Working Partnerships (#3): Linking research-based projects with HMOs, clinical centers, and Medicare

Working Partnerships #3:  Linking Research-Based Projects with
HMO's, Clinical Centers, and Medicare


CHESS
David Gustafson, Ph.D., Professor, Industrial Engineering and
Preventive Medicine, University of Wisconsin

The idea behind CHESS is to put computers in the homes of people
with chronic health problems.  We deal with patients with AIDS,
breast cancer, and other health problems.  Our research consortium
talks about heart cancer, as well.

I will describe how the breast cancer program operates.  When a
woman is diagnosed with breast cancer, in about 16 medical centers
across the country a computer is given to her for 3 to 6 months.
When they turn on the machine, this is what they see:  there is no
login interface.  They only have to enter a code name and number
which gives then access to some information, but not to other
information.  About 450 questions asked by women with breast cancer
are answered and 150 articles on breast cancer are provided, as well
as personal stories by women with breast cancer.  Also, there are
discussion groups of women with breast cancer, and it encourages
changes in daily behavior -- such as adopting a low-fat diet.  Women
spend a few hours with the computer when first diagnosed getting
familiar with the services online on the system.  There is an
introductory program which takes you through a guided tour of the
services in order to get the patient warmed up to the system.

Women with breast cancer suffer from a need for emotional support;
the are experiencing stress and anxiety.  Women with breast cancer
state that they want to keep track of the process they are going
through in trying to deal with breast cancer.  So CHESS provides
them a way to do this.  Things go on in her life which she wants to
share with other people.  People talk about eating two pounds of
broccoli a day, hoping to stop the disease -- so they may bring this
up online.

You can track the scores of your health progress on a health
progress report.  It can indicate when there is enough change in
your lifestyle so that the problem can be reversed.  For example,
let's say I'm concerned about issues of recurrence.  If you enter
"issues of recurrence" into the search option, you could get 2 to 3
pages of information to read.  But if you enter a key word such as
"recurrence" and select that you want to read articles on it, then
you will get 8 or so articles that address the issue.

Other options include reading a woman's personal story on a 5-screen
overview.  Then you can go to sub-stories that give more depth to
the story.

We also offer a series of discussion groups.  For example, we put a
prayer group on to the Chicago system and it is very active.

We research certain aspects of the topics being brought up in the
discussion groups.  The way we start a project is to do a critical
incident approach.  We ask: "What was it like when you first felt a
lump?  What went through your mind when your doctor told you that
you had breast cancer?"  From the discussion group responses, we see
a need to be met.  We create a survey, and with the data collected,
we can see how much research we should pursue.

Let me talk briefly about the evaluation.  We have tests of CHESS,
some of which are clinical trial tests.  The results of these tests
indicate a number of things.  First, use tends to be fairly high.
If a discussion group becomes a group of 30 women, each will use the
system 55 times over the course of 3 months.  That means about 2
times a day they join in the discussion.  Women use the system 40%
more than men -- a surprising discovery.  Some in our test groups
who are less educated tend to use the action plan more than people
more educated.  Even though this is the hardest program to use.
Maybe this is because they don't have a lot of experience with
making choices.  We looked at the amount of time spent with
physicians.  For example, for patients with AIDS it is lower.  For
time spent in hospitals, the patients in the control group it
increases, but patients involved in CHESS stay in the hospital less
time -- and this does not increase over time.

Quality of life improves with the use of CHESS.  For women with
breast cancer, the impact is improved quality of life and fewer
doctor visits.  It improves the situation of the patient involved in
chemotherapy.


Q:  This program has been used in life threatening situations -- for
people desperate for help.  Is there any reason this program cannot
be extended to other groups at this time?

A:  Currently there are 7 major health care facilities across the US
that help us think through how to create the programs, and think of
other areas to increase our study in and which have smaller
providers.



All Kids Count
Farrokh Alemi, Ph.D., Health Administration Program, Cleveland State
University


Dave and I have worked together on computer technology advances for
18 years.  It has taken a direction neither of us had predicted.
Dave thought that the phone and not the online system would be the
wave of the future.   Operational and commercial development are the
topics for today's discussion.  I will focus on All Kids Count, an
immunization project, using a phone based city wide network.  We
have placed it in the context of a series of projects done by a team
in Cleveland. The purpose of the team is to improve health care
delivery through telecommunication technology.

There are 4 projects of this team.  The first is the computer
telephone service linking cocaine addicted women to their
physicians.  The second is an outreach program to new mothers to
encourage immunization, the third is primary care screening in
Cleveland of alcoholics, and finally the project to link the use of
phone service with care providers.

The projects are working with 5,000 patients from 15 providers in
the Cleveland area.  Ford is moving from a stand alone concept to an
integrated concept, meaning that if we build a system inside the
provider location, it will reach even more, and you have a greater
chance of healing people.

Location is very important.  It is important to go where the health
communication technologies fit the health care provided, especially
in formal service.  Go to a place where the patient has the most
access and is most likely to have contact with a physician.  It is
important to encourage the patient to make the call to the
information service when the patient makes the first contact with
provider.  If a person who has an appointment then makes a
telecommunication call, makes the patient more likely to show up
again in the doctor's office for a follow-up visit.   If the patient
has access to a phone library service, the information received will
clarify the patient's condition.  The phone service makes it less
likely to repeat intervention by doctors.  It allows the patient to
gain greater continuity of care, greater quality of interaction
between patient and doctor.

It is important to know where do patients live?  Usually it is in an
apartment, not in a home.  Sometimes the patient is homeless.
Sometimes the computer is intrusive in the home.  If the phone is
the connection to the computer there are many benefits.  A phone
service is inexpensive, efficient (no learning curve), and
perception of information is high, and most importantly, the phone
is available wherever you are -- even from a public phone.

The team's vision was to reach patients and to allow follow-up
questions for a medical procedure.  Patients need to find the
services compelling and must continue to use them.  Also it is
important to find out if the cost of the service in the future is
feasible.

I'll answer the following 3 questions:  The impact of patient
behavior, the impact of physician behavior, and the impact of
provider behavior on the effectiveness of the telecommunications
information system.

First I'll detail the phone information system.  The phone service
has a voice mail and voice bulletin board system.  It has an option
to leave a message for an expert, and to receive a message.  There
is no human interaction on the system.  There are accessible
libraries.  The decision support tool is available where the users
are guided through asking them questions to find the caller's needs,
and then contacting sites that are preprogrammed to provide the
services requested.

Bulletins are better on the phone because you can hear emotions
better than online.  The expressed need for assistance can be met in
the triage system, better than on computers.  The triage system is
better on the phone because you can have a quick reference to a
formal service provider.  The system is built to adapt to specific
conditions, such as if the caller indicates having diabetes, a
pregnancy, AIDS, or other health issues.

Now we will discuss the findings of the projects the team was
involved in and the benefits of the phone system.

In the first study, the team tracked 65 drug using or recovering
mothers.  For those women who received face to face counseling and
the phone service, the number of clinic visits declined over time.
The number of calls to the clinic was greater of those who did not
use the phone service.

In the second study, the team followed 196 mothers.  Half were
called by computerized voice mail responses reminding them to get
their children immunized.  Those who got the calls were more likely
to immunize their children on time.

In study number three on alcoholism screening before a primary care
visit, 157 patients were told to call back to the computerized
system before the visit.  Some didn't have access to technology.
Because of language barriers 21% were not interested, and 10% didn't
want to talk to a phone service.  When there was a computer
generated report of alcoholism of a patient,  there was more likely
documentation on the patient's health chart of reported alcoholism.
50% of doctors preferred to get the form before the patient came on
site.

The fourth study on provider care came about because VNA -- a
provider -- wanted to keep closer contact with patients.  VNA was
required to train 700 staff on the phone system from the start.  The
provider saw the advantage of being able to make the call to a
patient after hours when the nurse was not in the office to make the
call.

A patient is introduced to the phone system as a source of help and
guidance to services in the community.  The phone system is in the
first year of operation.  They already have patients using this
system to get direct service intervention.

Many patients come with several needs to the phone system and it is
not always clear to the physician which ailment or both did the
patient seek information on through the phone service.  Did the
patient get the diabetic intervention or the hypertension
intervention or both?  This is an area of the system that needs
further development.

The All Kids Count program is unique in the community because it
offers a wide development exchange service.  The program is Internet
based.  City clinic and private large group practices contribute
their data to a large file as a repository of information the phone
system can use.  It is a service to new mothers to target
immunization needs.  This is a place mothers can get information on
requirements and conflicting information clarification.


Q:  What are clinical options in the future and abilities to
demonstrate the  technology?

A:  The system must allow guidelines for services, and it needs
monitoring of clinics to make sure the guidelines are up to date and
effective.

Q:  People are either information seekers or not -- one or the other
-- is an assumption of these projects.  Is this true in your
experience?

A:  Having access to people with similar conditions make some
individuals  information seekers.  There are individual differences
of course.

The Anderson Model is very useful in categorizing who will use the
phone system.  There was a paper that was released in January using
the Anderson Model to accurately predict the people who would use
the system more, and who would get more out of the service.

By examining individual characteristics of information seekers, we
could predict that women use the service more than men, emotionally
distressed individuals used it more than angry or physically
constrained people, those that came to us through a service rather
than direct mail appeals, and being unemployed made it more likely
to use the service than employed.

One of the single highest occurrence of improved health was the use
of the phone service.