Summary: Patients and clinicians need to work together so patients with diabetes can adopt and sustain the health promoting behaviors so necessary to assure good outcomes. Information technology is transforming the way patients receive education and support and clinicians need to utilize these approaches to maximize their reach and effectiveness. One example, the online version of the NIH’s Diabetes Prevention Program, has been shown to effectively help overweight and sedentary adults lose weight and keep it off.
A revolution is needed in healthcare for patients with, or at risk for, diabetes. The seeds have already been planted, but to this point, most of us have only been able to see the emerging sprouts of these changes. It is hard to see that small advances in healthcare are happening – but as is usually the case during a paradigm shift – it is only obvious in hindsight.
Cause and Effect
The roots of this revolution come from the changing causes of diabetes-related morbidity and mortality. As recently as 40 years ago, most people died from sudden, massive heart attacks or infections such as pneumonia. Advances in medicine now indicate most of us will die late in a disease process from a chronic illness such as diabetes, cancer and heart disease. This increase in the prevalence of chronic diseases means a fundamental shift in the role physicians and other healthcare providers play in improving patients’ health. Estimates of the contribution to the prevention and treatment of chronic diseases ascribe approximately 10% to healthcare, 30% to a person’s genetic makeup, 20% to the environment, and 40% to the individual’s behaviors. (Steven A. Schroeder, M.D We Can Do Better – Improving the Health of the American People; N Engl J Med 357; 12; 1221-8. September 20, 2007). Given this distribution, to treat or prevent these chronic, lifestyle-driven diseases, quality medical care will only be part of the solution. Advanced medicine will have to be coupled with behavior modification to have a major impact on our lifespan. But, herein lies another important aspect of the healthcare revolution – we no longer strive to simply increase lifespan, but also performance span, or how long we live healthy and active lives. One of the strongest factors that will drive this revolution in healthcare is an increase in financial incentives to support patients’ health-promoting behaviors.
New Focus of Healthcare
With this new focus of healthcare, providers will be expected to coordinate care for a panel of patients who live with incurable chronic conditions. Clinicians will have to collaborate with their patients and focus on improving their behaviors, because treating diabetes and other chronic conditions requires more than medication. Providers will need to put emphasis on supporting patients in the ongoing process of adopting and sustaining health-promoting habits. Regrettably, given the significant time constraints of a busy medical practice, healthcare providers often do not have the time to adequately support all aspects of an effective behavior change intervention. To be successful, patients must not only understand their condition, but also obtain the skills and attitudes to set goals, solve problems, monitor outcomes and overcome barriers to action.
This is especially true for patients with diabetes who often need a complex set of services and support ranging from glucose monitoring, insulin and other medication management, psychotherapy and social support, to physical activity promotion, nutrition counseling and more. Integrating these supports into a patient’s therapeutic regimen presents challenges that need to be addressed through a variety of strategies.
Self-management support interventions that are clinically-linked and enabled by technology
Patient self-management of diabetes enabled by web-based information technology is becoming an important factor in the way providers deliver healthcare. Approaches using this technology to support clinical services are being dramatically altered by the confluence of several trends:
Patients want an active role in managing their own health and a collaborative relationship with their healthcare providers.
Widespread, low-cost internet access is erasing existing geographic, economic and demographic barriers to obtaining health information online, and with advanced Web 2.0 technologies high levels of interactivity can engage the patient.
Clinicians and researchers now have a deeper understanding of how people learn and respond online, and that knowledge can be crafted into solutions that produce effective, long-term behavior change.
Technology-enabled approaches that show great promise in improving outcomes use new models of service provision in which technology-enabled self-management support provides patients with:
just-in-time delivery of tailored messages and experience that speak to each person based on their unique characteristics, their performance on key behaviors and their needs at that moment in time;
ways to easily and accurately keep track of their performance and use that knowledge to plan and implement new approaches to reaching their goals; and
opportunities to link directly to family and friends for critical support, as well as to their many providers to help integrate medical care with everyday life.
With the increasing sophistication of diabetes treatment protocols and diabetes-related devices, clinically-linked, web-based self-management support interventions offer a remarkable opportunity for clinicians and patients. Clinicians can now have a major impact on diabetes outcomes by providing robust, affordable and always available online support to large numbers of patients who want to improve their diabetes outcomes through self-management.
Online tools can extend medical practices and provide effective support through cost-effective programs that help clinicians guide their patients to better manage their diabetes. The best internet self-management education and support programs are rich in pertinent content, provide engaging interactive elements, and offer a tailored, personalized learning experience. They contain self-assessment tools and ways for the individual to monitor performance and changes in biological measurements such as blood sugar, insulin dosage, physical activity, weight, blood pressure and mood. The patient can access their information, input their data, and receive support 24 hours a day â€“ at a time and place most convenient for them, and not limited to clinicians’ office hours.
Web-based learning and support benefits both clinician and patient. Patients learn to overcome barriers and to self-document activities and interactions, permitting clinician review and feedback at any time. In addition to automating much of the educational content, this time shifting element is one of the keys to making the process efficient and low cost. The ability to perform an automated review of the patient’s activities and performance also provides clinicians with a valuable tool that increases both effectiveness and efficiency.
As with online intervention, a virtual coach can provide individualized guidance and support based on readily available analyses of each patient’s characteristics and performance. In addition, the clinician can communicate frequently and efficiently, offering personalized email support to each patient without requiring in-person meetings, as well as monitor virtual support groups where patients interact with others online via informational monitored chat rooms and blogs. By incorporating web-based patient self-management and support into traditional treatment methods, one clinician can effectively support many patients – one patient at a time.
Online Diabetes Prevention Program
For example, to create an approach that could serve large numbers of overweight and sedentary patients, researchers from the University of Pittsburgh translated the landmark Diabetes Prevention Program (DPP) into an online intervention called Virtual Lifestyle Management (VLM) service (www.vlminfo.com) (McTigue, et al., “Using the Internet to Translate an Evidence-Based Lifestyle Intervention into Practice,” Telemedicine and e-Health, VOL. 15 NO. 9, November 2009). The DPP is a weight management approach developed by the University of Pittsburgh under a federal research grant from the National Institutes of Health (NIH). It proved that overweight and sedentary adults could be counseled to eat better, be more active, and lose weight to improve their long-term health. The challenge was bringing the benefits of the DPP to enough patients at an affordable cost.
To create the VLM service, the University of Pittsburgh, along with DPS Health, took the principles of the DPP and used them to develop a year-long, engaging, web-based learning, goal setting, tracking, and motivation program. To date, VLM has been implemented in a variety of healthcare settings including three diabetes centers in Canada (McMaster’s Diabetes Care Program, Hamilton; Mt. Sinai Hospital, Toronto; Centre Studies in Family Medicine, University Western Ontario).
Through VLM, patients improve their physical activity and nutrition habits and sustain these new behaviors to live longer, healthier lives. VLM increases clinician efficiency by automating patient learning, planning, self-monitoring and encouragement, and provides support through limited personalized electronic coaching. For more information go to www.vlminfo.com
By incorporating information technology into patient care, clinicians today have the opportunity to provide their patients with the ongoing support they need. In addition to reducing patient travel and scheduling conflicts, web-based learning and support can extend the clinician’s reach as they engage and support patients in healthy behaviors over the long term. Online programs can also improve monitoring, tracking and reporting, so population-based risk assessments can be better managed.
The use of internet technology to support patient self-management is becoming an integral part of delivering healthcare and lifestyle support, and enabling patients to better manage their own health by adopting and sustaining new health-promoting behaviors. Today, clinicians can use web-based learning, coupled with traditional treatment approaches, to support large numbers of patients with diabetes in an economical and practical manner.