TLC-Asthma: an integrated information system for patient-centered monitoring, case management, and point-of-care decision support.

TLC-Asthma: An Integrated Information System for Patient-centered Monitoring, Case Management, and Point-of-Care Decision Support William G. Adams, MD1 , Anne L. Fuhlbrigge, MD2,3, MS, Charles W. Miller1 , Celeste G. Panek1 , Yangsoon Gi1 , Kathleen C. Loane, RN 3 , Nancy E. Madden, RN 3 , Anne M. Plunkett, NP3 , and Robert H. Friedman, MD1 1 Boston University School of Medicine/Boston Medical Center, 2 Channing Laboratory, Brigham and Women's Hospital, Harvard Medical School, and 3 Harvard Vanguard Medical Associates, Boston, MA ABSTRACT A great deal of successful work has been done in the area of EMR development, implementation, and evaluation. Less work has been done in the area of automated systems for patients. Efforts to link data at multiple levels – the patient, the case manager, and the clinician have been rudimentary to-date. In this paper we present a model information system that integrates patient health information across multiple domains to support the monitoring and care of children with persistent asthma. The system has been developed for use in a multispecialty group practice and includes three primary components: 1) a patient-centered telephone-linked communication system; 2) a web-based alert reporting and nurse case-management system; and 3) EMR-based provider communication to support clinical decision making at the point-of-care. The system offers a model for a new level of connectivity for health information that supports customized monitoring, IT-enabled nurse casemanagers, and the delivery of longitudinal data to clinicians to support the care of children with persistent asthma. Systems like the one described are well-suited, perhaps essential, technologies for the care of children and adults with chronic conditions such as asthma. INTRODUCTION The application of information technology to medical care involving patients as users has traditionally relied on stand-alone desktop computers in patient homes.1,2 More recently, advances in telecommunications technology have made it possible to link patients in their homes to computer networks via computer, telephone, and other devices3 – creating new opportunities for the application of information science to support the ambulatory care of patients and consumers. These new technologies are especially well-suited for the monitoring and care of chronic conditions such as asthma. Asthma is the most common chronic disease of childhood and its prevalence has been increasing in the U.S.4 Despite the success of modern pharmacotherapy, asthma care in the U.S. is often sub-optimal. Anti-inflammatory drugs have been under-prescribed by clinicians and under-used by patients.5 Patient self-monitoring of peak expiratory flow rate (PEFR) using a peak flow meter (PFM) as recommended by the NAEP and others is frequently not done. In addition, asthma severity is often under-diagnosed due to a lack of information regarding symptoms of persistent disease outside the clinical encounter. Efforts to improve the quality of asthma care have focused primarily on the areas of patient education and case management. However, these approaches are labor intensive and costly, and thus are practical only for the most severe patients with asthma. Furthermore, both approaches are often limited by the lack of information regarding asthma symptoms at home. Computer-based telecommunication technology offers great potential as a cost-effective tool for 1) monitoring asthma symptoms and patient knowledge outside the clinical encounter; 2) providing enhanced education and case management when problems are identified; and 3) EMR-based provider communication to support clinical decision making at the point-of-care. In this paper, we describe an integrated information system developed to link patients, case managers, and their primary clinician in an effort to improve AMIA 2003 Symposium Proceedings − Page 1 the quality of asthma outcomes and care using: 1) a telephone linked patient communications system; 2) a Web-based alert reporting and nurse case management system; 3) transfer of patient reported information to primary care clinicians; and 4) use of EMR-based reporting for clinical decision making at the point-of-care. The system has been developed for use within a multi-specialty group practice in eastern-Massachusetts. Our goals are to describe the design of the system, highlight some of the unique features and considerations of a computer-based telecommunication system for children, and offer a model for an integrated information system that combines patient-centered monitoring and education, Web-bas ed case management, and EMR-based reporting and decision support (Figure 1). TLC asks the patients questions to monitor their health conditions; it also provides education and behavioral counseling for targeted health-related behaviors such as medication taking, diet and exercise. After each conversation, TLC stores the information the user has communicated in a database. Either the patient or TLC may initiate a conversation. Should the patient fail to call when expected, TLC will call the patient. In addition to questioning the patient, TLC provides education and behavioral reinforcement, such as counseling on how to take medications at prescribed times. TLC conversations were designed to emulate telephone conversations between patients and health professionals. A typical conversation lasts between three and five minutes, depending on the number and complexity of the topics addressed and the user's responses. The telephony system runs on a Windows NT computer using a D120x Intel/Dialogic board to interpret DTMF tones and play compressed voice files. The system was programmed in Visual Basic and Visual Voice platform. Automated faxing and reporting features are developed in Visual Basic and faxing is provided by FacSys Fax Server. Data is stored in an Oracle 9i database. Figure 1. TLC Asthma System Architecture PATIENT-CENTERED MONITORING AND EDUCATION The TLC (Telephone-Linked Communications) system is a computer-based telecommunications system developed to be an at-home monitor, educator and counselor for patients with chronic health conditions.6,7 TLC carries out totally automated telephone conversations with patients. During TLC telephone conversations, the system speaks to patients using computer-controlled digitized human speech. The patients, in turn, communicate with TLC by pressing the keys on their telephone keypad or by speaking into the telephone receiver. During TLC conversations, TLC-Asthma is designed for use by children between the ages of five and sixteen with mild moderate persistent asthma and their parents. Educational materials and scripts have been prepared for four groups based on current grade in school (K-1, 2-3, 4-6, 7+) to provide material appropriate to the cognitive/developmental stages of children and the differing roles that parents play in disease management at these different ages. TLC-Asthma conve (...truncated)