A New Prescription for Improved Patient Outcomes: Chronic Disease Management with Automated Telephone Monitoring

Chronic diseases are among the most prevalent and costly of all health problems in the United States [1]. The pervasiveness of chronic disease accounts for three quarters of total national health care expenditures [2]. Over 90 million Americans suffer from one or more chronic diseases, and they account for 7 of every 10 deaths. [3] 

Chronic disease is recognized as a prolonged condition(s) that often does not improve and is rarely cured completely. Thrombosis, congestive heart failure, diabetes, depression and asthma, are just a few examples. If the monitoring for patients suffering from chronic disease is less than optimal, the repercussions can be extensive, ranging from adverse medical events or hospital readmission to, in some cases, death. Poor patient monitoring is frustrating, causes additional work and unnecessary stress for medical staff.

Medical health professionals know quality clinical information – which often involves continuous monitoring and treatment adjustment – is key to chronic disease management.
For example, in the case of thrombosis, a chronic disease characterized by the development of clots in blood vessels, patients must maintain an optimal level of a blood-thinning agent in their bodies. Regular blood testing is required to assess the need for possible, and sometimes frequent, adjustments to their dosage of blood thinner. The high level of human interaction required for patient test scheduling, rescheduling test if patients fail to show up, communicating test results and dosage changes has lead to optimal disease management that is often beyond what healthcare systems can afford.

Automated calling for effective disease management
As health care institutions endeavor to improve chronic disease management programs, more and more are shifting their focus to interactive voice response systems (IVRS) to assist with patient monitoring. IVRS are automated calling systems that deliver two-way, phone-based monitoring or education. They are speech-enabled and capture, analyze and store information. Alerts can also be provided when intervention is required. Implementations involving screening for disease symptoms and communicating changes to prescription dosages have also been explored. So far, the results show IVRS’s are making a significant impact on the overall improvement of chronic disease management.

These systems are compelling because:

IVRS reduce overhead costs: Traditional disease management, appointment reminder, and administrative phone calls require the time and effort of a nurse, administrator, or other staff at a high cost. The nature of call-back monitoring programs can cause workload to bottleneck for several reasons: (1) it may take several tries before patient contact is established, (2) patient follow ups and symptoms are not always collected in a standard, thorough manner, and (3) the nature of shift work and multiple attempts to establish patient contact can lead to incomplete profiles. These elements, along with the national shortage of health care staff, can cause the nurse call-back process to become convoluted and costly.

Health care institutions have used IVR technology to make the initial call to assess a chronically ill’s health status or notify patients of changes to their dosing. The IVRS can be programmed to retry patients until the call is answered by the patient. Once patient data is collected, the IVRS has the ability to consolidate data, track and flag issues immediately. In a recently published study at the Ottawa Hospital Thrombosis Unit, in Ottawa, Ontario, the clinic looked at the effect of an IVR system on an oral anticoagulant management. The clinic experienced an impressive 33% reduction in staff work load. Additionally the independent study found that there was also a 25% increase in appointment attendance when automated reminder scripts were incorporated.

Phone calls offer ubiquity and immediacy that beats the Web. While the Internet has made great strides in reaching a high percentage of the population, it is still not as ubiquitous as the telephone. [4] Keeping in mind, the phone is a critical channel for reaching the growing senior population, of which only 52% of whom go online at least monthly. [5] In addition to the phone’s advantage in terms of adoption rates, outbound calling provides a degree of immediacy that the Web can’t match.

As speech recognition technology becomes more robust, speech self-service application becomes more common in our daily lives. Significant advancements in speech acoustic models in IVRS’s have enabled systems to recognize non-standard but otherwise correct responses. CallAssure, by Vocantas Inc, for example, has been selected for use in a number of independent clinical studies because it uses Nuance speech recognition software. Nuance is recognized for its 97% accuracy when responding and recording responses – this is 16 points higher than human to human audibility and recognition. The health care industry can confidently adopt this technology becoming more innovative while increasing their reach in patient monitoring.

Patients prefer phone outreach. A study of automated patient assessments after outpatient surgery showed a high patient acceptance rate, where two-thirds of the patients expressed a preference for the automated system over a personal follow-up call. Patients remembering the automated call also reported the system easy to use (82%) and comprehensive (86%). [6]  Interestingly, patients felt that they could be more honest with the automated system, as there was no immediate judgment or bias associated to their responses.

Automated calls deliver high value and positive outcomes. Another independent study found that an automated system is just as effective as a human in communicating with thrombosis patients about frequent dosing adjustments required to prevent blood clots. CallAssure, the solution used in the independent study, kept thrombosis patients in the proper dosing range an impressive 80% of the time, up from the 56% more typically seen in the region. [7]  The IVRS interaction also encouraged an overall patient compliance in that the automated contact and questions helped patients continue taking their medication and remain involved in their care plan. “Automated telephone systems have become fairly common in health care and other fields, but this is the first study to look at providing therapy instructions without human intervention,” said the study’s senior author Dr. Alan Forster. “We are very encouraged by these results and pleased that all our patients will now have an opportunity to benefit from this system.”

The real victory in this study is the information gathered by the system showed health care professionals many of their patients in the monitoring program were in good condition. With calling and scheduling tasks addressed, health care professional could focus on the patients in need of hands-on care and expertise the most.

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Health care professionals understand chronic illness can have a profound effect on a patient’s physical, emotional and mental well-being. However, in many cases, deterioration in health can be minimized by effective monitoring. Medical institutions should investigate further how IVRS can contribute to the improvement of their chronic disease monitoring program. IVRS have demonstrated they can be a supportive alternative that fit seamlessly into any IT and phone systems and enable health care providers to effectively and efficiently monitor patients remotely. With more resources freed to focus on chronic disease management, skilled clinical resources can be put to better use by devoting time to patient care rather than spending unproductive time trying to reach patients by telephone.
So, why isn’t every health institution using it?

References:
[1] CDC. Indicators for chronic disease surveillance. MMWR Recommendations and Reports. 2004 September 10, 2004:1-6.
[2] Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002 Oct 9;288(14):1775-9.
[3] CDC. Chronic disease prevention. Atlanta, GA: U.S. Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion; 2006 [updated 2006; cited 2006 December 13]; Available from: http://www.cdc.gov/nccdphp/.
[4] According to the North American Technographics® Benchmark Survey, 2008, 86% of US households have a landline, and 81% have at least one mobile phone, while only 73% are online at least monthly. Penetration of the Internet in US homes is slightly lower, at 71%.
[5] According to the North American Technographics Benchmark Survey, 2008, 52% of seniors (defined as those 64 and older) go online at least monthly.
[6] Alan J. Forster et al. Automated Patient Assessments After Outpatient Surgery Using an Interactive Voice Response System. American Journal of Managed Care 2009 July;  14:429-436.
[7] Natalie Oake MSc, Carl van Walraven MD MSc, Marc A. Rodger MD MSc, Alan J. Forster MD MSc. Effect of an Interactive Voice Response System on Oral Anticoagulant Management. Canadian Medical Association Journal 2009 180(9):927-33.