Patient Self-Management Tools: An Overview...Patient Self-Management Tools: An Overview| 5 THIS...

Patient Self-ManagementTools: An Overview

June 2005

Patient Self-ManagementTools: An Overview

Prepared for:

CALIFORNIA HEALTHCARE FOUNDATION

Prepared by:Critical Mass Consulting

Author:Michael J. Barrett

June 2005

AcknowledgmentsThe author would like to express his gratitude to the individualsand organizations listed in the Appendix. Their insights informevery aspect of this report.

About the AuthorCritical Mass Consulting conducts strategic and market researchwithin health care and the life sciences, with a specific focus onthe use of information technology by providers, consumers,health plans, and medical device and pharmaceutical firms.Michael J. Barrett can be contacted at [email protected].

About the FoundationThe California HealthCare Foundation, based in Oakland, is an independent philanthropy committed to improvingCalifornia’s health care delivery and financing systems. Formedin 1996, our goal is to ensure that all Californians have access to affordable, quality health care. For more information, visit us online (www.chcf.org).

This report was produced under the direction of CHCF’sChronic Disease Care Program, which seeks to improve thehealth of Californians by working to assure those with chronicdiseases receive care based on the best scientific knowledge.Visit www.chcf.org/programs/ for more information aboutCHCF and its programs.

ISBN 1-932064-85-0

Copyright © 2005 California HealthCare Foundation

http://www.chcf.org

http://www.chcf.org/programs/

Contents4 Executive Summary

5 I. Introduction

6 II. Self-Management Tools: Definition and Driving Forces Clinical Care Factors

Economic and Political Factors

Consumer Factors

Technological Factors

9 III. Segmenting Self-Management Tools by Patient Role Tools for Subordinate Roles

Tools for Structured Roles

Tools for Collaborative Roles

Tools for Autonomous Roles

21 IV. Conclusion

22 Appendix: Contributors

23 Endnotes

4 | CALIFORNIA HEALTHCARE FOUNDATION

DEMAND FOR PATIENT SELF-MANAGEMENT TOOLS—technologies used by consumers to manage their healthissues outside formal medical institutions—is gainingmomentum. This surge of interest springs from a variety ofconverging influences: new ideas about clinical care, universalconcern about costs, political interest in stimulating competi-tion among providers, shifting consumer habits, and anexplosion of technological innovation.

Some analyses of this market sort self-management toolsinto an overwhelming number of micro-segments. Otherscategorize the market by user group without differentiatingmuch among the technologies themselves. This reportattempts to create a typology that distinguishes tools primarily by patient role and secondarily by variations in the complexityof technology.

The various tools may be described as follows:

n Technologies that support subordinate patient roles provide modest patient discretion within a strong supervi-sory context. The approach is similar to the one adoptedby the automobile industry, in which the expanding roleof devices has reduced the possibility for human error.

n Tools for structured roles involve more active but limitedpatient participation. In these cases, technologists haveproceeded cautiously because of physician wariness aboutsharing control.

n Tools for collaborative roles involve patients using theirown knowledge and making decisions jointly with clinicians. Such tools engage physicians and patients inthe shared decision-making envisioned by disease manage-ment advocates and clinical care theorists.

n Tools that facilitate autonomous roles help patients takehealth matters in hand without major participation byclinicians.

While each of these self-management roles has kindled a growing market for new technology, not all have inspiredcorresponding changes in clinical care delivery. As patientscontinue to adopt self-management tools, clinicians will needto better understand these tools and how best to apply themin caring for their patients.

Executive Summary

Patient Self-Management Tools: An Overview | 5

THIS REPORT IS AN OVERVIEW OF AN EMERGINGmarketplace. Patient self-management tools are instruments of self-care, mobile care, and home care. They help con-sumers deal with their own medical conditions, or those ofloved ones, outside the walls of formal institutions. Interestis mushrooming and businesspeople are betting that futuredemand will be strong. Knowing about these technologieshas become important to doctors, nurses, administrators,policymakers, and businesspeople, not to mention membersof the public.

Sometimes patients take up a self-management product on the advice of a clinician. Sometimes they act on their own—exploring a Web site for information about a treatment, forexample—but tell their doctors afterward. And sometimes theyact on their own and never tell anyone because they don’t havea doctor, forget, view their action as irrelevant, or feel thatthe matter is private.

It follows that self-management tools are patient-focused butnot always physician-focused. It follows, too, that not allself-management tools are used in conjunction with disease-management programs, in which doctors and nurses havea central role. A considerable number of these productsadvance patient-clinician collaboration of the kind that disease-management programs recommend, but just as many exist to help people handle problems more or less on their own.

Because these tools straddle the health care and consumer sec-tors, their evolution rests not only on concepts of clinical carebut also on broader influences, some of them economic andpolitical, some of them involving consumer behavior, andsome of them technological. As with other products subject tosuch complex forces, self-management tools can be improvedby law and regulation and disciplined by supply and demandbut, ultimately, controlled by no one. What can be said withconfidence is that these tools will produce more benefit ifhealth care professionals know about them, discuss them withcolleagues and patients, and take part in improving them. This report hopes to advance such knowledge, discussion, and improvement.

I. Introduction


EACH YEAR A WAVE OF NEW PRODUCTS AIMS TOgive patients greater control over their illnesses and chronic conditions. External defibrillators deal with sudden cardiacarrest at home, hemoglobin testing kits sell direct to diabeticconsumers, and sensor-based systems let the elderly stay inbetter touch with relatives. The list goes on.

This report covers these technologies and many others. Itdefines a patient self-management tool broadly, to mean “tech-nology used by a patient or informal caregiver to managehealth problems outside formal institutions.” The term encom-passes an extraordinary and expanding array of products sharing a common characteristic: They focus on making non-expert control of health and health conditions easier or better.

The forces influencing the development of these tools fall into four categories: clinical care, economics and politics, consumerism, and technological innovation.

Clinical Care FactorsAs the population ages, chronic care becomes increasinglyimportant. The contrast with acute care is significant: A doctor can often address an acute problem with a procedure or prescription, but a patient’s chronic problem remains dayafter day, hour after hour. Because a doctor or nurse can’t bepresent all the time, the consumer must handle the situationon his or her own, with occasional help and advice from clini-cians. As one team of experts flatly stated, “Patients withchronic conditions self-manage their illness. This fact isinescapable. Each day, patients decide what they are going toeat, whether they will exercise, and to what extent they willconsume prescribed medications.”1

Clinical care theorists acknowledge the influence of the patientand the concept of shared decision making. A popular, ifsomewhat wordy, definition of disease management is “a system of coordinated health care interventions and communi-cations for populations with conditions in which patient self-care efforts are significant.”2 These approaches replace the con-ventional notion of the clinician as expert with a partnershipmodel in which “patients accept responsibility to manage theirown conditions and are encouraged to solve their own prob-lems with information, but not orders, from professionals.”3

II. Self-Management Tools: Definition and Driving Forces


Technology vendors, observing these develop-ments and spotting an opportunity, have devel-oped innovative ways to support patient-cliniciancollaboration. Such collaborative products consti-tute a major part of the marketplace in patientself-management tools, the four segments ofwhich are discussed later in this report. (See“Segmenting Self-Management Tools by PatientRole.”)

Economic and Political FactorsThe rising cost of American health care continuesto plague public and private payers, promptingthem to examine new ways of reviving an oldidea: people caring for themselves and their lovedones at home. On the government side, unlesstaxes are raised or benefits cut, annual expendi-tures by Medicare’s Hospital Insurance trustfund, its biggest pot of money, are expected toexceed annual revenues by 2012 and exhaust totalassets by 2020.4 In the private sector, GeneralMotors reports that expenditures to insure itsAmerican employees, retirees, and dependentscame to $4.8 billion in 2003, more than itsworldwide net income for the same year.5 FordMotor’s story is worse: In 2003 it spent $3.2billion on health care—six times the company’sworldwide net income.6

Numbers like these underline the potential valueof patient self-management tools. Consider homemonitoring and messaging systems, with whichpatients connect to peripheral devices, take vitalsigns, test for other physiological values, andtransmit results to remote clinicians. These sys-tems allow routine procedures to be performedby patients or informal caregivers, rather thannurses or doctors, in settings less expensive thanthe clinic or the office.

In Washington, meanwhile, advocates of reformare shaping an agenda that identifies excessivehealth care costs as a symptom of an ailing

market, but the absence of competition as theunderlying disease. They view this competitiveproblem as stemming not from any shortage ofdoctors and hospitals, but from the system’s overall lack of “transparency.” In other words,buyers—consumers included—don’t haveenough information about the relative perform-ance of health care providers, so they can’t makecomparisons and negotiate among them. Thecure? Support hard measures of relative per-formance, and then encourage development ofself-management tools that translate these meas-ures into easy-to-understand comparisons.

In April 2004 the president established the Office of the National Coordinator for HealthInformation Technology. Of the four objectivesits new director has enumerated for his tenure, hecalls the third personalizing care, which he definesas “well-informed patients... equipped to activelyparticipate in their own care and decision mak-ing.”7 He explains: “Innovations in technologyare emerging to give patients electronic access to their health record and the ability to gatherspecific information tailored to their illnesses, chronic conditions, and health characteristics. ...[Patients’ decisions] should include not onlywhat actions to take on their behalf but alsowhom they select to treat them and where theyseek treatment.”8

Consumer FactorsPublic opinion surveys, followed up by markettests and pilot programs, suggest that consumersare price-sensitive about health care services andare likely to change behavior in response to high-er charges.9 These findings have added moreimpetus to the development of market-orientedself-management tools, such as comparisonengines that draw on expanding stores of data to compare health insurers, hospitals, and evenindividual doctors. Consumer Reports, theMedicare program, and the Leapfrog Group, an


organization sponsored by large employers, alloffer online engines to help consumers balancequality and financial factors when making healthcare choices.10

But, as motivating as prices are, they are not theonly considerations that prompt people toembrace self-management tools. Consumers arealso interested in saving time and gaining con-venience; they are just too busy to sit aroundwaiting rooms. Home monitoring and messagingsystems trade off personal service by professionalsin exchange for avoiding trips to the doctor’soffice. An expert observer of the trend, a doctorwho runs the telehealth programs of the VeteransHealth Administration, writes, “Patients areshowing that, as health care consumers, theywant their experiences to mirror their expecta-tions as consumers in other areas of their life. ...[This means] giving people more involvementin deciding what health care they want to receiveand how they want it delivered.”11

Technological FactorsBy the standards of mainstream laboratory science, innovation in information technology(IT) moves at lightning speed. The World WideWeb, the publicly accessible face of the Internet,pervades every aspect of modern commercial life,yet it was devised only 16 years ago, a periodscarcely longer than the development cycle of asingle prescription drug.

IT’s progress since has been relentless. Micro-processor chips continue to get smaller, cheaper,more pervasive and, of course, more powerful.The impact of such gains is magnified byparallel innovations in telecommunications,most recently in wireless applications. Together,microprocessors and telecommunications makepatient self-management tools possible.Constant refinement is blurring the lines thatonce separated information technology, medicaltechnology, and assistive technology, regardless

of which label might once have applied; recentmedical and assistive technologies incorporatecomputing and communications features thatmake them, in the vernacular, “smart.”

These days, the technological transition from“dumb” to “smart” happens so routinely that it is hardly noticed. Not long ago, for example, thetypical treadmill in the basement did not featureadvanced electronics. But now a user can dial inweight, select an exercise duration, choose amongroutes hilly and flat, and generate a customizedworkout. During exercise, the treadmill offersdigital feedback on distance, time, and caloriesconsumed. It also connects to a chest-strap moni-tor and displays heart rate. And some of the lat-est models can upload readings into laptops orPCs for longitudinal record-keeping and cardiachealth analysis.12 For a heart patient who needs tocontrol his or her weight and get moderate exer-cise, this machine qualifies as a self-managementtool.

Today IBM, Intel, Fujitsu and others pushresearch and development aimed at makingeverything smart, with an early focus on mobileand home health care. Under the banner of ubiq-uitous or pervasive computing, researchers workon bringing the cost and size of microprocessorsand sensors down to where they can attachcheaply to light switches, water faucets, closetdoors, drawer handles, kitchen cabinets, ovendials, and pill boxes. One idea is to use sensors toprofile the activities of frail elderly patients livingindependently so that abnormal activity alertsloved ones to possible problems. When will thecost of sensors be low enough for such distrib-uted application? As an upcoming section of thisreport discusses, one startup company believesthe time is now. (See “Tools for SubordinateRoles.”)


THE FIELD OF PATIENT SELF-MANAGEMENT TOOLSis new, and researchers define the market in many differentways. Some scatter products across a confusing array ofmicro-segments. Others go to the opposite extreme, segment-ing by users—elders, baby boomers, and so on—withoutdrawing useful distinctions among the technologies them-selves. A better approach is to classify self-management toolsin a typology matrix formed along two lines: The primaryaxis defines the range of roles that patients play when usingthe tools; the second axis traces the complexity of the tech-nology. (See Figure 1.)

The product groups cited in Figure 1 are illustrative, notdefinitive. Altogether different ones could have appeared in their stead and, judging from research underway in suchcompanies as Johnson & Johnson, Motorola, and Samsung,still others will come along. The central point of the matrix isthat technology development relates directly to the roles thatconsumers play as they cope with health problems. These

III. Segmenting Self-Management Tools by Patient Role

Sensor-based surveillance

Video camera surveillance

Interactivetelemedicine consultation

Monitoring andmessaging systemwith multipleperipherals

Home andportable testingperipheral

Chronic diseasemanagement aids;decision supportaids

Patient educationmaterials online

Patient educationmaterials on paper

Advanced assistive technologies

Online supportgroups; providerand health plancomparisonengines

Self-help books on paper

Subordinate Structured Collaborative Autonomous

Patient Role

Low-tech

Tech

no

log

y

High-tech

Figure 1. Patient Self-Management Tools: Typology and Illustrative Product Groups


roles are dynamic and can change under theinfluence of the technology itself. This said,they vary from subordinate to structured to col-laborative to autonomous, each explained here:

Subordinate. Tools that facilitate subordinateroles provide modest patient discretion amidcontrolling and supervisory technology. Anexample is a video camera system used for safetyin a home or residential institution. Home sur-veillance based on ubiquitous sensors representsan advanced form of the same idea. At firstglance, such technologies might not appear towarrant inclusion in this typology. But, on fur-ther reflection, living with automated rather thanhands-on solutions is an option like any other.The adopter’s motivating instinct might bedependence, but it might also be a liking for costsavings, convenience, precision, consistency, andavoidance of human error. Typically the resi-dent—or a family member—remains aware ofthese devices and learns how to retain a measureof privacy and control in their presence. On theother hand, sometimes a patient gives informedconsent and the rest of the matter passes com-pletely out of his hands (as with implantedstents, for example). In these cases, the tech-nologies are simply too controlling—and thecorresponding element of patient participationtoo minimal— to warrant inclusion in a typologyof self-management tools.

Structured. Tools for structured roles involvemore active, though still limited, patient partici-pation. Because self-management is an unfamiliarvariable to much of organized medicine, technol-ogy vendors proceed cautiously on the issue ofpatient latitude. Many of them erect boundariesto placate physicians, whom they see as waryabout losing control of their schedules or medicaldecisions. In scripting the back-and-forth ele-ments of its online consultations tool, vendorRelayHealth limits the patient end of the con-versation strictly to the clinical subject at hand,

assuring doctors of the kind of control over virtual visits that they have, presumably, overface-to-face encounters.

Vendors may also constrain the patient role to accommodate a rather different clinician expectation: that the patient will be frail, unsureabout new technology, and uncomfortable usingit except in simple situations. And sometimes,unambiguously, the most important considera-tion is prudent medicine rather than physicianperception. If the tool is new or at least new tomany patients, and the readings, doses, or otherfeatures must be carefully calibrated, good rea-son exists for a careful structuring of patient discretion.

Collaborative. Tools for collaborative rolesinvolve patients drawing on their own knowledgeand making decisions jointly with clinicians.Such tools support the progressive models ofphysician-patient interaction envisioned by dis-ease-management advocates and clinical-care theorists. Some would say these technologiesserve the true ideal of patient self-management,in which professional and layperson work coop-eratively on a medical problem and in so doingemploy tools: for diabetics, perhaps a blood glucose meter that downloads readings into a PC;for cancer patients, perhaps a Web site providingdecision support.

Autonomous. Tools supporting autonomousroles stand at the opposite end of the spectrumfrom subordinate patient tools and help patientstake matters in hand without much participationfrom clinicians. Reasons for acting alone vary.Sometimes health insurance does not reimburseclinicians to provide the pertinent care; weightmanagement is a common example. Sometimespeople lack insurance altogether. Sometimes theyare habitual self-helpers and are unimpressedwith experts. And sometimes they have doctors,trust them, and still use an independent tool onthe side to address a vexing problem.


Technology, the vertical and secondary axis inFigure 1, ranges from low-tech to high-tech.These terms lack exact definitions and are offeredas approximate descriptions, but they define aspectrum of complexity that helps with analysis.As Figure 1 indicates, two self-managementtools that qualify as low-tech are educationalmaterials on paper, often dispensed by cliniciansto patients expected to assume collaborativeroles; and self-help books, typically purchasedby patients bent on assuming autonomousroles. Paper materials like these have a place inthis typology, first, because they play importantparts in the real world of patient self-manage-ment and, second, because print, lest we forget,is a powerful innovation, albeit a simple orlow-tech one by today’s standards.

It bears mentioning that technology appears todescribe a steady evolutionary course from low to high. But trends in the role of patients aremore complex. Demographics—a better-edu-cated populace, for instance—argue for adiminution over time in patient subordinationand a corresponding increase in autonomy. Butit’s also the case that the same patient mightbehave collaboratively with one doctor andautonomously with another, or subordinately atone stage of an illness and collaboratively atanother, and so on. For that matter, innovationssuch as interactive telemedicine can involvepatients in either structured or collaborative roles.Personal health records can encompass an evenwider range of participatory styles, from struc-tured to collaborative to autonomous, dependingon how much data access the layperson has. Ingeneral, the lay role depends on the choices ofpatient, doctor, and institution, and on thenature of the condition. What’s most telling isthat market trends do not point to the emergingdominance of any one style or the pendingeclipse of any others. Instead, innovation is flour-ishing with regard to all four.

Tools for Subordinate RolesAs previously mentioned, using a video camera toobserve a stroke patient or distributed sensors totrack the movement of frail elders are instances ofself-management tools that entail subordinatepatient roles. Optimism about demand for suchtools rests on demographic developments such asthe number of people living into their 80s andbeyond, some proportion of whom will want orneed the extra measure of assurance that control-ling and supervisory technologies provide.

Because of staff shortages in hospitals, nursinghomes, and assisted living facilities; video camerasurveillance is already common. But Intel,Eastman Kodak, Hewlett-Packard, and others seebigger opportunities in coupling microprocessorswith transmitters and sensors that detect sound,motion, pressure, temperature, and the presenceof other objects. The goal is to devise smalldevices that can not only detect subtle signals butidentify them—as heartbeats, for example—andcommunicate the information to other devices.These sensors might someday be embedded ineveryday objects throughout the home, allowingthe elderly and their loved ones to use them insubordinate self-management.

A commercial form of this technology could beon the market as soon as the end of 2005. Todescribe market trends more fully, Figure 2 goesbeyond the general product groups named inFigure 1 and cites particular tools that representeach group. One of them is the LusoraIntelligent Sensory Architecture (LISA). For awholesale cost that it insists will be around$1,000 per residential unit, LISA’s originator, acompany called Lusora, proposes to providehome security vendors and property managementfirms with its installation kits. The kits includemotion and temperature sensors the size of cigarette lighters; they are designed to attach todoors, windows, medicine cabinets, and refrig-erators. Residents can also opt for tiny LISA


cameras; they go into the housing behind con-ventional light switches, where they can operateoff the existing wiring and monitor a roomwithout the need for an independent powersource. Consumers may also buy a wearableLISA pendant that is part tracking device, partemergency alarm, and part automatic fall detec-tor. The concept: If a frail relative doesn’t activatea room sensor by getting up in the morning, ordoesn’t activate a door sensor by moving aboutfor an extended time, or if the pendant detects asudden gravitational shift of the sort associatedwith a fall, LISA will alert caregivers using a conventional phone, a cell phone, email, or aWeb interface.13

Additional research into subordinate self-manage-ment tools is taking place at Oregon HealthSciences University (home to an “intelligent bed”for tracking sleep patterns), the University ofVirginia (site of a “smart chair” for monitoringbreathing and heart rate), Georgia Tech (develop-ment of a “digital family portrait” for displayingdata from home monitoring to distant family

members) and the University of Rochester (setting for gait analysis and memory-assistanceprojects).14

Such undertakings—as well as many discussed inthe next section, “Tools for Structured Roles”—embody a general technology trend found insideand outside medicine: the shift from human-in-charge to device-in-charge. Representative toolsaccomplish feats not only of mechanical and electrical engineering but of social engineering.In some cases, they prod humans to do thingsthat humans would otherwise not do, but in others they do things better than humans do andsteer users away from the center of the action.

Automotive innovation illustrates the generalpoint. For decades, drivers have been responsiblefor slowing down their cars, with mixed results.Then carmakers introduced the antilock brakesystem (ABS), which harnesses sensors and com-puterized electronics to detect, and compensatefor, driver error. If the driver brakes too hard, theABS pulses the brake mechanism on and off toprevent wheel lockup and skidding. The conse-

Lusora’s LISAsystem for sensor-based surveillance

Code Alertresident monitoring by RFTechnologies

PartnersTelemedicine

Health Buddymonitoring andmessaging system

CoaguChek hometest for PT/INR levels

LifeScan glucome-ter; decision support aids byNexCura

Online educationby AmericanDiabetes Assn.

Healthwise patienteducation books

Philips’ HeartStartHome defibrillator;J&J’s IBOT humantransporter

eDiets; Medicare’sprovider comparison engine

Back PainRemedies forDummies and otherself-help titles

Subordinate Structured Collaborative Autonomous

Patient Role

Low-tech

Tech

no

log

yHigh-tech

Figure 2. Patient Self-Management Tools: Typology and Specific Examples


quence is that drivers do less braking on theirown and the number of accidents comes down.

In health care, as well, patients are assumingmore dependent roles as technology becomesmore active. The so-called artificial pancreas, now under development by Medtronic and oth-ers, embodies device-in-charge principles withinthe field of implanted prosthetics.15 Today,insulin-dependent diabetics monitor blood sugarlevels with the aid of glucose meters and injectinsulin as results indicate. By combining aspectsof a glucose meter and an insulin pump, the artificial pancreas aims to take both tasks out ofhuman hands. Attached to a diabetic’s abdomeneither internally or externally, the ensemble willcontinuously check glucose levels, inject properamounts of insulin, and then check again. Inother words, it will collect physiological infor-mation, “learn” from it, and modify futureaction accordingly.

The prosthetic pancreas is not yet ready to standin for the natural one, but developers are makingsteady progress, whittling away at the need forhuman intervention in both the monitoringand injection processes.16 When the device isperfected, a diabetic will give his or her consentand have the appropriate components implanted. The patient will remain ultimately responsiblefor self-managing the diabetes but will surrenderimportant day-to-day decisions to the tool.

Tools for Structured RolesThe home monitoring and messaging systemsalluded to earlier, in which patients test for vitalsigns and other physiological values, entail activeself-management but in conditioned and bound-ed ways. Prodded by sound and text remindersoriginating from a table-top appliance or perhapsa personal digital assistant (PDA) or cell phone,the patient takes his medications, steps on aweight scale, dons a blood pressure cuff, uses ablood glucose meter, or performs other basicchores. These peripherals respond via cable or

wireless transmission back to the messagingdevices, which process, display, and store databefore transporting it beyond the home overtelephone lines or other means to a nurse ordoctor. Many devices also engage the patient insimple yes-no dialogues regarding compliancewith a doctor’s orders and experiences of recentsymptoms.

Because of the growing population of chronicallyill and the escalating costs of home health nurs-ing, interest in these systems is strong. Estimatesfor the size of specific markets vary but can pro-vide order-of-magnitude guidance. One researchfirm pegs 2005 U.S. revenues at $2.65 billionand projects annual sales growth of 8.5 percentfor home and portable peripherals, the productfamily consisting of the aforementioned bloodpressure/pulse cuffs, blood glucose meters, andweight scales plus electronic thermometers, electronic stethoscopes, peak flow/respirationmeters, coagulation monitors, pulse oximeters,apnea monitors, cardiac monitors, cholesterolmonitors, fetal/pediatric monitors, neurologicalmonitors, and other tools.17

Big business has seen the growth potential ofthese tools and moved in: Honeywell through a 2004 acquisition, Matsushita/Panasonic in a 2003 joint venture with Bayer, and Philipsthrough a 2002 acquisition. (See Table 1.) Today,these large-company offerings, like those of thesmaller companies against which they compete,are improving but still lack many helpful fea-tures. Products present users with reminder mes-sages, immediate test results, and perhaps somebasic questions. But patients do not see trend-ing information, do not receive on-the-spoteducation about the implications of any specificresult, and are not presented with context-specific decisions to make and actions to take.Occasionally, systems instruct users in simplematters of technique—how to operate a bloodpressure cuff, for example—but not in the higher-order problem-solving skills called for by chroniccare advocates.18


Company Year Founded Clinical ConditionsEmphasized

Home and Portable Devices Peripherals Accommodatedby Devices

Alere Medical 1996 Congestive heart failure (CHF); disease-managementprogram for CHF isaccredited by NationalCommittee for QualityAssurance (NCQA)

DayLink home unit Weight scale

AMDTelemedicine

1991 Firm’s major businessis conventionaltelemedicine; homemonitoring addedrecently

CareCompanion homeunit, AMD videophone

Blood pressure/pulsecuff, electronic stetho-scope, glucometer,pulse oximeter, weightscale

AmericanTeleCare

1993 Multiple diseasestates

Monitoring Station(non-video) home unit,Video Patient Station(two-way live video)home unit, digital camera

Blood pressure/pulsecuff, glucometer, prothrombintime/InternationalNormalized Ratio(PT/INR) device, pulseoximeter, telephonicstethoscope, thermometer,weight scale

Cardiocom 1997 CHF; recent additionsinclude asthma, coro-nary artery disease,chronic obstructivepulmonary disease(COPD), hypertension,and obesity

CareStar home unit,TeleScale weight scale

Blood pressure/pulsecuff, glucometer,oxygen saturationmeter, peak flow/respiration meter,thermometer

CybernetMedical

1988 CHF, COPD, diabetes, hypertension, wound care

MedStar home unit,PALStar home communications unit,digital camera, video phone

Blood pressure/pulsecuff, electrocardiogram(ECG), glucometer,thermometer,peak flow/respirationmeter, pulse oximeter, spirometer, thermome-ter, weight scale

Health HeroNetwork

1988 Multiple diseasestates. Disease-management programs for CHF,COPD, diabetes, andhypertension areNCQA-accredited

Health Buddy home unit

Blood pressure/ pulsecuff, glucometer, peakflow/respiration meter,weight scale

HoneywellHomMed

1999(Honeywellacquisitionin late 2004)

Multiple diseasestates

Sentry and Genesishome units, digitalcamera, pager, video-phone

Blood pressure/pulsecuff, ECG device, glucometer, peakflow/respiration meter,PT/INR device, pulseoximeter, spirometer,thermometer, weightscale

Table 1. Representative Vendors of Home and Portable Monitors


These limitations spell missed opportunities forthe telehealth programs of which they are part.The task of engaging the patient more actively—if it is performed at all—falls upon a nurse ordoctor working in a conventional non-electronicencounter. Although personal attention fromproviders is essential, better devices would rein-force the lessons of the professionals and providesome of their own.

In this respect, the Health Buddy products mar-keted by the Health Hero Network take a stepforward. Thanks to well-developed content andsophisticated branching logic, the Health Buddyis clinically smart. It offers voice and textreminders (“Hello. It’s time to take your bloodpressure.”) and asks questions (“Are you moreshort of breath today than you were yesterday?”).But it also offers education (“Do you understandwhat to do if you have shortness of breath?”). Iteven provides triage assistance (“Increased short-ness of breath can be a sign of worsening heart

failure, or other medical problems. Please call[provider’s name and contact information] toreport your symptoms.”).19

Features like these nudge users beyond a struc-tured role and in the general direction of col-laboration. When a patient pushes a button toanswer a question or enter information, theappliance follows up with another question,which impels the patient to generate anotherresponse, and so on. Because the Health Buddyholds up its end of the conversation with sub-stantive content, the patient can associate partic-ular vital sign measurements with recent dietarychoices, medication consumption, and exercise inan exchange similar to one that he or she mighthave with a clinician.

That’s not to say that the Health Buddy is fullyevolved. The high cost of any proprietary appli-ance renders it most suitable as a transitional tutoring device, not a permanent addition to the household. Only the vendor benefits if the

Company Year Founded Clinical ConditionsEmphasized

Home and Portable Devices Peripherals Accommodatedby Devices

iMetrikus 1999 Asthma, diabetes AirWatch airway function meter,MediCompass onlinehealth record and caremanagement site,MetrikLink modemdevice for downloadingglucometer readings

Glucometer, insulinpump uploads

Philips MedicalSystemsTeleMonitoringServices

2002 (Philipsacquisition)

CHF TeleStation home unit Blood pressure/pulsecuff, ECG device,weight scale

ViterionTeleHealthcare(Bayer-Panasonic)

2003 CHF, diabetes Viterion 100 andViterion 500 TeleHealthMonitor home units,digital camera, video-conferencing unit,videophone

Blood pressure/pulsecuff, ECG device, electronic stethoscope,glucometer, peakflow/respiration meter,pulse oximeter, thermometer, weight scale

Table 1. Representative Vendors of Home and Portable Monitors (cont.)


patient never graduates to tracking physiologicalactivity in a less complicated, less expensive way.A really useful product would reinforce inde-pendent behavior and help avoid long-termdependency. Providers should insist that productcontent prepare the abler patient for the daywhen he or she will strap on an ordinary bloodpressure cuff or other peripheral, record readingswithout the aid of a special storage and transmis-sion tool, and consult a doctor, a nurse, a book,or the Web on appropriate next steps. Whatevertelehealth organization is paying the bill or caringfor patients can then reclaim the device foranother user. The Visiting Nurse Association ofBoston, a Medicare-certified home health agency,is exploring ways of helping patients transitionaway from appliances and towards greater self-sufficiency.20

Philips Medical Services, meanwhile, is pilot-testing a system that would conduct homemonitoring and messaging through broadbandtelevision, a platform that could support muchmore effective teaching about self-sufficiency andother topics.21 If Philips and Comcast, its broad-band partner, can market this product, calledMotiva, at an attractive price, weaning patientsoff expensive proprietary equipment couldbecome a moot concern because the equipmentitself might become less expensive.

Self-management tools that structure patientroles are appearing in a growing number of situations. Patients with mechanical heart valvesrequire lifelong treatment with anticoagulants,usually warfarin, to ensure that blood clots donot adhere to the devices. To ensure they’re tak-ing the proper doses of the drug, users need totest their blood regularly for InternationalNormalized Ratio (INR) levels, which are indica-tors of anticoagulation characteristics. Untilrecently, patients had to travel to a clinic to havethis done. Now they can use testing kits to drawblood samples and test INR levels at home, butthey must call in results promptly to clinicians orinteractive voice response systems.22 Warfarin

dosing is time-sensitive and safety-critical, soalthough the kits provide self-managementwhere none existed before, they’re programmedto keep the patient’s role structured.

Tools for Collaborative RolesTraditional ideas of the physician-patient relation-ship involve the doctor acting as the sole source ofexpertise and decision-making authority.23 Recentalternatives to this conception go by differentnames—shared decision making,24 collaborativemanagement,25 the chronic care model,26 thepartnership model,27 patient empowerment28—but concern the same idea: Patient, physician,and family members should pool informationand make choices together, whether what’s atissue is an acute disease or long-term condition.When experts on chronic care urge clinicians toincorporate “self-management education” and“self-management support” into their repertoires, collaboration is what they have in mind.29

One conviction underlying this embrace of col-laboration is that patients have the right to takepart in crucial decisions affecting their health.30

Another is that they are capable, with the rightsupport, of making valuable contributions tothese decisions.31 A third is that assertiveness isinevitable in this day and age, and relationshipswill be less strained if doctors acknowledge asmuch. For social and generational reasons,today’s consumers—not all but many—are pre-disposed toward taking an active part in decisionsthat were once relegated to experts—personalhealth included.32 According to a poll commis-sioned by the Pew Internet and American LifeProject, 93 million American adults so far havegone onto the Web for health or medical pur-poses.33 These 93 million people constitute 46percent of all adults in the country, an amazingfigure.

Given the realities of such patient preparednessin the Information Age, the question for manyclinicians is not whether to share information


and decision making but how. In the case of conditions that are serious, chronic, or both,technologies stand ready to help. Tools that support collaborative role playing fall into foursubcategories: decision support aids, online inter-ventions, chronic disease management aids, andonline health education materials.

n Decision support aids are interactive tutorialsand assessments focused, as the termimplies, on discrete decisions and majorturning points in care. They are “designedto help people make specific and delibera-tive choices among options by providing, atthe minimum, information on the optionsand outcomes relevant to the person’s healthstatus.”34 The better aids link to clinical trialfindings and other professional discussionsand involve users in decision-tree analysisand relative risk calculations.

A recent evaluation of decision aids by theCochrane Collaboration reflects the inroadsmade by the Internet. Of 131 products thatappear to be complete and up-to-date, 14are paper-based, 20 are video-based, two are on CD-ROM—and the other 95 areposted on the Web.35 A meta-analysis byCochrane of randomized clinical trialsinvolving the aids called for stepped-upresearch but found generally positive results.The aids “had positive effects on the deci-sion-making process... enhanced participa-tion in decision making, lowered decisionalconflict... and improved agreement betweenvalues and choice.”36

n Online interventions focus on long-termbehavior change. They provide ongoingassistance and encouragement for dealingwith problems ranging from depression to headaches to eating disorders toHIV/AIDS.37

Like decision support aids, online interven-tions are patient-focused even though theirinitial adoption often depends on profes-

sional initiative and their design facilitatescollaborative problem solving. With theircontent depth and ease of presentation,they’re intended for repeated use by thesame patient. A meta-analysis of 22 studiesfound that these interventions producedgenerally positive outcomes, such asincreased exercise time, enhanced knowledgeof nutritional status, increased knowledge of asthma treatment options, increased participation in care, slower physicaldecline, improved body shape perceptions,and 18-month weight-loss maintenance.38

n Chronic disease management aids helppatients shoulder the responsibility of livingwith long-term conditions. As these indi-viduals negotiate the terrain of chronic disease with the episodic help of clinicians,a myriad of self-management tools areavailable to help.

For example, since 1993, with the publica-tion of results from a large clinical trial, self-monitoring of blood glucose has been a recommended step in diabetes control.39

Today, diabetics can get the job done withthe help of 25 or so commercially availableblood glucose meters, which, with everynew model, incorporate more computation-al power and become more useful. LifeScan,one leading vendor, markets what it calls an“ultra-smart” device that has the look andfeel of a PDA. In addition to drawingblood, the unit stores readings and chartsthe results. Users can also upload datadirectly into their PCs and, with the help of11 pre-formatted charts and graphs, analyzeit in detail.40

Thanks to higher survival rates and length-ening life expectancies, many types of cancerhave become chronic diseases, as well. Thenonprofit Association of Cancer OnlineResources (ACOR) maintains about 140publicly accessible email lists dealing with


various forms of the disease. Participantsprovide emotional support and answer eachother’s questions about treatment, sideeffects, and hospital care. Volunteer “own-ers”—patients with special expertise—comb postings to ferret out bad informa-tion and unwelcome marketers.41 ACORreports delivering more than 1 million cancer-related email messages every week.42

n Online health education materials are“broader in perspective, helping people tounderstand their diagnosis, treatment, andmanagement in general terms.”43 They areless rigorous than decision support aids andWeb-based interventions and less function-ally oriented than chronic disease manage-ment aids. They contain the general infor-mation for which the Web is famous andoccasionally infamous.

Regardless of one’s assessment of Web-based health information, it’s safe to saythat improvements to online health educa-tion materials are on the way. Nonprofitorganizations like Consumers Union, publisher of Consumer Reports, and theAmerican Association of Retired Persons(AARP) are stepping up their production ofcontent about health care. And the federalAgency for Healthcare Research and Quality(AHRQ) recently announced a plan todevelop state-of-the-art discussions of theeffectiveness of treatments for 10 top con-ditions affecting Medicare members. Theinformation, in different versions for con-sumers and health professionals, is slatedto become part of the U.S. government’sNational Guidelines Clearinghouse.44

There appears to be little, if any, data on thedegree to which doctors actually create collabora-tive relationships with their patients, much lessuse Web-based tools to support the process. Onthe other hand, consumer surveys provide occa-sional insight into situations that patients view as

collaborative. For advocates of collaboration,these numbers, while sparse, are encouraging.According to Pew, 48 percent of patients whotalked to a doctor about something they foundonline recalled that the doctor was “somewhatinterested,” and 31 percent said he was “veryinterested.”45 Another survey, this time by theNational Cancer Institute and involving peoplenewly diagnosed with cancer, found that thosewho went online to educate themselves about ahealth issue were more likely to describe theirrelationships with doctors as a “partnership” thanwere those who did not go online (74 percent vs.54 percent). Ninety-one percent of the newlydiagnosed who went online thought that theinformation they retrieved helped them talk totheir doctors.46

Tools for Autonomous RolesVarious reasons impel people to tackle a condi-tion alone, or largely so, without consulting professionals. At some point, even with someonewho has collaborated previously with clinicians,the steepest part of the educational slope willhave been scaled, the need for support will persistbut at less intensity, and the patient, perhapsaided by a family caregiver, will begin to managelargely on his own. As a matter of medicine, economics, and personal psychology, such atransition to autonomy will often be considered a good outcome.

In other cases, cost considerations motivatepatients to pursue independent courses. Not onlydo people with health insurance confront risingcopayments and deductibles; oftentimes, cover-age for mental health and other problems is subject to ceilings, while issues such as weightmanagement and wellness get no coverage at all.Then, too, those with insurance can lose it, andothers won’t have it to begin with. Take somecombination of these factors and mix in theindependent instincts of American consumers,and a lot of autonomous activity is going tomanifest itself.


Technology vendors cater to the autonomous.The most-heavily trafficked Web site in thehealth and fitness category is eDiets, a for-profitenterprise whose 200,000 dues-paying membersselect meal and fitness plans and interact withonline support groups.47 Recently, in response tomounting public interest in weight as a healthissue, eDiets shifted emphasis “from vanity tovitality.” Its new online magazine rearranges theorder of articles according to the preferences indi-cated by individual readers. A subscriber with an interest in “Living with Diabetes” or “HealthyHeart” sees a relevant topic on the cover, fol-lowed by related content inside.

One thing eDiets does not do is assume thatmembers also consult health care providers, whocan seldom bill insurers for weight counseling.An eDiets representative says there’s no specificdata but guesses that “90 percent of our membersare self-motivated,” meaning, she says, that “theytake part without checking with their doctors orbeing under a doctor’s care.”48 Her estimate addsanecdotal support to the more scientific findingsof a 1997 household survey, which found that61.5 percent of alternative and complementarytherapies (including diets) were used withouttheir being discussed with a medical doctor.49

Off the Internet, assistive technology helps peo-ple with disabilities perform day-to-day activities and remain independent. Some assistive tools—walkers, tub seats, grab bars, and the like—arelow-tech. Others are quite the opposite. At the 2004 International Conference of theRehabilitation Engineering & AssistiveTechnology Society of North America (RESNA),attention focused on mobile wireless technolo-gies and their potential to serve as “universalremotes” for accessing and controlling otherdevices. Other priorities included sophisticatednavigational and wayfinding tools for peoplewith visual impairments.

The market in wheelchairs offers other examplesof assistive technology and self-management toolsin the service of autonomy. Some new modelsrequire the user to employ some manual effort,which is important for fitness, but also drawupon battery power and motors plus sensors andmicroprocessors. On steep or difficult surfaces,the sensors and processors calculate the differencebetween the effort the user applies to the handrim and the total force needed to propel thewheelchair forward. Then the motor weighs inwith just the necessary power to get the wheelsgoing.50

Independence Technology, a division of Johnson& Johnson, markets the most recent innovation,the IBOT, a wheelchair originated by DeanKamen, who also invented the Segway personaltransporter. Like the Segway, the IBOT incorpo-rates gyroscopes into the process of locomotionin order to maintain balance while traversinggrass, gravel, mud, and curbs. Users can also ele-vate themselves until they’re eye-to-eye with thosewith whom they’re talking. They can climb anddescend stairs without help.51

Another product, the home heart defibriliator,serves the autonomy of informal caregivers ratherthan patients. It is for use in the event of suddencardiac arrest, which occurs more often in thehome than in other places and requires a quickresponse beyond the capacity of most emergencyteams. In a somewhat controversial action, theFDA has deemed the defibrillator, made byPhilips Medical Systems, safe and effectiveenough to be sold without a doctor’s prescrip-tion. Novice users learn to apply the electronicpaddles to a victim’s chest by reading the manu-facturer’s written instructions and consulting atutorial conducted by a machine-generatedvoice.52


Clinical investigators do not spend a great deal oftime studying autonomous behavior and its asso-ciated tools, which represent a world apart fromdoctors and nurses. Good data is rare, especiallyon clinical outcomes—a situation that invitesremedial action by professionals. When severalinvestigators set out recently to do a meta-analy-sis of research involving online communities andelectronic support groups, they had to settle forstudies of multiple interventions in which theeffects they sought could not be isolated; theycould not find a single randomized trial evaluat-ing Internet communities alone.53

Lack of professional interest aside, the incidenceof autonomous behavior on the Internet alone isstaggering. As of April 2004 there were almost25,000 electronic communities listed in thehealth and wellness section of Yahoo! Groups.54

The Pew Internet Project reports that about 28million adult Americans—about 14 percent ofall the grown-ups in the country—have goneonline to take part in a “support group for amedical condition or personal problem.”55

Undoubtedly, people do some of this in coopera-tion with their doctors, as instances of collabora-tive role playing. But it’s likely that much, andprobably most, of the activity is autonomous.

Reasons for the upward march in adoption are as various as people’s personal circumstances.“Online groups,” noted researchers in a study ofself-help communities for depression, “make itpossible for anyone with a computer to overcomemany of the logistical barriers to mutual-helpparticipation, such as geographical isolation, lackof transportation, lack of groups for rare condi-tions ... [and] physical disabilities that makeattendance difficult.”56

Add to the multitude of Internet users the num-bers of people employing assistive technologiesand the numbers purchasing products, such as the home defibrillator, that promote activeself-sufficiency, and the market for autonomousself-management tools is substantial.


ROBUST MARKET GROWTH IS LIKELY FOR TOOLSenabling all four self-management roles: subordinate, struc-tured, collaborative, and autonomous. Tools supporting subordinate roles offer added convenience, greater precision,fewer errors, and less stress. Tools for structured roles encour-age adoption by clinicians and serve sensitive situations.Collaborative tools suit better-educated and more confidentpatients, as well as the aspirations of some doctors. Tools supporting autonomous roles accommodate a host of personalpreferences and circumstances.

Disease-management experts have done a good job examiningcollaborative patient behavior. But less attention has been paidto the other roles that patients play and to the tools theyemploy; on these fronts, commercial innovation may be out-pacing professional know-how. Yet it’s the matching of threefactors—patient role, technology, and professional response—that makes for high-quality medicine. Self-management mar-kets will keeping growing, as will the need for clinicians to playa contributing role in identifying, developing, and applyingeffective techniques.

IV. Conclusion


Dan Barton, director of marketing, Telemonitoring Services, Philips Medical Systems

Jeffrey Blander, instructor, Harvard Medical School and Massachusetts Institute of Technology

Cynthia Cardoza, R.N., CEO, Visiting Nurse Association of Southeastern Massachusetts

Adam Darkins, M.D., chief consultant, VHA Telemedicine, Veterans Health Administration

William Dromgoole, R.N., Visiting Nurse Association of Boston

Karen Hockhousen, R.N., VNS Home Health Services of Narragansett, Rhode Island

James Jirjis, M.D., assistant professor of medicine, Vanderbilt University Medical Center

Richard Jones, chairman, Lusora, Inc.

Merilee Kern, eDiets

Matthew Kim, M.D., assistant professor of medicine, Johns Hopkins

David Klonoff, M.D., associate clinical professor, University of California, San Francisco

Rita Kobb, R.N., director, Sunshine Training Center, Veterans Health Administration

Joseph Kvedar, M.D., director, Partners Telemedicine, and assistant professor, Harvard Medical School

Fran Lorion, chief information officer, Visiting Nurse Association of Boston

Julie Lowery, Ph.D., VA Ann Arbor Healthcare System

Barbara McKinnon, consultant, Point-of-Care Partners

Sandy McNeely, R.N., Visiting Nurse Association of Houston

Kate O’Neil, R.N., vice president of operations, Visiting Nurse Association of Boston

John Piette, M.D., associate professor, University of Michigan Medical School, and research scientist,VA Ann Arbor Healthcare System

Adele Pike, R.N., consultant, Visiting Nurse Association of Boston

Patricia Ryan, R.N., acting director, VISN 8 Community Care Coordination Service, Veterans Health Administration

Corinne Smith, R.N., Veterans Health Administration

Donna Vogel, R.N., director, Care Management, VISN 1, Veterans Health Administration

Appendix: Contributors


1. Bodenheimer, et al. 2002. “Patient Self-Management ofChronic Disease in Primary Care.” Journal of theAmerican Medical Association 288 (19); 2470.

2. Disease Management Association of America, Definitionof Disease Management (http://www.dmaa.org/definition.html), accessed March 8, 2005.

3. Bodenheimer, et al. 2002. “Patient Self-Management ofChronic Disease in Primary Care.” Journal of theAmerican Medical Association 288 (19); 2470.

4. 2005 Annual Report of the Boards of Trustees of theFederal Hospital Insurance and Federal SupplementaryMedical Insurance Trust Funds, p. 2 and 13.

5. Porretto, John. 2004. “GM Chief: Health Care NeedsBipartisan Approach,” Associated Press, August 31; GeneralMotors Corporation 2003 Annual Report.

6. Reuters. 2004. “Ford Urges ‘National Solution’ to U.S.Health Care.” April 7; Ford Motor Co. 2003 AnnualReport.

7. U.S. Department of Health and Human Services, Officeof the National Coordinator for Health InformationTechnology (ONCHIT), “Goals of StrategicFramework,” December 10, 2004(http://www.hhs.gov/healthit/goals.html).

8. Ibid.

9. See, for example, Newhouse, Joseph P. 2004. “Consumer-Directed Health Plans and The RAND InsuranceExperiment.” Health Affairs 23 (6) November/December;Tu, Ha T., and Hargraves, J. Lee. 2004. “High Cost ofConventional Medical Care Prompts Consumers To SeekAlternatives,” Center for Studying Health SystemChange, Data Bulletin No. 28, December.

10. Note the interactive comparison tools provided onmedicare.gov, which bills itself as “the official U.S. government site for people with Medicare,” (www.hospitalcompare.hhs.gov) and on Consumer Reports Best Buy Drugs, a new Web site,(www.crbestbuydrugs.org), aimed at translating complexevidence-based medical information into terms under-standable to consumers.

11. Darkins, Adam William, and Cary, Margaret Ann. 2000.Telemedicine and Telehealth: Principles, Policies,Performance, and Pitfalls. Springer Publishing Company.p. 31.

12. http://www.consumersearch.com/www/health_and_fitness/heart_rate_monitors/fullstory.html. See alsoLong, Don. 2004. “Hybrid Devices, Hookup to EMRGive Focus to Health IT Rollouts.” Medical Device DailyFebruary 26.

13. Author’s interview with company founder; Lusora. 2005.“Lusora Launches at DEMO@15! with Wireless PersonalSecurity System that Enables Seniors to Stay LivingSafely in their Homes,” company press release, February14; Swisher, Kara. 2005. “Home Economics: Tech ShowHighlights Home-Monitoring Systems.” Wall StreetJournal February 17; Bulkeley, William M. 2005.“Wireless’s New Hookup,” Wall Street Journal February 24.

14. Center for Aging Services Technologies, TechnologyDemo on Capitol Hill program, March 16, 2004; Center for Future Health, University of Rochester, Aging Well: Motion/ Activity Monitoring(http://www.futurehealth.rochester.edu/research/aging.html).

15. Author’s interview with David C. Klonoff, M.D., clinical professor of medicine, University of California,San Francisco.

16. Malone, Michael S. 2002. “Welcome to FeedbackUniverse.” Forbes ASAP October 7.

17. Freedonia Group. “Patient Monitoring Devices: U.S. Forecasts to 2008 and 2013.” (http://www.freedoniagroup.com/).

18. The importance of reinforcing higher-order patient skills in planning and problem solving is argued inBodenheimer, et al. 2002. “Patient Self-Management ofChronic Disease in Primary Care.” Journal of theAmerican Medical Association 288 (19) November 20. p. 2471.

19. Marketing materials for McKesson TeleHealth Advisor, a rebranded version of the Health Buddy system.

20.Visiting Nurse Association of Boston. Author’s inter-views.

21. Author’s interview with Dan Barton, director of market-ing, Telemonitoring Services, Philips Medical Systems.

22.Jacobson, Alan K., M.D., director of anticoagulationservices, Loma Linda (California) VA Medical Center,“Point-of-Care INR Patient Self Testing,” ClinicalApplications & Beyond seminar, Beaver Creek, Colorado,July 29–August 1, 2004, accessed athttp://www.sjm.com.

23. Charles, et al. 1997. “Shared Decision-Making in theMedical Encounter: What Does It Mean? (Or It TakesAt Least Two To Tango),” Social Science & Medicine 44(5); 681–92.

24. Ibid.

Endnotes

http://www.dmaa.org/definition.html

http://www.hhs.gov/healthit/goals.html

http://www.crbestbuydrugs.org

http://www.futurehealth.rochester.edu/research/aging.html

http://www.freedoniagroup.com/

http://www.sjm.com


25. Von Korff, et al. 1997. “Collaborative Management ofChronic Illness.” Annals of Internal Medicine Vol. 127;1097–1102; Bodenheimer, et al. 2002. “Patient Self-Management of Chronic Disease in Primary Care.”Journal of the American Medical Association 288 (19);November 20.

26.Wagner, et al. 2001. “Improving Chronic Illness Care:Translating Evidence into Action,” Health Affairs 20 (6);November/ December.

27. Holman, H., Lorig, K. 2000. “Patients As Partners inManaging Chronic Disease.” British Medical Journal,Vol. 320; 526–527.

28. Funnell, et al. 1991. “Empowerment: An Idea WhoseTime Has Come in Diabetes Education.” The DiabetesEducator Vol. 21; 37–41.

29. Wagner, et al. 2001. “Improving Chronic Illness Care:Translating Evidence into Action,” Health Affairs 20 (6)November/ December; Bodenheimer, et al. 2002.“Patient Self-Management of Chronic Disease inPrimary Care.” Journal of the American MedicalAssociation 288 (19) November 20. p. 2470

30.Charles, et al, op. cit.

31. Wagner, et al, op cit.

32.Charles, et al, op cit.

33. Rainie, Lee, and Horrigan, John. 2005. “A Decade ofAdoption: How the Internet Has Woven Itself intoAmerican Life,” also titled “Internet: The Mainstreamingof American Life,” Part 4 of “Trends 2005.” PewResearch Center January 25.

34.O’Connor, et al. 1999. “Decision Aids for PatientsConsidering Options Affecting Cancer Outcomes:Evidence of Efficacy and Policy Implications.” JNCIMonographs No. 25, p. 67.

35. Ibid. p. 17.

36.Ibid, p. 29.

37. Wantland, et al. 2004. “The Effectiveness of Web-Basedvs. Non-Web-Based Interventions: A Meta-Analysis ofBehavioral Change Outcomes.” Journal of MedicalInternet Research October 11.

38. Ibid.

39. U.S. Food and Drug Administration, “Blood Glucose &Diabetes Management” (http://www.fda.gov/diabetes/glucose.html).

40.“On-Line Diabetes Resources,”http://www.mendosa.com/meters.htm; http://www.lifescan.com.

41. Landro, Laura. 2003. “Special Report: Personal Health,Finding What You Need in the Flood of CancerResources.” Wall Street Journal February 11.

42.“What is ACOR?” (http://www.acor.org/about/about.html).

43. O’Connor, et al. 2004. “Decision Aids for People FacingHealth Treatment or Screening Decisions.” The CochraneDatabase of Systematic Reviews Vol. 4.

44.Agency for Healthcare Research and Quality. 2004. “List of Priority Conditions for Research under MedicareModernization Act Released.” Agency press release.December 15; Landro, Laura. 2005. “The InformedPatient: Are Treatment Guidelines Reliable?” Wall StreetJournal January 28.

45. Fox and Rainie, op. cit.

46.Fleisher, et al. 2002. “Relationships among InternetHealth Information Use, Patient Behavior and Self-Efficacy in Newly Diagnosed Cancer Patients WhoContact the National Cancer Institute’s (NCI) AtlanticRegion Cancer Information Service (CIS).” Proceedingsof the AMIA Fall 2002 Annual Symposium, p. 260.

47. eDiets. 2004. “eDiets.com Reports Q3 Results.”Company press release, October 28.

48. Author’s interview with Merilee Kern, Feb. 1, 2005.

49. Eisenberg, et al. 1998. “Trends in Alternative MedicineUse in the United States, 1990–1997,” Journal of theAmerican Medical Association 280 (18) November 11. p. 1573

50.Webster, Joseph B., M.D., “Advances in Technology andAssistive Devices for Seniors,” (http://www.aapmr.org/zdocs/assembly/04handouts/C147.pdf).

51. http://www.independencenow.com/ibot/index.html.

52.Smith, Stephen. 2004. “FDA Approves Sales of HomeDefibrillators.” Boston Globe, September 17.

53. Eysenbach, et al. 2004. “Health Related VirtualCommunities and Electronic Support Groups:Systematic Review of the Effects of Online Peer to PeerInteractions.” British Medical Journal, Vol. 328, May 15.This meta-analysis showed no negative effects attributa-ble to online groups but found few positive results forthe complex interventions overall.

54. Ibid.

55. Rainie, Lee, and Horrigan, John. 2005. “A Decade ofAdoption: How the Internet Has Woven Itself intoAmerican Life,” also titled “Internet: The Mainstreamingof American Life,” Part 4 of “Trends 2005” Pew ResearchCenter January 25, p. 64.

56.Salem, D., and Bogat, G. Anne. 2000. “Characteristicsof an On-Line Mutual-Help Group for Depression.”International Journal of Self Help and Self Care 1 (3).

http://www.fda.gov/diabetes/glucose.html

http://www.mendosa.com/meters.htm

http://www.lifescan.com

http://www.acor.org/about/about.html

http://www.aapmr.org/zdocs/assembly/04handouts/C147.pdf

http://www.independencenow.com/ibot/index.html

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