Winning a second chance at survival with a liver transplant a year and a half ago, John Pickering is serious about staying alive. The 57-year-old diabetic logs on to a Web site once a day and enters his blood sugar and blood pressure levels. If the nurse detects a problem, she will call Pickering directly to assess his status and immediately alert his physician, William Parker, M.D.
Welcome to the future of disease management.
Healthcare Internet sites are now going well beyond consumer education to help physicians assume a day-to-day role in managing patient care. A bevy of disease management companies are leapfrogging past the advice offered on sites like drkoop.com and Intelihealth.com to offer real-time medical services.
The disease management market is about $350 million annually, according to an estimate by the online publication Jenks Healthcare Business Report, and it could reach the $50 billion to $100 billion range within the next decade.
Although the exact number of online programs is difficult to quantify, their significance is expected to grow in coming years.
"Some sites are providing a limitless treasure trove of information about every conceivable disease and condition and syndrome for patients to access until they feel that they have found the most specific information that can help guide their decisionmaking," says James Couch, M.D., editor of The Health Care Professional's Guide To Disease Management: Patient-Centered Care for the 21st Century. "Others are actually building up a knowledge base about each individual patient based on past medical history, current diseases and conditions, and medications he or she may be on and then customizing a health status improvement plan to meet each patient's specific needs." Couch is vice president of strategic development for American Re HealthCare, based in Princeton, N.J.
Among those companies is LifeMasters Online, based in Newport Beach, Calif. Patients with chronic illnesses such as congestive heart failure, diabetes, chronic obstructive pulmonary disease, asthma and coronary artery disease regularly enter their vital signs and symptoms onto an Internet homepage. Doctors refer patients to LifeMasters, which is generally contracted by health plans. The physicians have the option of customizing the parameters of the health management program or utilizing LifeMasters' clinical standards. The information entered by patients becomes part of the LifeMasters database.
Consulting algorithms that outline a course of action for each possible medical circumstance, LifeMasters nurses are able to recognize the warning signs of a change in health status and are prompted to take appropriate action. Over time, an archive of critical data is created and graphed out in easy to read charts and tables.
Not only can the patient track his own progress and setbacks, but physicians can regularly access information about patients that traditionally has been available only sporadically at the office visit.
Depending on how sick the patient is, nurses will call daily, weekly or monthly with reminders about important aspects of self-care or upcoming medical appointments.
LifeMasters currently has an enrollment of 15,000, with about 1,500 using the Web program and the others using a voice-activated telephone response system.
Most patients welcome the opportunity to seize more direct control of their health by tracking their progress and learning about self-management.
"Definitely, many of my patients who never were involved in their illness are now intimately involved," says Parker, a family practitioner in Leominster, Mass. However, he and others suggest that frequent reminders and interventions teeter on the brink of overkill, leading some to dub the system "Life Harassers." Parker says he contacts patients once or twice a month.
Still, most patients will begrudgingly admit the service is helping them stay healthier.
Key customers for Internet disease management services are HMOs that have pioneered disease management and now stand poised on its technological edge.
Accordant Health Services, a Greensboro, N.C., provider of Web-enabled disease management programs, is negotiating four contracts to provide clinical support and self-management tools for HMO enrollees affected by such diseases as multiple sclerosis, lupus, Parkinson's disease and hemophilia.
One contract, with Partners National Health Plans of Winston-Salem, N.C., covers 500 enrollees. And Anthem Blue Cross Blue Shield of Colorado recently signed a five-year contract covering 300 enrollees.
Blue Cross Blue Shield of Michigan provides its 4.6 million enrollees with Internet-enabled technology allowing for the use of healthcare data for
customized self-management tools. The health plan contracts with Upper Saddle River, N.J.-based Franklin Health.
Worcester, Mass.-based Fallon Community Health Plan has approximately 850 diabetic patients using Internet-based disease management and is considering equipping others with personal computers in the future.
"It makes a lot of sense to take care of your sickest populations," says Patricia O'Mara, Fallon's director of disease management. "But it's important to point out that this service does not in any way replace the expertise of the physician . . . but is a way to give the patient good information about their disease. And it's a way to help physicians in their practice with reminders with a tickler file (about when to administer timely interventions)."
Similarly structured programs for patients with congestive heart failure and chronic obstructive pulmonary disease have proven effective and popular with patients, she says.
While research tracking clinical outcomes for patients "wired" to Internet monitoring is scarce, one company-sponsored study of 27 patients published in the American Heart Journal showed promising findings. Patient education materials, automated reminders for medication compliance, self monitoring of daily weight and vital signs, and facilitated telephone communication with a nurse monitor reduced hospitalization for cardiac patients to 0.8 days from 9.5 days per patient per year. Still, additional clinical study is needed.
"We are being sold the notion that LifeMasters and similar programs improve outcomes and decrease cost," says Parker. "I think the reason we (Fallon Clinic) are working with LifeMasters is to see if that is true."
While most physicians would welcome the prospect of partnering with patients in disease management, not all like the idea of handing their patients over to an invisible cyberforce with whom the physician doesn't always agree. "Some interference with the doctor-patient relationship is present," says Parker, "(with) patients being told to call their doctor immediately for something the doctor doesn't perceive as urgent."
LifeMasters CMO Jeffrey Davis, M.D., says physicians who don't respond well on satisfaction surveys of their service are typically "those who don't want anybody touching their patients, it's their patient and their territory, and the fences are up."
Still other physicians are simply too busy to think about a new method of care. But from the patient's perspective, this system improves access, Davis says.
"They are getting monitored, and patients really feel good about this. From a plan perspective, they can go out to their members and say we now have a quality initiative that gives you all the access you want."
Rick Toren, president and COO of e-MEDx , a Bethesda, Md.-based company that deploys software for care management serving more than 1.5 million patients, concurs that "e-care" can be a hard sell to Internet-shy physicians but a valuable tool for those who are won over.
"(Doctors) end up getting valuable office visits instead of wasted ones," says Toren. "What a doctor hates about his everyday practice are the mundane things that don't improve patient care or generate revenue. The whole idea is to take the mundane health stuff away from the doctor and to use the doctor for the more challenging stuff . . . the Internet gives him the ability to provide the care he was trained to do and have the computer do the more simple things."
The computer's value in sorting through simpler things, such as data collection and analysis, has been fully harnessed by Jonathan Bortz, M.D., who heads a multidisciplinary diabetes control center in St. Louis.
Bortz has developed a semi-automated glucose reading and graphic reporting system that provides patients and their physicians with information needed to improve glucose control. He is contracting with e-MEDx to combine his system with the company's self-care software, making the product available on the Internet to diabetics and their physicians worldwide.
"Patients get reports that are readable by both professionals and patients, and that makes the whole therapeutic intervention component much more understandable to patients," says Bortz. "They are able to see progress or deterioration . . . the logic behind medication changes."
Some physicians view such data management services as only scratching the surface of the possible. Princeton-based endocrinologist Ned Weiss, M.D., believes that many online data repositories function only as a substitute telephone. "Just to relay numbers, there is nothing special about the Internet," says Weiss. "The computer would be a great tool to do simulations and coach people around adjusting their insulin based on their past experience with insulin levels after eating specific foods. You have to combine counting carbs with systematic trial and error in diabetes management. The computer can be a tremendous tool for this."
Others caution that although self-care clearly can play an important part in helping patients get better, it nonetheless poses inherent risks. The accuracy with which the patient can monitor his own parameters is an open question, particularly for those who are not trained to do so by health educators.
Another concern is that e-care may sacrifice patient privacy if firewalls are inadequate for protecting the confidential information being transmitted. Watson Wyatt consultant Helen Darling expresses yet another concern that some self-care sites may be linked to direct-to-consumer pharmaceutical advertising, compromising the integrity of the service.
As physicians increasingly take advantage of Internet technologies that will soon become more sophisticated and valuable, will they eventually spend more time with monitors than patients?
"We will have to be very careful that we don't become dependent on numbers and figures we see on our e-mail and let that be the predominant determinant of how we treat our patients," cautions AMA trustee J. Edward Hill, M.D., a family physician in Tupelo, Miss. "An enormous amount of our ability to treat patients stems from the very subtle parts of face to face meetings . . . the nuances of the way people express themselves."
Yet with consumer health rapidly becoming the driving force behind Internet growth, Internet care will likely follow fast on its heels. "Over the next 10 years we are going to see the predominance of that kind of care," says Hill. "Physicians can take care of many more patients in a shorter period of time than if they had to see every chronic patient individually to manage their regimen. And it will become a great educator as patients become more involved in their disease management."
Genevieve Belfiglio is a Cranbury, N.J.-based healthcare writer and editor.