This document is based on in part and at times verbatim on an article in the Supplement to Medical Care authored by Farrokh Alemi and Richard Stephens and titled "Computer services for patients: Description of systems and summary of findings." In addition, it is also based on a chapter by Alemi F and Stephen R titled "Electronic communities of patients: computer services through telephones" and published in Brennan P, Schneider S. (Editors) Community Health Information Networks, Springer, 1997.
A quiet revolution is underway about how care is being delivered to patients in the United States. Information Technology is radically changing the nature of clinical practice. In the following sections we review examples of how this is being done and speculate about the implication of these changes for organization of health care. In discussing the impact of IT on clinical practice, we focus primarily, though not exclusive, on online services. This is one of the newer areas of growth of IT and provides some of the most striking ways in which IT affects health care.
Like all technological innovations, early implementations of technology do not raise later implications. No one in the early days of black and white television could have imagined that this technology could lead to increased violence in our society or affect presidential elections. But new media often goes beyond what it was planned for. Slowly but surely changes are underway that will radically alter how Health Maintenance Organizations (HMO) are organized and how providers deliver services. The remainder of this section reviews existing research on impact of information technology on practice of care and lays out one scenario of how the near future would be like. This section helps you think through these technologies and understand how it will affect providers and health organizations.
Providers and patients can use computers to do many activities. Among these are: health education, social support, appointment making, taking history, and home monitoring.
Several HMOs are using computer services to patients' homes for educating their members. There is overwhelming data that health education (predominantly through books) is effective in reducing cost of care and improving quality of services. Data suggest that consumers who know more about their health engage in more active self -care, are more likely to comply with their treatment, are more effective participants in choosing treatment options, and have lower health care costs., One approach to providing health education at home is through telephone access to a nurse. Patients call a nurse who, usually based on a computer protocol, advises callers to seek the appropriate level of care.- Another approach uses a librarian who helps patients shape an inquiry and then searches computerized files for the requested information. The librarian either provides the information to the patient over the telephone or mails the information to the client. In a third approach to health education, patients can telephone a computer; press touch-tone telephone keys corresponding to a particular taped health message, and listen to it. In a fourth approach, investigators have tried to educate patients by providing them with a computer and allowing them to interact through the computer with health professionals. Patients type their questions and the computer sends these questions to the computer of a health provider, who types in a response at a later time., Finally, in a fifth approach patients call a computer and record their questions, the computer calls the provider, who records his/her response, and then the computer calls the patient back to deliver the answer.
Some HMOs are using computers to help patients who have similar illness to talk and exchange opinions with each other. No matter how well informed patients are about their medical condition, most need the reassurance of talking to others who have been in similar situations, who can demystify the health delivery system, and who can provide emotional and social support when things are not going well. Lack of social support, obviously, increases loneliness and puts one at risk for depression and mental illness. Lack of social support also affects physical illness and drug use. Studies demonstrate that face-to-face group support is important to a patient's recovery, but experiences of self-help groups such as Alcoholics Anonymous and Narcotics Anonymous meetings show that clients miss many group meetings. Chronic illness restricts participation in social activities. When patients lose their own community of friends, or find that their existing friends cannot satisfy their illness related information needs, patients may attempt to organize or participate in new communities and self help groups. Naturally, they seek to organize these communities around their illness. Distance from each other, lack of time, chaotic and busy life styles, and confidentiality limit patients' participation in support groups. To facilitate the creation of intentional communities of patients, some have suggested the use of electronic bulletin boards., Through these bulletin boards patients at long distances from each other can communicate in an asynchronous and confidential manner. With the spread of Internet and commercial on-line services there are increasing numbers of electronic bulletin boards. Investigators at the Maryland School of Nursing have provided electronic bulletin boards to disabled persons. Others have used the computer to assist in promotion of controlled drinking among early stage problem drinkers.,, In Washington, CapAccess provides a platform of bulletin boards and computer services for a diverse patient population. In Miami, elderly use computer bulletin boards to break their isolation and have mental simulation. In Cleveland, caregivers of persons with dementia are using computer bulletin boards. In northern California, a major HMO is using voice-bulletin boards to allow recovering alcoholics to have access to each other.
Some HMOs, e.g. Blue Cross Blue Shield of Northern California, are working on ways of allowing patients to make appointments using their computers. The main advantage of computer based appointment making is the possibility that the patient can set and learn through the computer about the urgency of the visit and the self care steps that they can initiate. In one scheme (not yet implemented), patients make an appointment, then answer questions about their symptoms. The computer analyzes these responses and sends them to a clinician; who based on his/her first hand knowledge of the patient, will record a response to the patient. The response may include a recommendation to (1) by pass the provider and seek advice from a specialist, (2) seek immediate care, (3) seek care after completion of laboratory tests, (4) wait and see how the illness progresses. These types of triage decision making are the core advantage of how computer assisted appointment making may radically reduce the number of intermediary office visits and lead the patient to the appropriate and final level of care.
Computers can be used to assess the patients before their office visits in order to alert the clinician about some underlying problems. Office visits provide a limited time for patient and clinician interaction. Computers can assist by gathering the necessary information ahead of time and alerting the physician to key findings in the patients' condition. In one study, patients were asked to call a computer and participate in risk assessment. The computer analyzed their responses, established whether they were suspect alcoholics, and sent the analysis to the patients' clinician. When patients came for visit, the clinicians reviewed the findings with them.
Computers can be used to monitor patients' health at set time intervals. For example, Visiting Nurse Association of Cleveland has designed a computer system that calls their patients with congestive heart failure and asks them a series of questions on a weekly interval to assess the need for out of plan visits to patients' homes. Patients answer the questions by pressing keys on their telephone pad or by recording their answers on the computer. If answers are recorded, the computer sends the recording to clinicians, who listen to and respond to the patients' responses.
Patients' reactions to computers are not simple. Patients may like some computer services more than other services. For the most part, on-line services seem to patients more like communication devices than data collection and calculation computers. Most of the systems involve a short interaction with a computer followed by a free-form interaction with other people through the computer. Data show that most patients welcome these communication aids. When hard to reach individuals were asked to rate computer calling them, versus an answering machine or a computer sales call, they rated computer services positively and similar to an answering machine; while they almost uniformly expressed a negative attitude towards computer sales calls. If computers help communication, patients will like them and will not think of them as they have traditionally thought of computers.
Some of the on-line activities (e.g. the systems designed to take medical history and to triage the patient) do involve extensive data collection and may irritate patients. While computers are expected to improve the interview process through standardization, it is possible that computerized assessment will anger and frustrate clients who have turned to the health care system in part because they needed human care and attention.
Data indicate that contrary to expectations, patients prefer computerized telephone assessments and CRT-based computer assessments to assessments conducted by an interviewer. This is especially true when patients must report on confidential matters (such as drug use, sexual preferences, suicidal thoughts, etc.). Such preferences have been known since the late 1960's and have been demonstrated in far too many studies to be considered just an artifact. One explanation for such preferences is that computer interviews are non-judgmental, while clinicians, by their very own status, may be perceived as judgmental. Another explanation is that patients prefer the self-paced self-administered nature of computer interviews. Still another explanation is that patients prefer a non-verbal interaction because it helps them be more introspective. Whatever the reason, it is clear that patients like computer interviews.
Our own experience is also telling. We created a system for automatically interviewing patients about their health risks, advising them about what lifestyle they should change, and referring them elsewhere. We compared reactions to this system to receiving health information from magazines, television or a health professional. Data were collected from 96 randomly chosen employees of Cleveland State University. Employees were invited to participate based on a stratified sample that encouraged enrollment of males and females and enrollment of faculty, professional and non-professional staff. When the subjects received a post card and a follow-up letter announcing the availability of the system and a phone number where they could call and use the computerized health risk assessment, the majority (71%) of subjects used it. When they called a computer interviewed them and based on their risks gave them advice for modifying their life styles. Those who did not call gave various reasons (some did not use the system because they could not read the material mailed to them). Less than 4% did not participate because they objected to a computer giving advice on health risks. Those who used the system rated it as more accurate, easier to understand, more convenient, more affordable, easier to use, and more accessible than health education received from television, magazines, or health professionals.
These data clearly show that subjects are open to and like computer interviews about their health risks, do not mind receiving advice from a computer, and prefer this method of screening to existing source of health education. These experiences further confirm the literature finding that patients, once familiarized with the technology, accept and enjoy it.
In our experience, the most negative reactions to computers advising patients and triaging them to care comes from those who represent patients (some clinicians, newspaper journalists, and lawyers). An example can demonstrate this. At the onset of our research, the local newspaper, Plain Dealer reported our funding in its first page and one of its editors wrote a very negative opinion. The editor ridiculed the use of computers for management of patients, in this case for drug-using pregnant patients. Shortly after the media attention, drug treatment groups organized a widespread boycott of our work and refused to allow their patients to participate. Eventually the boycott broke and we were able to recruit patients and conduct our work. Contrary to the editor's claim the data showed that patients liked our services; used our services; and these services improved their care. The self-appointed advocates of patients took a position different from the wishes and the best benefits for these patients. So, do patients resist computer interviews? No and certainly not as much as their advocates do.
Satisfaction with a computer system depends on how the system is organized. Most individuals are familiar with computer calls through telephone marketing calls. Since these marketing calls are frustrating, most people believe that if a computer calls, they will hang up on it. Consider the circumstances under which people hang up on computers. These calls often arrive at unwanted times, interrupting other activities, and furthermore, they are about topics of little interest to the receiver. Thus, it is not surprising that people hang up on these calls. Suppose it was not a computer calling but a sales representative at your door. When a salesperson shows up at your door, in the middle of your dinner, and tries to sell you something that you do not need; obviously, you tell him to go away. Now, consider if he were to come back every other day. Naturally, you would be frustrated. The point is that your frustration is not with the door-to-door salesperson's existence, but with what he is selling and with his lack of judgment and timing. The same applies to computerized telephone calls. Computers, who call when the patient has asked, deliver messages that the patient cares for, and do so in a reliable fashion, are not frustrating.
Perhaps the most telling story of patients' reactions to computers is what happened when we tried to stop on-line services that were monitoring patients on a weekly basis. Our funding had run out and after five months of weekly computer calls, we announced that we were planning to stop. The reaction was swift and overwhelmingly negative. These patients did not mind that a computer called them and interacted with them, but were angry when it did not. One patient put it this way: "For months you have been calling and mothering us. How dare you stop?" It seems that patients who become accustomed to on-line services may be frustrated if the service is withdrawn. Computer services to patients may seem like a value-added service right now, but when it is widely in use, it may become entitlement.
In the end, the most obvious test of whether patients' are satisfied with computer services is their use of these services. Data suggests that many patients are using these services, making it the question of whether they like computer services rather irrational. Why would patients use a service that they do not like? We will review some of these data later when we examine the potential impact of on-line services on patient outcomes.
Caregivers to Alzheimer's patients improve their abilities
Investigators gave computers to caregivers of Alzheimer's patients and provided them with on-line services. Patients were randomly assigned to the control and the experimental groups. After providing them with support through computer bulletin boards, both the experimental and the control caregivers still felt isolated. Access to the computer did not change their sense of isolation. However, significant differences were observed in clients' coping skills. In particular, patients who had access to computers were more confident about their own abilities to cope with the burden of giving care.
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Lower cost of care for AIDS patients
Based on Gustafson DH, Hawkins RP, Boberg EW, Bricker E, Pingree S, Chan CL. The use and impact of a computer-based support system for people living with AIDS and HIV infection. Proc Annual Symposium Computer Applications Med Care, 1994: 604-608
The clearest evidence that on-line services could help reduce cost of care comes from a recent study on HIV/AIDS patients. Investigators provided 200 HIV patients with a host of computer services, including a computer bulletin board for support, email, question and expert answers, library of information, and decision aids. Patients were randomly assigned to control and experimental groups. Only the experimental group had access to the computer services. Among the various computer services provided to the experimental patients, computer mediated social support was the most frequently used service. Investigators evaluated the project after 3 months and 6 months. Surprisingly, they found that access to the computer led to higher quality of life in several dimensions including social support and cognitive functioning. The experimental patients also had fewer office visit (dentists, primary provider and alternative care providers) and shorter time per visit to the primary care provider, HIV and mental health providers. The experimental patients were also less likely to be admitted to a hospital and more likely to have a short stay. In summary, there was 33% reduction in total cost of care. These data confirmed the importance of social support in bringing about behavior change and showed that use of electronic groups as well as other computer services could lead to drastic reduction in cost of care.
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Based on Alemi F; Stephens RC; Javalghi RG; Dyches H; Butts J; Ghadiri A. A randomized trial of a telecommunications network for pregnant women who use cocaine. Medical Care, 34(10 Supplement): OS10-20 1996
A study examined the impact of electronic communication (use for provider contact, for on-line testimonials and religious services) and electronic home health education, on care of 179 drug using pregnant patients. Patients were randomly assigned to control and experimental groups, only the experimental group had access to the on-line services. Patients were interviewed at enrollment (usually during the third trimester), at delivery and at 6 months post delivery. The electronic communication portion of the system was used on the average 2.3 times per week per patient. The home health education portion was used 0.2 times per week per patient to leave a question and 1.9 times per week per patient to listen to questions. These data showed that poor, drug using, pregnant, under educated, and multiple resident clients could use on-line services. Most patients used the service to communicate with clinicians and their friends, and not to learn more about their condition. However, a sizable minority (45%) of the patients used the health education component at least once. Unfortunately, despite this use there was no difference between the experimental and control group in outcomes of care. Mere access to, or occasional use of, the system did not lead to any significant difference in outcomes of care. On-line services had a benefit, when patients used the systems more extensively. Patients, who used the system more than 3 times a week (about 1/3 of the experimental group), were 1.5 times more likely to be in treatment than patients who used the system less frequently; this finding persisted, even when controlling for differences among patients at baseline.
There seems to be a threshold after which the use of on-line communication systems has a positive impact on treatment compliance. Despite the success in bringing some of the experimental patients to drug treatment, participation in formal drug treatment was not effective in reducing the drug or the alcohol use of this population.
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Based on Alemi F, Stephens RC, Mosavel M, Ghadiri A, Krishnaswamy J, Thakkar H. Electronic self help and support groups: A voice bulletin board. Medical Care 1996, 34(10 Supplement): OS32-44.
One study examined the use of electronic support groups. The study was conducted on 53 recovering drug users. Half were assigned to electronic and half to face to face support groups. On the average, patients used the bulletin board 2.18 times per week and 96% of the patients used the voice bulletin board. Patients were more likely to participate in the voice bulletin board than in the face-to-face meeting.
The mean number of biweekly participants in the voice bulletin board was 8.09 times higher than the face-to-face group. The majority of the comments left in the bulletin board (54.6%) were for emotional support of each other. There was as much expression of emotional support in the early parts of the meetings as in the later parts. No "flaming" or overt disagreements occurred. The more clients participated in the voice bulletin board the more they felt a sense of solidarity with each other.
Members of the experimental group used significantly less health services than members of the control group; and lower utilization of services did not lead to poor health status or more drug use. These data suggested that voice bulletin boards might be an effective method of providing support and that electronic supports groups reduce use of health services without any apparent impact on health status of patients.
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Based on Friedman RH, Kazis LE, Jette A, Smith MB, Stollerman J, Torgerson J, Carey K. A telecommunications system for monitoring and counseling patients with hypertension. American journal of Hypertension 1996, 9 (4): 285-292.
This study examined the impact of computerized home monitoring and counseling on elderly patients with hypertension. Investigators randomly assigned 267 subjects to control and experimental groups. The control group received their usual care. For six months and on a weekly basis, patients in the experimental group called a computer and reported to it their self-measured blood pressure. During these telephone calls the computer interacted with the subjects to increase their knowledge of the disease and side effects of the medication. In addition, the computer reported subjects' adherence to medication use to their clinicians. The experimental group members were 6% more likely to adhere to their prescribed medication than the control group. There was no difference in systolic blood pressure. However, the experimental group reduced their diastolic blood pressure by 5.2 compared to 0.8 mm Hg for the control group.
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Based on Alemi F, Alemagno SA, Goldhagen J, Ash L, Finkelstein B, Lavin
A, Butts J, Ghadiri A. Computer reminders improve on-time immunization
rates. Med Care 1996 Oct;34(10 Supplement):OS45-OS51 .
This study examined the impact of computer reminders on on-time immunization rates. The experimental group received computer reminders to keep their appointments and the control group did not. The patients included infants, who were less than 6 month of age, were being seen at the outpatient clinic for a first visit, and were patients of three attending physicians and three nurse practitioners. These infants were compared to 77 infants from the same clinic, less than 6 months of age, and seen for the first visit during the same period by the same providers.
The patients who received computer reminders were more likely to show for their appointments. The on-time immunization rate for experimental subjects was 1.19 times higher than the control group. These data suggested that computerized reminders of the patients led to an increase in the show rate at the clinic and an increase in on-time immunization.
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Based on Wasson J, Gaudette C, Whaley F, Sauvigne A,
Baribeau P, Welch HG. Telephone care as a substitute for routine clinic
follow-up. JAMA 1992 Apr 1;267(13):1788-1793.
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Patients with access to interactive video disc on benign prostatic hyperplasia had 11%-39% lower surgery rates than patients without access.
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Men who viewed the educational videotape were better informed about Prostate Specific Antigen screening test, prostate cancer and its treatment; preferred no active treatment if cancer were found; and preferred not to be screened. They were 9.9% less likely to have a PSA test by next visit. This tendency for less PSA was not repeated in a second study.
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Providers who participated in a personalized decision aid were 26% more likely participate in hepatitis B vaccination than the group which received only information.
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The following additional resources are available to help you think through this lecture:
The growing number of studies on impact of electronic patient education and social support on patients changes the question from whether these interventions are effective to under what conditions they are effective. For a detailed discussion see enclosed review.
Advanced learners like you, often need different ways of understanding a topic. Reading is just one way of understanding. Another way is through writing. When you write you not only recall what you have written but also may need to make inferences about what you have read. The following questions are designed to get you to think more about the concepts taught in this session.
Please read the following 7 articles and prepare 1 of the following articles to discuss in class. One of the best ways to master a topic is to teach it. By presenting one of these articles, you get to have in-depth understanding of the topic. For the article you plan to present, prepare a slide show. Bring the slides show to the class. Your presentation will be judged successful to the extent that you can solicit your colleagues comments and input.
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Question: How is online support different from online treatment?
Answer: Online support is peer to peer while couneling inolves clinicians. Online counseling follows a specific counseling intervention while peer to peer support groups are free form and any content may be included. In general, online counseling requires a great deal more online contact over a longer period of time, going through specific issues that the client needs to work through.
Suggestions for Improving "Online Clinical Services"
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This page was organized by Farrokh Alemi Ph.D. on 05/07/07 and last revised on 05/07/2007. This page is part of the course on Electronic Commerce & Online Market for Health Services.