Monitor patients online?

New disease management programs are enabling physicians to do just that. Can this help you improve care, or is it just another boondoggle?

By Ken Terry
Managed Care Editor

David Resneck-Sannes, a family physician in Scotts Valley, CA, is pleased with the Web-based disease management program for congestive heart failure that his IPA introduced a year and a half ago. He has six elderly patients in this program, run by Irvine, CA-based LifeMasters Supported SelfCare. These patients use the Internet to access educational information and to transmit data on their conditions to a nurse care manager.

"They get monitored nearly every day, which for CHF patients is ideal," says Resneck-Sannes, a soloist. "They check their weight and blood pressure and send those numbers to the nurse, who alerts me if there's a significant shift. Plus, the nurses give me weekly updates on how the patients are doing. That constant observation allows me to detect little changes before they become big problems. It frequently keeps me from having to hospitalize patients."

While some of the patients had never used the Internet before being enrolled in the program, they love the Web now, Resneck-Sannes says. "They feel empowered, and they don't feel isolated, even though most of them live alone. They take care of themselves a little better, and they're more regular about taking their medication."

But another FP in the same IPA, Arnold S. Leff, has a different point of view. He dislikes LifeMasters because he sees no reason for the IPA, Physicians Medical Group of Santa Cruz County, to pay an outside vendor to do things that physicians could do. At $50 per patient per month, he adds, the program is very expensive. "The money could be spent a lot better if you gave it to primary care physicians to do a better job."

Leff's viewpoint reflects the opposition of many physicians to disease management in general. Some of this skepticism flows from disgruntlement with managed care plans, which have designed or paid for many disease management programs. But some doctors also feel uncomfortable about outside entities' taking over some of their patient care duties.

"I just hope that the world doesn't move in the direction of removing care management from physicians," says internist Robert B. Keet of Santa Cruz, who practices part time while working as medical director of Axolotl, a Web-based clinical messaging company. "The tendency for insurance companies to remove more and more of this from physicians and to pay themselves or someone else to do it is a little distressing. It weakens what we do as physicians."

Other doctors view the new technology as an opportunity to do a better job. Family practitioner Larry Stubblefield, a soloist in Seagoville, TX, has several CHF patients in a program designed by Health Hero Network of Mountain View, CA. Staffed and paid for by his IPA, Dallas-based Heritage Southwest Medical Group, the program involves having patients answer personalized questions daily on a Web-connected device called a Health Buddy. They also receive information and messages tailored to their needs. Care managers alert Stubblefield when there's a problem, and he also views patient data daily on the Internet.

Stubblefield doesn't feel that the program's care managers are usurping supervision of his patients' care. "Basically, they're just giving me information," he says. "I contact the patient and make any changes. It's been an extremely valuable tool for me, and I don't feel I've lost any control over the patient's situation, because care managers can't do anything without my permission."

What the new tools add to disease management

The recent evolution of Internet-based methods promises to boost disease management efforts. Some of these new systems rely on patients answering questions through simple devices like the Health Buddy; others use the Internet directly a la LifeMasters; still others employ biometric devices that upload data to a central station. What these systems have in common is that they all automate data collection and analysis so that care managers can quickly focus on patients who need help. This enables them to carry a larger case load, which increases the cost-effectiveness of the programs and theoretically allows more patients to participate.

"Disease management would have died without the Internet," declares internist David B. Nash, a health policy professor at Jefferson Medical College in Philadelphia. "It really didn't work from an economic standpoint. It was too expensive, and the communication systems weren't robust enough."

Al Lewis, executive director of the Disease Management Purchasing Consortium, which brokers deals between health plans and vendors, counters that disease management was in no danger of dying. Indeed, he says, the $350 million a year business is growing faster than ever. But he believes that use of the Internet and biometric monitoring have helped cut the cost of disease management programs by 35 percent in the past four years.

"The Internet is going to supplement traditional programs that have often been managed either through phone calls, mail, or office visits," says Stan Bernard, an e-health consultant in Neshanic Station, NJ. "It's yet another way for care providers to reach out and interact with patients in an efficient, convenient, and inexpensive way."

Preventive-medicine specialist Molly Joel Coye stresses that Web-based care can be as important in increasing patient compliance as in monitoring health conditions. "Research shows that patients forget much of what doctors say as soon as they leave the office," says Coye, the founder of Health Technology Center in San Francisco and a former head of state health departments in New Jersey and California. "So systems that use automated ways of reminding the patient—such as a Web site that contains the doctor's instructions and the explanation of the disease—can help patients remember what the doctor told them."

The Internet can also be used to tailor educational materials to a patient's demographics, comorbidities, and medical history, Nash points out. "There are hard-to-control diabetics, easy-to-control diabetics, and juvenile diabetics. But historically, we communicated with them as though they were all the same," he says. "The Internet allows us to customize information for each of these subgroups in a way that we couldn't do previously."

Biometric devices aren't magic, but they have their place

Press reports have touted exotic new monitoring devices such as the LifeShirt, a garment that can measure 40 vital signs, and an implant that allows a doctor to check a patient's cardiac functioning over the Internet. But in disease management, the key biometric devices have been available to patients in their homes for some time. They include digital scales, blood pressure cuffs, glucose meters, peak-flow meters, spirometers, and oximeters.

What's new is that these devices are being hooked up to central databases via the Internet. For instance, the Alere system, now being offered by PacifiCare Health Systems/Secure Horizons to members with congestive heart failure in four states, uses a digital scale connected to a monitor that sends data to a central station.

The Alere system asks CHF patients physician-designed Yes/No questions about their symptoms. And when the patient weighs himself, the value goes into the database automatically, rather than being reported by the patient. That can improve accuracy—an important consideration when a two- or three-pound weight gain can land a patient in the hospital.

CorSolutions, a traditional disease management company that handles patients with a variety of conditions, is now testing a system that uses multiple biometric monitoring devices, including blood pressure cuffs, scales, glucose meters, pulse oximeters, and spirometers. Data from these devices are transmitted to a Palm-type computer. The patient can upload the data via the Web by placing the handheld in a cradle connected to a PC or a phone line, if the Palm has a modem. The Palm can also be used to send alerts and reminders to the patient, just as the Health Buddy and Alere's DayLink monitor do.

LifeMasters has patients provide values from biometric devices on the patients' own Web pages. (They can also call in the readings through interactive voice response.) LifeMasters is now experimenting with ways to upload data from the devices automatically.

"The reason we haven't gone in that direction until now has to do with behavioral change," says pediatrician Jeffrey M. Davis, the company's chief medical officer. "If patients have to type values into a computer or a handheld, they have to think about why they're doing it."

Only 5 percent of patients enter false values, says Davis, adding that LifeMasters' nurses are trained to pick up abnormal patterns. But for the 5 to 10 percent of patients who have difficulty conveying data accurately over the phone or the Internet, says Davis, "we see a great use for those Web-enabled devices."

Health Hero CEO Steve Brown also believes that more patient involvement in data reporting leads to greater compliance, even if the data aren't quite as accurate. "It's all the little things the patient does that add up to the outcome. You need to empower the patients and make them feel they're a trusted part of the management."

Even if the automatic uploading of data from biometric devices can help care managers to better track patients' conditions, there's general agreement that patient contact with those care managers remains crucial. "The existence of a trusted caregiver is the single biggest factor in reducing the short-term risk of complications," says pathologist Richard P. Vance, chief medical officer of CorSolutions.

Observers and vendors caution that little is known yet about how biometric monitors affect outcomes, and some studies suggest that the use of certain devices doesn't necessarily result in better care. Notes preventive-medicine specialist Helga E. Rippen, director of medical informatics for Pfizer Health Solutions, "The bottom line with all these devices is this: What are you going to use it for? What about it is going to change the outcome or the treatment of your patient? If it's just used for the sake of having a toy, it doesn't help anyone."

There are also questions about whether patients with chronic diseases, many of them elderly, can or will use these devices. If it's just a matter of stepping on a digital scale, the answer is Yes. But internist Peter J. Bell of Chicago has found that the majority of patients who have home glucose meters and spirometers don't use them regularly. While he's in favor of biometric monitoring, he says, "You can't overwhelm patients with a lot of things, because that tends to turn people off. The less you ask people to do, the more likely they are to buy into it and be compliant."

Some observers argue that it's easier to train elderly patients to use biometric devices or simple monitors like the Health Buddy than to teach them how to use the Internet. But an Intel-funded study of LifeMasters' program at Physicians Medical Group of Santa Cruz County showed that CHF patients, who were 79 years old on average, could function well on the Internet. Intel bought the computers for this group, but Davis says that 15 percent of the 34,000 patients cared for by LifeMasters nationwide are already using the Web to report their vital signs. "Two years ago, it was less than 5 percent," he says.

E-disease management's economic value is debated

The LifeMasters study also showed that the Santa Cruz IPA could save money through a Web-enabled CHF program. Overall costs for CHF patients in the study group dropped $2,400 per patient per year, while costs of those in the control group rose more than $1,200 a year. "We found there was a total saving of about $80,000 on professional costs, and nearly $400,000 in institutional costs," says pediatrician Wells Shoemaker, the IPA's medical director. "The main savings were in avoided hospitalizations."

Although the physicians didn't see much of those savings because of the IPA's risk-sharing arrangement with the hospital, the results were promising enough so that the IPA kept LifeMasters and started paying for it.

Can Web-enabled efforts save more than some traditional disease management programs do? There are some indications they will. A Health Hero program for CHF at the Mercy Heart Institute of Sacramento reportedly showed a greater reduction in bed days and overall costs than a conventional case management program alone. And when PacifiCare recently tried four disease management programs for CHF in different regions, it found that the two programs that used daily device monitoring showed a better return on investment than the two that relied on traditional nurse outreach.

Most health plans are still taking a wait-and-see attitude toward Web-enabled disease management. Observers point out that the HMOs are operating on thin margins and want to be sure they can get a quick return on investment. "Health plans still are focusing on the cost-effectiveness of these programs and devices within a time frame of one to two years," says consultant Stan Bernard.

Humana, which has been using CorSolutions for several conditions, is working with the vendor on its new Palm link with biometric monitors, says GP David Steele, Humana's medical director of e-health. One reason Humana is willing to fund this is that CorSolutions will repay some of its fee if it doesn't achieve promised savings. (This kind of risk arrangement is common in the disease management field.)

While e-disease management firms are targeting the same conditions that traditional vendors have addressed, such as CHF, diabetes, and high-risk pregnancy, they're starting to expand into areas that haven't received as much attention, such as coronary artery disease. That's because many CAD patients are active, middle-aged people and are easier to reach on the Web than on the telephone, says Bernard.

One vendor, Accordant Health Services, is using a combination of Web and telephone interaction to improve care for patients with less-common conditions, such as multiple sclerosis, hemophilia, and Parkinson's disease.

So far, there's little evidence that health plans are capitalizing on the cost-effectiveness of e-disease management to reach beyond the high-risk population. But one HMO executive predicts the industry will move in that direction. FP Gordon K. Norman, vice president of health care quality for PacifiCare, points out that the plan's vendor-supplied CAD program already evaluates asymptomatic patients with multiple risk factors. "The threshold for disease management will move upstream as techniques are refined, as best-practice interventions are better defined, and as the cost of intervening is reduced through the use of the Internet and other technologies."

Physicians are caught between a rock and hard place

While physicians such as Larry Stubblefield like Web-based disease management because it enables them to monitor patients more closely than before, most doctors who employ these programs don't want to be contacted unless a patient is showing signs of distress. Fewer than 2 percent of physicians go to the part of the Alere Web site that has aggregate data on their patients, says company President K. Randall Burt. And in some disease management programs, doctors will even give care managers standing orders about how medications are to be adjusted in various situations.

Much of this has to do with the time pressures on physicians. It's also related to the fact that doctors don't get paid for most nonvisit care, whether it's checking patients' vital signs on the Web, e-mailing them, or spending time with them on the phone.

"The current reimbursement system penalizes the physician who wants to improve patient care in that way, because it just pays for office visits," notes Molly Joel Coye, who helped write the Institute of Medicine's latest indictment of the health care system, "Crossing The Quality Chasm."

Nevertheless, she hopes that physicians will eventually embrace Internet-based techniques that improve care of chronic-disease patients. "If a Web-enabled monitoring system allows a person with CHF to remember to take his medications or monitor his weight more effectively than he can do working with the physician on his own, I'd hope that clinicians would support it."

Can these programs actually help patients more than doctors can on their own? The data on reduced hospitalizations and ER visits certainly suggest that. "In most cases, it's very difficult for individual physicians to make substantial improvements, because they don't have automated reminder systems and a lot of the other infrastructure needed to be efficient in trying to change care," says Coye.

Even in California, where groups and IPAs have had a lot of experience with managed care, few of them have been able to create and sustain successful disease management programs, notes Gordon Norman of PacifiCare. Internist Peter Bell of Chicago, who's in a 25-doctor multispecialty group, points out that large practices can at least afford to hire some nurse educators and case managers. The value of a disease management program, he says, would be much greater for a physician in a small practice who didn't have any of these resources.

Soloist Arnold Leff feels that the jury is still out on LifeMasters, because the study of its program in his IPA compared well-funded care for specific patients with a control group of patients who were provided the usual care by doctors who weren't paid extra to take care of them. A properly designed study, he says, would equalize the resources expended on patients in both groups. "If you want me to better case-manage patients, pay me to do it, and I'll be glad to do it."

But Larry Stubblefield of the Heritage Southwest IPA argues that physicians should accept technologies that benefit their patients, even if they aren't moneymakers. "There are two ways you can react to change," he says. "You can either embrace it and let it work to your advantage, or let it run over you like a steamroller. So I'm all for embracing it."

 

Ken Terry. Monitor patients online?. Medical Economics 2001;14:67.