SIGSAC Software: A tool for the Management of Chronic Disease and Telecare

Abstract

Chronic disease management is highly complex because multiple interventions are required to improve clinical outcomes. From the patient’s perspective, his main problems are dealing with self-management without support and feeling isolated between clinical visits. A strategy for providing continuous self-management support is the use of communication technologies, such as the telephone. However, to be efficient and effective, an information system is required for telecare planning and follows up. The use of electronic clinical records facilitates the implementation of telecare, but those systems often do not allow to combine usual care (visits to the health clinics) with telecare. This paper presents the experience of developing an application called SIGSAC (Software de Información, Gestión y Seguimiento para el Autocuidado Crónico) for Chronic Disease Management and Telecare follow up.

Introduction

For patients with chronic conditions, self-management is much more than just a matter of controlling symptoms (1). From the perspective of health care systems, the management of chronic disease must include multiple interventions in order to improve clinical outcomes, to bring about lifestyle changes and to better the quality of life of the person living with a long-term condition.

Based on the results of the baseline needs assessment (2), the School of Nursing (SON) at Pontificia Universidad Católica de Chile (PUC) started in 2004, with the financial support of the National Science Fund (FONDEF/ Nº D04i1174), to design and implement a telephone-mediated chronic care model – The ATAS Model (Apoyo Tecnológico para el Automanejo de Condiciones Crónicas de Salud) which was conceived to improve self-management, metabolic compensation and satisfaction of those patients with Type 2 diabetes enrolled in public cardiovascular health programs (CVHP), as a contribution to Chile’s health system of universal access with explicit guarantees (AUGE PLAN).

The ATAS self-management support model was created as an additional component of the patients with type 2 diabetes health care networks which include the CVHP, use of emergency room and hospital, urgent care and secondary care services, and contributes both to reduce fragmentation and to improve the continuity and timely delivery of care. In coordination with the patient’s primary health care team, the patient receives self-management support between face to face visits; and relevant information obtained through the nurse telephone counseling calls is incorporated into a shared electronic record, which is available in the health care centers where this project was implemented.

The results of the ATAS project have shown that the telecare support model had a positive effect on the intervention group (3). The main component of the ATAS model was the systematic telephone counseling interventions provided by nurses with clinical primary care experience and training in decision and self-management support, as well as in motivational interviewing techniques.

The CVPH which participated in the ATAS project used an electronic health record (EHR) that was shared with the telecare nurses who were located in a call center outside the Primary Health Care Centers (PHCC). The primary care team used that electronic record to make recommendations to the telecare nurse, regarding contents to be addressed in the telephone counseling intervention, and the telecare nurses incorporated relevant clinical and psychosocial information in the shared EHR to be readily available for the clinicians (Figure 1).

Figure 1:

Incorporation of the ATAS model as a component of usual care.

However, most of the PHCCs in Chile, outside Santiago, do not have access to an EHR, which is an element that immensely facilitates the process of articulating usual care with telecare-self-management support. The positive impact of these technologies on chronic illness care has been demonstrated in international research studies (4).

Methodology

Based on the experience of 3 years with the ATAS project, and the follow-up of 2,000 patients, the telecare nurses who are faculty members at the SON designed the Software for Information, Managing and Follow up for Chronic Self-Care “SIGSAC” (Software de Información, Gestión y Seguimiento para el Autocuidado Crónico) with financial support of the National Science Fund (FONDEF) in alliance with the Information Technology Department at PUC. According to Tang & Mc Donald’s definition of electronic health records, SIGSAC can be considered an EHR because it serves as a repository of electronically-maintained information and adds information management tools to provide clinical reminders and alerts, linkage with knowledge sources for health care decision support, and analysis of aggregate data, both for care management and for research (5).

The development was done by an interdisciplinary team, led by nurses, with active participation of an engineer and a senior programmer analyst. It involved the following steps:

• - Development of a diagnostic information management system

• - Definition of specific needs for the service operation

• - In situ observation

• - Development of proposed programming

• - Meetings with technical teams (nursing-information technology)

• - Programming settings

• - Use on simulated patients

• - Application of in-service operation, pilot version

• - Product delivery

SIGSAC allows the following processes:

1. To schedule agendas

2. To make telephone calls to patients

3. To act as an information and feedback system for nurses and administrative staff

4. To be a repository of key information from service users and archiving of clinical records, lab test results and follow up of self-care activities

5. To be a warning system for the internal users. It can be programmed according to different criteria, for example: incomplete data, contacted the service more than three months ago, patient-specific clinical risk

6. To be an update system according to emerging needs of the self-management support service.

7. Parameterization of any health center staff using the system of privileges and control over information.

All licenses used for the construction of SIGSAC are Open Source and based on Web development technologies. The tools used are: PHP as a programming language that is built into the system, Apache web server and MySQL as the database manager where all the records of the system are kept. SIGSAC also has self-installation software and user manual which allows the users to install and operate the software without too much support from technical staff.

SIGSAC can be installed in any health care center, regardless of their complexity and size, as the requirements of hardware elements depend on the number of patients and staff.

In a standard health care center, SIGSAC can be installed on a PC network or on an already installed server. An important consideration is to secure the information. There is no difficulty when using a local network, but if you want to access SIGSAC from the Internet, you must enable security features such as a Firewall. The technical requirements for a health center should be provided. As an example, for 1,000 patients, 2 telephone agents, 4 nurses and 3 doctors, the requirements are as follows:

• Basic Server: 4 GB RAM, 300 GB HDD (Linux operating system suggested, but can also be Windows)

• HDD 300 GB backup

• Basic PC for each nurse

One of the key aspects of a telecare intervention for chronic care is to ensure the fidelity of the professionals with the conceptual framework which was used to develop SIGSAC. In this sense, the nurse can use SIGSAC as a guide for her intervention. The intervention starts with the general assessment and ends at the item “Self-Care Follow up” (Figure 2).

Figure 2:

Example of the self-care and self-management follow up included in SIGSAC.

At this point, the nurse updates the patients’ stage of behavior change (Prochaska, DiClementi, 1983) (6) and their state in the decision-making process, and she prioritizes with the patient the area of self-care to intervene, and, finally, both nurse and patient agree on a “Self-Care Plan”. This allows any professional who provides self management support to the patients in the future to track the achievement of goals and make self-care plan adjustments.

Telecare nurses receive training that ranges from technology issues to various theories and models from the disciplines of nursing, psychology, etc. It is also very important to develop the skills to decide which tools will be used in each context of interaction in order to provide effective care (7). Table 1 summarizes the framework used by the nursing team and the skills required for the development of the SIGSAC for self-management support interventions.

Table 1.

Framework for the development of telephone counseling to support self-management on chronic diseases

Topics	Author	Implications for Tele-care in Chronic Care
Self-Care Deficit Theory of Nursing	D. Orem	Self- care is the practice of activities that individuals initiate and perform on their own behalf in maintaining life, health and well being
Trans theoretical Model of Health Behavior Change	Prochaska & Di Clemente	Change implies phenomena occurring over time, is a process-involving progress through a series of six stages
Self-Efficacy	A. Bandura	One’s confidence in one’s ability to take action
Health Belief Model	Rosenstock	People will take action to control ill-health condition if, among other factors, they regard themselves as susceptible, if when they evaluate potential consequences they consider that there are more benefits than costs to change their behavior .
Health Decision Support	A. O’Connor	Health decisions are often difficult to make. Patients often have decisional conflicts. Decision support can help the patient to understand the range of options available, the probable consequences for each option, help him recognize what is most important to him (value sensitive) and the pros and cons of the decision.
Motivational Interviewing	Miller & Rollnick	Express empathy, develop discrepancy, roll with resistance and support self-efficacy

Conclusions

The ATAS intervention, in low income patients with type 2 diabetes attended in public primary care centers, stabilized hemoglobin A1c, reduced emergency room visits and improved adherence to planned visits in the primary care center.

The SIGSAC tool was completed in 2009, and since then has been available to be adapted and used for free in primary care centers that do not have electronic medical records.

SIGSAC is a chronic care management tool which can be used to promote, follow up, support and evaluate health behavior changes and self-care practices. It also helps to monitor quality of care.

SIGSAC is an easy-access technological tool for safe and efficient chronic disease management.

SIGSAC meets the needs of primary care centers that do not have electronic medical records and it can be used in Chile and in other Spanish-speaking countries.