March,
2007
High-Tech
Counseling: An Untapped Market for Today’s Dietitian?
By Dina Aronson, MS, RD
Today’s Dietitian
Vol. 9 No. 3 P. 46
Imagine turning on your computer, pulling up
a list of your clients, and clicking on any of their files to
check progress, send a motivational message, or tweak a diet
plan. Imagine your clients logging onto a program that allows
them to record, view, and save their health records and monitor
their progress over time. Imagine being in touch with your clients
as they need you but wasting no time tracking them down, scheduling
appointments, or having them wait.
This is the direction healthcare is heading.
As such, it is our responsibility to provide a continuum of
care. Dietetics has come a long way in the last 50 years, but
the trade has not, for the most part, kept up with technological
advances. Such advances have permeated the healthcare industry
at an unprecedented rate, yet dietitians have been relatively
slow to embrace new technology. As healthcare organizations,
other healthcare providers, and health insurance organizations
use online formats, we must be ready for these advances, as
accurate information transfer depends on our use and acceptance
of new technology.
The American Dietetic Association has called
such advances telemedicine and defines it as “the practice
of healthcare delivery, diagnosis, consultation, treatment,
transfer of medical data, and education using interactive audio,
video, or data communication.”1 Stated benefits (also
quoted elsewhere in the literature) include the following:
• reaching more people (providing care
to anyone, any time, anywhere);
• allowing better access to healthcare (not only for the
client but also for the professional, as it provides better
information access and management);
• providing quality care (providers, experts, and clients
can be easily linked); and
• offering value (online care is less expensive than in-person
care).
Thus, it is important for dietitians to not only embrace but
also become proficient users of healthcare technology.
Models of High-Tech
Counseling
There are myriad approaches to high-tech counseling, which may
be broken down into three main models: a value-added service
to traditional counseling, Internet-only communication, or use
in combination with long-distance telephone counseling.
• Value-added service. With this approach,
you can offer clients optional services that require the Internet.
For example, on your Web site, you could set up an electronic
food diary, which your client would fill out over several days
and submit with a click of the mouse. You would then generate
a nutrition analysis based on the client’s input and send
it back via e-mail. At your next visit, you would review the
diet and discuss recommendations and a plan.
• Internet-only communication. This is
the least used approach because it relies solely on computers
and does not involve verbal communication. However, because
so much of the process can be automated, this method involves
the least time, allowing you to bill far more clients than you
could ever see in the same time period. By nature, this approach
is limited and best used for clients who are well and only seeking
general diet information or perhaps diet analysis or meal plans.
This method may be used via e-mail and/or a Web site.
• Combination telephone counseling. This
seems to be catching on as the most common way to use high-tech
counseling. As dietitians become more specialized in their particular
area of knowledge, they are sought for their special skills.
For example, a dietitian known for her expertise in gluten-free
diets may counsel dozens of clients all over the world via phone
because clients cannot find such a specialist in their area.
The telephone consultation, similar to a face-to-face meeting,
is then followed up via e-mail. This approach may or may not
utilize additional online tools.
These models are general; since there are so
many different high-tech tools, there are endless possibilities.
Some prefer a high degree of participation on the client’s
part (where the client inputs information online) while others
prefer to use the Internet as a means to simply provide information.
Dietitians should structure their own unique style, using technology
as they see fit for their particular needs.
Benefits
If you, as a private practice dietitian, could identify the
biggest problem facing your business today, what would it be?
Insufficient income? Time management? Client retention? All
three? Going high-tech can address these challenges and more.
Increase Flexibility
With the Internet as your friend, the possibilities for quality
care are endless. You have more freedom and resources to serve
people all over the world, and you have the flexibility to work
part-time, work from home, or work another job.
Save Time
What is the maximum number of clients you could see in one day?
How often do you see that many? If you were able to reach your
maximum client load every day, would the resulting income be
worthwhile? Would your time constraints allow you to prepare
for and document each case sufficiently?
Traditional counseling entails a compulsory
time limit and a “client saturation point,” after
which quality of care starts to decline, and you may start to
experience burnout. But think outside the box: What if dietitians
were to exclude the limiting factors of time and client load
yet maintain high quality? Dietitians can do it but not with
traditional counseling practices. Dietitians would need a new
structure for pricing, visits, and communication.
By counseling online, dietitians can multitask
in a way that’s impossible during a traditional visit.
Much of the communication happens during downtime; the Web technology
keeps your clients engaged, motivated, and learning while you
are occupied with other clients or other aspects of business.
An additional time benefit to online counseling:
By not having to see clients face-to-face, you don’t have
to spend as much time getting ready in the morning or commuting
(if you switch to a home-based business).
Save or Eliminate Office
Space
Cutting out in-person visits means more freedom with office
space. This is one reason why online counseling is ideal for
dietitians who prefer working from their home or a local Internet
cafe.
Earn More
Certainly, buying software and setting up shop for online counseling
are costly. But over time, the investment pays for itself. In
addition to office-related expenses such as rent, maintenance,
utilities, and cleaning, consider the money saved when you eliminate
or decrease the use of business attire and dry cleaning services,
cut down on automotive/transportation expenses, and eliminate
items such as scales, food models, posters, and paper handouts.
Furthermore, if you earn more money with your new high-tech
approach, you can double or triple your net income.
Streamline Work
You probably already use computer software for much of your
work-related tasks: scheduling, e-mailing, and word processing.
If you use software to exchange information with clients, everything
can be done electronically. Information/record management becomes
a breeze. You can get more done in less time, uphold high levels
of confidentiality, maintain a neater workspace, and possibly
even achieve a paperless office.
Retain Clients
Certainly, client retention is a top concern among counseling
dietitians. Long-term success depends on regular follow-ups,
but clients usually drop off after only a few visits. This compromises
successful outcomes for the client and business success for
you.
From the modern client perspective, checking
in with their dietitian online saves them money and time and
reduces or eliminates the need for in-person visits. But they’re
still getting quality, customized care. Ongoing and published
studies on efficacy of online intervention have been promising
thus far.2-4
Provide Continuity of
Care
Doctors and other healthcare providers are already using secure
online communication and tracking tools with patients (eg, personal
health records). Depending on the software used, information
may be shared among all healthcare providers and patients. If
healthcare is concentrated in one online “place,”
the quality of care increases.
Stand Out Among Your
Competition
Offering online counseling gives dietitians a unique competitive
edge, as it offers clients something new, different, and valuable.
In fact, in my own experience and in conversations with fellow
nutrition professionals, clients of dietitians using technology
have a high perception of the value of their service. This only
makes sense because they are already witnessing this trend with
their doctors (who are now required to use high-tech tools such
as electronic medical records), so dietitians maintain that
professional consistency. In addition, being tech-savvy earns
dietitians a higher perceived value among fellow healthcare
professionals, leading to higher referral rates.
According to Megan Moran, RD, CDN, CDE, who
has been practicing online counseling via her Web site www.megrd.com
for the past five years, clients love the services they receive.
She points out that not all clients are good candidates for
online counseling; her typical client is one who wants a sample
diet to follow as opposed to those with complex nutritional
issues who are better suited for typical visits.
Besides Moran, other dietitians stand out as
pioneers in online nutrition counseling. Alanna Nimau Vigil,
MS, RD, manages http://yourrdonline.com
where she offers counseling via e-mail, private chat rooms,
and/or by telephone services. Nadine Fisher, MS, RD, LD, has
done her homework on online counseling; she offers a CD for
dietitians interested in launching a counseling practice online
that can be found at www.nutritionnetworks.com/clients.htm.
Drawbacks
Of course, there are some drawbacks to counseling online. First,
you and your clients suffer the loss of nonverbal communication
(body language), which often relays important information. Second,
it may take longer for your clients to establish trust. Finally,
depending on your personality, it may take a toll on your morale,
as moving toward online counseling can be isolating.
Not every private practice dietitian is a good
candidate for online counseling. If you shine as a motivator
by the rapport you have with your clients and/or obtain great
results with group counseling, Web-based communication is probably
not your best option. However, offering certain online tools
will provide your clients added value.
Certain populations are poor candidates for
online counseling. For example, seniors, who may not be as comfortable
with computers as younger folks, may not adapt well to this
change. Other groups that are usually not appropriate for online
counseling include low-income populations, children, those with
complex nutritional issues, and those under a doctor’s
care for an illness such as cancer.
Online counseling also has a unique set of risks
involved. A complete analysis of HIPAA concerns, ethical concerns,
and legal, privacy, security, and professional issues is beyond
the scope of this article, but comprehensive reviews are available
in other works.1,5-8
Barriers to Acceptance
With such potential benefits of online counseling, why have
dietitians been slow to embrace the technology? Possible reasons
include a force of habit and comfort with the current system,
high initial costs (real or perceived), a learning curve, resistance
to a paradigm shift, fear of the unknown or failure, and an
unclear view of the risks and benefits.
According to discussions on dietetic e-mail
listservs, results have not been fantastic among RDs who have
tried online counseling. The primary reason given for a lack
of success is that clients fail to keep up the e-mail communication.
This is an interesting point and suggests a need for an alternative
to relying on regular e-mail as the main client communication
strategy. If your message gets stuck between an offer for Viagra
and a forwarded joke, your client may miss your message or find
it out of context and not be in the right state of mind to accept
the communication. But if, for example, there were a dedicated,
secure place online where your clients could go to connect with
you, compliance would be much greater. And this is where online
counseling is headed; products such as MyProconnect (see sidebar)
address this and other concerns to maximize the efficiency and
success of online counseling.
Getting Started
You don’t need to go it alone; Moran suggests starting
small. You don’t necessarily need to create a Web site
at first. You can try working with clients from one place, such
as a fitness center, and grow from there, she says.
Fisher’s CD is a good resource to help
get you started. Practice groups such as Nutrition Entrepreneurs
and local dietetics groups offer plenty of support and guidance.
Network with other dietitians who have had success with online
counseling. Ask your clients what they would think of doing
more of your communication online. Read about technology in
dietetics in this magazine as well as the Journal
of the American Dietetic Association and newsletters
of practice groups that encourage alternative and new approaches
to learning and practicing.
Technology is here to serve us, not intimidate
us. What may seem overwhelming now may become your preferred
way to work in a short time. Software companies offer standard
and customized solutions for online counseling designed specifically
for effective communication and information transfer (see sidebar
for examples). They make user tools easier than ever before;
depending on which approach you take, you may be able to start
offering online services in days.
Client Perception
Your clients are already online, and they’re hungry for
information. According to a recent Pew Internet report, 10 million
American adults looked online for health information on a typical
day in August 2006.9 But only one quarter of them admitted to
checking the source and date of the information. People want
and need a personalized, customized experience, and we can offer
it to them.
The clients who opt for online counseling are
usually satisfied, according to Moran. They appreciate her use
of technology and find value in the process. They know up front
what to expect and enjoy the flexibility and novelty of the
service. I have had similar feedback from clients I serve. Depending
on the fee structure, online counseling also helps clients save
money and keep their motivation high. For example, you can charge
a monthly fee with unlimited messaging so clients don’t
have to wait for the next visit to ask questions or follow up
and subsequently feel like the dietitian is always there for
support.
Providing online services requires a shift in
dietitians’ thinking. In many ways, it seems to go against
what dietitians have learned as the gold standard in nutrition
counseling. I’m not suggesting dietitians ditch business
attire and become glued to their computers. Seeing clients in
person on a regular basis is still the prevailing counseling
approach for most dietitians. But being receptive to alternative
counseling styles, as well as keeping up with changing technology
and how it affects healthcare overall, will benefit all dietitians.
Moran shares her secret to success: Try to break
out of your usual structure and think outside the box. But most
of all, “don’t be afraid of technology. It’s
only going to grow.”
— Dina Aronson, MS, RD, is a nutrition
consultant, a freelance writer, and a speaker specializing in
dietetics-related technology and vegetarian nutrition.
Ways to Use the Internet in Place
of or in Addition to Traditional Counseling
• Complete online client management and communication.
• Access and update existing online personal
health records (already accessible to clients’ other healthcare
providers).
• Track a client’s diet, exercise,
and progress over time.
• Nutrition assessments based on client
survey
• Diet analysis (generated in real time
or by the RD, who sends results to the client electronically)
• Meal plans, supplement plans, exercise
plans (customized or static)
• Detailed intake, exercise, assessment,
goal, and weight change reports
• Message boards and blogs
• E-mail newsletters
• Online calculators that provide client-specific
information, such as body mass index, ideal body weight, and
exercise calculator (done by client in real time)
• Creation of client’s own page
on your Web site with customized links, motivational messages,
recipes, photos, and other features that keep clients engaged
• Food, supplement, and wellness information,
either via leasing existing databases or writing own content
— DA
Web-Based Products for Online
Counseling*
• ESHATrak: Application to record intake and exercises,
analyze intakes, and generate reports
www.esha.com/eshadata/eshatrak
• Lifestyles Tech (DietMaster Web): Application
allowing RDs and clients to create profiles, set goals, track
progress, assign meal plans, and more www.lifestylestech.com/page13.html
• MyProconnect (powered by Pronex, Inc.):
A complete database-driven nutrition communication management
tool geared toward the nutrition professional for use with clients,
including customized meal/supplement/exercise plans; intake
analysis; assessment reports; client log-in area to record food
intake, journal entries, read/send messages, etc; RD log-in
area to analyze diet, assign meal plans, read/send messages
www.myproconnect.com
• Nutribase: Companion to its PC software;
allows RDs to generate customized assessment reports, provide
recipes, and more: www.nutribase.com
• Nutrihand: Assessment tool for RDs,
including meal/exercise plans, diet analysis, and client assessment,
including reports
www.nutrihand.com
• United Medical Network: Company that
offers a customized site for tracking clients’ health,
meal plans/grocery lists, and selling supplements
www.unitedmedicalnetwork.com/ch_partner_program.asp
— DA
* Note: This is an incomplete list. Exclusion
of a particular product is unintentional and does not reflect
the opinion of the author or Today’s Dietitian.
