We reviewed the literature on PWP-delivered interventions and disease management support targeting persons with diabetes and or enhancing diabetes care and found that PWP systems enhance patient-provider communication [20
], increase overall satisfaction with care [9•
], expand access to health information [21
], and improve disease management [9•
] and patient outcomes [29
] in diabetes. The recent body of PWP evaluation studies has established the usefulness of PWPs for improving care and clinical outcomes, but many of the studied PWPs have unique functionalities.
It is difficult to determine which specific aspects of PWPs are necessary for patients and providers to benefit most. For example, feedback on aggregated results over time may be presented in many ways, which could impact utility and use by providers and patients, and the studies do not directly contrast specific design decisions. Several studies, showcased in this article, have begun to analyze which specific functionalities of PWPs are necessary and which tools are most useful to patients [21
]. Future PWP evaluation studies should follow suit, and evaluate the impact of specific PWP functions and tools (e.g., frequency and quality of provider feedback, personalized patient education, provider decision algorithms, visual graphing of clinical data trends, and cell phone messaging and reminders) on diabetes care and outcomes.
As a supplement to PWP evaluation studies, PWP usability studies have helped illuminate the processes through which diabetes patients choose to use or not use PWPs. Usability and user choice are critical to delivering PWP tools to patients. Usability studies have found that many patients are open to the use of technology in their disease management, regardless of their age. However, more extensive training and assistance may be needed to increase PWP use among older, less computer-literate populations [37
]. Other sociodemographic variables, such as sex, race, and socioeconomic status, are glaringly absent from PWP usability studies with diabetes patients. It is possible that this oversight is attributable to the qualitative nature and small samples of many of the usability studies. However, explorations of sociodemographic factors in general patient populations have found substantial differences in access to and use of web-based health tools based on age, health literacy, socioeconomic status, and gender [38
]. Future PWP research and usability testing should identify sociodemographic differences in access and use, and explore ways to effectively deliver PWPs to all patients.
Usability studies have also highlighted the value patients and providers place on relationships. Patients value the continuation of personalized relationships with their providers, and some fear that PWPs will come to replace personal office visits and educational conversations with their providers [20
]. Providers also stress the importance of a personal relationship and continued office visits [24
]. In the current health care environment, PWP interest and use is linked to the quality of the relationship between patient and provider. Interestingly, patients who have a strong relationship with their provider may fear the PWP will replace that relationship, whereas patients who feel the communication with their provider is insufficient may view PWPs as a welcome method for obtaining access to personal health information and education [22
]. When introduced correctly and well received by patients, PWPs can be a powerful supplement to the patient-provider relationship [41
]. PWPs can also help diabetes patients normalize their lifestyle changes by framing recommendations as healthy choices for all people instead of diabetes-specific restrictions [19
Most importantly, usability studies have demonstrated the importance of assessing usability before implementing a PWP. Each specific PWP, in each population of use, had different strengths and weaknesses. Usability studies allowed PWP developers to better understand the needs of the patients and address concerns to make PWP tools more effective [41
]. Additionally, providers reported an enhanced sense of community and renewed focus after collaborating to develop and improve a PWP [41
]. Each health care organization implementing a PWP to improve diabetes disease management would be wise to include usability assessments in their development procedures.
Studies of PWPs have evaluated added functionality [22
], population of use [30
], and perceived ratio of cost to benefit. New functions have been tested, including screening prior to medical appointments [45
] and suggested health reminders. Patient education [46
] and engagement using PWPs have been shown to improve patient-provider communication [47
], patient satisfaction [47
], and the quality of the patient visit [48
]. Investigators have also evaluated patient and provider acceptance of and attitudes about PWPs [41
]. Although studies are typically supportive, the effectiveness and acceptance of PWPs into patients’ health monitoring and clinical practice has been mixed [44
]. Widespread acceptance of PWPs may be limited because patients are concerned about privacy, the relevance and validity of the information within a PWP, ease of use, and barriers to availability [22
]. However, as more health care organizations adopt EHR systems [52
], the acceptance of PHRs and even PWPs will likely increase.
Despite our use of a thorough search strategy, some PWP-delivered intervention studies may not have been identified and included in this review. Specifically, we did not examine unpublished documents and reports on this topic. Instead, we focused on peer-reviewed publications. Importantly, a meta-analysis was not possible due to scant intervention outcome research on PWPs in diabetes, and the few published articles available had various data collection methods and outcomes reported. In addition, it was unclear throughout the studies examined herein whether improvements in outcomes (e.g., patient satisfaction, perceptions of health care quality, health behaviors, and glycemic control) were the direct result of using a PWP or due to other mechanisms, such as improved patient-provider communication during office visits, the type of educational content delivered through the PWP, and/or unlimited access to such educational material. Future research should explore the mechanisms through which PWPs have their impact.
In spite of these limitations, this is the first systematic review to our knowledge that specifically examines the impact of PWPs on diabetes care and outcomes and addresses critical success factors associated with such interventions. Insights regarding clinical outcomes of this emerging platform for intervention delivery and possible ways of making it more effective are presented in an organized manner, and future research directions in this area are recommended based on this systematic review.
According to the recent National Research Council report “Computational Technology for Effective Healthcare” [54
], health information technologies (HIT), including PWPs, must be designed and implemented to fit the needs of patients and providers. Although HIT research in other areas has identified patient age, socioeconomic status, and health literacy as barriers to using web-based health tools, PWP research in diabetes has not explicitly related those factors to use or outcomes. The impact of PWPs on health care utilization in diabetes has also not been explored, and should be included in future research. The keys to successful implementation, reiterated in the National Research Council report, are to 1) understand the complex interacting factors affecting care; 2) measure critical processes and outcomes; 3) design innovative and robust PWPs focused on improving those outcomes; and 4) measure the overall feasibility, sustainability, and utilization of PWPs and their specific functions across a broad range of patient populations. The challenge remains for developers and researchers to create and evaluate integrated systems of care that includes a diverse sample of patients in the design and usability processes, permits transparency, enhances collaboration between providers and patients, emphasizes a patient-centered approach to care, and maps onto improved clinical outcomes.