PHR

Model: Shift how patients manage Type II diabetes by using integrated PHR to cause a 10X increase in patient compliance as evidenced by reduced hospital admission, increased success in managing daily blood sugar, improved test results such asHgbA1C, decreased dependence on or eliminate need for medications. Three Levels of Culture Artifacts: Structure/beliefs of healthcare delivery in the healthcare facility and at home. -change Healthcare equipment and tools for healthcare provider and patient in managing DM.-change (See appendix A.) Espoused Beliefs and Values: I want my healthcare to be the way it always was. I am too busy - change I cant manage my DM, I am not tech savvy, my healthcare provider should take care of me. -change I value good health. -anchor I value being able to do the things that I want when I want -anchor I am healthy and already do all the things that I need to do to be healthy - change Underlying assumptions: I want to be healthy, Im overwhelmed and scared of diabetes Influence strategy before culture analysis Family helps patient create schedule where patient is in comfortable settings to encourage daily tracking.

5 Whys -I have no time or energy. 1.Why dont I follow my DM treatment plan? I dont have time/energy to monitor my DM. Im busy; I have other things to do. I feel fine. 2. Why should I take time to enter data in my daily tracker? Tracking my DM is fun, when I use Facebook Healthseeker/DS didget/PHR daily tracker, they show trends/progress, which prompts me to exercise/watch my diet. 3. Why keep diet, exercise, and blood glucose in check when I feel fine? It helps control my DM, now and long term. 4. Why should I control my DM? It helps to prevent complications of DM. 5. Why prevent complications? So I can live longer and have better quality of life.

PHR Group, A Shared Mental Model Culture analysis scope Stakeholder group: Patients with DM type II Vital Behavior: Access PHR, track daily, and submit weekly to provider: Daily glucose readings Meds taken (oral, insulin) Food intake journal Exercise log Change Issue: Getting the patient motivated and engaged

Clinic provides software/training for free Coach patient as they practice entering health information into the PHR and send to provider Provider gives opportunity for patient to access PHR Actions tool for practice. At provider appointment, have patient access the Advice tool and ask a question Show video of a patient successfully using a PHR to enter glucose level, food journal, and exercise log and send to the provider Provider discusses with patient about concerns of privacy and shows how the provider will manage the information. Current Mental Model What I know I have a diagnosis of Type II Diabetes (DM), healthcare provider gave me a treatment plan. I dont have time to enter my meds, food intake, or exercise. The doctor doesnt want that information from me anyway. I have no time or desire to exercise besides I can always take more meds if I need to. I have always scheduled an appointment to see my provider when needed.

Influence strategy after culture analysis (See appendix B for further discussion) Enlist the family to support and help patients to feel capable in managing DM and in using the PHR (emotionally/technically), by showing how following a good plan of care can interrupt the disease process. Provide scheduler within PHR, to allow for breaking tasks into smaller steps. Encourage delegation of chores to family when able. Give immediate feedback via Text/email, with completion of daily tracker, and provide opportunities to earn points for gift cards. Provide hands on experiences to use the PHR, to increase patient adoption, (as exposure increases the fear decreases). Show video of a patient successfully using a PHR to enter glucose level, food journal, and exercise log and send to the provider, in a group visit with other patients with DM, and who are part of the PHR group. Help the patient vicariously experience how the body reacts to type II diabetes. Have patient meet with DM educator to learn importance of steps they can take to control/manage DM on daily basis. Show how these steps help to maintain health. Reinforce positive behavior by sharing with others, demonstrate how: Facebooks Healthseeker, PatientsLikeMe, Nintendo DS Didget, and the PHR tracker point system, can help support and reward the patient. Provide opportunity to demonstrate how data is managed, to help the patient feel comfortable sharing information via social network. Provide opportunity for discussion; include PHR users in the group. What I value Being healthy Being able to work Being able to do the things that I want when I want. Participating in family/friend activities. Being able to take care of my family Target Mental Model What I know I have a diagnosis of Type II Diabetes I can make a difference in my health. I know that it is important for my DM management to make time to track my data. If I find a friend to exercise with, Im more inclined to do it. I get A1C level drawn, so I can see how well Im doing and to share with others on PatientsLikeMe site. Sharing my health data with my provider, allows my provider can see how Im doing.

Assumptions Current Basic Assumptions My health is important to me -anchor If I feel ok, I must not be that sick and I dont have to worry -change Patients shouldnt be a partner in their care change I have to take care of everyone/everything else before myself - change Do I lack the ability to control the outcome? -change New Basic Assumptions I feel ok now, but I know that diabetes can have serious complications if not properly managed I can make a difference in my health outcomes, by taking steps I need to take care of myself to do the things that are important to me I am in charge and know best what to eat and when to exercise My health information is private Shared EHR PHR care delivery model is a good way to manage DM It is important to make time to track my diabetes data daily The provider is a trained expert we work together to manage my DM I value being able to do the things that I want when I want

How I feel Overwhelmed with DM management. I worry that I will complications in the future? I have anxiety about using the computer. I dont really feel sick, do I really need to do this? Ill die of something anyway, so why does it matter? I dont feel different when my A1C is too high so that means Im okay. Will my physician see me as partner in my care? Can I really do this? What if I fail? I am not sure that my information will be safe.

How I feel Capable of using PHR to track DM Im positive about my DM management, now that Im using the PHR/Facebook Healthseeker/Didget, its fun, and Im getting rewards. I am successful managing my DM. I feel that I have a good understanding of diabetes and what I need to do to stay healthy. To keep feeling good, I need to check the PHR actions and advice tools. To keep feeling good, I need to monitor my glucose level and adjust my diet and exercise accordingly. I want to decrease my dependence on medication.

What I value Being healthy Being able to Work Taking care of myself. Taking care of my family. Being able to do what I want, and participating in family/friend activities. I want to enter my data online because I can compare how Im doing with others like me and learn from them new tips or ideas for feeling great. Feeling good. Its important to me that my healthcare provider is following my plan of care, and will make changes quickly if needed.

PHR Group, Part lll Draft Appendix A. The current structure/beliefs of the healthcare delivery system include the following: 1. Physician directed patient health care delivery model process (call make appt., give info. to healthcare provider, receive plan of care, go home manage care, repeat. Healthcare provider and patients retain their own information until healthcare visit) 2. A Clinic / Physician Office 3. Professional Image of a physician 4. Scheduled appointment 5. Medication bottles 6. Documented treatment plans 7. Documented Educational plans 8. Food intake Journal 9. Exercise Log 10. Glucose log 11. Glucometer 12. Computer 13. Computer software 14. Lab Result showing Diabetes Appendix B. Detailed discussion of influence strategies: 1. Have patient meet with a diabetic educator to gain knowledge of diabetes and importance of things that they can do to control and manage disease on daily basis. Show how these steps will help in maintaining health. Allow, and demonstrate to the patient, vicariously, how the body reacts to type II diabetes. Show, in detail, how its different from a non-diabetic patient. Utilize a video for the experience. Providing an example of a patient with type II diabetes. The video will depict through animation outlining what is going on inside the body when blood sugar is high, and how that affects the heart, energy level, and the body tissues starving from lack of O2 and nutrients. Show example of foot ulcer and through animation, explain why it cant heal properly. Show how arterial blockage in the coronary arteries (and fragile vessels) leads to a heart attack. Why it works vicarious experience helps the patient to see how it will work in their own life; helps to explain why diabetic patients are more prone to heart disease (i.e., show video/animation of the slow/sluggish blood in a test tube vs. non-diabetic patients blood & how that affects tissues if not getting a good blood supply). 2. Provide a video of patient successfully using a PHR to enter glucose level, food journal, and exercise log and send to the provider, and utilizing social networking sites (see below). Show this video in a group visit with other diabetic patients that are going to be part of the PHR group. Have discussion on how group members think that they will be able to incorporate these steps into their already busy lives. Have a current PHR user present on how they were able to make a successful commitment to daily tracking and maintain/improve health status. 4. Provide a real time setting where provider/staff can coach patient and family as they practice entering health information into the PHR and send to provider. Then have provider send feedback to the patient to show how they will partner in care management. Help the patient and family create a one week trial schedule based on what they think will work for entering daily information based around other things that are important for the patient. Talk with patient to see if schedule is working and if not help them adjust, utilize activity scheduler/viewer that can be individualized, and can break tasks into smaller time slots, making it easier to succeed in PHR tracking. Send Patient immediate feedback daily, via text/email (patient can sign up for preferred method of communication) to provide reinforcement for their efforts and to show partnership in care. Show trending in weekly reports via text/email (as preferred). 5. Give opportunity to earn points with completion of daily tracker, in PHR, short term and long term. Obtainment of increased levels of health=more points. Points can be cashed in for gift card of choice. Providing rewards will encourage daily tracking behaviors. 6. To increase incentive, make management fun. Provide links to (within PHR), and discuss/demonstrate, DM management gaming devices such as Nintendo DS Didget DM management/glucometer gaming system. (http://www.bayerdidget.co.uk/) 7. To increase incentive, encourage social networking/support group activity. Provide links to (within PHR), and discuss/demonstrate, DM management utilizing social networking applications/web based support groups: Facebooks Healthseeker (http://apps.facebook.com/healthseeker/welcome), and Patients like Me, to encourage support between patients with DM.