3 Ways to Tame Chronic Disease With Technology

How health systems are using apps, at-home monitoring, and virtual care to bring chronic disease management into control.  

This article appears in the January/February 2020 edition of HealthLeaders magazine. We invite you to also read a companion article, Reimbursement: The Key to ROI.

In the quest to lower healthcare costs and simultaneously improve patient outcomes, healthcare organizations are turning to high-tech initiatives to monitor, treat, and control chronic disease.

Today's marketplace is flooded with wearable and biometric devices that allow individuals to measure vital signs, blood glucose levels, and more from the convenience of their home.

However, the challenge for health systems and hospitals is collecting and analyzing that data in real time so care teams can intervene before problems escalate and result in office or emergency department visits, hospitalizations, or readmissions. Some healthcare organizations are leading the way by using technology to develop new models of chronic disease management. That could mean breaking into territory where healthcare doesn't typically operate, amping up resources, or investing in innovations that can scale across an enterprise.

Collectively, these efforts stand to make a significant impact. Chronic diseases are the leading drivers of the nation's $3.5 trillion in annual healthcare costs—specifically, they're responsible for 90% of that cost and seven out of 10 deaths, according to the Centers for Disease Control and Prevention (CDC).

"As we're working towards reducing the cost and burden of chronic disease, it's imperative that we continue to innovate and take advantage of new and emergent technologies," says Karen Hacker, MD, MPH, director of the CDC's National Center for Chronic Disease Prevention and Health Promotion. Looking to the future, she says, we will require better technological solutions to address chronic disease. Those who master new approaches now, says Hacker, will have a competitive edge. 

HealthLeaders takes a look at three health systems that tackle chronic disease management with technology along with the impact these initiatives produce.

Ochsner Takes a Cue From Apple

When Ochsner Health System decided to tackle chronic disease management to improve its patient outcomes and lower the cost of care, the organization ditched most conventional practices. Instead, it turned to technology to transform its approach to care—taking a cue from the consumer technology company, Apple, to coax patients into the digital realm with a retail operation akin to an Apple Genius Bar.

"For chronic disease management, we need an entirely new system of care," says Richard Milani, MD, FACC, FAHA, chief clinical transformation officer at Ochsner Health System, a New Orleans–based nonprofit academic health system with 40 owned, managed, and affiliated hospitals and specialty facilities.

About five years ago, as the system began assuming risk for an increasing number of patients, work commenced on creating a new model of care for chronic disease. In 2015, Ochsner began testing it, initially focusing on hypertension and then expanding to cover other disease states. The program now has 8,500 participants enrolled, and Milani says that 100% of Ochsner's primary care physicians refer patients into the program. 

The new model is designed to address flaws with current approaches to care, says Milani. Two or three annual measures of blood pressure, A1C levels, and the like are not sufficient to manage disease processes that are continually changing, he says. In addition, a 15-minute session with a provider offers limited opportunities to educate patients or to address the behavioral changes, lifestyle modifications, and social determinants of health that are often concomitant with chronic disease, says Milani. Medication adherence is an additional issue. "Roughly 50% of patients with chronic disease are not on guideline-based therapy," he says.

Creating an interactive, consumer-experience model of care

The new approach, says Milani, differs from traditional practices in a number of significant ways:

• Retail locations to shop for devices and apps: Ochsner's participants select their own remote monitoring devices from an O Bar location—a retail concept modeled after the Apple Genius Bar. An on-site expert guides the selection of products. Devices from multiple manufacturers, as well as hundreds of apps, have been curated and screened to meet Ochsner's criteria, which ensures information is based on scientific principles while remaining user friendly, Milani says.

Anyone can shop in the O Bar; no physician referral is necessary. The visit is designed as a positive, interactive consumer experience that helps patients and shoppers overcome technical issues and fears about using these solutions to improve their health.

Lack of technical expertise sometimes prevents patients from participating in home monitoring programs, explains Milani. Overcoming that barrier is essential for patients enrolled in Ochsner's digital medicine program because data from their devices will help the team guide their care. "The magic ingredient that allows us to do this is the O Bar," he says. While Ochsner can provide kits to patients directly, O Bar visits are encouraged because of the extra support provided.

For example, if a diabetes patient enrolled in the digital medicine program stops by the O Bar, she can check out a variety of blood glucose monitors and scales, as well as apps that could help address dietary, weight, or exercise issues. With the genius pointing her to appropriate options, she can examine the devices, test drive the apps on one of the store's iPads, and discuss the benefits of each. Once she selects a device or app, the consultant then helps her set it up on her phone or tablet, demonstrates how to use it, and makes sure she is comfortable operating it before she departs.   

The shop, which has multiple locations and a mobile unit, sells everything at cost with no markup. "O Bar was not designed to be a profit center," Milani says.

Ochsner is breaking ground in this area, says Jeff Becker, MBA, senior analyst at the Boston location of consulting firm Forrester. Just as nontraditional players are making strides by crossing into the healthcare arena, the O Bar is an example of a healthcare organization traversing the divide into new operating territory, Becker says. "It's one of the very few examples we have in healthcare of a hybrid patient experience that is physical and digital," he says.

• Custom-built remote monitoring platform: Ochsner developed its own remote monitoring platform from scratch, custom built into the Epic EMR. It enables direct input from patients' smartphones and tablets. In the case of the aforementioned diabetes patient, each time she activates her blood glucose monitor, the results are automatically transmitted from her biometric device, through her phone, into the EMR—all she has to do is operate the glucose monitor.

Once patients start using their devices—scales, blood glucose meters, blood pressure monitors, inhalers, and such—data flows into the monitoring center multiple times a week. This enables the care team to work with patient information almost in real time, helping patients better control their symptoms and prevent escalations that may lead to office visits, hospitalizations, or readmissions, says Milani.

• Composition of dedicated care teams: Rather than employing physicians and nurses, Ochsner's digital care team includes doctoral clinical pharmacists who specialize in hypertension, diabetes, and COPD, with a focus on medication adherence. In addition, there is a team of health coaches who interact virtually with patients and address social determinants of health. The coaches have a variety of backgrounds, including expertise in nutrition, exercise, or public health, and receive training in lifestyle management and behavior change theory. Coaches and pharmacists communicate with patients via phone calls, alerts, texts, and the patient portal. Patient education is fortified with videos created by Ochsner.

As the diabetes patient moves through the process, she has ongoing communications with her coach, watches educational videos, and reviews other content about how to take greater control of her health. When her blood glucose falls outside acceptable parameters, an alert is issued to the team, and the pharmacist might reach out directly to modify her regimen or her medications. The coach also works with her to address issues related to transportation, affordability of medication, and other social determinants of health.

There are other important aspects that make the program successful, says Milani. "You need to create a mechanism by which the data can be consumed and managed," he says. "We have dedicated teams that can manage this. If you try and throw that at the … primary care physician, who's already got an overburdened workday, it would be impossible. We're taking work off the back of the physician, not adding more to it." To maintain engagement and ensure everyone stays informed, physicians and patients receive monthly reports regarding the patient's status and progress. 

Improving outcomes as a 'mechanism for reimbursement'

Ochsner measures its return on investment in terms of producing better patient outcomes and has published multiple peer-reviewed studies demonstrating the success of its digital health program. Here's a look at a March 2019 publication in Health Affairs based on a six-month study of patients with hypertension. Compared to a control group, digital medicine patients:

• Had more frequent interactions with their care team (130 versus 12)
   
• Demonstrated greater medication adherence (improved 14% compared to a 2% decline)
   
• Achieved greater blood pressure control (79% versus 26%)
   
• Exhibited higher levels of satisfaction (84% versus 72%)
   
• Made fewer in-clinic visits to their primary care physicians (29% reduction)

Because Ochsner is involved in numerous at-risk contracts, this approach to chronic disease management makes financial sense, says Milani. "The reimbursement model really has to do with where the country is going—in a good way—towards risk-sharing or risk-bearing contracts to manage patients and population health," he says. "Obviously, these kinds of programs promote better health outcomes, which is what we should be doing, so that's our mechanism for reimbursement."

As other health systems explore new approaches to chronic disease management, Milani notes that "you can't just throw the technology at it; you need to have a dedicated team." In addition, he recommends adopting a strategy to redesign care delivery. "This is doable," he says. "It works; it's effective; it lowers costs; it produces better outcomes and higher satisfaction. It wins however you judge it. But you want to think in broad strokes," he says. "If you think in those terms, you could really make a tremendous impact on your patients."

Ascension Beams Entire Care Team Into Patients' Homes for Intensive Virtual Encounters

When fragile patients with chronic diseases are discharged from select Ascension hospitals, they depart with an extra little suitcase. Tucked inside is a computer tablet and an assortment of biometric devices, depending on the patient's needs.

That little package has delivered some powerful results because it has become the catalyst that marshals an entire team of providers to virtually enter each patient's home for an intensive four-month span, says the executive director in charge of the program, Mark Steiger, MBA, of AscensionConnect—Central Region. The initiative has reduced the chance of readmissions from about 28%, he says, to somewhere between 2% and 7%.

Ascension's approach has a number of distinctive characteristics:

• Monitoring is not specific to a particular chronic disease
   
• RNs coordinate multiple team members from a broad array of disciplines to deliver care virtually into the home
   
• Data from patients' biometric devices does not feed directly into the EMR
   
• Tablets are cellular enabled, meaning the patient doesn't need an internet connection
   
• Enrollment is limited to about four months and requires a physician referral
   
• There is no charge to patients for these services

While the program does not involve reimbursement from payers or patients and it was not designed as a new source of revenue, Ascension says it is evaluating reimbursement models as they evolve.

Currently, the hub of the program is located in Austin, Texas, which monitors patients in four of the 20 states where Ascension operates, says Steiger. There are plans to roll out the program to all of the nonprofit faith-based health system's 150 hospitals, and another facility is already operational in Indiana.

Remote monitoring functions under the auspices of AscensionConnect, an initiative launched in January 2019 that brings all patient access points, including scheduling, the call center, switchboard, virtual care, remote monitoring, bed placement and transfer, and more, under one umbrella. About a dozen teams work together in a 30,000-square-foot facility that operates 24/7 and employs about 300 people.

The remote encounters are led by RNs, licensed to practice in all states where Ascension offers the service, with additional care provided by practitioners in a variety of disciplines.

Foolproofing the patient experience

Ascension uses an outside vendor, Vivify Health, to supply the program's devices and technology platform, which the health system further customized. "We tried to make the [patient] experience extremely foolproof," says Steiger. That involves the extra expense of using cellular-enabled tablets, so patients don't have to figure out how to connect their system to the internet, he says. In addition, because the devices are already paired to the Ascension platform, the home experience begins literally with the push of one button, which is marked with a red sticker.

Each morning, the patient responds to a series of questions on the tablet, which are customized to the patient's conditions. For example, questions might ask if the individual is short of breath and whether medication was taken as prescribed, Steiger explains. The system then prompts the patient to take appropriate biometric measures, such as a blood pressure reading. After patients complete the measurements, they may have educational videos or content to review.

Biometric data feeds into the technology platform at the remote monitoring center—not the EMR. "We didn't do a full integration on purpose," says Steiger. "We don't want to have three sets of vital signs flowing into the EMR every single day if there's not an action that we're asking [providers outside of the monitoring center] to take." Instead, the data lives in the monitoring center's platform; weekly summaries, as well as information about interventions and escalations, are exported to the EMR.

"There is integration," says Steiger, "but we're intentional about what flows and what doesn't." The platform is EMR agnostic and can interface with the multiple brands used across Ascension facilities.

An intensive, limited virtual engagement

The interactions with Ascension's team can be more intensive and comprehensive than typical remote monitoring programs, which may involve interactions with only one care team member, says Steiger. The 120-day intervention is designed to deliver the support, resources, and education patients need to improve outcomes and change their health trajectory, he explains.

Each day, a nurse reviews patients' responses, answers questions, responds to alerts, and organizes support to help course-correct patients whose data falls outside of acceptable parameters. Each intervention is tailored to the patient, and nurses have access to advanced practice providers, as well as physicians, to guide their decisions, Steiger says.

"In any given engagement," he says, "you may have a two-way video interaction with your nurse, but also maybe a social worker, a nutritionist, someone for behavioral health, or a pharmacist or pharmacy tech. We also have a chaplain who can provide spiritual care. It brings the entire care team to the home." This results in faster interventions if something is wrong, he says, and helps prevent escalations that could lead to an emergency department visit or readmission.

A focus on improving outcomes

Patient selection is crucial to the process. Inpatients are screened to determine whether they are at risk for an adverse outcome, says Steiger. "We have evidence-based protocols we've written to help us determine [whether] we will engage with that patient … and offer them a Vivify solution to deploy to their home post-discharge."

Unlike many remote patient monitoring programs, Ascension's patients are not segmented by disease. "Patients who are most at risk typically have multiple chronic conditions along with social and behavioral health issues," says Steiger. "Rather than try to box patients into one chronic disease, we built our care pathways to be as flexible as possible in terms of the way that we manage chronic conditions. What we've learned is that, using evidence-based best practices, you can be flexible in terms of managing multiple chronic conditions at once. We also layer in the social and behavioral support that [sometimes] prevent someone from even tackling their health issues."

In addition, any Ascension physician can refer patients with chronic conditions into the program; patients don't need to be hospitalized first. "We tell them 'don't overthink it,' " says Steiger. "If somebody is fragile and has chronic disease, just send them our way. Even if a kit isn't the right thing for them, we've got other resources at AscensionConnect that can help them." The Austin team includes nine social workers, and team members can provide access to discounted prescription drugs, supply transportation and housing assistance, or address other issues related to social determinants of health.

Improving patient outcomes was the primary motivation for developing the program, says Steiger.

Preventing readmissions delivers 'huge value'

Ascension's involvement in risk-bearing contracts is minimal in the states where remote monitoring is currently taking place, Steiger says. While CMS has bolstered reimbursement for remote monitoring and an additional CPT code was added in January 2020, "other payers have been slower to adopt that," he says. "But we also know that there is a broader conversation about value, and we know that a prevented readmission has a huge value to us as a health system."

Some 5,500 patients have enrolled in the program in the nearly two years since its launch, says Steiger. During that period, readmission rates for patients with similar profiles who did not participate in the program ranged from 28% to 35%, depending on the season, he says. The rate for participating patients ranged from 2% to 7%. While the health system is measuring many other data points, including the program's return on investment, Steiger says Ascension is not ready to share that information publicly.

For other health systems exploring these opportunities, Steiger says, "don't wait for the reimbursement environment or the published studies to be perfect. It's worth just testing some new use cases and doing your own measurement. It does take an up-front investment in people and resources."

He continues: "Development is really the key because a lot of this doesn't exist out of the box related to what the clinical pathway should look like or what the evidence-based protocols are. You will have to develop some of that on your own. At Ascension, we've seen such success so early that we know that it's the right thing to do for our patients and the right way to stay sustainable and scalable. Like everybody says, 'think big, start small, move fast.' That's our advice."

Intermountain Healthcare Invests in Digital Innovation; Begins Scaling With Employees

How did Intermountain Healthcare get nearly 1,500 prediabetic employees healthier in 26 weeks without deploying a single resource in its own healthcare system? By testing and investing in an innovation from an outside company, Omada Health, which it helped nurture through early stages of growth.

Launched January 1, 2019, the digital diabetes prevention program is available at no cost to Intermountain employees and their dependents who participate in SelectHealth, the Salt Lake City nonprofit health system's insurance plan. Participants self-refer but must first complete an online assessment and have a confirmed lab result indicating they are prediabetic, says Elizabeth Joy, MD, medical director of community health, health promotion and wellness, and food and nutrition at Intermountain Healthcare, which operates 24 hospitals and has 40,000 employees.

The program aims for participants to lose 5% of their body weight to prevent the development of incident Type 2 diabetes, says Joy. "If we can identify people [with prediabetes] and intervene early with comprehensive lifestyle change, we know we can reduce downstream consequences, which are costly for individuals, health systems, and payers."

Employing technology to address a weighty issue

Once enrolled, participants receive a Bluetooth-connected scale and access to Omada Health's online platform, which is accessible via mobile devices and computers. Backed by multiple peer-reviewed clinical studies that document its effectiveness and recognized by the CDC as an approved diabetes prevention program, the solution uses a combination of online coaching, educational modules, and online community support to institute behavior changes that lead to weight loss. Losing weight, says Joy, is the key factor in preventing development of Type 2 diabetes.

Losing 3% of body weight is clinically significant, says Joy, and the goal is for enrollees to lose 5%. Omada's benchmark for those who reach this milestone at week 26 is 29%. About 2,000 people have enrolled in Intermountain's program since the beginning of 2019. The 1,450 participants who have been enrolled for at least 26 weeks have attained the following milestones:

• 48% have lost 3% of their weight
   
• 31% have lost 5% of their weight
   
• 21% have lost 7% or more of their weight
   
• Total participant weight loss since January 1, 2019, is 9,162 pounds
   
• Patients engage with the platform an average of 33 times per week

Nurturing an innovation from an early stage

While Intermountain outsourced the program to Omada Health, it has close ties with the company.

In 2016, Intermountain launched a partnership with Omada in conjunction with the AMA "to zero in on diabetes prevention via some type of digital solution," says Nickolas Mark, MBA, managing director and partner at Intermountain Ventures, which functions as the health system's investment firm and has invested in the company.

"We believe that bits and bytes have a marginal cost of close to zero," says Mark. "If you really want to bend the cost curve, you've got to find a way to apply technology inside of a patient population community to drive better outcomes."

Joy says there is another reason the program works. To improve health, "we need to reach people where they live, learn, work, play, and pray," she says. "Digital therapeutics is key to achieving this vision."

While Intermountain would not disclose its billing arrangement with the company, Omada cofounder and CEO Sean Duffy, MD/MBA candidate, says its billing model is based on outcomes. For its prediabetes program, "We bill according to weight loss success. If we're able to get someone further in a journey toward health, we charge more; if we're not, we don't charge."

Why outsource such a program rather than rely on internal resources? Joy says the convenience and simplicity of the solution enables Intermountain to rapidly make an impact. And, as the health system begins rolling out its digital strategy during 2020 to the 47,000 patients in its prediabetes registry, it wouldn't be "financially feasible" to build a program from scratch and hire "enough dietitians or certified diabetic educators."

"We know that investing in diabetes prevention pays off in the long run in terms of making healthcare more affordable to everyone in our community," says Joy. "That's how we justify the investment, and it aligns with our mission of helping people live their healthiest lives possible."