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.

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 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 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

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

• Lifestyles Tech (DietMaster Web): Application allowing RDs and clients to create profiles, set goals, track progress, assign meal plans, and more

• 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

• Nutribase: Companion to its PC software; allows RDs to generate customized assessment reports, provide recipes, and more:

• Nutrihand: Assessment tool for RDs, including meal/exercise plans, diet analysis, and client assessment, including reports

• United Medical Network: Company that offers a customized site for tracking clients’ health, meal plans/grocery lists, and selling supplements

— 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.