Using Information Systems to Support Patient Engagement
Until recently, most patient-provider interactions took place during office visits and, to a lesser extent, on the telephone. However, these methods can be inefficient and inconvenient. Communication technology clearly supports patients’ becoming more informed and engaged in their own care. This section reviews the many tools that have evolved to help people with diabetes become more self-sufficient and convey information between the health care team and patient outside of in-person encounters. Privacy and security continue to be important considerations when it comes to integrating information systems into a health care practice.1
Patient portals and electronic drug refills—Some information systems have a patient portal, where a member can get information, such as laboratory test results, after-visit summaries, or notes from their visits. This access is an important step in self-management and continuous patient support.
More advanced information systems allow email communication between the health care professional and the patient, allowing two-way contact. While significant evidence for improved overall care is lacking, there is evidence that exclusive use of an electronic refill function improved statin adherence from 71% by 6% and improved LDL cholesterol levels in both the white population and all minorities.2
Transmitting self-monitored blood glucose data to the provider—Emerging data has shown electronic upload of self-monitored blood glucose (SMBG) meter data via the Internet to the provider has been effective.2
SMBG data are electronically forwarded from the glucose meter (usually via computer or Bluetooth upload) to the health care practice’s warehouse. After a clinician decision is formulated, resulting advice is sent to the patient. A meta-analysis of seven studies done when that contact was by telephone revealed a statistically significant A1C improvement of 0.4% compared to usual care in patients with type 1 diabetes.1 A separate systematic review that included phone and email or text message reports to the patient found benefits to both type 1 and type 2 patients, including some on oral medications. While reviewers found that those who sent data to the physician more frequently improved A1C to a greater extent, they found that those who sent less frequently also improved.1
Text messaging, including “push” technology—There is emerging evidence that this technique has the advantages of email, but with increased access to patients. In 2011, over 82% of American adults owned a cell phone that received text messages. A recent text messaging review reported improvement in self-management of diabetes, patient desire to continue receiving messages, and patient preference for mobile phone messaging versus email.3
Electronic surveillance and reminders—Poor adherence to diabetes, blood pressure, and lipid-lowering drugs has frequently been documented. A systematic review found that electronic monitoring identified poor adherence and that interventions that included reminders improved adherence significantly.4
Tele-ophthalmology—Selected specialties provide consultation with images and patient history, returning a consult in 24 to 48 hours. For example, tele-ophthalmology can be used to install the retinal eye exam in the primarily care setting by sending a retinal camera photo taken in primary care to an eye specialist for reading at a distant site.4
Replacement of visits by video conferencing—Tele-medicine consultations are currently reimbursed at the same rate as a face-to-face visit in most states and provide access to expert opinions and management advice for primary care providers and patients. They are also useful for homebound patients and those who cannot travel to the medical center. For example, the health care professional in the office can interact with a team member in the home and give advice to those who perform wound care and/or support home care providers. While data are still sparse, a Cochrane review of all tele-medicine combined found a 0.31% drop in A1C, 12 mg/dL decrease in LDL cholesterol, and over 4 mm Hg decrease in systolic blood pressure all significant.5 A subset of eight videoconferencing randomized controlled trials was also beneficial.
Email—While a recent review concluded there was insufficient evidence to prove value for email communication between health care professionals and patients, it cites email’s advantages of timeliness, convenience, and low-cost delivery of information.3
Automated telephone calls—A meta-analysis showed marginal benefit for calls to improve overall A1C control. However, a subset using treatment intensification during the call was beneficial.5
Computer-generated messaging—With increasing communication and analytics, support for the patient can come as computer-generated messages. These can be to provide a decision-supported “next step” if needed or a supportive message if there is improved performance toward personal goals. While no review on computer-generated messaging for diabetes was found, a meta-analysis, which included smoking cessation and lifestyle change, found “dynamic tailoring using iterative assessment and computer-based communication channels was effective for delivering intervention content.”6
Sensor augmented insulin pumps—Sensor augmented pumps combine information from real-time continuous glucose monitoring with an insulin pump and have shown promising results in special situations.7
Wearable sensors—Wearable sensors can also provide metrics. The use of these devices is just now being defined related to medical care. One of the simplest applications is a mobile app that acts as a pedometer/accelerometer, measuring steps and daily activity.6
Remote blood pressure monitoring—Remote blood pressure monitoring has shown favorable results, as documented in the Million Hearts® campaign and elsewhere.8
Mobile apps—Nineteen percent of U.S. adults have downloaded and regularly use a mobile app to improve their health.7 A recent Cochrane review concluded mobile apps may be more effective than interventions delivered over the Internet.9 One meta-analysis concluded that A1C declined 0.5% with use of mobile apps in people with type 2 diabetes and 0.8% in people with type 1 diabetes.8
Expanded educational tools—The National Diabetes Education Program (NDEP) has patient materials reviewed for content and effectiveness. For people with diabetes, NDEP offers online resources and publications to learn how to manage diabetes.
Self-monitoring tools for fitness tracking—Self-monitoring tools for tracking fitness have the ability to transmit results to health care professionals, but valid outcome comparison results are few.
Social media—There is an ever-growing number of social media platforms from a variety of sources for patients with diabetes. Most are not associated with either national or local provider organizations and are usually supported by people with diabetes. Content and control varies. A recent systematic review identified social media’s benefits as increased interactions with others; more available, shared, and tailored information; increased accessibility and widening access to health information; peer, social, and emotional support; public health surveillance; and potential to influence health policy. Limitations primarily consisted of quality concerns and lack of reliability, confidentiality, and privacy.9