Dr. Harold Goldberg is the Principal Investigator on the project entitled A Randomized Controlled Trial of Diabetes Disease Management Over the Internet at the University of Washington in Seattle.

What is unique and/or innovative about your study?
The Internet has been proposed as a vehicle for overcoming barriers facing minorities in obtaining self-management support, yet controlled evidence in this regard is lacking. Accordingly, we’re conducting a yearlong RCT of usual diabetes care versus case management over the Internet among disadvantaged African-Americans. Intervention subjects are being trained to use a module comprising six Web sites accessed from home via links displayed within the University’s “MyUW” Internet portal. The module allows patients to:

1) View their electronic medical record (EMR) including clinical reminders, the same record used by providers,
2) Upload blood glucose readings stored in digital meters,
3) Enter medication, nutrition, and exercise data into an online diary,
4) Communicate with providers regarding treatment using a clinical e-mail service,
5) Browse an education site with sanctioned content, and
6) Collaboratively generate action plans intended to enhance self-efficacy.

Control subjects are also being trained to use a provided personal computer to access Internet knowledge resources, but will not have access to the case management services and module being evaluated. Many eHealth projects are exploring just access to the medical record, or the automated uploading of glucose readings alone. We’ve tried to include all the communication components required to simulate the exchanges that routinely occur during office visits.

What are the greatest challenges in eHealth and more specifically, your project?
The greatest challenge we’ve faced is training participants, two-thirds of who lacked previous Internet experience. We are grateful that the University offered its expertise, gained from training foreign students who arrive in Seattle sans computing skills. Undergraduate members of its Student Access & Computing Group (SACG) conduct classes at the UW’s learning laboratory in Mary Gates Hall, the first ever use of this facility by patients from the community. Subjects from both the intervention and control trial arms are exposed to a six-hour session on basic computing, Internet, and e-mailing skills. Intervention patients then stay on for an additional two-hour session on use of the Web module. The SACG instructors also install computers in patients’ homes and provide follow-up home visits as needed.

How is your project progressing so far?
We are halfway through our 30-month total timeline. Finalizing the details of patient enrollment and training have taken several months longer than originally planned, yet nearly two-thirds of subjects have already entered the trial.

What prompted you to explore this research?
The nation’s current delivery system, based on short and infrequent office encounters, has failed to produce adequate chronic disease outcomes. Results from the most recent NHANES survey indicate that only 37% of adult Americans with diabetes have had their high blood sugar adequately lowered. This is occurring even though effective drug treatments have existed for 50 years or more. This is why the Institute of Medicine’s 2001 report “Crossing the Quality Chasm” recommended a shift from care based on office visits toward care based on continuous healing relationships. Even when monitoring a single condition, the pressure of both patient and provider work schedules can make extended synchronous communication over the telephone between visits extremely difficult. Hence, there is a need to develop alternatives based on the kinds of asynchronous exchange of varying types of information that the Internet can more easily perform.

We at the UW had previously created the first production institutional Internet EMR, MINDscape, in 1995. Like most clinical computing systems, however, it was originally designed to improve providers’ ability to deliver office-based care. We undertook the development of a compatible Web module to specifically test the feasibility of allowing patients with type 2 diabetes to co-manage their disease from home, completing a six-month alpha test at the UW’s General Internal Medicine Clinic amongst middle-class patients who were already Internet savvy. We felt that disadvantaged diabetic patients with little or no computer literacy would also need to be exposed to eHealth applications, lest we risk widening the existing digital divide. Diabetes prevalence among adult blacks in Seattle-King County is 2.6 times the rate in whites, and the death rate is 3.7 times higher. Nationally, fewer than 5% of African-Americans treated with oral hypoglycemics -- and fewer than 30% of black patients on insulin -- self-monitor blood glucose at least once a day.

How would a typical end-user utilize the final product/results of your research?
We hope our research will produce positive results in helping our patients achieve glycemic control. If so, the module’s functionality will be available to diabetic patients around the country as an adjunct to the EMR “CliniPro” that is commercially available from our industry partner NuMedics, Inc. (Beaverton, OR).

In what ways would you like to see eHealth evolve?
Because of common genetic and behavioral antecedents, we are beginning to think of chronic illnesses as occurring in combinations, not just as individual diseases. For example, the “metabolic syndrome” of diabetes, hypertension, dyslipidemia, and obesity has been declared a global epidemic in both adults and adolescents. Only a scandalously low 7% of adult Americans with diabetes have had all three of their “ABC risk factors” for vascular disease (A1c, blood pressure, and cholesterol) lowered to recommended levels. Thus, we believe that eHealth systems need to evolve towards the treatment of multiple prevalent conditions. They will need to be able to treat, not only patients’ diabetes from home, but also their hypertension, and/or lipid levels. Currently, 48% of all patients with chronic conditions have more than one. By the year 2030, as baby boomers continue to age, fully half of the US population will be both chronically diseased and wired.

How do you stay informed of advances and innovations in eHealth?
My wife, Yuki, is the “Information Specialist” for the Department of Health Services at the UW. She’s always sending me e-mails about eHealth or bringing home interesting stuff to read. Being married to a librarian is a great way to stay abreast of developments in almost any field you might think of. I highly recommend it.

Harold – this is great information. Thanks for the update!

In March, Dr. Virginia Carrieri-Kohlman will discuss her research project at the University of California.