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Service Delivery Innovation Profile

Interactive, Web-Based Educational Program Enhances Knowledge, Attitudes, and Health Outcomes in Individuals With Diabetes


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Snapshot

Summary

In partnership with an unrestricted grant from dLife.com (a for-profit company with a weekly educational television show and a public self-management Web site focused on diabetes), researchers at Geisinger Health System conducted a randomized controlled trial in which they offered individuals with diabetes round-the-clock access to an interactive, user-friendly, Web-based educational program that supports them in managing the disease on an ongoing basis. Under this program (known as Technology Intervention for Diabetes Engagement and Self-Care, or TIDES), patients met with clinicians to establish personalized goals and create an account that provides access to a suite of Web-based tools and content. Weekly lessons and tips delivered lifestyle intervention content with links to the Web site, interactive quizzes, videos, and an online community forum. Periodic automated phone calls and mailings encouraged use of the program. During the 6-month trial comparing TIDES to usual care, TIDES stimulated high levels of engagement, significantly improved knowledge and attitudes about diabetes and self-care, and led to greater reductions in hemoglobin A1c levels among the subset of individuals showing improvement. Based on the trial's success, Geisinger plans to continue the program in partnership with dLife.com.

Evidence Rating (What is this?)

Strong: The evidence consists of a randomized controlled trial (RCT) comparing key metrics in 116 patients with type 2 diabetes randomized to the TIDES program to 49 similar control-group patients receiving usual care; additional evidence includes post-implementation assessments of the level of engagement in the program and anecdotal feedback from participants and their primary care physicians.
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Developing Organizations

Geisinger Health System
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Date First Implemented

2010
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Patient Population

During the initial trial, the program primarily served low-income individuals, many of whom lived in rural Pennsylvania. Going forward, it will serve all patients with diabetes and their families.end pp

Problem Addressed

Diabetes is a common, costly condition that can have devastating (and sometimes life-threatening) consequences, particularly for populations without easy access to timely, effective care and self-management support. Time-pressed primary care providers often lack the time, knowledge, and resources to work with patients to set self-management goals and engage them in their care.
  • A common, costly, devastating condition: Nearly 26 million American adults and children—8.3 percent of the population—have diabetes, and another 35 percent of adults (including half of those over the age of 65) have "pre-diabetes," which puts them at increased risk of developing the disease. Diabetes is the leading cause of kidney failure, nontraumatic lower-limb amputations, and new cases of blindness among adults; is a major cause of heart disease and stroke; and represents the seventh leading cause of death in the United States. The direct and indirect costs of diabetes total an estimated $174 billion a year, and overall medical costs for the typical person with diabetes are more than double the average individual without the disease.1
  • Especially for vulnerable populations with limited access: Those with limited access to health care, including low-income individuals, minorities, and rural residents, face an even higher risk of diabetes and its related complications. For example, compared to non-Hispanic White adults, African-Americans face a 77-percent greater risk of getting diabetes, with the risk also being higher among Hispanics (66 percent) and Asian Americans (18 percent).2 
  • Need for self-management support: Effective management of diabetes requires that patients monitor their condition and make lifestyle changes, such as adhering to a rigid testing and medication regimen, eating an appropriate diet, and engaging in more physical activity. Many individuals with diabetes need help in managing their condition (only about one-third have the condition adequately controlled), including making and adhering to treatment choices, setting goals, making lifestyle changes, and solving problems.2 Although a plethora of educational resources on diabetes exist online and in print, most patients find it difficult to find and comprehend information when they need it, as it resides in many different locations and often is written at a high school level or above. 
  • Inability of primary care to provide such support: Primary care providers (who treat 90 percent of type 2 diabetes patients) often lack the time, incentives, knowledge, and/or resources to support patients during brief office visits.3 Even when physicians provide such support, patients tend to quickly forget the messages delivered during infrequent (often rushed) visits and generally get little or no additional support outside these visits.

What They Did

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Description of the Innovative Activity

In partnership with dLife.com, Geisinger Health System offers individuals with diabetes round-the-clock access to the TIDES program, an interactive, user-friendly, Web-based educational program that supports them in managing the disease on an ongoing basis. Patients meet with clinicians to establish personalized goals and create a Web site account that provides access to a suite of Web-based tools and content. Weekly lessons and tips deliver lifestyle intervention content with links to the Web site, interactive quizzes, videos, and an online community forum. Periodic automated phone calls and mailings encourage use of the program. Key elements of the program as implemented in a 6-month trial are outlined below:
  • Program enrollment: Using its electronic health record (EHR), Geisinger contacts eligible individuals with diabetes to inform them about the program. Most diabetic patients qualify, except those with very serious complications (e.g., unstable angina) that might make it risky to follow some of the lifestyle-related advice. During the initial trial, Geisinger sent eligible patients letters that briefly described the program and invited them to schedule a visit to learn more.
  • Initial visit to establish personalized goals: Interested patients meet with a nurse and/or physician to learn about the program, get introduced to the onsite content, and set up a password and account. The nurse or physician spends a few minutes helping the patient identify several health-related goals, such as engaging in more physical activity, losing weight, and/or eating a more appropriate diet. (During the initial trial, a nurse also performed or ordered various tests to establish baseline data for program evaluation purposes, such as checking blood pressure and hemoglobin A1c levels, measuring height and weight to calculate body mass index, and ordering a fasting lipid panel.) 
  • Round-the-clock access to user-friendly, easy-to-navigate content: Once the account has been set up, patients can access the Web-based system at their convenience. The site contains a plethora of user-friendly, easy-to-navigate material, organizing 54 gigabytes of content into "bite-sized doses," with the goal of motivating but not overwhelming the patient. Much of the material has been structured to be interactive so as to stimulate engagement. Key features of the system are outlined below:
    • Personalized home page: Whenever a patient logs into the system, he or she comes to a personalized home page that includes his/her name and specific goals.
    • Weekly tips and advice: Each week, the site features new tips and advice related to a particular theme, with an emphasis on giving practical guidance and strategies for managing diabetes. Content covers a variety of issues, such as how to test blood sugar, pragmatic exercises and tips for engaging in physical activity, and recipes for eating healthfully. Content often relates to seasonal issues, such as healthy barbecue recipes and advice on how to obtain and use fresh fruits and vegetables during the summer, or tips for making healthful meals during the winter holiday season. During the initial trial, much of the advice was tailored to the many participants living in rural areas.
    • Interactive quizzes: The site includes 10 separate interactive quizzes that cover a variety of topics. For example, one quiz, entitled Diabetes Mythbusters, helps patients distinguish truths from myths about diabetes. The interactive nature of the quizzes engages users by making learning enjoyable and letting them see how their knowledge improves over time. 
    • Expert advice: The site includes a searchable database of more than 6,000 frequently asked questions, with answers written by experts in the field, including endocrinologists, exercise physiologists, and diabetologists. Patients can post questions not covered by the database; experts who work with dLife.com respond, with a notice going to the individual who submitted the question and the answer being added to the database so others can access it in the future.
    • Online community forum: The site hosts an online forum, moderated by a certified diabetes educator from dLife.com, that allows patients to interact with each other. Through it, patents share practical advice and lessons related to various aspects of managing diabetes, such as how to find a good doctor, test blood sugar, exercise safely, and prepare healthful meals.  
    • Videos: The site provides access to more than 500 original videos related to diabetes. Videos share the stories of how real people cope with the disease, including both "regular" people and well-known celebrities. Videos also review basic diabetes education, show cooking demonstrations, and offer expert insights on managing the disease. 
    • Food and nutrition resources: The site includes a searchable database of roughly 25,000 foods (with key nutritional facts on each), 2,500 recipes (including carbohydrate rating and full nutritional information), and 100 articles on diabetes-related food and nutrition issues.
    • Educational presentations and articles: The site provides access to roughly 3,000 articles and 60 slide presentations on diabetes through a searchable learning library. 
  • Proactive outreach to encourage use: Patients receive weekly e-mails, periodic phone calls, and occasional mailings designed to keep them engaged in the program, as outlined below:
    • Weekly e-mails: Each week, patients (and their caregivers, if appropriate) receive an e-mail tied to that week's theme, with links to relevant portions of the site. These motivational messages encourage individuals to access the site, with the goal of keeping them engaged in self-management.
    • Interactive voice phone calls: During the initial 6-month trial, patients received roughly four phone calls using interactive voice technology that offered positive reinforcement and reminders to access the new content on the site.
    • Mailings and postcards: During the initial trial, participants received several mailings and postcards reminding them about the benefits of using the site.

Context of the Innovation

A large, physician-led, integrated health care delivery system in central and northeastern Pennsylvania, Geisinger Health System operates three hospitals on two campuses (a closed-staff hospital in Danville and a two-hospital campus in the Scranton/Wilkes-Barre area); the Geisinger Clinic, which employs more than 750 physicians and has community-based clinics in 32 counties; and the Geisinger Health Plan, which covers approximately 220,000 enrollees, including 25,000 individuals with diabetes. All Geisinger sites are linked by a common EHR that integrates evidence-based protocols that guide the care of patients with diabetes and other chronic conditions. For diabetes, these protocols call for the provision of 14 care processes, such as regular foot and eye examinations, flu shots, and hemoglobin A1c testing.

Established in 2004 by an entrepreneur who lives with diabetes, dLife.com is a private, for-profit company that seeks to assist consumers in overcoming the practical, real-life challenges related to managing diabetes. The company offers an online diabetes site that attracts more than a million unique visitors each month, a weekly television show, mobile applications, and other consumer and professional programs to promote proactive diabetes self-management.

The impetus for this program came several years ago, when Howard Steinberg, chief executive officer and founder of dLife.com, contacted Margaret Rukstalis, MD, a clinician investigator at Geisinger, about the potential for Geisinger to partner with dLife.com to provide patients seen in the primary care setting with greater self-management support. Recognizing the inadequacies of primary care–based support (discussed earlier in the Problem Addressed section) and problems with the accessibility of existing patient resources, Mr. Steinberg and Dr. Rukstalis decided to create a program leveraging the latest technologies and media channels to give patients round-the-clock access to self-management support as an augmentation to support given by providers.

Did It Work?

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Results

TIDES stimulated high levels of engagement, significantly improved knowledge and attitudes about diabetes and self-care, and led to greater reductions in hemoglobin A1c levels among the subset of individuals showing improvement.
  • High levels of engagement: During the 6-month randomized controlled trial (RCT), over three-fourths of participants (76 percent) engaged in the program at some level, with half being moderately to highly engaged. For example, roughly 10 percent of participants viewed more than 1,200 pages on the site over the 6-month period, while another 38 percent viewed more than 400 pages. Roughly one-third of participants opened 75 percent or more of the e-mails, with another 37 percent opening more than one-fourth. Over one-third (37 percent) of participants completed 150 or more quiz pages, with another 22 percent completing between 60 and 150 pages. Overall engagement rates for the site are roughly two to five times that of the typical public Web site, with the opened e-mail rate being three times the average.
  • Enhanced knowledge, better attitudes: In the trial, 116 diabetes patients who participated in the program over a 6-month period scored twice as high on the Diabetes Knowledge Questionnaire and displayed better attitudes and behaviors in 9 of 11 categories related to self-care than did 49 similar patients receiving usual care. Improvements occurred in the following areas: measuring and recording symptoms, progressing along the path to behavior change, understanding how to take action if symptoms change, taking action when symptoms change, sharing in care decisions, taking medications as recommended, knowing about their condition and treatment, and arranging provider appointments as recommended. The amount of learning tended to be greatest for those most engaged in the program.
  • Better blood glucose control: Average hemoglobin A1c levels improved in both participants and members of the control group, with the overall rate of improvement not being significantly different across the two groups. Among the subset of individuals showing improvement, however, program participants experienced a significantly greater decline (0.8 points vs. 0.3 points in the control group).
  • Positive feedback from patients and physicians: Through anecdotal feedback, trial participants expressed appreciation for the 24-hour availability of the program, in contrast to the episodic support available through visits with diabetes educators. Those living in rural areas commented on the significant time savings the program generated for them, eliminating the need to set up appointments and drive several hours to the clinic to see a diabetes educator. For their part, primary care doctors in participating clinics also spoke very highly of the program and its impact on their patients.

Evidence Rating (What is this?)

Strong: The evidence consists of a randomized controlled trial (RCT) comparing key metrics in 116 patients with type 2 diabetes randomized to the TIDES program to 49 similar control-group patients receiving usual care; additional evidence includes post-implementation assessments of the level of engagement in the program and anecdotal feedback from participants and their primary care physicians.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Securing leadership support: Dr. Rukstalis approached Fred Bloom, MD, head of Geisinger's community-based primary care sites, to describe the program and its potential benefits. Dr. Bloom quickly endorsed the idea and worked with Dr. Rukstalis to make it a reality.
  • Creating Web-based system: Over a period of several months, dLife.com staff (primarily diabetes educators) took the lead in creating the Web-based content and choosing program features and functions. Much of this work involved simplifying existing dLife.com content so that it read at an appropriate level (roughly 5th grade) and making it more interactive and engaging. Dr. Rukstalis and other Geisinger staff periodically reviewed this work, giving feedback and guidance to dLife.com.
  • Conducting pilot test in three sites: Leaders at Geisinger wanted to test the program in diverse sites. To that end, they chose to conduct a 6-month pilot in three clinics—one in Scranton (an urban area), one on the main campus in Danville (a rural area), and one in State College (a college town). 
  • Ongoing refinement and future testing: Program leaders continue refining the program and plan to test it further. Additional analyses will determine which program components are most effective for different population subsets. Leaders also plan to expand distribution channels, tools, and applications, including adding data collection and reporting functions to TIDES that will be integrated with Geisinger's EHR, thus facilitating program evaluation and monitoring of patients by physicians. (At present, the program's educational content encourages patients to share TIDES-related information with physicians, but no formal mechanism exists to integrate the doctor into the program.)  

Resources Used and Skills Needed

  • Staffing: The program does not require the hiring of new staff by Geisinger. As noted, existing staff dedicated a portion of their time over a period of several months to get the program up and running. On an ongoing basis, dLife.com staff handle program-related activities.
  • Costs: Geisinger will pay dLife.com a fixed fee for TIDES, regardless of the number of users. The level and structure of fees for any organization adopting this type of program would depend on the partner and the specific components selected from the menu of tools available.    
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Funding Sources

dLife.com
dLife.com funded the initial trial through an unrestricted grant to Geisinger; further analyses will be funded through support from the University of Southern California and RAND Corporation. end fs

Tools and Other Resources

Information about dLife.com, along with its publicly available educational content, can be found at www.dlife.com. A video featuring Dr. Rukstalis and several patients who participated in the Geisinger trial can be seen at http://www.dlife.com/geisinger.

Adoption Considerations

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Getting Started with This Innovation

  • Consider financial implications and need for risk-sharing: This program works best for organizations accepting capitated risk for diabetes patients (i.e., a fixed fee to cover all health care needs); examples include many insurers, health plans, and integrated provider systems. The program could have a negative financial impact on providers receiving fee-for-service payments, as improved self-management often translates into fewer physician appointments, emergency department visits, and/or inpatient admissions. To address this issue, fee-for-service–based provider organizations should consider partnering with major insurers or purchasers to create a shared-risk payment model that allows the financial benefits from reduced utilization to accrue to both payer and provider. 
  • Pick and choose appropriate components: The program need not be as comprehensive as that created by Geisinger and dLife.com. Would-be adopters can pick and choose elements based on the needs of the organization and the target patient population. 
  • Consider interactive quizzes, community forum: Geisinger has found the interactive quizzes to be both popular and effective, with many patients taking the same quiz multiple times. The community forum has also proven quite popular, particularly among men. Although equal numbers of men and women visit the forum portion of the site, men tend to participate more actively in discussions and postings.    

Sustaining This Innovation

  • Monitor usage and solicit feedback to facilitate refinement: Certain aspects of the program will inevitably be more popular and effective than others. By monitoring usage and getting regular feedback from patients, adopters can identify elements that should be changed, eliminated, and/or expanded.
  • Evaluate and share data on program impact: Data that demonstrate the program's positive impact on patient outcomes and health care utilization can help maintain enthusiasm and support among physicians and organizational leaders.
  • Look for ways to integrate physicians: As noted, Geisinger is working with dLife.com to add functions and features that will allow physicians to monitor patients' progress and use TIDES-related materials to educate and support patients during office visits. Physicians should also be reminded to encourage their patients with diabetes to access TIDES regularly.
  • Consider similar program(s) for other chronic diseases: Effective self-management is critical to achieving good outcomes in patients with other chronic conditions, including obesity, heart disease, asthma, and depression. As with diabetes, volumes of information related to self-management of these conditions exist, but patients often have a hard time finding and understanding this material. 

Spreading This Innovation

A large, national insurer worked with dLife.com to create an 8-week version of the program that is currently being tested with Medicare Advantage members.

More Information

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Contact the Innovator

Margaret R. Rukstalis, MD
Clinical Investigator
Geisinger Center for Health Research
Volunteer Clinical Faculty
Wake Forest School of Medicine
100 North Academy Drive
Danville, PA 17822
Phone: (570) 412-4056
E-mail: mrrukstalis@geisinger.edu

Innovator Disclosures

Dr. Rukstalis has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

Footnotes

1 Centers for Disease Control and Prevention. National Diabetes Fact Sheet for 2011. Available at: http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
2 The Chronic Care Model: self-management support. Improving Chronic Illness Care, MacColl Institute for Healthcare Innovation, Group Health Research Institute. Available at: http://www.improvingchroniccare.org/index.php?p=Self-Management_Support&s=22
3 Baron RJ, Desnouee E. The struggle to support patients' efforts to change their unhealthy behavior. Health Aff (Millwood). 2010;29(5):953-5. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: March 14, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: March 26, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: February 20, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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