Participants randomized to the intervention group receive a home telemedicine unit (HTU) (American Telecare Inc., Eden Prairie, Minnesota) with four main functions: synchronous videoconferencing, self-monitoring of fingerstick glucose and blood pressure, messaging, and Web access. The device is a Web-enabled computer with modem connection to an existing telephone line (Table 2).
Telemedicine Intervention Capabilities for Patients, Primary Care Providers, and Nurse Case Managers
The HTU has several components: a video camera that provides 8 frames/sec video and a microphone for voice conferencing with nurse case managers at the Berrie Diabetes Center at Columbia University (urban component) or the Joslin Diabetes Center at SUNY Upstate Medical University (rural component); an FDA-approved home glucose meter and blood pressure cuff connected to a generic medical device data port, so that home readings can be uploaded into a high-performance computer database (the New York Presbyterian Hospital clinical information system repository56–59
) that supports patients' access to their own clinical data through graphical and other data displays; secure messaging, including e-mail; and access to a special educational Web page in English and Spanish, created for the project by the American Diabetes Association.
The nurse case managers are trained in diabetes management and in the use of computer-based case management tools that facilitate interactions through videoconferencing with patients.
Medicare beneficiaries with diabetes make an average of 6.8 provider visits per year.60
The intervention seeks to extend these interactions by incorporating telemedicine technology into clinical care using approaches justified by behavioral theory61–63
and prior intervention research. The approach is patient-targeted and aims to build self-reliance, elicit well-defined behaviors, and reduce provider burden by empowering patients. The intervention strategy also draws on a growing body of research suggesting that telephone outreach is an efficacious strategy for influencing health-related behaviors,64
that tailored messages are an important strategy for influencing behavioral change,65,66
and that videotelephone contact may be more effective than voice-only contact.67
We hypothesized that the intervention will improve patient outcomes by several mechanisms. More frequent interactions between patients and providers will enable patients to initiate more rapid behavior changes (e.g., self-monitoring, compliance) as well as changes in their treatment regimens, without an office visit. Closer monitoring (e.g., glucose, blood pressure, diet) will be coupled with quicker feedback from the provider. In this way, better and more rapid glucose and blood pressure control may be achieved and maintained.
Face-to-face interaction by videoteleconferencing with a case manager will enhance compliance and promote maintenance as well as initiation of positive behavior changes. Having visible contact with a health care provider is important to most patients, especially when the provider is knowledgeable, empathic, and interested in the patient's diabetes as well as in the patient as a person. In allocating telemedicine case manager time, we projected one full-time equivalent for each 200 diabetic patients, allowing ample time for one contact every two weeks, but with higher intensity during periods when needed.
Finally, patients' diabetes educational needs are now usually addressed through on-site classes and print materials, but the all-at-once approach may produce information overload rather than useful learning and enhanced self-efficacy for participation in care. Education and information in small pieces, related in time to patient-specific information needs, may be a more effective way to provide self-management education for diabetes. Education and information are available in this way from the case managers and from the project Web site.
The case managers actively invite and coach patients to use these information resources. For example, to a patient who is having difficulty controlling diet, the case manager might suggest a chat group and point to specific educational and motivational resources. Access to monitored chat groups, where patients can learn from each other, share problems and solutions, and gain and give psychological support, may also enhance effective learning for sustained behavior change.
We use version 2.2b (updated May 2000) of the Veterans Health Administration (VHA) Clinical Practice Guidelines for the Management of Diabetes Mellitus in the Primary Care Setting.68
These guidelines are flexible, annotated, evidence based, and algorithmic in format. They were designed with input from a number of federal health–related agencies, including the VHA; the Diabetes Division of the National Institute for Diabetes, Digestive and Kidney Diseases; the Division of Diabetes Translation, Centers for Disease Control and Prevention; the Office of Managed Care, CMS; and the Pharmacoeconomic Center of the Department of Defense, United States Air Force. The content of other guidelines, especially those of the American Diabetes Association, have been largely incorporated in the VHA guidelines. The majority of these algorithms are suitable for automation and incorporation into triggers in the case management software. Case managers are trained to follow these algorithms.
Intervention subjects are assigned to a project case manager under supervision of diabetologists at the Joslin Diabetes Center in Syracuse and the Naomi Berrie Diabetes Center in New York City. Case managers interact with patients using the HTU and case management software. The primary care physicians of intervention patients retain full responsibility and control over their patients' care. When a case manager believes that a change in management is indicated, he or she contacts the primary care physician (by e-mail, fax, or phone) just as a visiting nurse going physically to the home would do. This avoids disruption of established relationships and patterns of care and ensures continuity of care for intervention patients after the project ends.