Dr. C. Martin Harris is the Principal Investigator on the project entitled The Potential of Technology to Improve Chronic Disease Management and Quality of Care at The Cleveland Clinic Foundation in Cleveland, OH.

What is unique and/or innovative about your study?
Using the eCleveland Clinic patient portal, MyChart, diabetic patients participating in the study can monitor their treatment plan and results; view their age, gender, and diabetes-based health care reminders; link to lay-friendly educational materials related to their results, health maintenance reminders, and diagnoses; view and schedule tests; and enter their finger stick blood glucose values and see pertinent alerts if the values are hypo- or hyperglycemic. The patient entered glucose values are electronically sent to the patient’s primary care physician in the EMR.

We recognize that some patients will be more predisposed to technology and some more predisposed to complying with their medical regimens than others. We hypothesize that we can identify these tendencies using a simple questionnaire and thereby divide the study’s diabetic patient population into the following four groups: predisposed to technology and to improving their compliance; predisposed to technology but not complying with their diabetic regimen; not predisposed to technology but predisposed to complying with their diabetic regimen; not predisposed to technology or to complying with their diabetic regimen. We put forward that the patients that either are not predisposed to technology, or not complying with their diabetic regimen, or both will be less likely to adopt the portal system and improve their diabetic management.

We further hypothesize that it may be possible to create non-adoption type specific interventions that will assist the technology challenged and non-compliant patients to adopt MyChart and improve their diabetic management. To this end we have designed the study to have all patients complete a questionnaire at the beginning of the study, then to introduce the diabetic portal technology to the “Experimental” group of patients. After several months have passed during which period of time the “Experimental” group has been enabled to use the MyChart diabetic functionality, we will analyze the ability of the survey tool to accurately predict which patients fall into the aforementioned groups. We will re-survey the patients to find if there have been any interim changes. Then we will implement the patient type specific interventions to the experimental patients who are either non-compliant, not using the technology, or both. The patients will be re-surveyed to explore the immediate impact of the interventions, and then will then be instructed to continue using the MyChart diabetic functionality for several months. A final survey will be performed at the end of the study. We will look both at patient portal usage, diabetic outcomes, and survey responses to determine the impact of the portal diabetic functionality and the portal interventions.

Our study seeks to determine:
1. If the patient portal can be used as a chronic disease management tool to empower diabetic patients to better manage their disease.
2. Whether non-adoption type specific interventions (such as training regarding technology, self-efficacy development, clinical reminders, etc.) will help the non-adopter patients become more predisposed to technology and complying with their diabetic regimen resulting in improved diabetic management and outcomes.

How is your project progressing so far?
In order to begin the patient recruitment, which began in January 2005, the following tasks were accomplished: completed the build-out of the patient portal, including the configuration of key applications (e.g., patients’ ability to enter their finger stick glucose values, patients’ ability to view these values displayed in flowsheet and graphical fashions, etc.); configured the electronic medical record (EMR) to allow the Patient Service Representatives (PSRs) to indicate patient acceptance of the study, and to cause the patient-entered data to flow to the patient’s primary care physician (PCP) and to a defined nursing pool for review; identified patients who were eligible for recruitment; built a secure process to automate the delivery of the information regarding patients eligible for recruitment; defined an operational plan for the study; and received IRB approval.

What prompted you to explore this research?
As practicing physicians working in informatics and observing the epidemic of certain chronic diseases and the advancements in medical technologies, it is natural to become passionate about applying medical informatics to improving patient care and outcomes. With our electronic medical record we collect and store, in a reusable fashion, a rich patient data set. This data set can readily be made available to patients through an EMR-based patient portal. In addition, from MyChart, patients can enter and view specific data and care alerts based on their self-entered data.

We believe that a patient is always going to be their own best medical advocate, and that offering patients with chronic diseases improved disease management tools and information will empower patients to better manage their disease.

For many patients, however, there are barriers to achieving these goals, which may have to do with their inexperience using technology-based programs, or with their attitude, subjective norms and perceived behavioral control. Attitude toward a behavior is determined by salient beliefs about the consequences of the behavior weighted by the evaluation of those consequences. Subjective norms are the perception of expectations of other people or groups weighted by the individual’s motivation to comply with those expectations. Perceived behavioral control reflects perceptions of internal and external constraints on behavior and access to resources and opportunities. These include facilitating conditions, the availability of resources and self-efficacy.

To widely institute a cost effective, portal-based chronic disease management (CDM) program, we wondered if we could accurately identify, using a simple survey tool, the patients most likely to readily adopt the disease management tool to achieve improved outcomes, from those that would not adopt the technology, or adopt the technology but not achieve improved disease outcomes. Given that this distinction can be accurately predicted, we then wondered if we could create specific interventions based on identifying the patient specific barrier(s) to adoption of the diabetic MyChart tools and use these interventions to help the non-adopters use the technology, follow their medical regimens and achieve improved outcomes.

How would a typical end-user utilize the final product/results of your research?
The typical patient end-user would use our patient portal system to self-monitor and manage their disease; in this case, diabetes. When entering out of range values, the patient will receive an automated alert message, informing them about the symptoms of hyper- or hypoglycemia and what to do in either case. The entered finger stick glucose values are then electronically transferred to the patient’s PCP and clinical care team. The clinician may choose to message the patient with encouragement, if the patient is doing well; or message instructions, or schedule an appointment if the patient is doing poorly. In addition to the patient entered diabetic data, we have created diabetes specific health maintenance guidelines that both the PCP and the patient can view. The patient can follow their guidelines, and when due, schedule the appropriate appointment. Patients can also hyperlink from any diagnosis, result, or health maintenance guideline to look up institutionally selected lay-friendly topic specific information.

If our hypothesis above is correct, the implications for this research at a clinical organizational level are clear. When instituting a technology-based CDM program, patients could first be surveyed. Those who are predicted to adopt the technology and comply with their medical regimen will not require additional interventions. Those predicted to need additional interventions can receive the intervention best suited to their successful adoption and/or compliance at the outset. Alternatively if we find that the survey consistently predicts patients that will not adopt a technology-based CDM program, even after an appropriate intervention, they might be better suited to another kind of CDM program that is not technology based, or we may need to explore creating additional interventions to help these individuals.

What are the greatest challenges in eHealth and more specifically your project?
One of the greatest challenges in eHealth is patient and physician adoption. Physicians are often concerned that eHealth advances will result in more work with less compensation, and all end-users are frequently uncomfortable with process change.

In our study, we found that patient recruitment was somewhat challenging, even with an IRB waiver of informed consent. We are recruiting patients to 14 different sites, using PSRs to distribute and process the study materials. This is a job with a very high turnover and multiple simultaneous responsibilities. After initial training of the PSRs and study recruitment initiation, we found some specific PSR training related problems. We performed some “secret shopping” investigations, identified problems, and initiated a more formal training that has been incorporated into the PSR training and will continue for the duration of the study recruitment period.

To further improve recruitment, we applied to the IRB and were granted a study addendum to incorporate an EMR-based study recruitment “Best Practice Alert” geared to the eligible patients’ primary care physician. The BPA will appear when the physician opens the patient’s visit encounter when face-to-face with the patient and will read,

" This patient is eligible for the Chronic Disease Management MyChart Diabetes Study. Please verify that the patient has received the study materials from the patient service representative, answer any questions the patient has about the study, and tell the patient to return to the Patient Service Representative at the front desk after the visit to indicate whether or not she or he wishes to participate in the study."

In what ways would you like to see eHealth evolve?
eCleveland Clinic MyChart and MyMonitoring programs currently allow for some subjective (MyChart -patient entered) and Objective (MyMonitoring device-based) data capture from patients where they live, work and play. We would like to see eHealth evolve to allow for secure internet subjective and objective patient data capture to develop EMR-based protocols to conveniently administer care remotely, empower patients to improve their health and disease management, improve healthcare efficiency and lower costs, and conduct research to advance the field of medicine.

How do you stay informed of advances and innovations in eHealth?
In addition to reading the pertinent medical and medical informatics journals, following eHealth news online, and attending and presenting at medical and medical informatics conferences, it has been a wonderful experience being a part of the RWJF eHealth research community. Participation in this group has both created a network of knowledgeable individuals working in the same field and helps to keep us abreast of some of the latest developments in eHealth.

Thank you Martin for the comprehensive update and thank you for reading. This was the final installment of Meet the Grantees. As results become available, they will be posted in our Grantee Research section.