The modern approach to the care of patients with chronic cardiovascular disease (CVD) embraces a system that provides increased access to healthcare providers and creates a communication and education system that engages the patient, provides motivation for self-care, and allows frequent feedback to maintain optimal health status. Episodic care for patients with chronic diseases such as heart failure (HF), stable angina, diabetes, and others is costly and inefficient. Such an episodic approach to care also risks leading to deteriorating health as the patient is subjected to recurrent acute exacerbations of their illness that often require heroic therapies; by contrast, a system of continuous surveillance with frequent small changes in care prevents acute recurrences.
Management of the pre-symptomatic phase of heart disease (hypertension, hyperlipidemia) is best achieved using a patient-centered approach that incorporates patient participation, improved health literacy, and monitoring of patient status through frequent communication between patient and healthcare provider. Nurse management has proved effective in improving diabetes,1 hyperlipidemia,2 and hypertension.3 Considering that the prevalence of these disorders is increasing disproportionately to the number of physicians and nurses, information technology could provide a solution for maintaining or improving clinical outcomes while containing costs.
A chronic care system should provide for measures of compliance, outcomes measurement, and routine reporting and feedback to patient, physician, health plan, and ancillary providers. Frequent surveillance of HF patients improves patient care and clinical outcomes.4 Provider-initiated telephone surveillance has been shown to reduce the incidence of acute exacerbations of HF,5 but is labor-intensive and expensive because direct phone contact with the patient by trained staff is needed to maintain the telephone surveillance system. The development of Internet-based communications offers a means to provide patients with access to their healthcare providers without traveling to an office or clinic and without depending on direct telephone contact. Internet-based systems can provide a framework for chronic medical management that facilitates patient–physician communication, personalization, and education but avoids the need for direct communication with a healthcare provider. A software-based disease-management system can be rapidly updated as new medical guidelines are developed, and is portable with no hardware required beyond a scale, sphygmomanometer, and access to the Internet.
Telemedicine System
We have used an Internet-based Telemedicine system to manage HF and CVD risk. The Telemedicine system (InSight Telehealth Systems, LLC, Valley Forge, PA) is a disease-management interactive health surveillance system comprising a secure Internet server and a database. Details of the Telemedicine system have been described in previous publications.6,7 This system provides Internet access to a personal health record (PHR) focused on CVD. The server contains the PHR database linked to a browser interface through secure firewalls. This arrangement allows patients to send data directly to their care provider via the Internet. Patient health information and the communication transactions are stored in the database. The website is divided into a patient domain and a provider domain. Each requires a login ID and password. This system provides Health Insurance Portability and Accountability Act of 1996 (HIPAA)-compliant 128-bit encryption with a secure socket layer and a public key infrastructure so that medical information is safely transmitted via the Internet.
Internet-based Chronic Disease Management
The foundation of our Telemedicine system (see Figure 1) is the PHR, which contains the information needed to follow a specific medical condition and make the required changes in therapy to maintain optimal care. Patients have the ability to self-monitor, review health trends, medications, and guidelines, and access educational information. Patients can access the Telemedicine system either by phone or by the Internet to transmit health data (i.e. weight, activity, blood pressure) via the Telemedicine system, as well as to send and receive messages to and from the practice. The Telemedicine system presents patients with several web screens (messages from their healthcare provider, input, medications, laboratory values, and a learning center). The input web screen prompts data entry of blood pressure, weight, minutes of activity, and symptoms. There is also a section on the data entry page for patients to type in messages for the healthcare team. Data can be entered daily, or several days’ data can be entered at one time. Patients can review all entered data, including medications and laboratory values, on the screen. Educational information about their disease, nutrition, exercise, smoking cessation, etc. is available in learning modules on the website.
Heart Failure Disease Management
An example of a chronic condition that produces frequent symptoms is HF. Patients with advanced HF are often symptomatic and require continuous surveillance to maintain a stable medical state. These patients are aware of their condition due to recurrent symptoms and have a need for constant communication with their healthcare providers. These patients can benefit from a Telemedicine communication system to maintain stable health status. HF is one of the most common causes of hospitalization in the US, costing more than $24.7 billion annually in direct medical expenditure, with more than 980,000 annual hospital admissions.8 Thirty-day re-admissions for HF average 27% of discharges.9 Often patients discharged after therapy for HF are not seen in follow-up for several weeks and experience exacerbation of symptoms due to inadequate medication compliance or incomplete education regarding diet and salt and water intake. Previous studies showed an annual average of 3.2 admissions totaling 26 days per HF patient.10 Using HF medications alone without ongoing management and surveillance does not provide optimal outcome at 90 days. With intensive home monitoring, Kornowski et al.10 reduced hospitalizations to 1.2 admissions per year. In a study from our center, we recorded one admission/patient/year in a group of HF patients who reported their health status using a specially designed Internet-based communication system, while patients provided with usual care experienced 1.7 admissions/patient/ year. As the number of elderly patients increases over the next two decades, it is anticipated that there will be a large increase in the number of HF patients requiring chronic care.11 To manage these patients, innovative methods of communication and access are needed. The growing use of the Internet provides a basis for both improving access to healthcare and increasing communication with physicians and nurses who provide their care.
We studied 48 patients with class II–IV HF who were randomized to standard care or standard care plus Telemedicine surveillance. This study7 sought to determine whether managing HF patients using the Telemedicine system could reduce the number and days of hospitalization. Emergency room visits were lower in the Telemedicine group. Re-admissions (see Figure 2) were significantly higher in the usual care group and hospital stays were significantly longer (p<0.025). Outpatient clinic visits, both scheduled and unscheduled, were similar for both groups.
Cardiovascular Disease Risk Reduction
Patients with increased risk for CVD may be unaware of their risk if hyperlipidemia or hypertension are undetected, as these patients are often asymptomatic. These patients benefit from a Telemedicine system for tracking their risk while asymptomatic and gain improved health by avoiding the long-term effects of high CVD risk. Although CVD continues to be a significant cause of morbidity and mortality in the US, recent data have demonstrated a significant reduction in CVD mortality, in part related to more aggressive management of modifiable CVD risk factors.12 While mortality from CVD is diminishing, several populations have not shared in this reduction. In particular, ethnic minorities and medically under-served populations are at increased CVD risk due to a high prevalence of obesity with accompanying glucose intolerance, hyperlipidemia, and hypertension;13 also, in under-served populations, lack of risk assessment and subsequent intervention allows these conditions to persist until an actual cardiovascular event occurs (heart attack, new angina, sudden death, or stroke).
Management of the pre-symptomatic phase of these disorders is best achieved using a patient-centered approach that incorporates patient participation, improved health literacy, and monitoring of patient status through frequent communication between patient and healthcare provider.
In a study of asymptomatic subjects with high CVD risk, we compared a nurse-managed CVD risk reduction program with a nurse management system augmented with Telemedicine communication. The Telemedicine system allowed subjects living in urban and rural medically underserved communities to report their weight, blood pressure, and physical activity and to receive frequent feedback regarding CVD risk management. We focused on blood lipid and blood pressure management as these involve both practice and patient participation to achieve treatment goals.
We studied 465 patients with a 10% or greater 10-year Framingham risk for CVD14 who were randomized to nurse management or nurse management plus Telemedicine communication. The patients were provided with resources for measuring blood pressure, weight, and daily activity at home and were followed for one year, with the primary end-point being a 5% reduction in their 10-year CVD risk.
Nurse Management. Nurse management involved office encounters with our research nurses at four-month intervals for one year. All subjects were provided with a digital sphygmomanometer, a scale if needed, and a pedometer to count their steps per day. Subjects were instructed to record their data (weight, blood pressure, steps/day, and cigarettes/day) at least weekly and enter the data in a logbook, which was reviewed quarterly during a clinic visit with a research nurse. Subjects received education and counseling regarding healthy lifestyle behaviors (blood pressure goals, weight loss, diet, smoking cessation, physical activity) at baseline and at each clinical encounter.
Telemedicine. Subjects in the Telemedicine group were provided with the nurse management program described above. In addition, each subject was provided with a login name and password to gain access to the secure Internet-based Telemedicine system and received instructions on how to access and use the Telemedicine system. Laboratory data and medications were entered into the Telemedicine system by a research nurse, and were accessible to the subject via the Internet. To increase computer access for subjects in the Telemedicine group, we identified community centers and libraries where Internet access was available.
Both nurse management and Telemedicine communication proved to be successful in reducing overall CVD risk. Communication between subjects and the research nurses in both groups provided the needed support to improve CVD risk. The subjects were provided with their individual lipid and blood pressure data and encouraged to discuss their CVD status with their physicians.
Because we expected a proportion of the subjects to reach goal in the two groups, we separated the total cohort into those who reached the goal of ≥5% reduction in Framingham score and those who did not. One hundred and twelve subjects (28.6%) achieved an improvement of ≥5% in their Framingham score. Table 1 shows the initial and final Framingham scores for the subjects who reached the goal of ≥5% reduction and those who did not. Improvements in score for both groups was significant at p<0.001. There were no differences in demographics between those who reached goal and those who did not. Those who reached goal had significantly higher initial risk scores than those who did not reach goal.
There were no differences in baseline score or in the final score when comparing nurse-managed subjects and Telemedicine subjects. The high baseline score was the main distinguishing feature of the group who reached goal. The greatest improvement in blood pressure occurred in the first four months of the study, and these improvements were sustained throughout the one-year study period (see Figure 3). The data suggest that Telemedicine may be useful for managing grade I hypertension, and indicate that patients with high CVD risk scores can lower risk through an education and surveillance system.
Cost of care should also be considered when using a clinic care system. Finkelstein et al.15 compared per-visit cost of traditional skilled nursing care at home ($48.27) with virtual visits using video-conferencing technology ($22.11) and with virtual visits using video-conferencing technology plus physiologic monitoring ($38.62) for the underlying chronic condition. They showed improvement in patient outcome at a lower cost with video-conferencing than with traditional skilled home healthcare visits. A system without video monitoring would cost even less.
Conclusions
Chronic heart disease is increasing in frequency as the populations of the US and other countries become older and improvements in therapy allow patients with chronic heart disease to survive longer with chronic cardiac conditions. Therapy for chronic heart disorders requires frequent surveillance. The use of Internet communication methods shows promise in allowing frequent access by patients to their providers without the need for frequent office visits or telephone calls between providers and their patients. The concept of the patient-centered medical home is an ideal basis for use of such communication systems.