Hypertension Online ManagementIdentifying Key Factors for Physician Adoption

1
Hypertension Online ManagementIdentifying Key
Factors for Physician Adoption

• Alice Watson MBChB, MRCP
• Center for Connected Health / Harvard Medical
  School
• Boston

2
Center for Connected Health

• Mission
• To develop new ways to deliver high quality
  health care to people outside the conventional
  care setting
• Motivation
• Current quality of care is variable and not
  patient-centered
• Capacity challenge
• Method
• Stakeholder engagement is critical to development
  of new programs

3
Hypertension is an important disease medically
and economically

• Hypertension is common and results in significant
  morbidity and mortality
• Currently affects 65M Americans
• 90 of middle-aged Americans will develop
  hypertension in their lifetime
• Major risk factor for heart disease and stroke,
  the first and third leading causes of death in
  the US.
• Hypertension consumes a significant amount of
  health care resources, at a significant cost to
  society
• 17.2 million office visits in 2002
• Direct and indirect costs of hypertension
  estimated to be 59.7 billion in 2005

4
Many factors point towards an opportunity to
utilize online tools in patient management

• Despite effective treatments, current management
  is often sub-optimal
• 70 of patients with hypertension do not have
  adequate blood pressure control
• The move towards pay-for-performance will provide
  an impetus to improve quality of care
• Moving from a fee for service model allows
  innovation in method of care delivery
• Consumers are seeking the convenience that other
  industries have offered them through online
  technology
• 80 of adults online are interested in electronic
  communication with their doctor
• Online technology is in place and waiting to be
  utilized
• 75 of Americans have an email address
• 60 of American homes have broadband access to
  the Internet

5
Assessing physician views and needs

• The specific goals of the project were to
• Establish current practice with respect to
  hypertension management
• Establish the current level of online
  communications between physicians and patients
• Identify the key factors influencing the success
  of an online hypertension management program
• Two methods were used to elicit physician views
• An online survey
• A series of ten one-to-one interviews with
  physicians

6
The Online Survey and Interviews

• An web-based survey was sent out to 250 primary
  care physicians linked to Partners Healthcare
• 53 physicians responded a response rate of 20
• Characteristics of the respondents
• Aged 33 - 74
• 57 were male
• 87.8 specialized in internal medicine, although
  other specialties were represented including,
  cardiology, nephrology, endocrinology, family
  medicine
• Ten 45 minute interviews were performed with
  physicians
• The physicians interviewed included
• 2 hypertension specialists
• 2 medical managers
• A range of technology usage
• Practices with different demographic
  characteristics
• Interviews were recorded and subsequently
  transcribed

7
Physician views on online activity

• Many physicians are already engaged in online
  communication with their patients
• 50 reported communicating with their patients
  using email
• I encourage patients to communicate with me
  electronically
• I very, very rarely suggest using email
• Patients are generally willing to communicate
  online (77) and are often proactively seeking to
  communicate online (57)
• Mainly patient led Im not proactively
  mentioning it to patients

8
Physician views on online activity

• Physicians are divided on the merits of online
  communication
• Efficiency a slim majority (53) agree that
  efficiency is improved
• Allows me to respond at my convenience
• For patients that do email, they like it it is
  much easier
• Patient care 50 disagree that communicating
  online improves patient care
• However, of those who feel that patient care is
  improved, 17 strongly agree
• The majority (85) believe that the
  Doctor-Patient relationship is not negatively
  affected by communicating online
• Allows me to respond more completely rather than
  a series of disjointed phone messages
• Allows rapid feedback and decreases oscillation

9
Receptivity towards use of online activities in
aspects of hypertension management

• While physicians identified many aspects of
  hypertension amenable to online management,
  certain aspects of management need to be
  performed in clinic

Im happy initiating or altering treatment
remotely I dont mind starting or changing meds
online, but I prefer to co-manage it with a
nurse I definitely wouldnt start a medication
online, but changing a dose might be OK
10
Views towards home monitoring of BP vary across
the physician population

• Home blood pressure monitoring is viewed
  favorably, though the majority do not feel it
  could replace the need for clinic measurement
• Home blood pressure monitoring is viewed as
  reliable (86), easy to do (88), and efficient
  (84)
• The vast majority (92) view home blood pressure
  readings as a useful adjunct to clinic readings
• First thing I do is tell them to buy a blood
  pressure meter
• I actively discourage home blood pressure
  measurements
• The value is that I can get more readings on
  which to base my decisions
• The majority (64) do not believe that home blood
  pressure readings could replace clinic readings

11
Physician requirements to adopt online
hypertension management

• Clinical Requirements
• Demonstrate equivalence of blood pressure control
  using the service with standard clinic-based care
• 67 believed demonstrating equivalence to be
  essential to their adoption of the service
• Demonstrating outcomes is the bottom line
• It would be totally fine for outcomes to be
  equivalent
• Demonstrate improved efficiency over standard
  clinic-based care
• 87 reported that it was essential that online
  communication takes no longer than a normal
  clinic visit
• Need to prove it saved time
• Need to know the impact on doctor workflow

12
Physician requirements to adopt online
hypertension management

• Integration with existing technology
• 71 felt it was essential that the service be
  linked directly to the electronic medical record
• Reimbursement for use of the online service is
  important, although does not need to be at the
  same level as a normal clinic visit
• 87 of respondents reported encountering a large
  amount of non-reimbursed work related to the
  management of hypertension
• The uncertainty of reimbursement made 67
  reluctant to adopt online communication methods
• Nevertheless, 69 were willing to be reimbursed
  at a level below that of a normal clinic visit

13
Physician requirements to adopt online
hypertension management

• Address issues of unrestricted patient access,
  security and increased medical liability
• 42 of physicians agreed, and 42 strongly
  agreed, that the volume of online communication
  from patients concerned them.
• Emails can be overwhelming paragraphs and
  paragraphs that I dont want to read
• I get emails about things they (patients) would
  never call about that is very annoying and
  time-consuming
• Increased medical liability was a concern for
  over half the physicians (52)
• The security of online communication was a
  concern for 46 of physicians

14
Summary

• Physician acceptance is key to the adoption of an
  online hypertension management program
• For widespread physician adoption the following
  conditions must be fulfilled
• Quality of care must be maintained
• Efficiency must be improved
• Some level of reimbursement must be obtained
• The medico-legal concerns of online management
  must be adequately addressed
• Reliable home blood pressure meters must be
  identified
• The service must build upon and integrate with
  existing technology

15
Acknowledgements

• Alastair Bell BMBCh MRCP MBA
• Joseph Kvedar MD
• Khinlei Myint-U MBA
• Doug McClure MIM
• Brian Hammond

16
What are your views on online communication with
patients?
Doctor and patient barriers currently prevent the
full benefits of online communication being
realized

Online communication is a valuable tool in
delivering high quality healthcare
Online communication enhances Doctor-patient
interaction
The mode of contact should be flexible and
determined by patient need
Email is convenient for patients and
doctors Allows me to respond at my convenience
(MF) For patients that do email, they like it
it is much easier (SH)
(3)
There are a number of barriers preventing doctors
extending their use of online communication
Lack of reimbursement inhibits further use of
online communication It is uncompensated care
(TL) If people were paid, a lot more would use
it (BC)
Doctors worry about the security of email
communications I have some background worries
about who is reading the emails I send (SH) I
have some concerns medico-legally (SH)
Doctors are afraid of opening the
floodgates Emails can be overwhelming
paragraphs and paragraphs that I dont want to
read (SH) I get emails about things they
(patients) would never call about that is very
annoying and time-consuming (BC) It is hard to
figure out the rules/boundaries (DB)
(2)
(1)
Dr. Alastair Bell MBA student Dr. Alice Watson
Research Fellow Partners Telemedicine

17
What is the role of online hypertension
management?
Online management is a valuable adjunct to
conventional methods of hypertension care
Doctors recognize the potential benefits of
online hypertension management
Doctors value traditional methods of care
Hypertension is a good disease target for remote
management
Clinic visits play a valuable role in
hypertension management
I think hypertension is an excellent target
there is a great opportunity to improve care
(TL)
Doctors prefer to make a diagnosis in clinic Im
not sure Id trust home measurements to make a
diagnosis (MF) Diagnosis needs to be done in
clinic (MF)
Clinic visits encourage patients to take
hypertension seriously In the initial stages I
would want them to come into the office to
reinforce the importance of the issue
(BC) Initial clinic visits are very important
for getting the message across (MF) The clinic
visit is important to check the patient
understands my instructions (WG)
(2)
Many aspects of hypertension care can be managed
online
Doctors see value in incorporating additional
features It would be useful for side effect
monitoring (MF) Handling blood work could be
done online (SH) More educational content could
be delivered (WG)
Doctors are more comfortable changing dose of
medication than starting new medications Im
happy initiating or altering treatment remotely
(CC) I dont mind starting or changing meds
online, but I prefer to co-manage it with a nurse
(DB) I definitely wouldnt start a medication
online, but changing a dose might be OK (WG)
Remote monitoring could replace some clinic
visits The long term outpatient monitoring is a
good target (MF) If I could rely on the service
then I could see my controlled patients once per
year (TL) Id preferably still see patients
with controlled hypertension once or twice per
year (SH)
(1)
A lack of consensus exists over the role of home
blood pressure measurement
(3)
Dr. Alastair Bell MBA student Dr. Alice Watson
Research Fellow Partners Telemedicine

18
What must be established before you use an online
hypertension management service?
Demonstrate that it makes sense for me and my
patients to participate
3rd party negotiations are required to overcome
key challenges
Research is needed to validate experience and
clinical outcomes
Some level of reimbursement is a key feature
The service should offer an enhanced experience
for doctors and patients
People would be willing to accept a lower level
of reimbursement for a shorter visit (BC)
Recognition for my additional out-of-clinic
contribution There is an emotional thing that
happens when you get reimbursed even if it is a
small payment (SH) Reimbursement is very
important our work should be recognized
(DB) In terms of sustainability there should be
reimbursement built in (MF)
Equivalent medical outcomes are
essential Demonstrating outcomes is the bottom
line (DB) Ideally it would be better than
standard care, particularly time to control blood
pressure (SH) It would be totally fine for
outcomes to be equivalent (MC)
Simplicity is absolutely key (BC)
(3)
(1)
(2)
Dr. Alastair Bell MBA student Dr. Alice Watson
Research Fellow Partners Telemedicine

19
Hypertension eManagement Physician adoption
characteristics
Number of new physicians using service
Time
EARLY ADOPTERS (visionaries)
EARLY MAJORITY (pragmatists)
LATE MAJORITY (conservatives)
LAGGARDS (skeptics)
20
Hypertension eManagement is a disruptive
innovation
Disruptions of health professionals1

• Hypertension is ripe for a disruptive innovation
• Well understood, easily measured, can be managed
  at a rules based level
• Disruptive innovations bubble up from beneath
  established systems / players and re-shape the
  industry
• Framing hypertension eManagement as a disruptive
  innovation helps explain the active resistance of
  many physicians
• eManagement disrupts standard health institutions
  by shifting components of care out of the office
• eManagement, if instituted in conjunction with a
  nurse practitioner, also disrupts the role of the
  physician
• Physicians with vested interests in the status
  quo will want to see eManagement fail

1 Will Disruptive Innovations Cure Health Care by
Christensen, Bohmer, Kenagy in Harvard Business
Review (Sept-Oct 2000)
21
Appendix 1 - Results of the online survey (1)
(2) Of those visits requiring management of
hypertension in what proportion is hypertension
the SOLE REASON for the visit?
(1) What proportion of your clinic visits involve
hypertension?

• Approximately 28 of office visits involve
  hypertension
• A far smaller percentage (14) of those office
  visits are only addressing hypertension
• If the service completely replaced the need for
  clinic visits (unlikely) it would save only 4
  of total clinic visits

22
Appendix 1 - Results of the online survey (2)
(3) On average how many visits does it take to
achieve adequate blood pressure control after the
diagnosis of hypertension is confirmed?
(4) While adjusting the treatment regimen to
achieve blood pressure control how often (on
average) do you see patients?
(5) Once someone achieves blood pressure control
how frequently do you follow them up in clinic
for their hypertension?
(6) How long is the average clinic visit that
deals only with hypertension? ?
23
Appendix 1 - Results of the online survey (3)
(7) How many hours do you spend managing your
hypertensive patients outside of normal clinic
time? (e.g. phone calls, checking results,
arranging further tests)
(12) What methods to you use to communicate with
your patients? (check all that apply)
24
Appendix 1 - Results of the online survey (4)
(8) To what extent do you encounter the following
when managing hypertensive patients?
25
Appendix 1 - Results of the online survey (5)
(11) What is your reaction to each of the
following statements regarding home blood
pressure monitoring?
26
Appendix 1 - Results of the online survey (6)
(13) To what extent do you agree with the
following statements regarding online (email or
web-based) communication with patients?
27
Appendix 1 - Results of the online survey (7)
(14) To what extent do you agree with the
following statements regarding barriers to your
further use of online (email or web based)
communication
28
Appendix 1 - Results of the online survey (8)
(16) What aspects of hypertension management do
you feel are amenable to being managed online?
(check all that apply)
(15) Do you believe that aspects of hypertension
can be managed online
29
Appendix 1 - Results of the online survey (9)
(18) For you to start managing hypertensive
patients online what would need to be
demonstrated about the online management service?
30
Appendix 2 Summary of physicians interviewed
Physician
Specialty
Principle function
Technology position1
General notes on practice2

• 1 Technology position was judged by relative
  progress with implementation of the longitudinal
  medical record (LMR).
• Advanced more than 5 years experience
• Intermediate less than 5 years experience
• Beginner yet to implement the LMR
• 2 Demographically diverse implies that the
  practice served significant numbers of
  non-English speaking patients

31
Appendix 3 Interview questions Part 1

• Part 1 - Establish current behavior with respect
  to hypertension visits
• Goals
• Method of management
• Workload
• Attitudes towards hypertension consults
• Complexity
• Difficulty of consult
• Frustrations / inefficiencies / pain points
• Questions
• When managing a patient with newly diagnosed
  hypertension how many visits, on average, does it
  take to achieve blood pressure control?
• How would you manage a newly diagnosed
  hypertensive patient
• Prompts protocol? No. clinic visits? Frequency
  of readings? Encourage home readings? Use of
  targets? Long term maintenance plan
• How do hypertension consults fit into your day /
  how do you view hypertensive consults compared to
  other consults?
• Prompts No per day? Hypertension only or
  multi-problem visits? Confident in managing? Look
  forward to them / dread them? Free-up time for
  other patients / consults the quickie visit?
• Describe any frustrations you have when managing
  your hypertensive patients?

32
Appendix 3 Interview questions Part 2

• Part 2 - Establish current remote communication
  with patients
• Goals
• Amount
• Content of correspondence
• Limitations
• Other online activities
• Questions
• Describe any current remote communication with
  patients email, phonecalls, texts etc.
• Prompts form and content of communication? Other
  online activities use Relayhealth already?
• What advantages, if any, does online
  communication offer?
• Prompts efficiency (time saving), cost savings,
  convenience, meets patient demand
• What prevents you from extending your use of
  online communication?
• Prompts medical liability, lack of
  reimbursement, patient acceptance, difficulty
  usingLack of data on hypertension readings?
  Difficulty getting patients to engage with
  management plans?

33
Appendix 3 Interview questions Part 3

• Part 3 - Establish attitudes towards online
  service
• Goals
• Intrinsically feel good idea or bad idea
• Reservations / attitude towards moving management
  to remote consult
• Elements of hypertension management that could be
  managed remotely
• Barriers to online model
• Proofs required to adopt (economic? Quality of
  care / health outcome? Patient demand)
• Questions
• We are developing a system for managing
  hypertensive patients online, do you feel
  hypertension is a good target for a remote
  consult model? Why?
• Which elements of the management of your
  hypertensive patients do you think could be
  managed on line? Why? What stops other aspects
  from being managed online?
• Prompts Diagnosis, treatment titration,
  organizing associated tests, maintenance visits
• What functionality would you like built into a
  service?
• Prompts home blood pressure readings, e-scripts,
  video-messaging, text messaging, audio messaging,
  education support (to Dr. and patient), ability
  to obtain second opinion within system,
  discussion board, feedback mechanism for sharing
  experience learning with the system
• How many blood pressure readings should people be
  taking at home to best guide your management?
• What would we have to demonstrate about the
  service to drive your / your colleagues
  adoption?