Using Information Technology to Improve Management of Chronic Diseases
Garry W. Welch, PhD, is director of Behavioral Medicine Research at Baystate Medical Center, a Tufts-affiliated hospital located in Springfield, Mass. He is also an assistant professor in the Department of Psychiatry at Tufts University School of Medicine. Welch is working to improve medical care and patient quality of life, while lowering the cost of care, by providing clinicians with computer-based case management tools that incorporate guidelines for clinical practice and patient self-management. Using a patient-centered approach called motivational interviewing, Welch’s group is developing new strategies for behavior change counseling during treatment for chronic medical conditions. By providing case managers with the decision support of a clinical-behavioral tool and enhancing their counseling skills, Welch hopes to help them work more effectively with high-risk patients.
Welch earned his doctorate in psychology from the Wellington School of Medicine and Health Sciences in New Zealand. After postdoctoral studies at Wellington, he worked at the University of Sydney, Australia, and the Royal Prince Alfred Hospital in Sydney. He then took a position at Harvard Medical School in the Department of Psychiatry, studying self-management and quality of life for people with diabetes and the application of information technology to these issues.
While at the Behavioral and Mental Health Section of the Research Division at the Joslin Diabetes Center in Boston, Welch was part of a group working on a web-based, comprehensive case management tool for type 2 diabetes. A typical case management tool features clinical practice guidelines to support the clinician’s decision making and treatment planning and provides alerts and reminders for necessary tests. The new comprehensive tool adds alerts about self-management barriers and behavioral challenges such as depression. Other challenges that diabetes patients face include binge eating, alcohol or substance abuse, and diabetes-related emotional distress. Welch’s group is implementing this new comprehensive diabetes management program (CDMP) at a Baystate satellite clinic in Springfield.
Welch has a five-year NIH R01 grant to compare the use of motivational interviewing (MI) with and without computer-assisted assessment of patient self-management and behavioral barriers. “Motivational interviewing is an exciting new area of counseling applied specifically to chronic illnesses, and MI can be helpful in a medical care system built on an acute care model, in which the passive patient is ‘fixed.’ MI attempts to activate the patient’s own motivation to carry out the daily tasks of living with a chronic illness,” says Welch. People with chronic illnesses must make substantial changes to their lifestyles ― such as eating and exercising a certain way and taking regular medications ― in the face of daily demands and nonhealth priorities. “A key issue is helping patients become activated to think through their natural ambivalence around behavior change and to find ways to improve self-care that are realistic and practical from the patient’s perspective,” says Welch. “Patients are best motivated by a plan that they have helped build and that they think is a good idea. Motivational interviewing attempts to figure out what we can offer them given their own motivations, interests, and priorities in life.”
Welch’s research group is also building case management tools for renal failure and bariatric (obesity) surgery. “Essentially, what we have with the CDMP is a wonderful platform to use for any chronic illness,” says Welch. “You have to go through a similar process, starting with getting a clinical team to help you build the content for another tool. So that’s what we’ve done with obesity surgery. We have the surgeon, the dietician, and the nurse ― principally the latter two ― with whom I’ve been brainstorming for a year. We have developed clinical guidelines and also self-management and behavioral assessments specifically for the postsurgical challenge.”
“We’re also looking at digital wireless home-monitoring devices to link in with these case management tools, to get a fuller picture of daily patient life,” says Welch. Devices for measuring blood pressure, blood glucose, and weight can be used by the patient at home within a 30- to 100-foot radius of a wireless tablet computer monitor. The data flow automatically by phone or cable to the case management server. Welch’s research group is working with several technology companies to develop these devices. The research group is also trying out an automated telephone assessment system in which patients can call a 1-800 toll-free number, be asked a series of questions, and have their answers automatically flow into the case management tool.
“We are also looking at using computerized adaptive testing (CAT) and developing questionnaires that are very short yet highly reliable and valid as opposed to longer paper and pencil ones. You can reduce the time it takes to fill out a questionnaire by 80% with a CAT approach,” says Welch.
“So we’re going to have a lot of fun playing with all these different things over the next few years and integrating them into clinical care. Our key focus is to develop the systems, gather pilot data, and then apply for stable NIH funding to test hypotheses about clinical usefulness, quality of life benefit, and economic impacts.”
For more information, please email Garry Welch at Garry.Welch@bhs.org.