+----------------+--------------+-------------------------------------+
| **Clinical     | **Solution** | **Lessons Learned**                 |
| Problem**      |              |                                     |
+----------------+--------------+-------------------------------------+
| Communicating  | Secure       | \+ Enables asynchronous             |
| requests,      | Messaging    | communication                       |
| clinical       |              |                                     |
| information,   |              | \+ Maintains audit trail of         |
| questions,     |              | communication                       |
| etc. between   |              |                                     |
| care givers    |              | \+ Helps patients communicate       |
| and patients   |              | personal health information         |
+----------------+--------------+-------------------------------------+
|                | Web based    | \+ Can audit when message is read   |
|                | secure email |                                     |
|                |              | \- Additional step required to read |
|                |              | secure message, i.e. opening a URL  |
|                |              | from a regular email that takes     |
|                |              | user to a secure message web site.  |
|                |              |                                     |
|                |              | \- Extra web servers add cost       |
+----------------+--------------+-------------------------------------+
|                | Desktop      | \- Difficult to set up and require  |
|                | Clients &    | storage of digital certificates     |
|                | Plug-ins     |                                     |
+----------------+--------------+-------------------------------------+
|                | Password     | \+ Easy to use                      |
|                | based email  |                                     |
|                |              | \- Requires secondary method to     |
|                |              | distribute passwords                |
|                |              |                                     |
|                |              | \- Least secure and least amount of |
|                |              | sender control                      |
+----------------+--------------+-------------------------------------+
|                | Key Exchange | \+ Least amount of effort for the   |
|                | w/Global     | receiver                            |
|                | Au           |                                     |
|                | thentication | \+ Can be used to identify when a   |
|                |              | recipient has not read a message    |
|                |              |                                     |
|                |              | \- Addition of Key server from      |
|                |              | hosting organization                |
+----------------+--------------+-------------------------------------+
|                | Telephony    | \+ Takes advantage of more          |
|                |              | ubiquitous technology               |
+----------------+--------------+-------------------------------------+
| Any            | Voice        | \+ Covers largest part of           |
| pe             |              | population.                         |
| rson-to-person |              |                                     |
| communication. |              | \+ Most familiar form factor        |
|                |              |                                     |
|                |              | \+ Nurse phone calls to patients in |
|                |              | disease management programs have    |
|                |              | been very effective in maintaining  |
|                |              | patient behavior changes            |
|                |              |                                     |
|                |              | \- No automated documentation of    |
|                |              | interaction                         |
|                |              |                                     |
|                |              | \- May need to make several         |
|                |              | attempts to connect with other      |
|                |              | party                               |
+----------------+--------------+-------------------------------------+
| Patient needs  | IVR inbound  | \+ Does not require internet or PC  |
| to provide     | (from        | proficiency,                        |
| caregivers     | patient)     |                                     |
| with           |              | \+ Enables asynchronous             |
| self-measured  |              | communication,                      |
| data.          |              |                                     |
|                |              | \+ Provides accurate transcription  |
|                |              | of discrete information             |
|                |              |                                     |
|                |              | \- Patient must remember PIN        |
|                |              |                                     |
|                |              | \- Information transferred limited  |
+----------------+--------------+-------------------------------------+
| Caregivers     | IVR outbound | \+ Can provide automated means of   |
| need to ensure | (to patient) | reminding patients to do certain    |
| the collection |              | tasks or to supply information      |
| of patient     |              |                                     |
| self-measured  |              | \+ Can provide patient option to    |
| data.          |              | listen to educational stories       |
|                |              | (example from San Francisco         |
|                |              | General)                            |
|                |              |                                     |
|                |              | \- Ensuring the intended party is   |
|                |              | the one who answered the call       |
|                |              | requires verification               |
+----------------+--------------+-------------------------------------+
| Provide daily  | Remote       | \+ Security ensured by direct dial  |
| biometric data | Patient      | up and individual associations      |
| information    | Monitoring   | between in-home hub, patient, and   |
| between the    |              | backend management software.        |
| PCP and/or     |              |                                     |
| other          |              | \+ Currently in use by disease      |
| clinici        |              | management industry                 |
| ans/caregivers |              |                                     |
| and the        |              | \- Lack of interoperability         |
| patient.       |              | standards across technology         |
|                |              | platforms                           |
+----------------+--------------+-------------------------------------+
| For            | Physical     | \+ Helps patients maintain contents |
| communicating  | Transport    | and control access to a Personal    |
| personal       |              | Health Record                       |
| health         |              |                                     |
| information to |              |                                     |
| clinicians.    |              |                                     |
+----------------+--------------+-------------------------------------+
|                | USB Flash    | \+ Most PCs have multiple USB ports |
|                | drives       |                                     |
|                |              | \+ Patient in control               |
|                |              |                                     |
|                |              | \- Ability to transfer patient data |
|                |              | from physician EMR to USB not       |
|                |              | always possible.                    |
|                |              |                                     |
|                |              | \- If no network back up of data,   |
|                |              | then hard to keep data synched      |
|                |              | between encounters with different   |
|                |              | providers                           |
|                |              |                                     |
|                |              | \- If lost or stolen, only secure   |
|                |              | if data is stored encrypted and     |
|                |              | with multiple identity validation   |
|                |              | controls                            |
+----------------+--------------+-------------------------------------+
|                | Smart Cards  | \+ Can accommodate either data on   |
|                |              | board, or ID and access permission  |
|                |              | on board with the data residing in  |
|                |              | a central server.                   |
|                |              |                                     |
|                |              | \- The infrastructure for smart     |
|                |              | cards in the US needs to be built.  |
|                |              | Includes standards for data         |
|                |              | representation and availability of  |
|                |              | readers on most PCs                 |
+----------------+--------------+-------------------------------------+
|                | Bar coded    | \+ Cost                             |
+----------------+--------------+-------------------------------------+
|                | Magnetic     | \+ Cost                             |
|                | stripe       |                                     |
|                |              | \- Data can be lost if strip is     |
|                |              | damaged (scratching, magnets, other |
|                |              | cards)                              |
+----------------+--------------+-------------------------------------+
|                | RFID         | \+ Very reliable                    |
|                |              |                                     |
|                |              | \- Cost and availability of         |
|                |              | scanners                            |
+----------------+--------------+-------------------------------------+
|                | Integrated   | \+ Transfer clinical data across    |
|                | EHR          | the continuum of care between       |
|                |              | providers and to and from a         |
|                |              | personal health record              |
|                |              |                                     |
|                |              | \+ Promotes full electronic         |
|                |              | exchange of information             |
|                |              |                                     |
|                |              | \- Complete continuum of care is    |
|                |              | not computerized                    |
|                |              |                                     |
|                |              | \- Electronic sharing of patient    |
|                |              | consents requires separate document |
|                |              | management component within or in   |
|                |              | addition to EHR                     |
|                |              |                                     |
|                |              | \- Will of caregivers to share      |
|                |              | information is not present, in part |
|                |              | due to financial incentives.        |
+----------------+--------------+-------------------------------------+
|                | HL-7         | \+ Mature standard for transferring |
|                |              | clinical information                |
|                |              |                                     |
|                |              | \- Variability in section of HL-7   |
|                |              | make it more difficult to interface |
|                |              | between competing vendor systems    |
+----------------+--------------+-------------------------------------+
|                | CCR/CDA      | \+ Content standard for             |
|                |              | communicating key clinical summary  |
|                |              | information                         |
|                |              |                                     |
|                |              | -   Immature standard, still needs  |
|                |              |     to gain acceptance              |
|                |              |                                     |
|                |              | -   (CCR is an immature standard    |
|                |              |     and is not yet in use. CDA is a |
|                |              |     mature standard but it is not   |
|                |              |     yet widely used                 |
+----------------+--------------+-------------------------------------+
|                |              |                                     |
+----------------+--------------+-------------------------------------+
|                |              |                                     |
+----------------+--------------+-------------------------------------+
|                |              |                                     |
+----------------+--------------+-------------------------------------+
|                |              |                                     |
+----------------+--------------+-------------------------------------+

Secure Communication Technologies in use for Disease Management

**Telephone**

The plain old telephone system is the most widely used technology for
communication between stakeholders in disease management programs.

Voice

At the basic level the telephone is used for voice communication between
patients and their caregivers. This is the most familiar and ubiquitous
technology. The advantages of voice communication include ability to
cover the largest population of the available technologies, is the most
familiar form factor, and proven effective. Voice telephony has the
disadvantages that documentation of conversation is not automated, and
stakeholders may need to attempt calls several times to execute
conversation.

Interactive Voice Response (IVR) Systems

Inbound IVR systems provide for ease and accessibility of voice
telephony with advantages of enabling asynchronous communication and
accurate automated documentation of data. Disadvantages include patients
needing to remember a personal identification number and phone number.
Also the amount of information that can be transferred is effectively
limited. Examples of use include South Carolina Heart Center that uses
an IVR for patients to call in weight, blood pressure and pulse
information as well as answering yes/no type questions about their
condition. IVR (when coupled with an ACD) can also be used to place
outbound calls to either provide information or elicit information like
done by the inbound IVR. This technology enables a care giver to provide
automated reminders to patients, provide information, or request
information. At San Francisco General Hospital they use an outbound IVR
to request clinical data information like SCHC does, and also enables
the patient to request educational stories. Disadvantages of outbound
IVR is ensuring that the person who answers the phone is the intended
party.

**Secure Messaging**

Electronic online messaging that provides for secure communication
between a member of the care team and the patient. Secure messaging
provides for asynchronous communication and an audit trail of all
communication. There are different technologies to provide secure
messaging. This technology is more complicated than telephony. Some
technologies such as web-based secure email require additional steps
from the user to get an email then navigate to a URL to read the actual
message. Key exchange systems provide improved ease of use by senders
and receiver, but require steps needed to register email addresses.
Password protected email is not practical for communication among larger
number of users as would be the case with a physician or disease
management nurse and their patients because of the need for
communicating passwords through another channel.

A barrier to secure messaging is the need for personal computers and
Internet access. There is added expense to maintain the password or
keys.

**Telemedicine (use of devices in home or Remote Patient Monitoring
RPM))**

Can use technology from POTS to broadband. Devices in the home are used
to transmit information to the caregiver. Devices can range from simple
scales, blood pressure cuffs, and glucometers, to systems that
incorporate video cameras to enable more advance communication.

Remote patient (or physiologic) monitoring through an in-home hub
communicating to some dedicated devices such as scales and blood
pressure cuffs is in common use today by disease management companies.
The devices are used to try and reduce telephone interactions, while
still achieving the behavior modification outcomes.

A system is in use as part of a pilot at SUNY and Columbia University
that incorporates blood pressure cuffs, glucometers and a video camera.
Patients can enter their clinical information automatically and allows a
nurse to check insulin draws before injection. Detroit Medical Center
uses a system that has a box in the patient home that records blood
pressure, pulse and weight and answers to some questions presented to
the patient, this recorded data is then sent over the phone lines to the
care giver. Other systems are becoming available that add additional
functions and full video conferencing but require specific broadband
carrier connectivity.

A barrier to wide spread use of these technologies is the need for
specialized hardware, and in some situations specialized broadband
connectivity. Physicians fear a loss of control in patient management.

**Personal Health Records**

Portable patient control health records are starting to gain use.
Several models exist on how to securely move information between
patients and care givers. Server stored systems enable password
controlled access through secure messaging technologies. There are other
models that use a smart card of USB flash drive key as a secure means of
physically transporting the information between patient and provider.

**Integrated Electronic Health Records**

Systems like Kaiser are providing completely integrated EHRs. Theses
systems provide secure access to the EHR through passwords (and possibly
biometrics). This enables clinicians to access a patients complete
clinical record. Extensions of this system enable a patient (and their
caregivers) to see portions of their record and add to the record as
part of a PHR. The data is an integral part of the EHR so the clinicians
involved in care can see the PHR information as well. Since the data
fully resides within the EHR there is less use of more global secure
communication technologies. The system then provides abilities to
escalate reminders to missing tasks to ensure patient/provider
compliance with best practices. The other technologies that enable
secure email or web services are available for transferring copies of
data or reports to external parties (i.e. outside the patient and care
team) through the other secure messaging technologies reported above.

**Barriers to secure communication**

Biggest barrier is the incentives to communicate at all. There are no
incentives for the physician to share data with other providers. There
is also concern in engaging in electronic communication with patients
that it will increase workload without commensurate revenue.

**Today's communication flows**

Family to patient: This is usually a very strong channel but not well
documented

Patient to clinician: This is usually a very strong channel, but not
continuous and often relies on patient memory to provide much of the
information

Patient to Disease Manager: This is usually a very strong channel;
information is collected closer to time of occurrence

Disease Manager to primary clinician: This communication channel is
often then weakest connection; much of the information sharing is done
via letters or through the patient.