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Context: Few telemedicine projects have systematically examined provider satisfaction and attitudes. Purpose: To determine the acceptability and perceived impact on primary care providers' (PCP) practices of a randomized clinical trial of the use of telemedicine to electronically deliver health care services to Medicare patients with diabetes in federally designated medically underserved areas of upstate New York, primarily those in rural areas and small towns with limited access to primary care. Methods: A longitudinal phone survey was completed by 116 PCPs with patients with diabetes in the treatment arm of the trial, and conducted 12 and 24 months after a PCP's first patient was randomized to the home telemedicine arm of the trial. The 36-item survey included measures of acceptability (to PCPs, time required), impact (on patient knowledge, confidence, perceived health outcomes), and communication. Six open-ended questions were analyzed qualitatively. Results: The quantitative data indicated positive responses in terms of acceptability of the telemedicine intervention to the PCPs and of the impact on the PCPs' patients. This was most evident in issues critical to good control of diabetes: patient knowledge, ability to manage diabetes, confidence, and compliance in managing diabetes. Key qualitative themes, on the positive end, were more patient control and motivation, helpfulness of having extra patient data, and involvement of nurses and dieticians. Negative themes were excessive paperwork and duplication taking more PCP time, and conflicting advice and management decisions from the telemedicine team, some without informing the PCP but none involving medications. Conclusions: Telemedicine was reported to be a positive experience for predominantly rural PCPs and their Medicare-eligible patients from medically underserved areas; several inefficiencies need to be refined.

Poor air quality has been associated with chronic illness such as diabetes. This can be of particular importance for older adults with diabetes and other chronic conditions who spend most of their time indoors. The purpose of this study was to assess home air quality and residents' awareness and concerns about air quality in rural underserved areas of upstate New York. Implications for home care clinicians are discussed.

Objectives: We examined the social impact of the telemedicine intervention effects in lower- and higher-socioeconomic status (SES) participants in the Informatics for Diabetes Education and Telemedicine (IDEATel) study., Methods: We conducted a randomized controlled trial comparing telemedicine case management with usual care, with blinded outcome evaluation, in 1665 Medicare recipients with diabetes, aged 55 years or older, residing in federally designated medically underserved areas of New York State. The primary trial endpoints were hemoglobin A1c (HbA1c), low-density lipoprotein cholesterol, and systolic blood pressure levels., Results: HbA1c was higher in lower-income participants at the baseline examination. However, we found no evidence that the intervention increased disparities. A significant moderator effect was seen for HbA1c (P = .004) and systolic blood pressure (P = .023), with the lowest-income group showing greater intervention effects., Conclusions: Lower-SES participants in the IDEATel study benefited at least as much as higher-SES participants from telemedicine nurse case management for diabetes. Tailoring the intensity of the intervention based on clinical need may have led to greater improvements among those not at goal for diabetes control, a group that also had lower income, thereby avoiding the potential for an innovative intervention to widen socioeconomic disparities.

Objectives: Adherence to diabetes self care is poor for Hispanic American and African-American patients. This study examined the change in adherence over time and in response to a telemedicine intervention for elderly diabetes patients in these groups compared to white diabetes patients. We also examined whether adherence mediated the effect of the intervention on glycemic control (A1c)., Design: The Informatics for Diabetes Education and Telemedicine project randomized medically underserved Medicare patients (n=1665) to telemedicine case management (televideo educator visits, individualized goal-setting/problem solving) or usual care. Hispanic and African-American educators delivered the intervention in Spanish if needed., Main Outcome Measures: Annual assessment included A1c and self-reported adherence (Summary of Diabetes Self-Care Activities scale). A simple model (only time and group terms) and a model with covariates (e.g., age) were examined for baseline and 5 years of follow-up. SAS PROC Mixed was used with non-linear terms to examine mediating effects of adherence on A1c, by performing tests of the mediating path coefficients., Results: Over time, self-reported adherence improved for the treatment group compared to usual care (p<0.001). There was no significant interaction with racial/ethnic group membership, i.e., all groups improved. However, minority subjects were consistently less adherent than whites. Also, greater comorbidity and diabetes symptoms predicted poorer adherence, greater duration of diabetes and more years of education predicted better adherence. Adherence was a significant mediator of A1c (p<0.001)., Conclusions: A unique, tailored telemedicine intervention was effective in achieving improved adherence to diabetes self care. However, African-American and Hispanic American participants were less adherent than white participants at all time points despite an individualized and accessible intervention. The finding that adherence did mediate glycemic control suggests that unique interventions for minority groups may be needed to overcome this disparity.

Objectives: To improve nutrition and physical activity of county employees and promote weight loss., Design: Random assignment to begin the program when first offered or after 3 months ("wait control" group)., Setting: Worksite., Participants: Onondaga County employees (n = 45) at risk for diabetes (n = 35) or with diabetes (n = 10). Mean (±SD) age = 51.2 (± 8.0) years and body mass index (BMI) = 37.3 ± (6.8 kg/m)., Intervention: Twelve weekly healthy lifestyle sessions based on the Diabetes Prevention Program curriculum, followed by monthly sessions for up to 12 months., Outcomes: Medical: Weight, BMI, waist circumference, blood pressure, fasting glucose, lipid, and hemoglobin A1c levels. Psychosocial/behavioral: Health-related quality of life Short Form-12, Impact of Weight on Quality of Life Scale), physical activity (International Physical Activity Questionnaire), eating behavior (3-Factor Eating Questionnaire, National Cancer Institute Fat Screener), job satisfaction., Results: The intervention group lost significant weight compared to the wait control group over the first 3 months (mean [95% CI], -2.23 kg [-3.5 to 0.97]) vs [+ 0.73 kg (+0.17 to +1.28)], with a decrease in BMI (P < .001) and waist circumference (P = .004), an increase in physical activity (International Physical Activity Questionnaire, P = .011) and lower dietary fat intake (P = .018). Over 12 months, 22.5% (9/40) lost more than 5% body weight and 12.5% (5/40) lost more than 7% body weight. After the first 3 months, there was gradual partial weight regain but reduction in waist circumference was maintained. The intervention group demonstrated significant improvement in Impact of Weight on Quality of Life Scale (P < .001), 3-Factor Eating (cognitive restraint P < .001, uncontrolled eating P = .003, and emotional eating P = .001), International Physical Activity Questionnaire (P = .011), and Short Form-12 Physical Component Summary (P = .048). No improvements were observed in blood pressure, lipid, hemoglobin A1c, or glucose levels. Job satisfaction was inversely related to BMI at baseline (P = .001) with a trend for improvement with the modest weight loss., Conclusions: A worksite intervention program can help government employees adopt healthier lifestyles and achieve modest weight loss.

Background: We examine the changes in waist circumference (WC) and body mass index (BMI) in older adults enrolled in a diabetes telemedicine program. The subjects were elderly Medicare beneficiaries participating in the rural (upstate New York) cohort of Informatics and Diabetes Education and Telemedicine, a randomized, controlled trial using telemedicine to improve diabetes care in which the primary outcome was glycemic control., Methods: Ninety-two percent of the subjects had BMI >25 kg/m(2), and 65.8% had a BMI > or =30 kg/m(2). Intervention subjects received home televisits with a dietitian or nurse educator every 4-6 weeks. Blood glucose and blood pressure values were reviewed, and lifestyle and medication changes were recommended. Non-intervention subjects received usual care through their primary care physicians. Change in WC, BMI, diet, and exercise behaviors and knowledge were examined at baseline and 12 and 24 months. A mixed-effects path analysis was performed to examine direct and indirect effects., Results: The telemedicine participants increased diet and exercise knowledge over time (P < 0.001). It was estimated that women in the telemedicine group reduced their WC over the 2 years by 1.2 cm, whereas women in the usual care group increased their WC by almost 1 cm (P = 0.02). Path analysis demonstrated that the intervention, through improved diet and exercise knowledge, was related to the decrease in WC (P = 0.006) and BMI (P = 0.004)., Conclusions: Diabetes case management using telemedicine improved self-reported diet and exercise knowledge, practices, and behaviors, which in turn was associated with reductions in WC and BMI at 2 years.

Purpose: To examine integration of electronic medical records (EMRs) by primary care providers (PCPs) in a diabetes telemedicine project (IDEATel) in medically underserved rural areas and assess if access to digital records is associated with diabetes intermediate outcomes., Method: PCPs (n=61) with patients in IDEATel participated in structured interviews to determine current (2006 to 2007) and projected (2007 to 2008) use of paper and/or electronic medical data. T-tests examined group differences., Results: 28% (17/61) of PCPs had comprehensive EMRs, but most electronic data were non-interoperative between offices; 6% of PCPs solely used paper; 92% of PCPs used mixed paper/electronic records. Half of 61 PCPs anticipated no migration within one year to an electronic record for common patient data, while one third anticipated that function would become greatly more electronic. Among 31 PCPs interviewed in depth in person, 70% (7/10) in private practice and 69% (9/13) in networks anticipated greater electronic media migration through system change, whereas 100% of responding academic PCPs (n=6) expected only system modifications. PCPs were most interested in data exchange for chronic disease management (94%), regional benchmarking (84%) and quality improvement (87%). Patient personal electronic health records were rarely mentioned. IDEATel patients of PCPs with or without access to comprehensive EMRs achieved similar haemoglobin A1c, blood pressure, LDL-cholesterol, and body mass index, but the small number invokes cautious interpretation., Conclusions: Our findings suggest an effective and complementary element of national health information technology (HIT) strategy, telemedicine, can be implemented by PCPs with success despite the lack of a concurrent EMR for efficient data exchange.

Background: The fear of reprisal, combined with the additional time required for reporting, are significant disincentives to reporting of medical events. Such considerations provided an incentive for the Upstate Medical University Hospital (Syracuse, New York) to develop monitoring systems to decrease the potential for drug harm. IMPLEMENTING A NONPUNITIVE REPORTING SYSTEM: Previously, a convenient, point-based score card system for punishment and remediation led to underreporting and hindered the identification of safety improvement opportunities in medication use processes. Nursing buy-in was accomplished through careful initial negotiations that emphasized that patients were best served by learning from errors in the medication use process. The revised medication event reporting policy, as established in October 2000 for all staff, severed the link between reporting errors and performance evaluations., Results: Data collected 18 months before the policy change was compared with data collected after the policy change was enacted in October 2000. The number of reports received each month increased from an average of 19 to 102 (p < .001)., Discussion: Substantive quality improvements in medication have been achieved by using a systematic approach to the analysis of the markedly increased number of reported medication events following the introduction of a nonpunitive reporting system.

Our goal was to identify reasons for enrollment or refusal to participate in a randomized trial of telemedicine case management of diabetes. We performed a prospective survey of participants and non-participants during recruitment for the Informatics for Diabetes Education and Telemedicine (IDEATel) study, a randomized trial of telemedicine case management of diabetes mellitus in medically underserved elderly. There were two recruitment areas: urban New York City, and rural upstate New York. A Participant Questionnaire (PQ) was administered at the baseline IDEATel visit, and a Non-Participant Questionnaire (NPQ) was administered during the recruitment telephone call. Both questionnaires listed possible responses; subjects could choose more than one response or give their own. Of 1,660 IDEATel participants, 99.7% completed the PQ. Most frequent reason for participation was the belief that the technology could help them (52% and 42% of urban and rural respondents, respectively). Of the 2,231 subjects refusing participation, 28% answered the NPQ (90% of respondents were from rural area). Most frequent reasons not to participate in the rural area were being too busy (23%), and discomfort with the technology (22%), and in the urban area the belief that the technology could not help them (71%), discomfort with it (52%), and not liking to participate in studies (52%). In multivariate analysis (rural respondents only), knowing how to use a computer was an independent predictor of participation (p < 0.001). In conclusion, perceptions and beliefs regarding technology, including the expectation to benefit from it, played an important role in the decision to participate.

We studied whether ambulatory blood pressure monitoring added to office blood pressure in predicting progression of urine albumin excretion over 2 years of follow-up in a multiethnic cohort of older people with type-2 diabetes mellitus. Participants in the Informatics for Diabetes Education and Telemedicine study underwent a baseline evaluation that included office and 24-hour ambulatory blood pressure measurement and a spot urine measurement of albumin-to-creatinine ratio (ACR). Measurements of albumin-to-creatinine ratio were repeated 1 and 2 years later. In bivariate analyses, ambulatory 24-hour pulse pressure was the blood pressure variable most strongly associated with follow-up ACR. Repeated-measures mixed linear models (n = 1040) were built adjusting for baseline ACR ratio, clustered randomization, time to follow-up, and multiple covariates. When both were entered into the model, ambulatory 24-hour pulse pressure and office pulse pressure were independently associated with follow-up ACR (beta [SE] = 0.010 [0.002], P < 0.001, and 0.004 [0.001], P = 0.002, respectively). Cox proportional hazards models examined associations with progression of albuminuria in 954 participants without macroalbuminuria at baseline, adjusting for all of the covariates independently associated with follow-up ACR in mixed linear models. Ambulatory 24-hour pulse pressure, but not office pulse pressure, was independently associated with progression of albuminuria (P = 0.015 and 0.052, respectively). The adjusted hazards ratio (95% CI) per each 10-mm Hg increment in ambulatory pulse pressure was 1.23 (1.04 to 1.42). In conclusion, ambulatory pulse pressure may provide additional information to predict progression of albuminuria in elderly diabetic subjects above and beyond office blood pressure.

Home telehealth involves the use of video conferencing or remote monitoring equipment in patients' homes. The installation of hardware and training of patients has historically been performed by nurses, typically RNs. This article examines the experience of RNs as telehealth installers in the Informatics for Diabetes Education and Telemedicine (IDEATel) project, where RNs were responsible for the installation of the Home Telemedicine Units (HTUs) and for training patients in the use of the HTUs, blood pressure cuffs, and fingerstick glucose meters. Average installation and training time was 166 minutes (SD 51 min). Structured interviews with RN installers revealed that patient education and training accounted for roughly two thirds of the in-home time. Technology-related problems, especially those related to telecommunications, were the primary cause of installation difficulties. Thematic analysis of installer interviews identified eight major themes and confirmed the importance of both clinical and technical knowledge during the telehealth installation process.

The authors' class structure incorporates individual meal and exercise planning in the group setting. This study was conducted to (1) determine if class participants can create their own meal and exercise plans, (2) determine if class participants feel they will be able to adhere to their meal and exercise plans, and (3) assess adherence to the plans over time. Subjects were recruited from the classes offered at the Joslin Diabetes Center. Following completion of class, patients completed the evaluation questionnaire. Two and 6 months later, study participants received follow-up questionnaires by phone or mail. Among respondents, 63% were able to determine their own carbohydrate goals, with 95.9% indicating they could adhere to the plan, and 82.8% felt the plan would be easier than previous ones. At 2 and 6 months, respectively, 89% and 92% of the participants felt they were following the meal plan either some or most of the time. One hundred percent of the respondents were able to determine their own exercise plan, with 98% indicating they could adhere to the plan, and 85.7% felt the new plan would be easier than previous ones. At 2 and 6 months, respectively, 70% and 73% felt they were following their exercise plan either some or most of the time. Individualized meal and exercise plans can be successfully created in a group setting.

Telemedicine has the potential to transcend geographic and socio-cultural barriers to the delivery of high quality health care to the medically underserved populations. However, there are significant cognitive and usability barriers. This paper presents a multifaceted cognitive evaluation of the IDEATel diabetes education and telemedicine program. The evaluation included a cognitive walkthrough analysis to characterize task complexity and identify potential problems as well as field usability testing in patients' homes. The study revealed dimensions of the interface that impeded optimal access to system resources. In addition, we found significant obstacles corresponding to perceptual-motoric skills, mental models of the system, and health literacy. The objective of this work is to contribute to a design framework so that participants with a wide range of skills can better manage their chronic illnesses.