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Managing Change: Experiences from a New e-Health Initiative for Patients with Diabetes and Cardiovascular Disease

Salys Sultan1, Permanand Mohan1 and Nazeer Sultan2 1The University of The West Indies, St. Augustine, Trinidad and Tobago

2Delta 55, Couva, Trinidad and Tobago {salys.sultan, permanand.mohan}@sta.uwi.edu, nazeer.sultan@gmail.com

Abstract

New Information and Communication Technology (ICT) solutions for e-Health are increasingly being implemented and deployed. Many studies associated with this venture usually include market research, usability studies, and testing. However one of the more important aspects which is often overlooked but directly affects the sustainability of the new technology is the management of the change process. This paper presents some guidelines grounded in the Social Sciences that could foster the success of implementing new ICT initiatives in e-Health. A case study is presented on the introduction of a mobile health care management system called myDR (my Daily Record). The objective of the research is to highlight the importance of the change management process and the role it plays in the deployment of new health care initiatives. The case study indicates that people are more inclined to use the new system if the proper change management mechanisms are in place. 1. Introduction

In the context of health care, too many times the following scenario is played out between a health care provider (HCP) and patient: HCP presents disturbing health results to the patient, insisting that urgent corrective action is needed. The patient becomes alarmed and commits to changes in behavior (nutrition, exercise etc.) almost immediately. Early attempts by the patient then fizzle out with him expecting ‘miracles’ on his next scheduled visit only to be hit with the harsh reality of no improvement or even health deterioration.

The preceding scenario illustrates how the success of health care initiatives is driven by the commitment levels of patients where they are expected to act more responsibly and employ more discipline and will in attending to their health. However, it is often difficult

to rise up to such expectations given the fact that human beings are creatures of habit. Thus, any attempt at self-improvement must address not only will power but also the building of new habits through the identification and creation of positive rituals to replace unhealthy ones [3].

In this paper we present some guidelines grounded in the Social Sciences that could foster the success of new ICT initiatives in health care. These guidelines concentrate on the human challenge of change. We then explain how these guidelines were incorporated into the design and development of a mobile telemedicine system for patients with diabetes and cardiovascular disease. The aim of the paper is to highlight the importance of the change management process and the role it plays in new e-Health initiatives. 2. ICT & Health Care – Managing the Change Process

In this section we describe two models for managing the change process borrowed from the behavioral sciences with a coaching emphasis: CCL’s Leadership Development Model [4] and LGE Keys to Building Engagement [3].

Figure 1. CCL’s Leadership Development Model

These models have been selected for the simplicity and practicality of their change management processes, and their applicability to the complex area of health care. The models are also complementary in that together, they focus on the elements critical for effecting and sustaining behaviour change – alignment with purpose, assessment/facing the truth, ritual-building and use of supporting systems/networks. 2.1. CCL’s Leadership Development Model

At the Center for Creative Leadership (CCL), coaching that focuses on leadership and personal development has long assumed a central role in helping individuals to become more effective leaders. The CCL has developed a framework for coaching that is supported by a well tested model [4] of leader development (Figure 1). This model is built on five areas: assessment, challenge, support, results and the context within which the coaching occurs. The framework uses coaching as one, but not the only way, to facilitate learning and change. When coaching is incorporated into a person’s day-to-day activities, it becomes a powerful tool which helps people to access and use their lessons of experience. Furthermore, the quality of the relationship between the change agent and the individual being coached is paramount. Therefore, commitment and collaboration between the patient and HCP enhance the chances of success, and this provides a good case for the use of ICT in health care initiatives.

By applying this framework to e-Health initiatives, the elements of assessment, challenge and support motivate the patient to focus his attention and efforts on learning and change and to use information and observations to develop a more complete understanding of his health status.

Assessment deals with the unfreezing of present perceptions, providing realistic benchmarks, and understanding developmental needs given the current state of the patient. E-Health initiatives which take into account knowledge of the patient and which can tailor the health care delivery to meet the patient’s individual needs have a greater chance of success. The objective of assessment is to obtain the fullest picture of the current reality and future change possibilities. Here the HCP, through the use of ICT, interprets, analyses, summarizes and distills assessment information with the patient, with the aim of motivating him to change. The patient’s information is then used as input into the design of the change programme. The information used can come in many forms and need not be limited to hard, quantitative and objective information like the medical metrics, but may also deal with the less

‘tangible’ to include information about the patient in the social domain, for example, attitudes, disposition, biases, preferences, beliefs, likes and dislikes.

The health care initiative must also challenge the patient by providing an improved pathway to the desired state. Learning is a crucial step in the actualization of the desired state [3]. Therefore, a clear road map on how this can be accomplished is required. Challenges come in many forms, for example changes in nutrition, exercise and self-awareness. However, they have one thing in common – they create ‘disequilibrium’ – an imbalance between the current and the desired state. Additionally, appropriate levels of change based on the patient’s handling capacity must be embedded in these challenges. In moving the patient to the desired state, the e-Health initiative must also focus on removing obstacles. Internal obstacles may include the patient’s conscious and unconscious thoughts and feelings that cause the patient to be in his present state, for example beliefs, assumptions and confidence. External obstacles are forces in the patient’s life such as time, work demands and lack of support and resources. The e-Health initiative should address these challenges by facilitating the removal or correction of these obstacles.

Support is also important as it creates safety for taking risks, ensures that motivation is maintained and provides the resources necessary for success. Support can be provided in many ways including by means of a caregiver in the patient’s environment, by making available information relating to the patient’s illness, and by providing feedback on the patient’s current status. Getting specifics about the ‘what’ and ‘how’ of the change programme as well as the provision of strategies and resources are key, but the e-Health initiative needs to also pay attention to celebrating small wins and managing setbacks, given the importance of motivation and commitment in any change effort [10].

The results refer to the direct and indirect outcomes; a desired state with lasting impact. In the context of patient-oriented e-Health initiatives, the desired result is often the patient being in an improved state of health. More specifically, results can focus on:

• Behaviour change – improved self-care habits

• Personal development – improved overall well being consistent with the patient’s values, objectives and goals

• Health performance – improved state of health in targeted areas

The last dimension is context; the environment in which the patient exists. For example, the patient’s

living conditions, the available state of technology, the level of health care, and literacy. In the case of e-Health initiatives the context will also influence the ICT that is being employed. For example, in a mobile telemedicine system, in order to utilize the mobile phone, some basic level of technology and literacy is desirable. Additionally, factors such as patient’s location, network connectivity, the device’s screen size, data entry methods, and the environmental elements that distract the user’s attention should also be taken into consideration [7].

2.2. LGE Keys to Building Engagement

Change is difficult. Human beings are creatures of

habit and routine; what we did yesterday is what we are likely to do today. The problem with most efforts at change is that conscious effort cannot be sustained over the long term. Will and discipline are far more limited resources than most people recognize [3].

For a new e-Health care initiative to be adopted it is important to build engagement. Engagement is the skillful mobilization of the energy required to achieve extraordinary results in any mission that really matters. This occurs when individuals are “physically energized, emotionally connected, mentally focused and spiritually aligned [3].” The LGE Keys (Figure 2) present the three steps involved in building engagement.

Figure 2. LGE Keys to Building Engagement

In the first step, the patient must face the truth and acknowledge that health care is important and required. The next step involves determining what needs to be done to achieve the desired state i.e. improved self-management and overall well-being. The third step is the conversion of the plan into action or doing what is required to achieve the desired objectives.

The researchers propose that the change the patient desires must be linked to one or more core values that matter deeply to him. Furthermore, by investing extraordinary energy in a new ritual for a minimum of

30-60 days the new ritual turns into a habit. A ritual in this paper is defined as a consciously acquired habitual pattern of thinking and acting that leads to a desired state.

When developing this new ritual it is necessary to be as precise as possible in both the timing and behavior to habitualize, as well as focus on acquiring only a few major rituals at any one time. Moreover, it is important to create an environment that is supportive during the ritual acquisition period.

In the health care context, it is expected that a HCP will work with the patient on the development of a change programme. This should result in an improvement plan consisting of new habits and routines thereby reducing the dependence on conscious self-regulated behaviors.

The key is to install good practices in the patient’s life through the creation of rituals. Examples could include introducing exercise into his life, changing eating habits and breaking a smoking habit. To support this change, the patient collaborates with the HCP choosing a number of supportive nutrition and exercise rituals to incorporate into his life. To the extent that these rituals are well chosen and crafted (given the patient’s values and challenges) and consistently practiced, the patient’s well being stands a greater chance of improvement in the targeted areas. It is in this process of ritual-building that ICT initiatives can make the biggest impact on the health care domain. 3. Case Study - myDR

myDR, short for my Daily Record, is a mobile software application for retrieving and storing readings from a patient’s health care meters (e.g. blood glucose meter and blood pressure meter). The myDR patient interface is one of the components of the Caribbean-wide Healthcare Management System called MediNet [1] currently being developed by researchers at The University of the West Indies.

Figure 3 illustrates the main functions of the myDR system. The Get Readings function allows the user to either automatically obtain or manually enter the patient’s reading from the meter. The Edit User Data function allows the user to update information relating to him. The View History function provides a log of past readings. The Tip of the Day is the feedback component of the system. myDR provides two levels of personalization: individual and group. It generates personalized feedback to the patient based on the patient’s last reading and other relevant factors [1]. Information relating to the disease and its management

is distributed to the patient group. The Settings feature allows the patient to configure the relevant meters to work in conjunction with the system. Finally, the Help feature provides context-relevant help information.

Figure 3. myDR Main Menu Screenshot

Several systems have been developed to address the

need for proper self-monitoring and recording through the use of mobile phones [8, 9]. However, myDR was designed with the change management best practices in mind. It promotes better self-management among patients by acting as a catalyst in the patient’s ritual building process. It empowers the patient by providing the assessment, challenge, support and results of the CCL Leadership Development Model at all stages of the ritual building process.

Change can be best managed if less focus is placed on will power and intention and more energy is placed on habit formation – better eating and physical movement routines [2, 5, 6]. This is one of the main objectives of myDR. Such routines, whether it is diet or exercise, must be built-in taking into account the issues outlined in the following sections.

(a) (b)

Figure 4. myDR View History Screenshots:

(a) Table View and (b) Graph View

3.1. Evidence and Accountability

myDR makes test results available to the patient on a continuous basis. Figure 4 shows two screenshots of the View History feature. The patient is able to keep a record of previous readings and is provided with two views: a table view and a graph view. This allows for greater self-awareness and places more control and accountability on the hands of the patient. It addresses the questions of: “What has been done?” “What is working or not working?” and, “What needs improvement?” The use of this new technology also plays an important role as evidence, by providing regular and reliable data to the patient. The patient is able to log readings, diet, and exercise activity which all aid in the improvement effort. This lends to both the assessment and results components of the CCL Leadership Model.

3.2. Establish the Mission/Desired State

Armed with assessment, the system should work with the patients to define current bad habits: what needs changing and to what extent? These desired health habits and targets must more importantly be linked to the patient’s values and passion. For example, showing them ‘how their son's graduation may be at peril, if their current health habits persist’ or ‘the dream house may not be materialized.’ The hard evidence linked to their aspirations hold great promise for unfreezing present behavioral patterns and promoting change. By establishing a compelling ‘Why’ for the change (defining purpose) current obstacles can be overcome. The next aspect is to address the gap between the current state and desired state of the patient. This challenge includes the identification of what the patient is going after and what changes need to be made. 3.3. Develop an Action Program of New Rituals

myDR works with the patient in establishing new habits and routines. Reminders are effective in changing behavior. The patient is reminded, via SMS, when to take his next reading and is provided relevant feedback based on his current health status. For example, if the blood sugar is too high, the patient would be advised to increase his fluid intake and take extra medication (see Figure 5). Through this recording and pattern recognition, accountability is developed and the patient becomes more empowered through the shifting of more responsibility to him.

The suggestions, tools and routines utilized should be simple and convenient and in keeping with the patient’s values and preferences. The myDR system tells the patient precisely what he should do on any given day in order to successfully support the change. Without a concrete and specific program, change is not likely to succeed. As mentioned before, the program must be rigorously adhered to for a period of 30-60 days for a new habit to be embedded by using the power of ritual. The ubiquity of the mobile phone allows for this habit to be maintained. The patient now has access to health care services anywhere and at anytime.

Figure 5. myDR Blood Sugar Feedback Screenshot

Figure 6. myDR Blood Pressure Feedback Screenshot

3.4. Support and Recognition

Helpful to the change process is the availability of a generous supportive environment both physical and psychological. To the extent that communication is

enabled and better supported between the patient and HCP, the HCP better understands the patient and is in a more helpful place to render personalized and holistic advice. The incorporation of family and friends in the exercise can lead to better results not only for the individual but for the entire family and community. Physical support such as measurement devices, exercise programs, schedules etc. all play a critical role in the habit acquisition period. This can also take the form of lifestyle management advice such as nutritional advice: healthier food choices, smaller portions and removal of unhealthy snacking.

The system also celebrates achievements. myDR provides positive encouragement, as shown in Figure 6, when the patient meets his targets and is taking good care of himself. Research has shown that in order to sustain improved rituals, people must be rewarded for goal directed behaviors [10]. 4. Focus Group - myDR

A focus group, comprising of 16 participants, was organized to review the myDR system. This research methodology was employed to draw upon participants’ attitudes, feelings, beliefs, experiences and reactions in a way that would not be feasible using other methods. The objective of this review was to obtain preliminary feedback on the design of the system from the target user group. The assumption is that with the change management process built into the design of the system, patients will be able to adopt and maintain better self-care rituals.

A questionnaire was given to the participants at the beginning of the trial to obtain information on their present health care practices. The myDR system was first demonstrated and then each user had the opportunity to use the interface. A survey was then administered at end of the trial in order to obtain feedback on the system’s design. The main questions that were asked included the following: 1. Do you find this method (mobile telemedicine)

better than your current record keeping process? 2. Are you inclined to use such a system (myDR)? 3. Do you believe that through use of this system

(myDR), it will impact your self-care in a positive way?

4. Who presently provides feedback/coaching regarding your health?

5. How often would you like to receive feedback on your status?

6. What changes to the system would you suggest?

Overall all participants agreed that the myDR system was better than their current record keeping system and all but one participant, were inclined to use this type of system. The participant that did not wish to use the system was not comfortable with using a mobile phone in general.

Most participants either kept track of their results mentally or through their doctor’s records. The participants also unanimously agreed that the system will improve their self-care process. They especially liked the idea of the reminder feature to take their next reading as well as the feedback obtained on each reading. Timely feedback was important as it kept them motivated.

Most participants depended on themselves or the doctor to interpret the result of the measurement. The main concern faced by the participants was the delay in receiving the feedback from the health care provider as their visit to the doctor was on average once every 3 months. All the participants agreed that receiving feedback at each reading is a useful feature and they also remarked on the importance of receiving relevant feedback versus the one size fits all approach.

For the last question some of the suggested improvements included:

• Having a care giver (family or friend) to assist/support in the use of the system

• Ongoing assistance should be provided in the use of the system until the user gets comfortable with using it on a day-to-day basis

• Providing different types of reminders • Providing more information on the disease

In the next stage of the project, clinical trials

will be conducted involving 150-200 patients. The objective of these trials will be to directly test the hypothesis – “patients using the myDR system over a period of time will experience a positive change in their health care status.” 5. Conclusion

Change management makes a significant difference in the sustainability of new e-Health initiatives as exemplified by the research that has been presented in this paper. Personal change is best nourished through new habits and routines. The paper has deliberately focused on a mobile telemedicine system that helps build new self-care rituals based on the availability and accessibility of patient health care information. Change management involves a number of issues involving assessment, challenge, support, results and the context,

and we have shown how these issues can be addressed when designing a mobile telemedicine system, ensuring greater chance of success. The key imperative here is personalizing to the patient’s needs as well as providing feedback that is both timely and relevant. The crafting of new rituals is built on this understanding.

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