The Next Step: Achieving Health Behavior Change Through Technology

Name the movie & the meme…

If you build it, will they come?

Research Questions• RWJ: RFP to evaluate patient portals (MyGeisinger)• For patients with chronic conditions (DM, CVD,

CHF), do e-health interventions influence:– Measures of:

• patient activation• patient self-management• treatment adherence• patient satisfaction with care• disease specific knowledge

– Process measures of appropriate CVD/DM/CHF care• HbA1c, LDL tests• Prescribed meds

– Clinical markers of cardiovascular/DM morbidity & risk• SBP, HbA1c, LDL

Intervention

• Web-based health behavior change program– Care For Your Health (HealthMedia, Inc)

• Objective:– create “expert patients” with the confidence, skills, and knowledge to

self-manage• Method:

– Patient completes initial assessment online (~80 items)– Customized “plan” that helps patients focus on:

• acceptance of condition• communication with providers• lifestyle choices• goal setting• medication/treatment adherence• planning skills

– Visit the site initially to complete assessment, return to review plan and use additional tools

Study DesignGeisinger Patients with Geisinger Clinic

primary care provider

Portal Usersn = 3,297

Non-Portal Usersn = 29,600

Intervention Groupn = 1,649

Control Groupn = 1,648

Non-Portal Usersn = 1,649

Matched selection

Diagnosisof: CVD, DM,

or CHF?

Randomize

Exclude

Registered MyGeisinger

User?

Yes

No

Yes No

Recruitment Model• First phase:

– Initial letter from director of Geisinger’s ambulatory clinics• Follow-up letters (2)• Follow-up emails (2)

• Second phase:– Letter from PCP

• Follow-up PCP letter (2)• Follow-up PCP email (2)

• Letter content: – General info about the study and intervention– Instructions on how to log into MyGeisinger & click the

link to Care For Your Health

Results: Overall• Primary Endpoints (6 and 12 month f/u):

– No effect on process measures• No difference in rates of appropriate testing (e.g. A1c,

foot exams) or appropriate use of medications (e.g. ACE-I for CHF)

– No effect on clinical measures• No difference in SBP, DBP, LDL, Total Chol, A1c

– No effect on patient-reported outcomes• Patient activation, adherence, satisfaction

What happened?

• Enrollment problems:– Only 247 (~) 17%patients enrolled in CFYH

• Were patients unaware of the intervention?– Interim survey

• Are patients just not interested in e-health?– Analysis of MyGeisinger vs. HMI use

Results: Interim Phone Survey• Surveyed 30 random non-enrollees to identify

reasons for non-enrollment (~11%)• Findings:

– 90% use the Internet at least once per week – 100% recalled receiving the invitation letter

• 67% did not recognize the physician signing the letter• 42% said recognizing physician mattered

– 47% - wanted more information– 67% - technical problems

• Conclusion: – they know about the intervention

Results: MyGeisinger Use• Analyzed 12 months of MyGeisinger use

– Analyzed log files• Results:

– 86% used the Internet for at least 3 sessions during the 12-month period

– Most popular functions:• Lab results, Messaging, Proxy access

– Clear presence of user “clusters”• Portal use for specific purposes: Proxy users, lab trackers,

appointment “preppers”, etc.

• Conclusions:– Patients like, and actively use, electronic tools for health-

related purposes

Conclusions• Study participants WERE aware of and using “e-health”

“E-health is an emerging field in the intersection of medical informatics, public health and business, referring to health services and information delivered or enhanced through the Internet and related technologies.”

– Eysenbach, J Med Internet Res 2001

• There is a fundamental difference in the process of engaging patient in accessing information (i.e. EHR, lab data) vs. health behavior change– Immediate gratification vs. long-term health

Conclusions (cont’d)• “Simple” solutions:

– Need to make it simple for patients– Patients need better information

• The primary care physician is important

• Complex solutions– Not all e-health is created equal…

• Accessing data vs. behavior change– Health behavior change is difficult on the web, just as it

is in a paper-based world– If you build it, “they” won’t necessarily come– Who are “they”

• Need to understand who, why, how to develop better approaches to engaging patients

Questions?

Future Research

• Understanding patient engagement and activation– Eysenbach (2001) – the law of “attrition”

• Important, but how do we engage them (non-early adopters) in the first place?

• Current studies– “Risk-informed engagement”

• eCVD-II• eAspirin

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