Opportunities to Improve Diabetes Outcomes through Electronic

Patient Engagement

July 24, 2018

The HITEQ Center is a HRSA-

funded Cooperative Agreement

that collaborates with HRSA

partners to support health centers

in full optimization of their

EHR/Health IT systems

HITEQ Center

• Web-based health IT knowledgebase

• Workshops and webinars

• Targeted technical assistance

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HITEQ Focus Areas

Session Agenda

• Part 1: Leveraging EPE Tools to Activate Patients in Self-Management of Diabetes

• Part 2: EPE Findings & Strategies

• Part 3: Implementation and Evaluation of EPE Approaches to Diabetes Management

Today’s PresenterNathan Botts, PhD, MSIS

• Senior Study Director – Healthcare Delivery, Research, and Evaluation, Westat

•Electronic Patient Engagement domain lead for the HRSA HITEQ Center project.

•Active in patient generated health data research and development with a focus on underserved populations 2007 - present

•HL7 Mobile Health Co-Chair and project lead for the HL7 Consumer Mobile Health Application Functional Framework

Part 1: Leveraging EPE to Activate Patients toward Self-Management of

Diabetes

Patient Activation & Engagement

• Patient activation refers to a patient's knowledge, skills, ability, and willingness to manage his or her own health and care

• Patient engagement is a broader concept that combines patient activation with interventions designed to increase activation and promote positive patient behavior.

Patient Activation Need vs Ability

Disagree Strongly

Disagree

Agree

Agree Strongly

N/A

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0%

Taking an active role in my own health care is the most important thing that affects my healthAcknowledgement

of the need for activation

Patient Activation Need vs Ability

Disagree Strongly

Disagree

Agree

Agree Strongly

N/A

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0%

I have been able to maintain (keep up with) lifestyle changes, like eating right or exercising.Personal

ability to be activated

Patient Engagement Opportunity

• Consumers want to access care on their own terms.• Patient engagement improves overall health outcomes,

while fostering meaningful collaboration between patients and healthcare providers.

• Effective ways for health centers to engage patients include:– implementing patient specific education– preventive care appointment scheduling– health tracking– comprehensive patient portal adoption

Electronic Patient Engagement Factors

• Can be a more reliable way to get in touch with some patients, such as those who do not have a stable address or phone number.

• Allows greater confidentiality for patients, avoiding the need for phone messages or undesired face to face contact.

• Patients may be more comfortable communicating about sensitive issues via secure messaging.

Policy-related factors: Constraints and Considerations

• Meaningful Use (now Promoting Interoperability!)– Difficult to meet Patient Electronic Access objectives. – Protection of Electronic Health Information measures makes it difficult

to entertain new innovations in electronic patient engagement tools

• HIPAA– Imposes significant constraints on deploying potentially high impact

electronic patient engagement opportunities.– Still many grey areas surrounding secure messaging and related HIPAA

constraints

• CMS Reimbursement– Reimbursement opportunity and rates for electronic patient

engagement implementation and use are still under development– However updated CPT Codes, primarily for telehealth are currently

being rolled out

Poll: Your Role and EPE Interest

• What best describes your role as it relates to interests in electronic patient engagement?

– Health Center Leadership– Clinic/Program Administrator– Clinical Staff– Health IT Staff– Patient Ed/Navigation Lead– Other health center staff

Poll: EPE Implementation

• What methods of electronic patient engagement are you using with your patients?

– Use of Patient Portal– Social Networking strategies– Text Messaging strategies– Mobile Health app strategies– Other EPE Tools– Not using EPE…yet

Focusing on Diabetes

• 21 million adults in the U.S. are living with type 2 diabetes

• This is approximately 9 percent of the adult population

• The number of adults with type 2 diabetes has risen in recent years as obesity rates continue to climb

• Another 1.3 million adults are living with type 1 diabetes

• Another 800,000 people are living with other forms of the condition, like gestational diabetes

BPHC Diabetes Improvement Goal• Performance Measure: Percentage of

patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period

• Target Goal: By the end of the project period, decrease the percent of adult patients with type 1 or 2 diabetes whose most recent HbA1c is greater than 9%

• Numerator: Patients whose most recent HbA1c level (performed during the measurement period) is >9.0%

• Denominator: Patients 18-75 years of age with diabetes with a visit during the measurement period

37.9%

22.5%

34.4% 33.4%

39.0%42.6%

29.6%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Problem Statement• Key barriers to effective diabetes care:

– lack of patient activation and engagement with their diabetic care plan– lack of medication adjustment by physicians during clinical encounters

• Patients have difficulty adhering to diabetes regimens including:– Glucose monitoring– Diet & Exercise– Medication adherence– Understanding care plans

• A myriad of factors impact a patient’s ability to manage their condition including:– Health beliefs– Current knowledge– Physical limitations– Related socio-economic factors (e.g., culture, education, economics)

Diabetes Education Impact Opportunity• Diabetes with complications is among the most expensive condition billed to Medicare, on

average 2.3 times higher than among those without the disease ($13,741 vs. $5,853).

• Notably, this burden falls disproportionately on low-income individuals, who are at higher risk for developing diabetes.

• Coupling personalized clinical care with real-time, patient-specific diabetes education leads to improved glycemic control in a short time and produces cost savings.

• Economic resources in the health care system are inadequate for preventive measures such as weight loss and other behavioral changes. Diabetes self-management training is a benefit covered by Medicare and most health plans when provided by a diabetes educator within an accredited/recognized program.

• The Association of American Medical Colleges projects shortfalls of both primary care physicians and endocrinologists by 2030.

Illinois PHCA EPE Study Case Findings

• Strategies being utilized to increase patient engagement in diabetes management:

• “Be Well Program” for type 2 diabetes– Extended clinic hours– Incentives, such as gym memberships, offered to patients that

commit to and are regularly keeping up with their care• Patients with A1Cs > 9% are provided with extended

services by the health center including home medication deliveries, and starter kits for glucose monitoring

Electronic Patient Engagement Opportunities

• Decisions most affecting diabetes management are made by the patients themselves

• Technologies that target patient/consumer engagement are having a significant impact on diabetes-related health outcomes.

• Provides opportunities to:– increase patient to provider communication– provide patients with personalized HbA1c reports– provide real time access to lab results and

education– increase patient involvement in their care

planning

Findings: EPE Impact on Diabetes• Assists in increasing glucose pattern management

• Motivates patients to perform self-monitoring of blood glucose (SMBG)

• Use of an electronic refill function can improve statin adherence from 71% by 6% and improved LDL cholesterol levels in all populations

• One meta-analysis concluded that A1C declined 0.5% with use of mobile apps in people with type 2 diabetes and declined 0.8% in people with type 1 diabetes.

• Further educates patients on their personal blood glucose levels and can inform better medication personalization

Health Apps and Diabetes

• One app does not fit all!

– Apps that provided feedback from healthcare professionals produced greater reductions in blood glucose levels when compared to apps that only offered automated

– Apps that allowed users to track more than three self-monitoring tasks produced greater reductions in blood glucose levels when compared to apps with three or less tasks

Poll: EPE for Diabetes Improvement

• What type of electronic patient engagement activities are you using for your diabetes patients?

– Use of Patient Portal– Social Networking strategies– Text Messaging strategies– Mobile Health app strategies– Other EPE Tools– Not using EPE for diabetes yet

Key Self-Management Variables

• Daily SMBG (four to five times per day) is important for patients with insulin-requiring diabetes

• SMBG is needed for pattern management or insulin dosing adjustment

• Through SMBG alone, insulin-using patients with type 2 diabetes were shown to lead to better health outcomes.

• Yet, sustained engagement with SMBG is critical and can be difficult to maintain

• EPE can assist in triangulating on the needed triggers to nudge and encourage patients

Fogg Behavior Model

Diabetes Management Behavior Change = MAT

• MOTIVATION: help patients understand the impact small changes in diabetes self-management can make

• ABILITY: anticipate objections, educate accordingly, and deploy the right interventions at the right time

• TRIGGER: get patients enrolled in a “project” that supports them in every step

Part 2: EPE Findings & Strategies

Diabetes Patient Engagement Best Practices

• National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Guidelines:

– Share-Decision Making: the patient must be well-informed of the treatment options and clinical evidence around managing diabetes.

– Motivational Interviewing: done through asking open-ended questions, affirming the patient’s responses, reflecting on their views and summarizing the discussion

– Goal Setting: assist patients in setting goals for self-care behaviors that include eating healthy, being physically active, adhering to medication and monitoring health.

Individualized Self-Management Advantages

• American Diabetes Association now recommends more realistic goals for patients that takes more of their medical history into account vs broader population controls such as A1c below 7%

• Use of tools such as patient portals to establish individualized plans could help patients control their blood sugar better — and could help save them an average of $13,000 in health care costs over their lifetime.

• Health policies and clinical programs that encourage an individualized approach to glycemic control for U.S. adults with type 2 diabetes reduce costs and increase quality of life compared with uniform intensive controls.

Crossing Healthcare Diabetes Self-Management Education Program

• Providers refer patients and an initial assessment is completed.

• Patients are then enrolled in a total of 10 hours of diabetes education classes across multiple days throughout the program.

• Three months later, a follow-up appointment is completed to review lab work changes, weight changes and where each patient is with their personal goals.

• Once they complete the entire education program, patients are then enrolled in a social media support group.

Crossing Healthcare Diabetes Program Social Network

1. Social media support group is provided to patients by giving them an online link to a closed Facebook group.

2. Patients are advised regarding confidentiality and their use of the social media platform.

3. Patients are required to answer questions about the types of content they are interested in receiving.

4. Diabetes and Prediabetes information is generated accordingly and conversations are lead on the platform to provide consistent and ongoing support.

White Memorial Medical Center Glycemic Control Project

• WMMC has created a Glycemic Control Project that is looking to better utilize Health Information Technologies (HIT) to improve their glycemic control targets

• WMMC diabetes educators have occasionally suggested mobile apps such as One Drop and Calorie King (WMMC KII).

DSME: Key to A1C Reduction

Diabetes HealthIT DSME Cost Savings Impact Example

Project HOPE Chicago - Mobile Phone Diabetes Project

• A primary-care–based mobile health (mHealth) program that sends health-behavior–related text messages to both type 1 and type 2 diabetes patients both improved outcomes and reduced costs.

• Treatment participants were an average age of 53 years old and had a diabetes duration of 8 years. Two-thirds were African American. About one-third each had HbA1c levels of 7% or less, 7% to 8%, and 8% or greater.

• Total healthcare costs declined by a significant $812 per patient over the 6 months, including a drop of $1332 for outpatient visits along with a $520 increase in prescription drug costs (P = .007 despite the offset).

• Costs of the mHealth program were estimated to be $375/participant, suggesting a net cost savings of $437/participant ($812-$375) and an 8.8% saving compared with the pretreatment period.

Part 3: Implementation and Evaluation of EPE Approaches to Diabetes

Management

Poll: EPE Evaluation• How are you evaluating the effectiveness of

your electronic patient engagement implementation?

– Frequency of use by patients– Patient satisfaction surveys– Population health outcomes – Cost-Benefit analyses – Other evaluation methods– Not really

EPE Adoption FrameworkConceptual Level Constructs Factors

Personal • Cultural• Financial• Education• Behavioral

• Significant differences to be expected depending on Socio-Economic Status

• Engagement and activation factors key to sustainability

Technical • Standards• Regulations• Precision

• U.S. HIE standards still primarily based within the clinical environment

• Precision of metrics and device ability to effectively report are in need of continued innovation

• Systems designs still not targeted to the underserved

Organizational • Workflow• Workforce• Reimbursement

• Few clinical workflows include procedures for incorporation of patient reported data

• Concerns by clinicians of responsibility to act (or not) on data provided to them

Policy • Security• Privacy• Quality• Prevention

• U.S. government is working hard to keep up in establishing policies that provide effective guidance toward patient portal adoption

• Need further work in finding the balance between protection and effective use

Adoption and Implementation Questions

• User Question: How can EPE tools support your patients in diabetes management? What barriers will they experience? – reminders/ appointment management / communication/ FAQs

• Technology Question: How well do certain EPE systems fit for the technology access and utilization patterns of your population?– email access / computers vs mobile / social networking

presence

Adoption and Implementation Questions

• Organization Question: How well does the EPE system integrate with our organizational practices and current resource constraints?– Patient Navigators / Staff Training / IT Support

• Policy Question: What privacy and security constraints need to be addressed in order to effectively integrate and deploy a particular EPE strategy? – Text and HIPAA / Patient Consent /Opt-in vs Opt-out strategies

Measuring ROI

• How will you determine whether you are achieving the desired results?

• What specific measures can be used to determine whether you are accomplishing the goals of your implementation?

• How will your report out on satisfaction and outcomes?

Measures vs Metrics

– Measures: concrete, usually measure one thing, and are quantitative in nature (e.g. I have five apples).• # of pageviews of clearinghouse content• Session duration on QI content

– Metrics: describes a quality and require a measurement baseline• Bounce Rate - percentage of single page visits (or web sessions)• Session Duration Average – the average amount of time a user spends on your

website for a given session

What is your Logic Model for evaluating your effort?

Inputs

• Policy/Regulations• Best Practices/Use

Cases• SMEs• Health Center

Staff

Activities/Process

• Analyze needs• Design Program• Develop/Acquire

Technology• Pilot & Implement• Evaluate

Outcomes

• Patient access to targeted education tool

• Improvement in diabetes program operations

• Net value effect of greater awareness and education across population

Impact

• Better educated health centers

• Better educated patients

• Increased control of diabetes systems

• Reduction in diabetes incidence

• Cost avoidance of increased diabetes care

Increase Diabetes Prevention Efforts• Increase the percentage of adults who receive weight screenings & counseling• Increase the percentage of children who receive weight screenings & counselingImprove Diabetes Treatment And Management• Reduce the proportion of persons with diabetes with an HbA1c value greater than 9 percent• Increase the proportion of health centers that meet the Healthy People 2020 goal for uncontrolled diabetes for each

racial/ethnic group

Performance Evaluation Measures

Process/Implementation : determines whether program activities have been implemented as intended.

• How well the program is currently working• The extent to which the program is being implemented as designed.• Whether the program is accessible and acceptable to its target population.

Outcome/Effectiveness: Measures short and long-term outcomes• The degree to which the program is having an effect on the target population’s

behaviors.

Impact Evaluation: Measures short and long-term outcomes• The degree to which the program is having an effect on the target population’s

behaviors.

Conclusion• There are significant opportunities for improving health center

populations through the use of electronic patient engagement tools

• Receiving diabetes self-management support in community health center settings through technology-based programs is becoming more available and affords increased access, activation and engagement.

• Adoption takes time, forethought, and investment, but there is a steadily growing base of research to indicate the long term advantages

Want more information?

HITEQ Electronic Patient Engagement Resources

• Patient Portal Technologies

• Mobile Health & Medical Devices

• Social Media Management for Health Centers

• Assessing Patient Engagement and Satisfaction

References• Dyer, J. S. (2013). Effects of Consumer-Facing Technologies on Patient Engagement, Behavior Change, and Type 2

Diabetes-Related Health Outcomes. Diabetes Spectrum, 26(2), 98-101. doi:10.2337/diaspect.26.2.98

• Grant, R. W., Wald, J. S., Poon, E. G., Schnipper, J. L., Gandhi, T. K., et al. (2006). Design and Implementation of a Web-Based Patient Portal Linked to an Ambulatory Care Electronic Health Record: Patient Gateway for Diabetes Collaborative Care. Diabetes Technology & Therapeutics, 8(5), 576-586. doi:10.1089/dia.2006.8.576

• Powers, M. A., Bardsley, J., Cypress, M., Duker, P., Funnell, M. M., et al. (2015, July). Diabetes Self-Management Education and Support in Type 2 Diabetes: A Joint Position Statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Journal of the Academy of Nutrition and Dietetics, 115(8), 1323-1334. doi:10.1016/j.jand.2015.05.012

• Botts, N., Horan, T., and Thoms, B. (2011). HealthATM: Personal health cyberinfrastructure for underserved populations. American Journal of Preventive Medicine, 40(5), s115-s112.

• Giardina, T. D., Baldwin, J., Nystrom, D. T., Sittig, D. F., & Singh, H. (2017). Patient perceptions of receiving test results via online portals: a mixed-methods study. Journal of the American Medical Informatics Association. doi:10.1093/jamia/ocx140

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