Tag Archives: chronic disease management


A Physician’s Perspective

Interview with an Endocrinologist About Patient Reported Outcomes

Health Helm’s Operation Lead, Lisa McCarron, sat down with an Endocrinologist to discuss the challenges of patient centered care for clients with diabetes.

1. What are some key challenges for physicians in helping patients manage chronic medical conditions?

The challenge becomes how to improve care between visits and how do we help the patient overcome the difficulties that they face. They may contact the office with questions or concerns and then the next time you see them in 3 or 6 months, they are not better off. This in between time is a “zone of darkness” with little feedback or communication.

Diabetes as a chronic condition has about 10% compliance to care plans in patients, with relatively poor outcomes. Drug compliance is difficult to quantify but I believe most patients take their medication although not as prescribed. We need a better way to communicate and motivate the patient. If we can’t motivate them to change their lifestyle, we can’t improve the outcome. Those who do get well at the beginning, after hearing their diagnosis, are motivated but that motivation diminishes over time.

A platform to communicate and motivate can help improve the doctor-patient relationship. There is no doubt that interacting with patients between visits would be beneficial. The patient feels that if the doctor cares more then they will care more and be more motivated.

2. What are some key challenges for patients as they manage chronic medical conditions?

Staying motivated is the most difficult. There is no feedback loop in between visits to let them know how they are doing against their plan. We even tried to incentivize patients with a $0 co-pay if they met their goals at the next visit. None were motivated by $0 co-payment.

Patients have to measure blood sugar and report to the physician’s office. Without feedback we can’t make adjustments to improve their condition. If the doctor doesn’t know what the patient is doing, they can’t motivate them.

Adherence to prescriptions is reasonable with about 50% compliance. Again, if the doctor could monitor this more we could then motivate them to do better or discuss issues with regard to cost, side effects, motivation, etc., in between visits.

3. What type of data do you have in supporting patients? What information are you lacking?

We use the glucose readings and weight primarily. Hemogoblin A1C is the gold standard for diabetes management. The higher the A1C, the higher blood sugar and the more likelihood of complications. The reading is an average blood sugar over 2-3 months.

We get feedback on patient’s progress every 3 to 6 to 9 months. Success is when patients call in between visits and then the doctor can monitor the status of the patient. A doctor is not going to call a patient in between visits. The patient needs to provide that information.

4. What makes for successful outcomes in managing chronic medical conditions?

Motivation is key to keeping the patient on their care plan, especially when there are complications. And preventative measures, based on feedback in between visits, would help to keep the patient motivated and aligned to their goals.

5. What will be most practical for doctors and their teams to get patients to share information on their care plan compliance and clinical status between visits?

The answer is TPC (Trusted Patient Coach). It provides proof of provider outcomes with data collection directly from the patient. It can also be a potential for reimbursement for monitoring patients in between visits.

Trusted Patient CoachTM is a reporting and engagement platform designed to connect and communicate with patients in acute and chronic care to improve outcomes and reduce costs.