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A Chat with our Experts

Understanding how patients use eHealth technology

Dr. Donna M. Zulman is a physician-investigator at VA HSR&D's Center for Innovation to Implementation in Palo Alto Calif., and an assistant professor in the Division of General Medical Disciplines at Stanford University. Her research focuses on improving health care delivery for patients with multiple chronic conditions and complex health care needs. She is also interested in optimizing health-related technology to personalize care and improve outcomes for patients with complex needs.

She is the lead author of a study titled "How Can eHealth Technology Address Challenges Related to Multimorbidity? Perspectives from Patients with Multiple Chronic Conditions," which was published in the Journal of General Internal Medicine's August 2015 issue. She spoke with VARQU about the study and her work in the area.

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Dr. Donna M. Zulman, with Stanford University and VA's Center for Innovation to Implementation in Palo Alto, has studied how patients with chronic disease use "eHealth" technology such as phone apps and VA's My HealtheVet website. (Photo by Joseph Matthews)

Dr. Donna M. Zulman, with Stanford University and VA's Center for Innovation to Implementation in Palo Alto, has studied how patients with chronic disease use "eHealth" technology such as phone apps and VA's My HealtheVet website. (Photo by Joseph Matthews)

VARQU: Would you tell us about the new study and its parameters?

Zulman: This was a study of patients who have multiple chronic conditions—for example individuals with diabetes, heart failure, cancer, and depression—who frequently encounter numerous and complex self-management tasks related to their different health issues. The goal was to understand how these patients currently use technology to manage and make sense of their health care, and to identify opportunities to provide better services for them in the future.

We first conducted a large survey with patients at a VA and an academic hospital to identify patients who had multiple chronic conditions, and who were already using technology—because we wanted to hear from the experts, in a sense. Then we conducted ten focus groups with patients to learn more about their technology use and needs.

What did you learn about how Veterans use eHealth technology?

There is a lot of discussion about a "digital divide" [the gap between those who have ready access to computers and the Internet and those who do not], and a common perception is that older adults and patients with more complex health issues are not really using technology.

Actually, we found that patients with multiple health issues are using technologies in a whole spectrum of different ways. They're using the Internet to find information; they're using email and secure messaging to communicate with providers; they're using social media to connect with other patients and with their caregivers, who are often at remote locations. They also use mobile apps and web-based programs to support their day-to-day activities, to track their health issues and medication use, and to support their decision making about treatments.

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Volunteer Ralph Stott, an Army Veteran, helps former Marine Clyde "Jess" Jesse get acquainted with VA's My HealtheVet website at the Captain James A. Lovell Federal Health Care Center in North Chicago. (Photo by Jerry Daliege)

Volunteer Ralph Stott, an Army Veteran, helps former Marine Clyde "Jess" Jesse get acquainted with VA's My HealtheVet website at the Captain James A. Lovell Federal Health Care Center in North Chicago. (Photo by Jerry Daliege)

For this study we selected for patients who already used some tools, because we wanted to hear from them about the challenges they were having, and their desires for future health care technology. But it was remarkable to hear about the range of technology that is in use, regardless of patients' age and health status and the presence of mental health conditions like PTSD and depression.

Is there a relationship between the conditions patients have and the technologies they use?

It's an interesting and important question, but the study wasn't really structured to answer it since we didn't have enough patients to correlate individual conditions with the specific types of technology that were used.

We did observe some interesting patterns in terms of types of technology used by older and younger patients. Older Veterans typically described using relatively older technologies, such as computer spreadsheets and health-related websites, although many also used My HealtheVet to communicate with their doctors, and several showed us mobile apps (programs on their phones) that they use to track their blood sugar and other health data.

Younger Veterans were more likely to use social media and newer communication technology such as Skype. We had a fascinating discussion with a group of younger women Veterans with PTSD who described how they regularly use Facebook to access their social network when they feel down or anxious.

What specific apps were Veterans using?

Patients were using apps on their phones to monitor specific conditions, like blood sugar levels and blood pressure, and to remind themselves about appointments and medications. They also used them to manage mental health symptoms like depression and anxiety. Several Veterans reported using the PTSD app that VA developed, which provides information and activities to help with symptoms. Younger patients described using Facebook to connect for social support, especially around mental health conditions and active symptoms.

We also found some patients with rare conditions were reaching out to international online communities to try to learn more about their disease and treatment options. Many patients used secure messaging to communicate with doctors, and some had used videoconferencing for virtual clinic visits with remote providers, especially doctors at specialized institutions.

What technology doesn't exist now that either your study indicated would benefit patients, or that patients themselves indicated would be beneficial in the future?

What emerged from the groups was that there is a lot of useful disease-specific technology, but there are very few applications and tools that help them with the complexity they have to manage due to having multiple different health issues that span different specialties.

We heard that many patients were getting care from multiple providers across different institutions, both inside and outside VA, and they wanted to be able to share their records across systems. That is currently very difficult—so they either want a portable medical record or some sort of uniform platform so that their records are easily transferred from place to place.

Patients also described a need for technology that consolidates information about all of their different conditions and medications. That's sometimes a challenge. And they wanted to be able to synthesize and reconcile information across different conditions, so that when they were taking medications, they could be sure that there weren't interactions between those medications.

And on the social media side of things, patients were interested in connecting with other patients who had similar constellations of issues. That was sometimes a challenge, because there are a lot of support networks for significant diseases—but those networks can be harder to find for someone who is simultaneously managing, say, diabetes and depression. It's hard for them to find a community of people who are struggling with the same issues.

What conclusions did your team draw, and what recommendations for future action did you make?

There are a lot of opportunities in patient-facing eHealth technology, but we're still in the early stages of developing these tools. So far, tools have been very much focused around specific diseases and specific tasks. We need to take a broader view of all of the patient's needs, and develop tools that can coordinate and synthesize information across conditions and support their needs in a more holistic way.

When it comes to communication technology, we need to make sure that patients can communicate with all of their providers and caregivers—in a synchronized way when possible—so that everyone working with the patient weighs in, reconciles information across all of the patient's conditions, and is on board with the patient's treatment plans.

VA provides care for a lot of patients who have extremely complicated needs across a lot of different medical and mental health issues. Polytrauma patients are a clear example of this. Their needs span different specialties, and there are a lot of clinicians and caregivers involved in their care. Building tools that will support these patients as individuals, rather than their specific diseases, is where we need to go in the future.

What other research have you done in this area and what are you doing now?

A couple of years ago, we completed a big survey of Veterans who were using My HealtheVet, in which we found that the vast majority of them were interested in sharing their health records with others, either family members who were caregivers or providers outside VA. This was somewhat a surprise as many of us thought that patients' privacy concerns would trump their desire to share information. At the time, My HealtheVet did not offer patients the option of authorizing a caregiver or outside provider to access their records, but there is now movement to change that.

We're doing a lot of work right now to develop new care models for Veterans with complex health issues who are at high-risk of hospitalization. We're piloting a program for patients to try to address all their needs in a very patient-centered way, using a multidisciplinary team. Part of that involves using telehealth to support chronic disease management, and getting patients signed up for My HealtheVet to facilitate communication with their providers. And we've found that the program significantly increases high-risk patients' use of these services.

Another area that we've started to look into is how we integrate information about social risk factors and needs into the electronic health record. A lot of patients face financial and social challenges outside of their immediate clinical needs. We're trying to learn how we can make that information available to providers at the point of care so that we can provide patients with social services and support that will improve their health and well-being.

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