Government Is Funding Technology to Monitor People's Health-Care Behavior by Having Them 'Visit' with Computers

By Marie Magleby | May 21, 2009 | 11:40 PM EDT

Sequential Multiple Analysis Computer at the Warren Grant Magnuson Clinical Center (National Institutes of Health photo).

( - “Health-care professional time is very, very expensive,” says Robert Friedman of Boston Medical Center. “We’re not going to constrain health-care costs by giving patients absolutely unlimited time with doctors or nurses--they’re too expensive.”

In an effort to increase efficiency in the treatment of certain health-care problems, the federal government has provided Friedman with about $22 million in grants since 1995 to develop technology that can save people actual visits to a doctor's office by allowing them to make "virtual" visits in which a computer speaks to them via a digitalized voice over the telephone.

Friedman has called the technology “Virtual Visit.”

“Telephone-Linked Care (TLC) technology has been developed and applied as an alternative to and a supplement for office visits as a means to deliver ambulatory care,” Friedman wrote in an article titled “The Virtual Visit,” in the November-December 1997 issue of The Journal of the American Medical Informatics Association.
Friedman currently has six active grants from the National Institutes of Health.
The TLC computer system works with patients to address common medical conditions such as alcoholism, asthma, depression, diabetes, heart disease, hypertension and spinal-cord disease through a telephone interface with the patient.
TLC can also be used to monitor personal behavior patterns by using computer-generated telephone calls and question-and-answer sessions to ask patients about such things as their fruit and vegetable consumption and their physical activity.  The computer can even praise patients for exhibiting positive behavior in the answers they give.

“The goal is to monitor patients who need monitoring daily rather than just when they are seen in the office,” Friedman told
According to Friedman, the computer-and-telephone system can increase efficiency in health care.

“The information we have [in TLC] is absolutely accurate, it’s absolutely up-to-date, the systems are inexpensive to deploy,” he says. “So what it means is that we can have, in our programs, much more contact time with patients than they’re ever going to get from doctors and nurses unless there are very, very unusual circumstances.”

After more than 20 years of research, TLC technology is now in its licensing stages. Once it is in place, doctors and patients may use TLC to monitor the patients’ progress between visits.

Although patients are expected to call TLC according to a set schedule, TLC initiates the call when patients do not. Patients are greeted and asked to enter a Personal Identification Number, after which their automated “conversations” with TLC begin.

Because the information from each visit is stored in a database, TLC attempts to tailor the conversations to the personal histories and needs of each patient.

By pressing numbers or speaking into the phone, patients answer closed-ended questions that prompt pre-scripted responses from the computerized voice on the other end of the line. TLC then offers information and counseling depending on the patient’s input.

"During TLC telephone encounters, the system speaks to patients using computer-controlled digitized human speech,” Friedman wrote in “The Virtual Visit.”

“The patients, in turn, communicate with TLC by depressing the keys on their telephone keypad or by speaking into the telephone receiver,” wrote Friedman. “During each conversation, TLC asks the patients clinical questions and comments on their responses; it also can provide information and counseling. Depending on the clinical domain of the particular TLC application and the patients’ responses, a conversation can last between 2 and 15 minutes."

TLC has been programmed to replicate a real physician as closely as possible.

“Much of the information, advice, support and counseling by TLC is done in response to the answers patients give to TLC questions,” Friedman wrote. “This TLC feedback also serves to maintain the human side of the conversation, supporting the ‘feel’ of the conversation as a true dialogue.”

For example, when patients answer TLC’s questions correctly, the computer-generated voice responds with “That’s right!” or “That’s good!”
Information from each “virtual visit” is stored and relayed to the patient’s regular physician in an electronic database, enabling them to monitor their patients without making frequent face-to-face consultations.

Although the system is not perfect, Friedman said it is an improvement from what is currently available.

"In many settings, time scheduled for an office visit has been drastically reduced, enabling more patients to be seen in the course of the day and driving down unit costs,” Friedman wrote.

“Although greater efficiency has been achieved, health care providers feel the stress of delivering high quality care in less time. In response, they are seeking new ways to care for patients that maximize both quality of patient care and practice efficiency.”
Friedman said he believes that TLC will complement the new federal health-care plans to be deliberated in Congress later this year.

“I think it fits in very, very well,” he told “The understanding that there is a problem in how our health-care system was organized and how it was paid for has been with us for decades. It’s just that doing something about it is not easy.”
“What will actually happen with these type of programs that we have created is that when they’re fully used and fully integrated, they really will change how health care is delivered in the office setting,” he added. “And then offices aren’t going to disappear, hospitals aren’t going to disappear, emergency departments aren’t going to disappear, but they should change.”

Friedman said that the development of his project is a step in the right direction because the current health-care system does not adequately treat patients with chronic disease and the U.S. spends more than $1 trillion annually to treat such conditions.

“It is well-recognized that technologies like this have been very slowly introduced into health-care delivery, compared to many other parts of the economy,” he told
While TLC is in its beginning stages in the U.S., Friedman said the technology could be useful in many countries.

“One of the overarching goals that I have is the way that TLC, which is telephone-based, is really ideal for use in countries that are under-resourced with respect to their formal health care system,” he told
NIH’s Fogarty International Center has also already provided Friedman with $86,000 to research the possibilities for deploying a system in China—in a grant entitled “Behavioral Health Informatics Capacity-Building in China.” The grant began in 2007 will continue through 2010. 
(China, according to the State Department, “is an authoritarian state in which the Chinese Communist Party (CCP) constitutionally is the paramount source of power.” It's approach to health care includes a coercive population control policy.) 
Friedman's NIH grant involving China aims at promoting "healthy behavior."

“The long range goal is to spread behavioral informatics research capacity throughout China and in other developing countries,” says the NIH abstract for Friedman’s “Behavioral Health Informatics Capacity-Building in China” grants.
“This project will result in the establishment of research capacity in China to develop, evaluate and disseminate an automated, low cost, culturally sensitive, easily accessible and effective program to promote healthy behavior in the population (e.g., active lifestyle, healthy eating, and smoking cessation),” says the NIH abstract.

“Should these programs be deployed in China, they would have the capacity to decrease the prevalence of many common chronic diseases and improve their control in the population,” says the abstract.

“For this project, a Chinese version of an effective NIH-funded automated, telephone-based physical activity (PA) promotion program will be developed,” says the abstract.
Friedman is also the principle investigator for five other active NIH grants, including one called “A Longitudinal Telephone and Multiple Disease Management System to Improve Ambula.”  This grant is designed to help people in their “self-management” and test whether the system results in “significantly lower utilization of acute care services." The research will determine what impact this has on “net payer costs.”
“Low-income patients with multiple chronic diseases are at high risk for complications after discharge from the hospital,” Friedman’s proposal said. “We propose an automated, telephone-based ambulatory care system, TLC-Complex Patient [TLC-C], to promote patient self-management and clinician decision-making. A randomized controlled clinical trial will test the hypothesis that patients using this system will have significantly lower utilization of acute care services and improved rates of ambulatory care utilization, quality of life (EQ-3D) and disease-specific health outcomes. Clinician satisfaction (G-CAHPS) and net payer costs will also be assessed.”
TLC will  record the information it collects from  "virtual visits" in a patient's “electronic health record.”

“The system monitors patients through ‘virtual visits’ and detects and notifies clinicians about important clinical problems to attend to,” Friedman wrote in his NIH grant abstract. “It also promotes patient self-care (e.g., medication adherence and appointment preparation). Data collected through TLC-C are integrated into the patient's electronic health record (EHR).”
Another active NIH grant for which Friedman is the principal investigator is entitled “Improving Dietary Behavior Through Tailored Messages.”  This grant aims at comparing the effectiveness of TLC technology with print and Web-based input in getting people to change their eating habits.

According to Friedman’s proposal, the research will “compare totally automated, population-based tailored (1) print, (2) telephony, and (3) Web interventions for promoting dietary behavior change. These interventions will use the same behavioral theoretical structure (the Transtheoretical Model) and similar content, designed to reduce cardiovascular disease risk by promoting intake of fruit and vegetables and reducing consumption of saturated fat.”

Although telephones have long been a useful tool for communication between doctors and patients, Friedman developed “one of the first interactive computer-based telecommunication systems that ‘speaks’ to patients and other consumers using computer controlled speech,” he wrote in 2003 for the American Medical Informatics Association.

Participants had varying reactions to “virtual visits” in a TLC trial study in 2003. On average, 63 percent reported having a positive experience.
“Positive reactions included that TLC was ‘fun’, made them more aware of what they ate or how much exercise they did, gave them helpful information, served as a ‘friend’ or ‘mentor’, and helped them change towards a healthier life style,” Friedman and other researchers wrote.
Other participants reported more negative reactions, including that “TLC talked down to them, treated them like a child, made them feel guilty, had an unpleasant or ‘disembodied’ voice, was inflexible and did not allow them to get or input information they thought important, was boring and repetitive and did not help them.”
According to data available on the NIH and Department of Health and Human Services Web sites, NIH has funded 14 different grants for TLC-related research since 1995 with a collective price tag of $21million. Friedman told that he has been receiving federal grants for research on this technology since the late 1980s.
The Department of Health and Human Services' Health Resources and Services Administration and the federal Centers for Disease Control and Prevention have also contributed funds to the research.