Breaking Boundaries with Web-based Disease Management

Several studies (not to mention common sense) have shown that better communication and coordination of care should reduce preventable adverse outcomes in patients with chronic disease. This approach to disease management has been greatly facilitated by Web-based monitoring and reporting tools, smartphones, and other technologies. The question confronting physicians, patients, and payers as we move ahead is: does any of this work?

“Monitoring of live-feed data from the homes of the elderly or infirm will tell clinicians and family members about medication taking, ambulation, consumption, and other aspects of autonomous daily living. Implantable devices with wireless feeds will report patients’ physiological status to physicians and monitoring centers and will report functional anomalies to the manufacturer and relevant federal agencies. And that is not to mention inputs about weight and reaction times from automobiles, ambient environmental sampling data linked to one’s location by wearable global positioning system (GPS) devices, exercise data from implantable stress monitors, and sensors at one’s desk for other kinds of stress. In short, the future of interoperability is to bind together a wide network of real-time, life-critical data that not only transform health care but become health care.” — David J. Brailer, MD, PhD, Former National Health Information Technology Coordinator (http://hcp.lv/c79e9N).

Just five years after Brailer’s Orwellian forecast, most of these predictions are already reality, spawned by our need to control an epidemic of chronic disease.

Chronic illness accounts for most of the disease burden in the United States. The cost, in lives and dollars, is staggering. Almost one out of every two adults has at least one chronic illness, and 70% of deaths are attributable to chronic disease (http://hcp.lv/bbCjIs). Chronic diseases consume 70% of healthcare expenditures, with a current estimated financial cost of $2 trillion per year and a projected cost of over $4 trillion by 2023 as the population continues to age (http://hcp.lv/cLyYLF). Most chronic diseases cannot be cured and, given our refractory lifestyle choices, are unlikely to be prevented. Can they at least be better managed?

Disease management

Disease management (DM) evolved from the rational notion that better communication and coordination of care should reduce preventable adverse outcomes in patients with chronic disease. The concept was enthusiastically embraced, perhaps prematurely, by insurers and large employers eager to find ways to reign in health care costs and improve the health of their beneficiaries.

Early models of DM involved the development of call centers staffed with nurses who routinely contacted at-risk patients to provide follow-up and advice. Interventions were targeted toward those with the most common chronic diseases: asthma, congestive heart failure, depression, diabetes, and hypertension. Poorly controlled diabetics might, for example, be asked to communicate daily blood sugars and symptoms to nurses trained to adjust insulin dosages, with the hope that the need for hospital admissions might be preempted. Such programs were liked by patients and were generally accepted as being of value, although this latter conclusion may have been supported more on the basis of commonsense assumptions rather than rigorous financial analysis. Nonetheless, DM has grown into what is currently a $2.5 billion-per-year industry (http://hcp.lv/bXwrNT).

As interventions expanded beyond the call center, a wider concept of what constitutes DM evolved. DM is now broadly defined as “a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant” (http://hcp.lv/aV51Xm).

Not surprisingly, technology is extending the reach and scope of DM. Advances in monitoring devices allow for less obtrusive, real-time patient monitoring, while the Internet is replacing the telephone as a means of educating patients and allowing them to communicate with their providers. Adoption has been further accelerated by the availability of devices that work faster, cost less, and are easier to use, coupled with greater access to broadband and wireless pipelines by more segments of the population.

Web-enabled disease management: no longer science fiction

Effective DM depends on frequent, regular monitoring of patients. Devices now exist that can unobtrusively monitor a wide variety of physiologic data with little or no effort on the part of patients. For example, a band-aid like device is currently available that can monitor respirations, oximetry, patient movement, temperature, and electrocardiogram—and display that information on an individual’s cell phone or transmit it via the Internet (http://hcp.lv/atzQg0). A sensor wire (the diameter of two human hairs) can be inserted under the skin by a diabetic patient to allow continuous wireless monitoring of blood sugars (http://hcp.lv/9CB4vM). A “smart-pill” system allows physicians to monitor medication adherence by attaching tiny microchips to patients’ pills; as each pill passes the stomach, the patient’s prescriber is notified by the patient’s smartphone via the Internet (http://hcp.lv/aXDu02). For $3,500, one can even purchase an “Intelligence Toilet” system, capable of measuring sugar levels in urine, blood pressure, body fat, and weight (http://hcp.lv/atsMO0). The toilet automatically transfers its data to a home network for analysis on a personal computer. Each of these devices is already commercially available. Other wearable innovations, such as a “smart tee shirt” used by the military to monitor vital signs and remotely detect gunshot wounds, will undoubtedly soon find their way into the DM armamentarium (http://hcp.lv/cww9bz).

The biggest current obstacle to smarter DM is not sensor technology, however. According to Steven

Eisenberg, MD, senior vice president and chief science officer at LifeMasters Supported SelfCare Inc, “Physicians are never going to have the time to spend going through volumes and volumes of data, so it is going to be up to the computers themselves to integrate, correlate, and analyze” (http://hcp.lv/dgCZpp). Currently, device technology leads development of those systems, but the latter will undoubtedly catch up.

Ultimately, however, it is the non-technological factors that will likely determine the face of DM in the 21st century. Continuous transmission of intimate physiologic details over wireless networks and the Internet demands rigorous security and personal privacy protections. Indeed, such technologies may well challenge society to re-examine the definition of “personal space” (http://hcp.lv/bXwrNT). Furthermore, DM must prove itself cost-effective in an era of dwindling economic resources and competing societal priorities.

Critics and skeptics are quick to point out that DM has not yet convincingly been demonstrated to be an effective strategy. A 2009 Rand report concluded that DM could increase employer and government spending in Massachusetts by $6.7 billion over 10 years with little overall benefit (http://hcp.lv/aDKIfq). This followed a 2008 analysis of a Medicare pilot project of 200,000 patients, which concluded that DM did not reduce hospitalizations, emergency room visits, or deaths from chronic disease. Proponents of DM argue that the study included patients who were not representative of those most likely to benefit and that Medicare did not extend the study long enough to see benefits. They cite contrasting studies, such as one study of elderly veterans that found a combination of home telemonitoring, video visits, and coordinated care resulted in a 40% reduction in emergency room visits, a 63% reduction in hospital admissions, a 60% reduction in hospital bed days of care, and similar reductions in nursing home care (http://hcp.lv/bq3cuh).

Both sides of the debate note that studies of DM to date have been of variable quality, often involved small numbers of patients, and may have used flawed assumptions in their cost-effectiveness analyses. A study published last month in the New England Journal of Medicine (http://hcp.lv/dBirb1) addressed these methodological concerns (also, see the accompanying editorial at http://hcp.lv/b9YRdu). This randomized controlled trial followed 1,653 patients recruited from 33 cardiology practices across the US who were recently discharged following hospitalization for heart failure.

The study demonstrated that telemonitoring did not reduce readmission rates or death over the six month follow-up period. Not surprisingly, the researchers found that by the final week of the study period, only 55% of patients were still using the system at least three times per week; 14% of patients in the telemonitoring group never used the system. (These latter observations are probably not unexpected by physicians; technological solutions alone are unlikely to ever overcome the intrinsic difficulties of motivating and changing human behavior.)

The authors concluded that their results “underscore the need for rigorous, independent evaluation of disease-management systems before their adoption. In an environment in which vendors promote their products to health systems that are under increasing pressure to reduce readmission rates, the knowledge that telemonitoring is ineffective suggests the need to consider alternative approaches to improving care” (http://hcp.lv/dBirb1). Studies of DM in other conditions should be forthcoming (http://hcp.lv/dBirb1).

In the meantime, action-oriented business leaders are already convinced; DM programs are currently offered by three-quarters of large companies and most Medicaid programs (http://hcp.lv/aDKIfq). Given this level of commitment by business and government, the future of DM would seem secure over the near term. The shape it will take, however, is less certain.

Moving forward

Currently, most formal DM is administered by disease management organizations contracted to insurers and employers. But this model has been criticized as being too remote from patients, both physically and personally. In an article in Business Week (http://hcp.lv/aDKIfq), General Electric’s Chief Medical Officer, Robert S. Galvin, MD, expressed skepticism that chronically ill employees would change unhealthy behavior at the direction of unfamiliar nurses calling from remote offices. This seems a salient point; behavior change is the ultimate determinate of effective self care, and most chronic diseases are, at least in part, the result of unhealthy habits. Galvin, a former primary care physician, stated it this way: “If you are going to influence someone, you need a social relationship with them.” He and others thus favor a different model of incentivizing patients’ own physicians to provide DM services from their offices.

Physician-directed DM is a central premise of the “patient-centered medical home,” a concept endorsed in a joint position statement by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association (http://hcp.lv/cPDxUy). In this model, it is the primary care physician who directs, provides, and coordinates DM within the context of an ongoing patient—physician relationship. Primary care physicians would, of course, expect reimbursement for providing these services, including the time spent reviewing and responding to remotely acquired patient data. There is uniform agreement that without major reimbursement reform, the patient-centered medical home and a shift toward physician-directed DM is unlikely to succeed.

Although the eventual form and ultimate impact of DM over the next decade remains speculative, the epidemic of chronic illness ensures that DM will play an increasing role in healthcare policy and delivery. Evolving technology will undoubtedly overcome remaining barriers, providing us with the capability to broadly scrutinize measures of health, disease, and behavior. These capabilities will continue to challenge our concepts of privacy and prompt us to re-examine fundamental assumptions, such as “What constitutes reasonable care?” “How should we prioritize healthcare funding?” and “What is the ideal patient—physician relationship?” In the end, however, we are still faced with the most daunting obstacle to chronic disease management: human behavior. Technology alone is unlikely to overcome this final fundamental barrier to better health.

Dr. Nace is an MDNG editorial board member and program director, Internal Medicine Residency and associate professor of Clinical Medicine, Department of Medicine, University of Illinois College of Medicine, Peoria, IL.