Patient-Centered Online Disease Management Using a Personal Health Record System

Engaging patients directly in their care is seen to be a critical aspect of successful chronic disease management. Traditional chronic disease management programs have relied primarily on in-person visits and phone contact with providers. Health information technologies (ITs), however, have the potential to significantly increase the engagement of patients by using personal health records (PHRs) to electronically connect them to their clinical data, care team, and educational materials.

This project evaluated a multidisciplinary team approach to diabetes care that was combined with technology tools, called the Personal Health Care Project (PHCP). PHCP was developed as a patient-centered care model and incorporated many strategies known to be effective in consumer use of health IT including responding to the needs and preferences of patients; providing continuous, convenient, online access to health records; and facilitating frequent communication with clinicians. The model includes an online disease management (ODM) system that supports the team, which includes a nurse care manager (NCM), a clinical pharmacist, a registered dietitian (RD), and the patient’s physician(s). The ODM is integrated with an electronic health record (EHR) and PHR.

The main objectives of this project were to:

• Refine the Personalized Health Care Program platform with a particular focus on enhancing the customization capability of the ODM system and ensuring a seamless incorporation of ODM into the workflow of clinicians on the care management team and with the self-management process of patients. 
• Evaluate the ODM program for diabetes relative to usual medical care, in a two-arm randomized controlled trial (RCT).
• Disseminate results of the RCT in the scientific literature, and deploy the PHCP program in Palo Alto Medical Foundation and other ambulatory care settings for use with diabetes and other chronic conditions.

The team evaluated the model with a RCT of patients with uncontrolled type 2 diabetes using the ODM program compared to usual care. The intervention consisted of wirelessly uploading the patient’s glucometer data to the EHR; creating a patient-specific Diabetes Summary Status Report; making available nutrition and exercise logs; offering a record for insulin tracking; providing secure messaging capability with the health care team via the PHR; access to a nurse care manager and dietician for advice and medical management; and electronic patient education materials including patient-specific text and video educational materials. The primary outcome measurement of the study was hemoglobin A1c (HbA1c).

At 6- and 12-months, patients in the intervention group reduced their HbA1c by a statistically significant amount. When comparing the reductions with the usual care group, the difference was statistically significant at 6 months but not at 12 months, since the usual care group also improved in that time frame. Amongst intervention patients who reduced their HbA1c by greater than 0.5 percent, those who obtain glucose readings and regularly uploaded them were able to sustain that reduction at 12 months. The PHCP appeared to be a successful way to engage patients in the care of their diabetes and improve their outcomes.