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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:
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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 Design
Geisinger Patients with Geisinger Clinic
primary care provider
Diagnosis
of: CVD, DM,
or CHF?
No
Exclude
Yes
Yes
Intervention Group
n = 1,649
Registered
MyGeisinger
User?
No
Portal Users
n = 3,297
Non-Portal Users
n = 29,600
Randomize
Matched selection
Control Group
n = 1,648
Non-Portal Users
n = 1,649
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 healthrelated 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
Pictures
Custom Animations