Patient-Centered Online Disease Management Using a Personal Health Record System (California)


Engaging patients directly in their care is seen to be a critical aspect of successful chronic disease management. Traditional chronic disease management programs have relied primarily on in-person visits and phone contact with providers. Health information technologies (ITs), however, have the potential to significantly increase the engagement of patients by using personal health records (PHRs) to electronically connect them to their clinical data, care team, and educational materials.

This project evaluated a multidisciplinary team approach to diabetes care that was combined with technology tools, called the Personal Health Care Project (PHCP). PHCP was developed as a patient-centered care model and incorporated many strategies known to be effective in consumer use of health IT including responding to the needs and preferences of patients; providing continuous, convenient, online access to health records; and facilitating frequent communication with clinicians. The model includes an online disease management (ODM) system that supports the team, which includes a nurse care manager (NCM), a clinical pharmacist, a registered dietitian (RD), and the patient’s physician(s). The ODM is integrated with an electronic health record (EHR) and PHR.

The main objectives of this project were to:

  • Refine the Personalized Health Care Program platform with a particular focus on enhancing the customization capability of the ODM system and ensuring a seamless incorporation of ODM into the workflow of clinicians on the care management team and with the self-management process of patients. 
  • Evaluate the ODM program for diabetes relative to usual medical care, in a two-arm randomized controlled trial (RCT).
  • Disseminate results of the RCT in the scientific literature, and deploy the PHCP program in Palo Alto Medical Foundation and other ambulatory care settings for use with diabetes and other chronic conditions.

The team evaluated the model with a RCT of patients with uncontrolled type 2 diabetes using the ODM program compared to usual care. The intervention consisted of wirelessly uploading the patient’s glucometer data to the EHR; creating a patient-specific Diabetes Summary Status Report; making available nutrition and exercise logs; offering a record for insulin tracking; providing secure messaging capability with the health care team via the PHR; access to a nurse care manager and dietician for advice and medical management; and electronic patient education materials including patient-specific text and video educational materials. The primary outcome measurement of the study was hemoglobin A1c (HbA1c).

At 6- and 12-months, patients in the intervention group reduced their HbA1c by a statistically significant amount. When comparing the reductions with the usual care group, the difference was statistically significant at 6 months but not at 12 months, since the usual care group also improved in that time frame. Amongst intervention patients who reduced their HbA1c by greater than 0.5 percent, those who obtain glucose readings and regularly uploaded them were able to sustain that reduction at 12 months. The PHCP appeared to be a successful way to engage patients in the care of their diabetes and improve their outcomes.

Grant Number: 
R18 HS017179
Funding Mechanism: 
Ambulatory Safety and Quality: Enabling Patient-Centered Care through Health IT (R18)
AHRQ Funded Amount: 
Principal Investigator: 
Tang, Paul
Palo Alto Medical Foundation
Palo Alto
Project Dates: 
September 1, 2007 to August 31, 2011
Project Status: 

Project Categories

Type of Health Information Technology: 
Clinical Decision Support (CDS) System
Health Information Exchange (HIE)/Regional Health Information Organization (RHIO)
Home/Remote Monitoring
Personal Health Record (PHR)
Secure Messaging
Care Setting: 
Family Medicine
Internal Medicine
Outpatient Clinic
Primary Care
Specialty Practice
Aspect of Care: 
Chronic Disease Management
Medication Management
Patient Education
Target Population: 
Chronic Care
Last Modified: August 2015

News and Publications

Tang P. Patient-Centered Online Disease Management Using a Personal Health Record System - Final Report. (Prepared by Palo Alto Medical Foundation Research Institute under Grant No. R18 HS017179). Rockville, MD: Agency for Healthcare Research and Quality, 2012. (PDF, 410.41 KB)
The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.

Project Activities