in the pipeline for pediatrics. Can speak to the status of mobile interventions for pediatrics? Some system to use for the schools to contact parents or professionals? At least we could diminish the problem in schools a bit. Dr. Siminerio: I don’t know about anything in the schools. I think it’s great to look at this. In work I did with the NIH, there was a call for better adherence in type 1 diabetes. Almost every proposal that came in had a technology piece in it for adherence. Every one of them had that as part of the intervention. The NIH is thinking about this. Carnegie Mellon is looking at a system through mobile phones aimed at the transition period from high school to college. This is a critical area. I know they are developing a study and an app. Dr. Kaufman: In the Loop is one out of Texas that I know of. They are involved in using technology to link parents to the school and doctors. There are a number of things going on. Q: I’m a CDE and optometrist in California. I’m wondering about two things: liability (medical malpractice) and the cost to the system. Dr. Kaufman: In my situation, I don’t talk about glucose, so the liability is minimal. We’ve had no problem and patients have signed consent forms. Ms. Peeples: We are providing self-management support. We’re not getting in to treatment decisions per se. The provider validates the information. One of the interesting things will be working through this with our EMR integration. It’s a field we’re working our way through and there are not hard and fast answers. As you introduce any new device you must figure out how you mange that. Dr. Siminerio: I was at a telemedicine meeting and many speakers were attorneys. They said they are really behind and the technology is so far ahead of where we are legally and policy wise. Dr. Kaufman: I don’t want to skirt the cost issue. The full annual cost ends up being $300 to access our VLM application. Paul Madden: You’ve answered my question just now. I know of some great clinics doing lifestyle intervention and it’s $5,000-$6,000 dollars per year. A model like that this is $300 is great. Thank you. Ms. Peeples: We’ve also reduced hospital visits and ER visits. We built our application to download to a data-enabled phone. The data plan is about $5 per month and some licensing fee around $20-$30 dollars per month. We’re thinking about the cost issue and how this can be deployed. Q: I’m wondering about integrating this technology with pumps and CGMs. Say you have a type 1 going into DKA overnight. Could that be integrated? Is there anything like that? Ms. Peeples: Great idea. We’re in the type 2 space right now because of the safety issues you run into in the type 1 space. We’re doing some type 1 stuff in the data recording space. I think those are great ideas but we’re moving along right now. Patients just put a blood sugar number in or a medication dose and we have a list of notes we can annotate. Q: If you have someone who may have limited ability due to visual impairment, is there any way to get some kind of audio? Ms. Peeples: Yes, there is speech to text. We’ve done a prototype. Apple applications have the ability to convert speech to text. That’s down the road. Dr. Kaufman: There are also ways to ask people questions and they just press A, B, or C to answer. Q: Do you see mHealth creating or eliminating diabetes educator jobs? Ms. Peeples: I see it as a huge way for educators to improve their reach, access, and engage people between visits. The recent workforce data shows the demand for educators is increasing. This is an opportunity to jump on something that is fast moving and gives you the capability to improve your reach and serve more geographic areas. I think it’s an incredible opportunity. Dr. Kaufman: I have a public health and pediatric mindset. If you wanted to do the DPP for everyone there simply aren’t enough coach supervisors to do it. And adding in the 74 million people with prediabetes, you can’t do it. Using technology, you can give a little amount to large number of people. And when people aren’t doing well, they can come in and get more support. But it doesn’t put people out of jobs, it allows them to choose which communication channel they prefer. This way, you raise the entire population’s outcome. If anything will take your job away, it’s the direct-to-consumer snake oil that people think works. Dr. Siminerio: I think educators will be central to all of this. We just need to secure the reimbursement. Imagine if you had that population of patients to bill for. Instead of ten or twenty patients, hundreds. Comment: I hope you’re right. |
