Exploring the Use of Personal Health Records in Diabetes Management A Pilot Study Linda Wells Freiberger, FNP-C, MSN

Acknowledgments The project described was supported by 1 U56 AE from the Department of Health and Human Services. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Department of Health and Human Services.

Contextual Background JUBILEE COMMUNITY HEALTH  A nonprofit (501c3) health clinic established in 1999 in Paoli, Indiana  Mission: To provide low fee-for-service primary care to uninsured populations  Partially supported through IU Health-Paoli and local community grants  Self-pay population for health care

Diabetes Costs  Estimated costs associated with diabetes as of 2007(NIH, 2011) Direct Medical Costs $116 billion—after adjusting for population age and sex differences, average medical expenditures among people with diagnosed diabetes were 2.3 times higher than what expenditures would be in the absence of diabetes Indirect Costs $58 billion-disability, work loss, premature mortality. Total Costs$174 billion, medical related expenses are twice as high in people with diabetes than those without.

Diabetes  Diabetes is a serious, costly and preventable chronic disease in the US. –As of 2010, 25.8 million(8.3%) have been affected in the US (NIH, 2011). –In 2011, 10.1% of Indiana adults reported having some form of diabetes(ISDH, 2012). –Racial/Ethnic and socioeconomically disadvantaged groups experience the steepest increases and the most substantial effects from diabetes (Beckles et al, 2011)

Study Goal and Objectives  Goal –To explore the use of a PHR by rural, uninsured patients with diabetes  Objectives –Texting and PHR use to improve glucose outcomes –Shared care between clinician and patient using PHR  Methodology –Use of a convenience sample (N=28) –Pre/Post Variables Examined A1c Glucose levels

Results  Early findings – –most were attempting use within 1 month –After 6 months 35.7% were actively engaging in PHR use and recording glucose readings

FINAL FINDINGS Glucose Controlled No Glucose Improvement 28.6% 21.4% 21.4% *N= 28 with 50% drop out *Calculations based on participants who completed the study

Patient Portal

PHR Member Summary

Data Sharing

PHR Glucose Log

Immediate Feedback Normal Glucose Message High Glucose Message

Benefits of Engagement  H. H. –“Oh, I will just go to the library and enter my sugar readings.” –Home PC failed during the study –Unable to afford A1c levels –Continued testing and entering glucose levels in PHR –Improved glucose: mg/dl

Benefits of Engagement “I stopped eating bags of candy at one time.” K. P.

K.C. The Super Engaged Patient 11/11 A1c= /12 A1c = 8.2 8/12 A1c = 6.2

ED VISITS & ADMISSIONS 6 Months Prior  1 ED visit  1 Admission 6 Months Post  7 ED visits –Trauma x 2 –Chest pain x 2, MI x 1 –Abdominal mass –Extended psych med/suicidal ideation  4 Admissions

Burden of Poor Engagement and Inadequate Self-care Management  S. B. Suffered Acute MI with stent placement in September 2012 –Estimated cost stent $12,978 –Estimated hospitalization cost $5,151 –Estimated ED visit charges $334 *Estimated Direct Variable Costs = $18,463

COST EXERCISE $20,000 Estimated cost 1 patient MI with stent $1,840,000 Estimated cost of treatment 1 uninsured patient per county in Indiana

Burden of Poor Engagement and Poor Self Care Management  E. C. Suffered amputation of a toe –Estimated total cost $11,271 Physician $ Hospital (~ per day) Anesthesia (1 hour, 15 minutes) (

Outcomes  Enhanced patient – clinician engagement  Potential to improve clinical outcomes of patients with diabetes  Uninsured populations can use Health Information Technology (HIT) tools to improve self-care management of chronic disease  Potential to reduce health care costs