Hospital • Disease Management • Diabetes
`
`Case Study
`
`Mercy Health Center’s Telemedicine Diabetes Disease
`Management Program Shows Significant Savings with Health
`Buddy® and Health Hero® iCare Desktop™
`
`Executive Summary
`Mercy Health Center in Laredo, Texas, a member of the Sisters of Mercy Health
`System-St. Louis Region, has shown significant reductions in hospital-based
`utilization with its Telemedicine Diabetes Disease Management Program.
`Mercy’s program was implemented to determine the impact of low cost, web-
`based, patient interface technology as part of an overall diabetes disease manage-
`ment program. The program features use of the Health Hero® iCare Desktop™,
`a web-based patient management tool, and the Health Buddy® appliance.
`
`Mercy Health Center, in collaboration with The University of Texas Health
`Science Center at San Antonio (UTHScC-SA), was awarded a $300,000 grant
`from the Telecommunications Infrastructure Fund Board of the State of Texas
`in 1999. The study, partially funded by this grant and sponsored by Mercy
`Health Center of Laredo with support from UTHScC-SA, aims to improve the
`health status of indigent border residents with chronic disease through the use
`of
`telemedicine technology. Mercy has utilized the grant to develop
`a telemedicine disease management program to monitor Laredo’s indigent
`congestive heart failure and diabetic patients. This program achieved all of its
`goals: decreased hospital-based resource utilization, improved patient compli-
`ance with treatment plans, improved level of satisfaction with health care serv-
`ices, and improved patients’ perceived quality of life.
`
`Analysis of the financial and clinical impact of Mercy’s Telemedicine Diabetes
`Disease Management Program after one year showed reductions in overall
`utilization and charges, as well as improvements in quality of life as measured
`by the SF-12. Patients in the program showed reduced overall charges of $747
`per patient per year (PPPY). Inpatient admissions were reduced 32%, ER
`encounters were reduced 34%, and outpatient visits were reduced 49%.
`
`The significant reductions in hospital-based utilization and improvement in
`perceived quality of life can likely be attributed to the patient’s enhanced abil-
`ity to self-manage their chronic disease state using the Health Hero interven-
`tion. Without remote monitoring, patient care is based on episodic encoun-
`ters between patients and their care providers. This program bridged the gap
`between office visits by providing a platform for daily monitoring of infor-
`mation from the patient, allowing patients and care providers to identify
`problems and intervene early. Early intervention can ultimately reduce the
`cost of care to the health care provider, payer and patient while increasing the
`overall well-being and quality of life for the patient.
`
`1
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`Bosch Ex. 2050
`Cardiocom v. Bosch IPR2013-00468
`
`

`

`Diabetes Mellitus
`Diabetes is a chronic disease in which the body does not produce or properly use insulin, a hor-
`mone that is needed by the body to convert sugar, starches and other food into energy. The cause
`of diabetes is not completely understood, although both genetics and environmental factors such
`as obesity and lack of exercise appear to play roles.
`
`The American Diabetes Association reports there are 15.7 million people in the United States who
`have diabetes. According to the American Heart Association (2000) the total annual economic cost
`of diabetes in 1997 was estimated to be $98 billion. That includes $44 billion in direct medical and
`treatment costs and $54 billion for indirect costs attributed to disability and mortality. In 1997,
`total health expenditures incurred by people with diabetes amounted to $77.7 billion including
`health care costs not resulting from diabetes. The per capita costs of health care for people with
`diabetes averaged $10,071, while health care costs for people without diabetes averaged $2,699 in
`1997. Approximately $27.5 billion was spent for inpatient hospital care of diabetic patients in 1997.
`Diabetes-related hospitalizations totaled 507,000 and the mean length of stay for hospitalization
`was 5.4 days.
`
`Outpatient treatment rates were extremely high in 1997 as well, and there were 30.3 million physi-
`cian office visits to treat people with diabetes. According to the National Institute of Diabetes and
`Digestive and Kidney Disease, diabetes is the seventh leading cause of death (sixth-leading cause
`of death by disease) in the United States. In 1997, 622,636 Americans (55% female) died from
`complications associated with diabetes.
`
`There are two main types of diabetes. Type 1 diabetes, which usually occurs during childhood or
`adolescence, is a disease that results from the body’s failure to produce insulin. Type 2 diabetes, the
`most common form of the disease, usually occurs after age 45. Of the nearly 16 million Americans
`with diabetes, 90-95% (14.9 million) have Type 2 diabetes. Type 2 diabetes results from insulin
`resistance (a condition in which the body fails to properly use insulin), combined with relative
`insulin deficiency. Often Type 2 diabetes can be controlled through losing weight and improving
`nutrition and exercise alone, but many people need oral medications and/or insulin injections to
`maintain glycemic control.
`
`Traditional disease management programs seek to improve patient care and reduce hospital-based
`utilization through the use of dedicated case management services. Usually a health care profes-
`sional oversees the care of the home based patient through assessment and education – working to
`improve compliance with medical regimens. Case management that encompasses behavioral
`change, knowledge building and symptom monitoring plays a key role in optimizing medical man-
`agement of chronic diseases such as diabetes. Common diabetic complications include blindness,
`kidney disease, heart disease, stroke, nerve disease, amputations, and impotence which are often
`manifested later in life. Nurturing the necessary skills of self-management improves the health of
`patients and reduces overall healthcare utilization. However, the use of a health care professional to
`effect such change with individual patients is usually a lengthy and expensive proposition.
`
`Through the use of a remote telemedicine disease management program, the case manager can
`detect early and repeated symptoms and intervene quickly with multiple patients simultaneously.
`The care manager is able to focus on those patients most in need. In this process, the case manag-
`er monitors daily patient symptoms (e.g., changes in weight, blood sugar, and fatigue) using the
`
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`electronically transmitted health values of his/her assigned patient population and intervenes in a
`timely and appropriate fashion. These timely and appropriate interventions may be as simple as
`obtaining syringes, filling prescriptions for diabetes medications, educating patients on diet
`modifications, or making physician referrals. In contrast to costly crisis management through
`ER encounters and inpatient hospitalizations, timely detection and response to patient symp-
`toms provides the opportunity for early, cost-effective, more appropriate intervention. Use of
`the Health Buddy and Health Hero iCare Desktop allows for the care management to be auto-
`mated, relying less on the nurse’s intervention and more on the patient’s ability to “self-manage”
`their condition.
`
`Mercy Health Center
`Mercy Health Center (MHC) is located in Laredo, Texas along the U.S.-Mexico border. MHC serves
`Webb County, one of the poorest counties in Texas. One in every three families lives at or below
`poverty level. There are 40-60 colonias, unincorporated areas with grossly sub-standard housing,
`in the Laredo area with an estimated 12,000 residents. Many residents speak only Spanish. The
`National Association of Community Health Centers ranked Webb as 7th in the nation as a “dou-
`ble jeopardy” county, that is chronically disadvantaged in both the overall health of its residents
`and in the extreme shortage of primary care physicians.
`
`Laredo is 94% Hispanic. Hispanics are more likely than any other ethnic group in the nation to be
`without health insurance. Approximately 50% of Laredo’s area residents are uninsured. MHC is the
`safety net for Laredo area residents in need of healthcare, providing millions of dollars of charity
`care annually. Given Laredo’s proximity to the border and its poverty rate, MHC is actively explor-
`ing ways to improve quality of life while reducing its risk as the primary provider to indigent resi-
`dents. This telemedicine disease management program has allowed MHC to improve care by
`focusing on maintenance and prevention rather than crisis management and achieve overall
`reduced costs in the process.
`
`The Health Hero Technology Service
`Health Hero provides its customers with access to a browser-based care management tool, the
`Health Hero® iCare Desktop™, and the patient communication appliance, the Health Buddy. The
`Health Hero technology platform provides healthcare professionals with an integrated, web-based
`solution that improves efficiency and effectiveness in managing the health of their chronically ill
`patients. The Health Hero iCare Desktop provides care managers with an integrated set of patient
`enrollment, scheduling and monitoring tools enabling the care manager to quickly communicate
`with and stay abreast of their patients’ day-to-day conditions and prevent critical situations by pro-
`viding early intervention. The care manager is able to access this daily patient information on a
`secure website. The Health Buddy assists the patient in monitoring their disease through educa-
`tion, reinforcement and prompts to action if indicated by daily values. The Health Hero technology
`platform is based on the following design elements:
`
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`
`

`

`* Flexibility is key in targeting and addressing the needs of sub-populations
`
`* Simplicity is essential to user compliance
`
`* Timeliness in data collection is required for managing disease progress
`
`* Cost is a critical issue in the practical application of disease management systems
`
`The Health Buddy connects to any existing patient phone line, much like an answering machine.
`It has a large easy to read screen and four large blue buttons for responses. Patients answer per-
`sonalized daily questions in English or Spanish that monitor their disease symptoms, medication
`compliance and disease knowledge as well as providing education about their condition(s).
`Patients’ responses are sent via a telephone line to Health Hero’s secure data center. Patients are not
`required to have internet access to use this system. Daily responses sent by patients can be catego-
`rized and prioritized to alert case managers to the most serious outcomes first.
`
`Methods and Program Implementation
`To qualify for participation in the study, patients must have been indigent or economically disad-
`vantaged adults. All patients had to be competent, have a telephone, be able to read or have some-
`one willing to assist them daily, have a physician/clinic in the service area and reside in the service
`area. The Health Buddy component of the intervention was delivered in both English and Spanish.
`Patients were referred to the program through the hospital, support groups, clinics, and doctors’
`offices. In addition to receiving the Health Buddy, diabetes patients received a glucometer, testing
`strips, and lancets for the duration of the study free of charge. Patients answer daily questions
`about their disease on their Health Buddy. The telemedicine case managers review patient answers
`Monday through Friday. If the values are alarming, or chronically outside of designated parame-
`ters, the patient is contacted. If warranted, the physician or clinic is notified. If it is known when a
`patient’s next appointment is, the collected information is forwarded to the physician or clinic
`prior to the appointment. A focus of this study was to measure the effect of the technology on
`patient behavior. Consequently, no protocols were established to adjust medications or treatments,
`and patients are referred to their doctor’s office when needed.
`
`Mercy incorporated Health Hero’s patient communication service in January of 2000. As of
`January 2001, approximately 169 patients had been enrolled in and remained in the telemedicine
`program. Patients enrolled in the Health Hero program received a Health Buddy appliance to
`receive and respond to daily sessions of questions and educational information from their care
`manager. The disease management program provided patients with 12 months of coaching, edu-
`cation, and reinforcement of self-care management skills. The critical program components were
`educational support, in-home daily monitoring and timely physician notification. The in-home
`daily monitoring and much of the reinforcement of self-care management was done through the
`Health Buddy. The Health Hero iCare Desktop enabled tracking of patients by Mercy’s telephonic
`support staff and nurses and involved regular communication with physicians.
`
`Results
`The utilization measures included inpatient, outpatient, post-discharge care (PDC), emergency room
`(ER) encounters, and charges. The data analysis compared 1999 hospital-based utilization data, dur-
`
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`

`ing which time patients were receiving standard care (care before enrollment in the disease manage-
`ment program), with 2000 utilization data during the time patients were enrolled in the Mercy
`Telemedicine Disease Management Program powered by Health Hero. Results from the analysis
`showed reduction in utilization in inpatient hospitalizations, outpatient visits and ER encounters.
`
`A 1999 comparative diabetic sample (standard care) was utilized to assess the changes in utilization
`and charge data when compared to the 2000 Health Hero interventional population. The popula-
`tions analyzed included 169 patients enrolled in the telemedicine disease management program in
`the period 1/00 through 12/00. There were 130 females and 39 males in this population with an
`average age of 53 for both sexes.
`
`Summaries of reductions in utilization and charges are shown in Tables 1 and 2 and Figure 1.
`Hospitalizations for diabetes-related causes were reduced 32% for patients enrolled in the telemed-
`icine disease management program. The number of diabetes-related inpatient hospitalizations was
`0.73 per patient per year (PPPY) for the standard care period and 0.50 PPPY during the program
`(Table 1, Z=1.80). Outpatient encounters for diabetes-related causes significantly decreased by
`49% (Z = 8.02 , p < 0.001). The number of outpatient encounters was 5.34 PPPY for the standard
`care period and 2.75 PPPY during the program (Table 1). ER encounters for diabetes-related caus-
`es decreased by 34%. The number of diabetes-related ER encounters was 0.61 PPPY for the stan-
`dard care period and 0.40 PPPY during the program (Table 1, Z=1.87).
`
`Analysis of the charge data between the 1999 diabetic sample and the 2000 intervention group
`indicated charge reductions of $747 (PPPY) (Table 2). As the effects of uncontrolled diabetes are
`long-term, Mercy plans to continue to measure changes in overall charges associated with patients
`enrolled in this program.
`
`Utilization Measure
`
`Inpatient Admissions
`PPPY
`
`Emergency Room Visits
`PPPY
`
`PDC Visits
`PPPY
`
`Outpatient Visits
`PPPY
`
`Reporting Period
`(approx.)
`
`Standard
`Care
`
`Health
`Hero
`
`Utilization
`Reduction
`
`[1]
`Z p-value
`
`0.73
`
`0.61
`
`0.18
`
`5.34
`
`0.50
`
`0.40
`
`0.10
`
`2.75
`
`01/99-12/99
`
`01/00-12/00
`
`32%
`
`34%
`
`44%
`
`49%
`
`Z=1.80
`n.s.
`
`Z=1.87
`n.s.
`
`Z=1.07
`n.s.
`
`Z=8.02
`p<0.001
`
`Table 1. Utilization of Healthcare Services: Health Hero compared
`to Standard Care
`Notes: [1] Z test for Proportions used
`
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`Cohort
`
`1999 Diabetic Sample [1]
`
`2000 Health Hero [2]
`
`Adjusted Charge Reductions Per Patient
`After HHN Intervention*
`
`Charges
`
`$8,376
`
`$7,629
`
`$747
`
`Table 2. Charges for Healthcare Services: Health Hero compared to Standard Care
`
`Notes: [1] 1999 Diabetic Sample are patients identified as having diabetes related inpatient and outpatient hospital
`encounters during calendar year 1999. This sample included the actual cohort of patients who were enrolled in the
`Health Hero program in 2000. Their 1999 utilization was measured and is included in the tabulation
`
`[2] 2000 Health Hero is the cohort of patients who were enrolled in the Health Hero program. Their utilization for
`2000 was measured and is tabulated.
`
`* 1999 charges were adjusted to reflect adjustment in hospital 2000 charge master.
`
`Total Costs per Member per Year, Diabetes Related
`
`$8,376
`
`$7,629
`
`$14K
`
`$12K
`
`$10K
`
`$8K
`
`$6K
`
`$4K
`
`$2K
`
`$0
`
`1999 Diabetic Sample
`
`2000 Health Hero
`
`Figure 1. Total Charges (annualized) for Diabetes-related encounters:
`2000 Health Hero compared to 1999 Diabetic Sample
`
`$14K
`
`$12K
`
`$10K
`
`$8K
`
`$6K
`
`$4K
`
`$2K
`
`$0
`
`Total Diabetes-Related Costs PMPY
`
`6
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`

`

`Quality of Life
`Quality of life was assessed using the SF-12. Surveys were completed by patients on entry to the
`program and quarterly during the program. Data from patients with completed surveys at time of
`enrollment and in the first 2 quarters were analyzed according to a repeated measures design.
`Differences within subjects over time were assessed to quantify changes for patients in the pro-
`gram. Table 3 shows summary statistics for the physical and mental sub-scales for the baseline and
`two subsequent quarters. The mean improvement in the mental component after 6-months in the
`program was 3.61, from 45.00 pre-program to 48.61. The mean improvement in the physical com-
`ponent after 6-months in the program was 2.60, from 41.83 pre-program to 44.42 (Table 3).
`
`Time
`
`Baseline
`
`Quarter 1
`
`Quarter 2
`
`Q1 - Base
`
`Q2 - Base
`
`Physical
`
`Mental
`
`41.83
`
`43.39
`
`44.42
`
`1.56
`
`2.60
`
`45.00
`
`48.17
`
`48.61
`
`3.20
`
`3.61
`
`Table 3. SF-12 Quality of Life Mean Scores at Baseline and two
`subsequent quarters. The Q1 – Base and Q2 – Base mean differences
`are calculated as means of within-subject differences over time.
`
`Patient Satisfaction with Using Health Buddy
`Results show that patients in Mercy’s Telemedicine Disease Management Program found the
`Health Buddy very easy to use on an ongoing basis and reported high levels of perceived value from
`participating in the program. From surveys conducted it was discovered that:
`
`* More than 95% of patients using Health Buddy reported increased satisfaction regarding the
`communication with their doctors or nurses on an ongoing basis.
`
`* All of the patients reported that the Health Buddy was easy or very easy to use. Ease of use increased
`over time from 75% saying it was “very easy” to use after the first three months to 88% at the end
`of the first year.
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`

`* 97% of the patients had no difficulty using the Health Buddy to answer daily questions (see
`Figure 2).
`
`3%
`
`97%
`
`had no difficulty
`using Health Buddy®
`to answer daily
`questions
`
`No Difficulty
`Difficulty
`
`Figure 2. Most patients had no difficulty using the Health Buddy® to answer daily questions.
`
`* An impressive 93% of the patients reported that they had a better understanding of their medical
`condition since being on the Health Buddy.
`
`* 93% of patients reported they felt better able to manage their disease.
`
`* 99% of the patients reported that they believed the Health Buddy helped them improve their
`health.
`
`* Over time, the percentage of patients that reported feeling more connected to their doctor, nurses
`and hospital went up from 88% after three months to 95% at one year (see Figure 2).
`
`96%
`
`94%
`
`92%
`
`90%
`
`88%
`
`86%
`
`84%
`
`3 months
`
`6 months
`
`9 months
`
`12 months
`
`Figure 3. Over time patients feel more connected to their doctors, nurses and the hospital.
`
`8
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`9
`
`Medication Compliance
`One of the key areas of concentration in Mercy’s Telemedicine Disease Management Program was
`medication compliance. Patients were asked on a regular basis about their medications, ensuring
`that patients understood why it was important to take them and that they remembered to take them.
`The results of a patient survey on medication compliance were:
`
`* At the beginning of the study period, only 34% of the patients reported no problems with miss-
`ing medication doses. 65% of patients reported missing medication doses before starting on the
`Health Buddy. After receiving the Health Buddy, 94% of patients reported that they take their
`medications more regularly (see Figure 4).
`
`Medication Compliance
`
`94%
`
`100%
`
`80%
`
`60%
`
`40%
`
`20%
`
`0%
`
`34%
`
`Before Health Buddy
`
`After Health Buddy
`
`Figure 4.
`
`100%
`
`80%
`
`60%
`
`40%
`
`20%
`
`0%
`
`Percentage of patients who take medication regularly
`
`

`

`Conclusions
`The encouraging evidence from this study is that Mercy’s Telemedicine Diabetes Disease
`Management Program powered by Health Hero Network reduces utilization in diabetes patients in
`all settings. Charge reductions in diabetes-related care for the disease management program were
`$747 PPPY compared with standard care. Inpatient admissions were reduced 32%, ER encounters
`were reduced 34%, and outpatient visits were reduced 49%. The reduction in utilization is an
`important finding and suggests the Health Hero intervention was effective in managing health care
`resource utilization by this indigent population.
`
`In addition to the reduction in utilization, quality of life was improved as evidenced by increases
`in the mental and physical components of the SF-12. The mean improvement in the mental com-
`ponent over a 6-month period was 3.61.The mean improvement in the physical component over a
`6-month period was 2.60.
`
`The challenges faced when caring for an indigent, bilingual population with chronic disease can be
`unique. These patients frequently have barriers to care including transportation issues, financial
`hardship that limits their access to care, and language barriers that make it difficult for them to
`understand and follow a prescribed regimen.
`
`Without remote monitoring, patient care is based on episodic encounters between patients and
`their care providers. This episodic approach relies on the patient’s ability and willingness to collect,
`record and act upon disease-related events over an extended period. The Mercy Health Center
`Telemedicine Disease Management Program’s use of Health Hero’s telemedicine technology,
`bridged the gap between office visits by providing a platform for making daily collections of infor-
`mation from the patient, and making it possible for the care provider to identify problems and
`intervene before problems escalate.
`
`It is well documented that active patient monitoring and case management of chronic conditions
`result in beneficial outcomes to patients and providers. Evaluation of Mercy’s Diabetes
`Telemedicine Disease Management Program suggests impressive reductions in health care utiliza-
`tion and encouraging improvement in quality of life. What sets this program apart from traditional
`case management programs is the element of technology provided by the Health Hero Networks
`iCare Desktop and the Health Buddy appliance. Not only does this technology connect the patient
`to healthcare system, it provides the patient with access to information and support for the devel-
`opment of self-management skills. Changing the self-management behavior of patients with
`chronic disease is fundamental to long term success with any disease management program.
`
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`References
`Bigelow, J.H., Cretin, S., Soloman, M., Wu, S.Y., Cherry, J., Cobb, H., and O’Connell, M.
`(2000). Patient Compliance With and Attitudes Towards Health Buddy™, RAND Health, Santa
`Monica, California.
`
`Drummond, M.F., O’Brian, B., Stoddart, G.L., & Torrance, G.W. (1999). Methods for the Economic
`Evaluation of Health Care Programmes. New York: Oxford University Press Inc.
`
`Landi, F., Gambassi, G., Pola, R., Tabaccanti, S., Cavinato, T., Carbonin, P.U., & Bernabeu, R. (1999).
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`(12), 1430-1434.
`
`O’Connell, M. and Cherry, J. (2000). The Health Hero® Online Service: A new internet-based com-
`munications platform for disease management, case management and performance measurement.
`Disease Management and Health Outcomes 7 (3), 149-161.
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