Business Case for a Diabetes Home Monitoring IT Program

Introduction

This proposal concerns the introduction of a diabetes IT program for a major healthcare institution, building on a successful eClinic initiative that has already involved patients in their heart care. Diabetes is one of the leading causes of death in the United States, and much of its management involves lifestyle modification — a set of strategies that is both community- and hospital-based. This makes an IT strategy particularly well-suited to the initiative. Diabetes co-morbidities are well-known and can be addressed through this model, and there is a great deal of information that needs to be collected and analyzed by both patients and healthcare providers.

The product presented here is a home healthcare diabetes monitor that is web-based, while also incorporating the digital download capabilities of common glucose testers — though such a liaison is not necessary for the program to function. Monitoring blood glucose levels and recording them through an internet interface allows both patients and healthcare providers to ensure that compliance is being tracked. By adding other indicators — including body weight and key dietary variables — patients give their families and healthcare providers a way to confirm that care is proceeding appropriately. This paper demonstrates that closer patient monitoring will result in better outcomes and an improved financial picture for the institution.

From its founding to its current status as one of the leading healthcare institutions in the world, the institution has been guided by physicians who seek to improve patients' outcomes and quality of life. Towards this goal, it has become a premier center for heart surgery, heart interventions, vascular disease, and ongoing heart care (Saydah, 2004). This diabetes initiative will build on those strengths and address a major cause of vascular disease. The treatment of Type II diabetes, which is related to obesity, lends itself particularly well to home- and community-based tracking and compliance monitoring. Type I diabetes, which is in some ways more immediately life-threatening, also lends itself to regular patient monitoring and can be built into a feedback loop that improves compliance and therefore outcomes.

Institutional Alignment and Strategic Rationale

It has been established in the literature that better diabetes control results in improved patient outcomes (Dunning, 2006; BCM, 2007). Better compliance means more accurate timing of insulin injections for insulin-dependent patients, as well as better control of glucose, weight, and diet. All of these elements can be managed by the patient and family in a home setting and have been shown to improve outcomes.

Since the institution serves many patients on a capitated basis, the ability to reduce the side effects of diabetes could result in a significant reduction in the sequelae of poor diabetes control. These benefits may include fewer heart attacks, fewer problems related to obesity, improved eyesight, and the reduction of other vascular disease consequences such as stroke and peripheral vascular disease (Thompson, 2006).

Diabetes monitoring at home is a logical extension of the work already done by this institution. It serves patients who are obese, who have vascular problems, and who experience other consequences of diabetes. By reaching out to the community and helping diabetes patients, the institution offers both a continuation of clinical treatment and an early-warning system that ties patients more closely to the institution.

By tending to patients within the capitated health plan, the institution can ensure better compliance and therefore lower patient costs. The greater Cleveland area is home to approximately 1.1 million people, and the number of diabetics is estimated at 44,000 — a figure derived from the nationwide prevalence rate of approximately 4% (12 million out of 300 million). This means the institution can offer outpatient IT-enabled services that improve market coverage while also improving patient care.

As demonstrated by the eClinic initiative, web-based tools have broad appeal in the community. By engaging the diabetes patient and his or her family, the institution can improve self-monitoring and identify problems before they result in symptoms requiring hospitalization. Furthermore, when patients visit an associated physician's office or the clinic itself, the treating physician and other healthcare professionals will have access to the patient's compliance record — including weight, glucose levels, and dietary data — in a way that informs clinical decision-making.

Patient Outcomes and Quality of Care

One of the most difficult aspects of patient management is evaluating self-reported history at the time of admission or office visit. There is reason to question the accuracy of patients' self-declared compliance and glucose monitoring (MedScape, 2007). To the extent that a patient's recalled therapy compliance can be corroborated by additional data — weight records, measured glucose levels including timing and frequency — the physician's ability to determine the appropriate clinical course is substantially improved.

There is also a direct benefit to the patient from using IT tools for self-monitoring. Reviewing one's own records at home creates an incentive to take measurements accurately. This also gives the patient's family a way to participate constructively in their family member's care (Rosenstock, 1985). Research has found that self-monitoring improves not only patient compliance but also provides additional diagnostic evidence for the physicians involved (Marks, 2005).

Since the staff has worked with the eClinic initiative for five years (Clinic, 2007), both patients and physicians are accustomed to accessing patient records online, whether at the clinic or in an outpatient or office setting. Adding diabetes monitoring tools will therefore represent a helpful extension of an already-familiar system (Clinic, 2007).

A concern sometimes raised involves patient use at home. While this may have been a legitimate concern five years ago, it is now clear that most of the target population has internet access and a computer and is able to perform the required functions. Since many treated diabetes patients are older, it is reassuring to know that most Americans in that age group have become comfortable with internet use; where they have not, spouses and family members can provide assistance (eMarketer, 2007).

Compliance is one of the greatest challenges identified by physicians and other healthcare workers in managing diabetes patients. Although many patients can have their glucose and other conditions brought under control during a hospital visit, a significant problem remains. As noted in a 2000 JAMA article:

"What's the hardest thing about taking care of people with diabetes? Many health professionals would answer that patients with diabetes do not do what they are told. It is common to hear them express frustration and sorrow that their patients just don't follow their diet or exercise plans, that they don't check their blood sugars or even take their medicines." (Funnell, 2000)

This proposal can therefore address one of the most difficult issues for physicians and staff: the fact that patients frequently present at the institution due to non-compliance with relatively straightforward regimens involving diet, exercise, glucose monitoring, and medication adherence.

The overall goal of this program is threefold: to increase patient health, improve patient outcomes, and enrich the patient-physician interaction when a visit is warranted. By supplementing in-hospital and in-office treatments with compliance monitoring, physicians can assess adherence without necessarily requiring frequent visits.

Once the initial tools are in place, it will be possible to extend the service in two directions: (1) providing information to diabetes care nurses who can conduct relatively frequent follow-up calls and/or home visits to ensure compliance and ongoing quality of care, and (2) implementing automated alerts that provide early warning if a patient's vital indicators — such as glucose levels or weight — shift in an alarming direction (O'Brien, 2004).

Home visits are expensive and difficult for the clinic to arrange at scale. Requiring patients to come to the clinic or physician's office for regular follow-up is also costly. While some office and clinic visits remain necessary and desirable, extending IT tools to at-home diabetes monitoring can project the clinic's expertise at relatively low cost, allowing it to concentrate resources on patients who become seriously ill (Eli Lilly, 2007).

Conclusion

The adoption of a diabetes home monitoring system will bring benefits to all concerned and help the Clinic meet and expand its mission. By ensuring patient compliance through feedback to the patient, his or her family, and the healthcare professionals, the patient not only improves his or her outcome but also reduces costs to the healthcare system. Since the Clinic already has substantial experience implementing patient- and physician-centered reporting through eClinic, this is a relatively straightforward program to deploy on existing internet and server infrastructure.

The staff will support this initiative because it makes patient monitoring more manageable. Better patient monitoring will result in better patient outcomes — which is the fundamental goal of the institution.

References

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Buchanan, T. X. (2002). Prevention of Type 2 diabetes by treatment of insulin resistance: Comparison of early vs. late intervention in the TRIPOD Study. 62nd ADA Scientific Sessions (Abstract No. 140-OR). New York: ADA.

Clinic, C. (2007). eClinic. Retrieved November 14, 2007, from EClinic.org: http://eclinic.org/

Clinic, C. (2007). Welcome to myConsult. Retrieved November 14, 2007, from Cleveland Clinic:

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MedScape. (2007). Alternative histories. Family Practice Management, 39–43.

O'Brien, S. M. (2004). The impact of an inpatient diabetes care pathway. Journal of Diabetes Nursing, n.p.

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Saydah, S. H. (2004). Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes. JAMA, 291(3).

Thompson, M. M. (2006). Mechanisms of vascular disease: A textbook for vascular surgeons. Cambridge: Cambridge University Press.