Abstract
Introduction
Over the past 20 years, the prevalence of diabetes in the U.S. population has increased from 5.5% to 9.3%, with greater estimates among older adults and minorities. 1 As this trend continues to escalate, innovative strategies to improve access to chronic disease care are necessary to reduce the burden of disease in the population and associated healthcare costs. Uncontrolled diabetes is a challenging clinical problem that can be effectively managed with the use of a physician-led interdisciplinary team. 2 –4 In 2010, the Department of Health and Human Services Office of the National Coordination for Health IT awarded grant funding to 17 communities through the Beacon Community Cooperative Agreement Program. The selected communities focused on strengthening health information technology infrastructure, health information exchange, and the development of innovative practices using technology to improve chronic disease outcomes. 5 As a funding recipient, our team designed a trial to explore patient accessibility to our multidisciplinary diabetes care team through the use of teleconsultation and videoconferencing.
Current literature describes potential advantages in the delivery of care using videoconferencing to patients with various disease states, including diabetes mellitus. 6 We are unaware of any studies that describe satisfaction and usability of FaceTime® (Apple, Cupertino, CA) as a tool to treat patients with uncontrolled diabetes. FaceTime technology is cost-effective and mobile and has demonstrated promise of increasing access for patients in a patient-centered medical home. In a recent study, seven military service member volunteers tested the usability and feasibility of the iPhone® (Apple) and FaceTime for the delivery of telemental healthcare; using hot-spot WiFi-to-cellular connections, 6 of 7 subjects indicated they would recommend the use of smartphone technology to talk to a medical provider. 7 FaceTime has also been used by plastic surgeons for remote real-time evaluation of limb-threatening and other complex wounds. 8 Although multiple potential uses of two-way video communication using smartphone technology in behavioral healthcare have been identified, there remains the need for usability and feasibility testing to determine which products and platforms are acceptable in the clinical setting. 9
This study describes the satisfaction and usability of both patients and members of a diabetes care team with videoconferencing capabilities of FaceTime using an iPad®2 (Apple). The data presented in this article are part of a larger randomized, controlled trial whereby patients were assigned to one of three groups: access to a multidisciplinary diabetes care team with video and home telemonitoring intervention group, a care manger control group without video or home telemonitoring, and a usual care control group. 10 This article describes the findings of the intervention group who had access to videoconferencing technology.
Materials and Methods
Study Design
Patients with uncontrolled type 2 diabetes mellitus, as defined by with a hemoglobin A1c level of ≥9%, were recruited from two practices of Cabarrus Family Medicine located in Cabarrus County, North Carolina. Patients were enrolled in a randomized controlled trial of video-enhanced home telemonitoring. 10
A multidisciplinary diabetes care team was integrated at each office consisting of a nurse care manager, pharmacist, nutritionist, clinical psychologist, and the primary care provider. Team members were provided with an iPad2 and training to access the home monitoring data. Patients were provided with an iPad2 with videoconferencing capabilities using FaceTime and a Honeywell (Brookfield, WI) HomMed™ telemonitoring device. The monitoring device facilitated the collection of biometric data including weight, blood pressure, and blood glucose readings. Participants were asked to check and transmit data daily using the home telemonitor. All participants received in-home installation support and device training. The intervention was conducted for 90 days. All technology was removed from the patient's home after the intervention period, after which patients were followed up for an additional 90 days.
All virtual visits and technology were provided to participants at no charge. Using care manager coordination, patients were scheduled for virtual visits using FaceTime with the nutritionist, the pharmacist, and the clinical psychologist. Encounters with each discipline were standardized to ensure consistency of education and care plan development among all visits. Initial visits with each member of the diabetes care team lasted approximately 1 h with follow-up visits lasting approximately 30 min.
This study was approved by the Carolinas Healthcare System Institutional Review Board.
Participant Survey
A 12-item survey was developed to evaluate patient satisfaction, technical issues, perceived value of virtual visits, and intent to continue using FaceTime for health needs. The survey was completed by participants following completion of the 90-day intervention period.
The survey assessed participant overall satisfaction using FaceTime technology for virtual visits and FaceTime as a tool to improve diabetes control and overall health. Response options on a 5-point scale ranged from “absolutely terrible” to “very good.”
Two items measured occurrence of technical issues when accessing the diabetes care team around connectivity, and three items measured convenience and usefulness of virtual visit encounters using a 5-point scale that ranged from “strongly disagree” to “strongly agree.” One additional item assessed if the participants completed a visit using FaceTime. An open-ended format was used to ask participants to specify any technology difficulties identified, any iPad2 applications used with the iPad2 to enhance their health, and their opinion of the overall value of FaceTime visits.
Participant intent to continue using the iPad2 following completion of the study was measured by two items using a 5-point scale ranging from “strongly disagree” to “strongly agree.” The first item asked participants if they would be willing to continue using the iPad2 to help control diabetes and improve health if possible. The second item assessed if participants would continue virtual visits with pharmacists, a nutritionist, and a clinical psychologist if possible.
Diabetes Care Team Survey
A 5-item electronic survey was developed to evaluate diabetes care team continuance intention, satisfaction, perceived usefulness, and confirmation using FaceTime for virtual visits. The survey was completed by members of the diabetes care team at Days 30, 90, and 180. A link to the survey was e-mailed to all members of the diabetes care team. The survey was completed anonymously through an online survey software program, SurveyMonkey® (
The survey assessed diabetes care team member overall satisfaction using FaceTime technology for virtual visits. A single item measured satisfaction with iPad2 technology. Response options on a 5-point scale ranged from “very dissatisfied” to “very satisfied.”
Diabetes care team member intent to continue using the iPad2 following completion of the study was measured by two items using a 5-point scale ranging from “strongly disagree” to “strongly agree.” The first item assessed intent of responder to continue using the iPad2 as long as it is available. The second item assessed if the responder would like to discontinue using the iPad2.
For perceived usefulness of virtual visits, a single item assessed if the iPad2 equipment enhanced effectiveness in managing a patient's health. Responses were measured using a 5-point scale that ranged from “strongly disagree” to “strongly agree.”
A single item measured confirmation of experience with using iPad2 technology for virtual visits. Diabetes care team members were asked to rank if the experience using the iPad2 was better than expected. Responses were measured using a 5-point scale that ranged from “strongly disagree” to “strongly agree.”
Study Population
Potential subjects were identified based on reports generated from the practice site's diabetes registry, referrals from their primary care provider, and office signage.
Inclusion criteria included patients ≥18 years of age, an appointment within the previous 12 months by a Cabarrus Family Medicine provider, hemoglobin A1c level of ≥9% at the time of study enrollment, ability to understand English and complete study enrollment forms, agreement or referral from the primary care provider to participate in the study, and access to a telephone in the home. Subjects were excluded if they were currently enrolled in another research protocol, if primary management of diabetes was not conducted by a Cabarrus Family Medicine provider, or if the patient suffered from dementia, aphasia, or any end-stage disease process including, but not limited to, renal or neoplastic disease.
Data Analysis
Data were analyzed using SAS® statistical analysis software (Enterprise Guide® 5.1; SAS Institute, Cary, NC). Descriptive statistics, including means, numerical counts, and percentages were used to report patient demographics and characteristics. Survey results are reported for the entire sample and percentages.
Results
One hundred forty-two patients were screened for study inclusion. After exclusion criteria were met, 119 participants were enrolled in the study. In total, 40 subjects were randomized to the FaceTime intervention group. Six patients dropped out during the study period (3 patients by the 90-day and 3 patients more by the 180-day review). In total, 34 subjects in the virtual care study arm completed the 90-day intervention and provided survey data.
Of the 40 patients enrolled, mean age was 52.1 years. Fifty-five percent of the subjects were male, and 78% were white, 22% African American, and 11% Latin American. The average hemoglobin A1c level was 11.3%, with an average fasting blood glucose of 231 mg/dL.
Overall, 252 diabetes care team visits were conducted with this study group, and 151 of these were conducted as virtual visits using FaceTime. The care manager and pharmacist used FaceTime for 41 of 68 (60%) and 52 of 77 (68%) total patient visits, respectively. The nutritionist and clinical psychologist used FaceTime for 46 of 68 (68%) and 12 of 39 (30%) total patient visits, respectively.
Results of the 12-item participant survey are shown in Table 1. The majority of patients (83%) reported that FaceTime visits were as helpful as and more convenient than an office visit. Additionally, 76% of patients reported that FaceTime helped improve their diabetes.
Patient Survey Results
In terms of supplemental applications used with the iPad2, 18 participants reporting using CalorieKing™ (
Results of the five-item diabetes care team survey are shown in Table 2. At the 180-day patient enrollment period, 87.5% of survey responders with the diabetes care team reported that use of the iPad2 enhanced their effectiveness in disease management; 75% expressed interest in using the iPad2 as long as it was available to them. Throughout the study period, overall satisfaction decreased from 100% at time of 30-day enrollment to 86% and 50% at 90- and 180-day enrollment, respectively. Open-ended responses regarding the value of FaceTime included the ability to observe a patient's home environment for fall risks, medication storage and foods available in the kitchen, opportunity for frequent connection with poorly controlled patients, and to offer extra support. It was noted that although this may be an effective means to reemphasize counseling points, there was a lack of personal connection and that patients often considered virtual encounters as a more casual encounter or as optional.
Diabetes Care Team Survey
Discussion and Conclusions
The results of this evaluation provided practical information using video technology to conduct diabetic care patient encounters. Overall both study patients and the diabetes care team provided positive ratings regarding usability and satisfaction with iPad2 capabilities for virtual visits.
Within the diabetes care team, each discipline noted specific advantages of using FaceTime to conduct virtual visits with patients. In general, all disciplines had access to reach patients who could not otherwise present for an office visit, providing an opportunity for education and follow-up. This technology allowed for real-time treatment and management of patient conditions, increasing convenience and efficiency in the management of diabetes and associated comorbidities. Additionally, the use of online resources during visits equipped patients with tools necessary to engage in the monitoring of their health condition. In many cases, subjects indicated that a connection to the Internet with the iPad2 allowed the opportunity to use applciations to improve health such as CalorieKing and MyFitnessPal. The nutritionist was able to use the video capability to view food items within the patient's home and could assist in the development of healthy eating plans. When conducting comprehensive medication reviews, the pharmacists had the capability of clearly viewing prescription bottles similar to as if they were sitting around the kitchen table.
In this study, behaviorists were not able to complete virtual visits as readily as other team members. Potential reasons for this include patients not as willing to discuss sensitive topics in their home environment, or patients feeling as though this is an impersonal way of communication. As such, it may seem patients are interacting with a machine rather than a face-to-face individual provider.
In terms of usability, our research provided valuable experience and information about some challenges using video technology to conduct patient encounters. Some patients indicated that it was difficult to hear the soft ring tone of FaceTime and consequently would often miss the scheduled FaceTime appointment with the healthcare provider. In effort to reduce missed encounters, the provider called the patient via telephone just prior to the scheduled virtual visit to confirm preparedness. In this study, successful virtual visits were dependent on network connectivity. Without optimal connection, FaceTime was not an effective method for patient encounters. In these cases, a telephone “visit” was completed in lieu of a FaceTime appointment to avoid lapse in communication or screen freezing. When conducting visits through this modality, it was important to remind patients of professional boundaries and specifically treating a virtual visit in the same fashion as a traditional in-office, face-to-face visit. Such components of professionalism include maintaining proper attire when presenting for a virtual visit, respecting mutually agreed-upon appointment times, and canceling appointment times in advance if needed. Additionally, there is a need to set limits on MiFi to avoid excessive data overage charges. In this study, we had one instance of a lost iPad2 during a car crash and one stolen iPad2 that was later returned.
Despite challenges identified with FaceTime technology, it can be used to increase patient access to a multidisciplinary care team. This technology may have great potential for high-risk, multiple-comorbid patients with transportation problems or patients who may benefit from recurrent medication adherence follow-up.
This study is limited by a small sample size and a relatively short 12-week treatment period. Although other standard usability tools are available, the investigators chose to use an alternate usability survey adapted from a previous study. 11 Nonetheless, the survey results provided valid usability information that will be beneficial to future healthcare research. Additional larger scale research is necessary to determine the economic and clinical outcome impact of video technology to manage chronic diseases using FaceTime.
Footnotes
Acknowledgments
The authors wish to thank Cindy Fink, RN, FNP, Robin Hudson, RN, Sandra Michael, RN, Lara Fink, RN, Cheryl Masters, PhD, Andrea Cochran, PhD, Wes Teeter, MA, Alex Bujold, MHA, Andrea McCall, RN, William Anderson, MS, and Emily Patridge, MLS, for their assistance with this research.
Disclosure Statement
A.R.B. serves on the Speaker's Bureau for Merck & Company. M.R., A.L., S.R., and T.G. declare no competing financial interests exist.