Patient-centered care is a vision for American health care in the 21st century. We have developed a Customized, Continuous Care Management (CCCM) model that actively supports a partnership between the patient and his/her multidisciplinary care management (CM) team using an online disease management (ODM) system. The CM team includes a care coordinator (CC), a clinical pharmacist, and the patient's physician(s). The ODM system is integrated with a comprehensive electronic health record (EHR) system that includes a personal health record (PHR) and secure patient-clinician messaging capabilities. We propose to rigorously evaluate our CCCM program for diabetes care, including medication management as a central focus of the intervention protocol. Historically, management of diabetes has been a good model for the care of other chronic diseases. Although treatment advances in diabetes offer the hope of reducing the mortality and morbidity of diabetes, treatment and adherence gaps still exist. Innovative interventions, particularly those that empower and support patients'active participation in the management of their health, are needed. We will evaluate the CCCM program, compared to usual medical care (UC), in a 2-arm randomized controlled trial (RCT) at the Palo Alto Medical Foundation (PAMF), a large, community-based, multi-specialty ambulatory care setting. We will randomize 400 established patients (200/arm) who are = 18 years of age and who have inadequately controlled T2DM (hemoglobin A1c [A1C] >7.5%) without severe complications, to CCCM or UC. A1C and a battery of secondary outcome measures will be assessed in both groups by lab testing, by EHR data extraction, and by an online questionnaire at baseline and at every 4 months post-randomization for 12 months. Our primary hypothesis is that patients in CCCM will have lower A1C at 12 months post-randomization than those in UC. Our secondary hypotheses are that compared with UC, CCCM will be associated with improved self-management practices, better processes of care, lower cardiovascular risk, enhanced patient experience and satisfaction, and improved patient psychosocial wellbeing at 12 months. We also will explore how and for whom intervention effects occur and document health care utilization by group. Based on successful outcomes of this study, we will deploy the CCCM program throughout PAMF and Sutter Health, a large healthcare system. Our CCCM program builds upon CM strategies proven effective in past studies and creates an ODM system that is built upon and fully integrated with a leading, commercially available EHR product - providing a blueprint for instituting customized, continuous care management for many different chronic conditions in a range of ambulatory care settings.
| Tang, Paul C; Overhage, J Marc; Chan, Albert Solomon et al. (2013) Online disease management of diabetes: engaging and motivating patients online with enhanced resources-diabetes (EMPOWER-D), a randomized controlled trial. J Am Med Inform Assoc 20:526-34 |
