Healthcare organizations are using digital patient questionnaires to gather real-time data from patients, allowing clinicians to adjust care management when and where needed.
Healthcare organizations are using digital health tools to gather more data about their patients, but the challenge has always been how to use that information.
At Ascension Illinois, care providers are using Measurement-Based Care (MBC) to improve outcomes in behavioral health treatment. The strategy is based on collecting information throughout treatment to assess outcomes, then modifying care management plans to improve treatment.
Chris Novak, vice president and chief operating officer for Ascension Illinois' behavioral medicine service line, says the process of gathering data to support treatment benefits not only the provider but also the patient. The health system uses a digital health platform developed by Owl to create a baseline assessment for each patient, then uses ongoing virtual questionnaires to demonstrate patient progress, giving providers the evidence they need to measure and then improve treatment.
The digital platform is important. It has allowed health systems like Ascension Illinois to move from paper-based questionnaires and subjective observations during visits to data collection at the point of care, saving valuable clinician time. It allows the provider to gain a better idea of what the patient is experiencing, and to collaborate with the patient on care management.
Chris Novak, vice president and chief operating officer for Ascension Illinois' behavioral medicine service line. Photo courtesy Ascension Illinois.
"It helps us to demonstrate to our patients in real time the improvements that we're seeing," he says. And in doing so, it allows clinicians to personalize patient care.
Data is often considered the cornerstone to improving clinical care, and innovations like digital health and telehealth have proven both beneficial and problematic. They allow healthcare providers to collect much more data than before, about patients as well as their home environment and daily habits, but that data must be sorted and analyzed. Without processing tools, providers are overwhelmed by data, unable to determine what information they can use.
"The field is evolving," says Novak, who sees home-based digital health platforms and wearables as the next evolution of MBC. The information contained in those platforms, he says, can greatly affect care management if used correctly. A care provider who can see into a patient's daily lifestyle can pinpoint activities or habits that affect health, and design care plans that reinforce good habits and steer the patient away from bad ones.
With the MBC platform used by Ascension Illinois, Novak and his colleagues gain insights from clinically validated assessments, offering objective data on a patient's care plan. The patient answers questionnaires electronically and submits the information to the care provider. For patients living with thought disorders or who might have problems answering questionnaires, the provider can administer those questionnaires with the patient during a session.
Those assessments give care providers the real-time information they need to improve care, and thus become the basis for value-based care.
"Across a wide range of treatment settings, there is a substantial gap between the outcomes achieved in randomized controlled trials and in routine mental health care," the study noted. "One of the main contributors to enhanced outcomes in randomized controlled trials is that treatment protocols include systematic measurement of symptom severity, followed by algorithm-based treatment adjustments when patients are not responding to care."
"Although there are numerous brief, validated symptom rating scales that reliably measure change in severity of symptoms over time, only 17.9% of psychiatrists and 11.1% of psychologists in the United States routinely administer symptom rating scales to their patients," the researchers continued. "On the basis of clinical judgment alone, mental health providers detect deterioration for only 21.4% of their patients who experience increased symptom severity. Detection rates are even worse for patients whose symptoms are not deteriorating but who also are not improving as expected. The failure to detect patients who are not responding to treatment contributes to clinical inertia (defined as not changing the treatment plan despite a lack of substantial improvement in symptom severity.) The use of symptom rating scales to monitor outcomes helps prompt clinicians to overcome treatment inertia and change the treatment plan when patients are not responding to treatment."
That study concluded that because behavioral healthcare providers weren't demonstrating the value of their treatments, payers weren't supporting the programs, leading to "chronic underfunding of mental health services." It argued that MBC could prove that value.
Then came the pandemic.
Novak says MBC proved its mettle during the pandemic, when most health systems shifted from an in-person model of care to a virtual platform to reduce the spread of the virus and enable care providers to treat patients in their homes. Through the platform, providers were not only defining the effectiveness of their treatments but also comparing the value of an in-person treatment program against a virtual program, or one that combines both virtual and in-person care.
It also allowed them to gain support from payers, who typically want to see proof that a new service will reduce costs and/or improve outcomes before they reimburse providers.
"Our discussions with payers have been positive," Novak says. MBC "quantitatively [demonstrates] that improvements are being made in a virtual setting, which is on par with in-person care."
The challenge, of course, lies in synching the data to the electronic health record (EHR), a process often complicated, if not hindered, by different platforms that store data in silos. Novak notes his health system currently works with four different EHRs, so it's easier right now to keep that data separate and integrate it later, when they move to one EHR.
That's where he sees this platform evolving. As the technology improves and systemwide integration is made easier, MBC will become a standard of care, with automated and adaptive testing that allows care providers to see the results in real time, adjust care management on the fly, and modify future assessments and tests to be more personalized.
"Behavioral health horizontally intersects all areas of medicine," he says, "and demonstrating the impact of effective care is critical."
Ballad Health and the East Tennessee State University Research Corporation are launching the Appalachian Highlands Rural Innovation and Entrepreneurship Alliance, which aims to combine healthcare research and innovation with community resources
A new collaboration in the Appalachian Highlands is integrating healthcare innovation with the local economy, thereby making the path forward a community endeavor.
Ballad Health and the East Tennessee State University Research Corporation are launching the Appalachian Highlands Rural Innovation and Entrepreneurship Alliance, which will “coordinate multiple local and national areas of research and idea development, particularly impacting the delivery of healthcare, through surveilling efforts, accelerating early-stage development, translating research into business opportunities and identifying scalable opportunities for investment, ultimately reshaping the overall economy, health and well-being of the region.”
Ballad Health’s network includes 21 hospitals, post-acute care and behavioral health facilities and a large multi-specialty group practice covering 29 counties across parts of Tennessee, Virginia, Nort Carolina, and Kentucky.
“When we created Ballad Health, we made a commitment that this new organization would leverage the regional strength of the Appalachian Highlands, reaching across all our communities in Northeast Tennessee and Southwest Virginia to enhance opportunities to turn good ideas into thriving businesses and economic opportunity,” Ballad Health Chairman and Chief Executive Officer Alan Levine said in a press release. “This center will not only leverage good local ideas into business opportunities for the region, but it will attract ideas from all over the world, which will support the enhancement of healthcare delivery and innovation, while also creating an ecosystem for those transformative ideas to grow and be put into practice all over the world.”
The partnership takes the typical digital health incubator one step further, so that healthcare innovation and delivery are integrated with the community.
It also builds on an existing relationship between the health system and the schools that has seen the launch of the Center for Rural Health and Research at ETSU, the Ballad Health Strong BRAIN Institute and Center for Trauma Informed Care, and the Appalachian Highlands Center for Nursing Advancement.
“Ultimately, the Appalachian Highlands Rural Innovation and Entrepreneurship Alliance will result in an interactive rural cooperative, and as the alliance grows, we expect new companies to anchor their operations in the Appalachian Highlands as they take advantage of the unique environment to create life- and industry-changing equipment, systems and technologies,” Tony Keck, executive vice president of system transformation at Ballad Health, said in the release. “The resulting economic benefit will support the multiple regional efforts to grow the economy, while providing an investment return for those in the region who believe in investing in the region.”
The program also speaks to the challenges faced by health systems across the country in competing for both patients and staff in a much larger ecosystem, which includes telehealth vendors, retailers like Amazon and Google, and even payers that offer their own healthcare services.
“The reality of our situation right now, is that regional employers aren’t just competing with each other for top workforce talent – we’re competing with businesses all over the United States,” added Bo Wilkes, managing director of the Ballad Health Innovation Center and president of Ballad Ventures. “We have a rich culture and history, excellent schools and healthcare and low cost of living, and now, we’re going to have the entrepreneurial alliance that draws in some of the best minds in the country. By all rights, the Appalachian Highlands should be a top destination for workers and families.”
Researchers have found that a digital therapeutic platform using gaming concepts can help adults diagnosed with major depressive disorder (MDD) improve their cognitive function
Researchers from Duke University and Stanford have found that a digital therapeutic video game can help people living with major depressive disorder (MDD).
In a study recently published in the American Journal of Psychiatry, adults diagnosed with MDD and taking antidepressant medication “significantly improved sustained attention” while playing the AKL-T03 game developed by Boston-based Akili Interactive. The mHealth game is designed to address cognitive challenges, including difficulties concentrating, decision making, slowed thinking, and forgetfulness, in people living with MDD.
“Society is facing a growing mental health crisis, with depression rates in the US increasing about 20% during the pandemic,” Richard Keefe, PhD, a professor of psychiatry at Duke University Medical Center and primary investigator of the study, said in a press release. “While mood symptoms are most often associated with MDD, equally concerning are the frequent associated cognitive impairments.”
“More than ever, we need safe and effective ways to support these patients – new tools that can be easily and broadly accessed,” he added. “Based on the results of this study, AKL-T03 has the potential to play a meaningful role in the treatment of MDD patients.”
Digital health companies like Akili have been developing mHealth games for several years to address a variety of health concerns, from behavioral health treatment to chronic care management for conditions ranging from diabetes and asthma to cancer. Many of the products have been tailored for children and young adults, who respond well to games and gaming concepts.
Digital health platforms are especially attractive to care providers because they can be administered at home, in a more comfortable environment for patients, rather than a clinic or doctor’s office, and they can be used when appropriate for the patient.
To address an older population, Akili modified its AKL-T01 digital therapeutic, branded as EndeavorRx and cleared by the US Food and Drug Administration to treat attention symptoms in children ages 8-12 diagnosed with ADHD. The company’s AKL-T03 is an investigational medical device not yet cleared by the FDA and designed on the same technology platform.
“Addressing cognitive impairments associated with depression has been an area of interest from healthcare professionals and companies over recent years, yet options remain limited for patients,” Anil S. Jina MD, Chief Medical Officer of Akili, said in the press release. “Akili’s technology is designed to target specific neural networks related to attention function and this study demonstrates the important role it could play in the treatment of patients with cognitive dysfunction in depression.”
In the study, titled the Software Treatment for Actively Reducing the Severity of Cognitive Deficits in Major Depressive Disorder (STARS-MDD), Keefe and Amit Etkin, MD, PhD, of the Department of Psychiatry and Behavioral Sciences and Wu Tsai Neurosciences Institute at Stanford, working with Elena Cañadas, PhD, and Deborah Farlow, PhD, both from Akili, tested the platform on some 80 adults over a six-week time span.
“The results in this randomized controlled trial of an at-home digital intervention for cognitive impairment in patients diagnosed with major depressive disorder indicate that the active intervention, AKL-T03, significantly improved performance on the primary outcome measure of sustained attention compared with the control condition in adults 25–55 years old,” they concluded in the study. “Across a range of secondary and exploratory outcome measures targeting a variety of cognitive domains, including working memory, processing speed, task switching (e.g., letter-number sequencing, symbol coding test), depressive symptoms, and subjective cognitive symptoms (e.g., HAM-D, PHQ, and CPFQ) and quality of life (e.g., WSAS and Q-LES-Q), the benefit of AKL-T03 was not superior to the control intervention.”
“In summary, compared with a control condition, AKL-T03 demonstrated significant improvement on the primary objective measure of cognition in patients with major depression,” they added. “The intervention was well tolerated and presented minimal adverse events. The digital nature of the intervention could help to increase access for patients who otherwise might not find a solution for their depression-related cognitive difficulties.”
The New York health system has launched Ascertain, an incubator backed with $100 million in seed funding to help innovative start-ups develop and commercialize AI platforms
Northwell Health has joined the growing number of health systems to launch an incubator for innovative start-ups.
New York’s largest healthcare organization is partnering with start-up studio Aegis Ventures to unveil Ascertain, a “joint company creation platform” aimed at developing and commercializing promising AI platforms. The new venture includes $100 million in seed-stage capital.
“Ascertain brings a unique structure, an innovative approach, and a compelling vision to create breakthrough healthcare AI companies that are set up for success,” Michael Dowling, Northwell Health’s president and CEO, said in a press release issued during the health system’s first-ever Healthcare AI Innovation Summit this week. “We are all driven by the idea that everyone deserves access to high-quality, affordable healthcare. Our aim is clear: to find new, cost-efficient ways to create and accelerate companies that deliver real, equitable solutions.”
And they’ve already started. One of the first projects, in collaboration with Northwell’s newly launched Center for Maternal Health, will focus on detecting and managing serious complications for pregnant mothers and babies, including preeclampsia, which disproportionately affects Black mothers.
“Existing approaches to the detection of preeclampsia often occur too late in pregnancy, once the condition has begun to manifest,” Burt Rochelson, MD, Northwell Health’s chief of maternal hedicine, said in the press release. “An important enabler for a solution to this challenge is predictive analytics, applying available knowledge of a patient's history to enable action far earlier with simple, yet life-saving, clinical interventions. We believe the AI solution Ascertain is currently developing will enable this.”
Northwell Health has joined a number of large health systems taking innovation into their own hands with programs aimed at developing home-grown technology that can be tested in-house before being offered to the healthcare industry. Organizations like the Cleveland Clinic, Providence Health and Penn Medicine have been fostering new companies for years.
And one of the more popular areas for innovation these days is AI, or machine learning, a topic that grabbed a lot of attention at the HIMSS22 conference and exhibition last month in Orlando. In March, the Mayo Clinic launched Platform_Accelerate, a 20-week program that allows innovative start-ups to collaborate with the health system on new projects.
"We are helping participants take a crucial step in their growth trajectory by providing startups with a disciplined focus on model validation and clinical readiness to show product value," Eric Harnisch, vice president of partner programs for Mayo Clinic Platform, said in a press release. "The program is integral to our Mayo Clinic Platform mission to enable new knowledge, new solutions and new technologies that improve patients' lives worldwide."
Northwell health officials say Ascertain will launch several companies during its first year that will focus not only on AI and maternal health, but also chronic disease detections and care management.
The National Association of ACOs has put together a task force of healthcare executives aimed at helping ACOs improve their data-gathering to meet electronc quality measures supported by the Centers for Medicare & Medicaid Services
Several healthcare executives have joined a task force aimed at improving the collection of data in accountable care organizations (ACOs) to meet federal benchmarks on digital quality.
The goal is challenging for ACOs who often work with a variety of electronic health record (EHR) platforms and healthcare sites. A NAACOS survey taken last year found that more than three-quarters of ACOs are working with at least six EHRs, and 37 percent are using data from at least 15 EHRs.
“Our EHR systems today have not yet achieved the real-world interoperable state needed to easily combine non-standardized patient data from various providers, a future requirement of CMS’s quality reporting for Medicare Shared Savings Program (MSSP) ACOs,” Katherine Schneider, MD, chair of the NAACOS Digital Quality Measurement Task Force and past NAACOS board chair, said in a press release.
“ACOs have broader concerns about the eCQM program as currently constructed, especially many unintended implications and consequences of mandating data reporting on total patient populations instead of just the MSSP as has been done since program inception a decade ago,” she added. “Nonetheless, we know digital quality reporting in general is the direction we need to move in, but we need to get it right, ultimately for the benefit of the momentum of value-based care and for patients, including those cared for by safety net providers. As of today, digital quality reporting presents major financial and operational challenges, requiring significant investment by vendors, practices, and ACOs for readiness according to the current timeline.”
ACOs not only target cost savings through collaboration, but improved clinical measures through adherence to quality standards, for which they are evaluated. The task force is scheduled to develop recommendations that will be published later this year, then confer with CMS, the Office of the National Coordinator for Health IT (ONC) and vendors to discuss those recommendations.
The new law allows providers to use telemedicine to prescribe most controlled substances, as long as they meet federal guidelines. It's an important step forward for a heavily-debated virtual care service.
A new law in Florida allows healthcare providers to prescribe many controlled substances via telemedicine, pushing the Sunshine State to the head of the pack in a heavily-debated virtual care service.
SB 312, signed this week by Governor Ron DeSantis, enables providers to use telemedicine to prescribe all but Schedule II drugs, while those prescriptions will be allowed via telemedicine if they meet one of four exceptions. Florida law had previously prohibited the prescribing of controlled substances via telemedicine except for a few situations.
The prescribing of controlled substances is a heavily regulated service, overseen at the federal level by the US Drug Enforcement Agency and the Ryan Haight Act, landmark legislation passed in 2009 that strongly limits how medications are prescribed online. Healthcare providers have to meet specific criteria to prescribe controlled substance via telemedicine, including conducting an in-person exam of the patient before moving to telehealth.
The healthcare industry, and telehealth advocates in particular, have long lobbied the federal government to ease those restrictions, saying they hinder access to care for those who can’t easily see a care provider in person and prevent a provider from reaching out to and treating more people in need of help (particularly in behavioral health and substance abuse services). The DEA has said in the past that it would relax those rules, but hasn’t done so yet, and federal waivers enacted during the pandemic to allow prescriptions by telemedicine will end with the public health emergency, which is scheduled to end later this year.
This makes Florida’s action particularly newsworthy.
“The law is a big win for Florida patients with medical conditions requiring controlled substances as part of the treatment regimen,” Nathaniel Lacktman, a partner with the Foley & Lardner law firm, chair of its telemedicine and digital health industry team and a national expert on digital health law, said in a recent blog post. “This includes, for example, endocrinology or substance use disorder (both of which use Schedule III medications now permitted under the new law), allowing these patients to obtain better access to more fulsome care. The law will also allow Florida clinicians to more easily prescribe refills in connection with their ongoing care management because the clinician can periodically conduct patient exams via telemedicine instead of requiring in-person exams even when those exams might be viewed as medically unnecessary.”
“Some stimulant medications commonly prescribed in psychiatry are Schedule II drugs, which could potentially meet one of the pre-existing exceptions if they are prescribed for treatment of a psychiatric disorder,” Lacktman added. “Most opioids are Schedule II drugs not allowed under this new law.”
Specifically, the new law amends Florida’s state statutes to allow providers to prescribe a controlled substance. That allowance is limited for Schedule II drugs to the treatment of a psychiatric disorder, inpatient treatment at a licensed hospital, hospice services, and treatment for residents in a nursing home.
Lacktman points out that the Florida law doesn’t supersede federal law, and providers need to make sure they meet both sets of laws. With the Ryan Haight Act, this means they still need to meet one of seven conditions that would allow them to prescribe a controlled substance via telemedicine without first scheduling an in-person exam.
But it puts Florida ahead of many states whose legislatures are still grappling with the idea of allowing doctors to remotely prescribe controlled medications. Opponents say the service offers too many opportunities for abuse, while supporters say it’s key component to improving clinical outcomes for underserved populations and others who can’t or won’t visit their doctor on a regular basis.
Partly in response to the pandemic, healthcare organizations have been launching remote patient monitoring (RPM) and hospital at home programs as a means of providing more services to patients at home and reducing hospital crowding. But federal and state governments have long had a heavy hand in regulating how healthcare can be delivered to the home.
Both federal and state regulators have kept firm control on telehealth by enforcing where it can be used and who can use it, to the point that advocates have long argued that government is hindering telehealth adoption. Only certain types of healthcare providers are allowed to use the technology to deliver healthcare services, and those services often must come from and go to specified healthcare settings, like a hospital, doctor's office, or clinic.
"Generally speaking, the hospital is a place," says Rachel Goodman, a partner with the Foley & Lardner law firm, specializing in digital health regulation. "In order to have a hospital license, you have to have that address," and regulators are cautious in approving services that extend outside that physical location.
In addition, she says, some within healthcare are questioning whether healthcare services for acute or critical care patients should be permitted at home, where the opportunities for clinical errors and even fraud are much more apparent.
The pandemic allowed for a surge in telehealth because the federal government and most states enacted several emergency measures aimed at expanding telehealth access and coverage. Those actions gave more care providers the freedom to use the technology, expanded the list of sites to include the home, and even expanded the types of technology that providers could use to include audio-only telehealth (e.g., over the phone) and RPM platforms.
Those measures are only in place until the end of the public health emergency (PHE), and while several states have permanently amended their telehealth rules to keep those expanded freedoms in place, there's still a lot of confusion—particularly at the federal level—about what happens when the PHE ends. This, in turn, has kept some health systems from developing long-term telehealth and RPM plans.
"It's certainly complicated," says Goodman. "We're not going back to the way we were [before the pandemic], but it's hard to tell what will happen right now."
This includes the Acute Hospital Care at Home program launched by the Centers for Medicare & Medicaid Services (CMS) in early 2020, as the pandemic was taking hold. The idea behind that new payment model was to give hospitals more leeway to treat patients with acute care needs at home, rather than having them take up a hospital bed at a time when those beds were in high demand for COVID-19 cases.
While hundreds of health systems have signed on to the program, there's little indication from CMS as to how long it will last. CMS is typically slow to reimburse for innovative services like telehealth, preferring to wait for several large-scale studies that prove the value of the new service in both reducing cost and improving outcomes. With the Acute Hospital Care at Home program just now gathering steam, that may take a few years.
Beyond the pandemic, Goodman sees the most growth in RPM around post-discharge services, such as rehabilitation and chronic care management, which are ideally suited for home monitoring. That's because those services apply to patients who have been discharged from the hospital.
"That's all really postacute care under a different name," she says.
For hospital at home and other services addressing acute care needs, she says, federal regulators will have to more clearly define whether a patient is discharged from a hospital into a home program (as opposed to a skilled nursing facility or similar rehab site), or whether that patient is still considered a part of the hospital's inpatient platform. That affects everything from quality and safety benchmarks to hospital staffing requirements.
Goodman expects it will take a few years for CMS to signal more aggressive adoption of hospital at home-style services. That'll prompt many health systems to go slowly with those platforms, as they need Medicare and Medicaid coverage to be able to sustain and scale up the offerings.
Supported by new technology that can access more data from any location, healthcare organizations are using remote patient monitoring strategies to bring care into the home.
With the healthcare industry's gradual shift to patient-centered care over the past two decades, healthcare organizations are realizing it's more effective to bring care to the patient, rather than forcing the patient to go somewhere to get care.
That strategy is based on the idea that healthcare is continuous, rather than episodic, and that a care provider will learn a lot more by going to the patient to learn about lifestyle, daily routines, and habits than waiting for that visit to the doctor's office, clinic, or hospital. It also requires a lot of data, from a lot of sources, so that a care provider can better understand the patient and the patient's environment while making decisions that impact care.
The remote patient monitoring (RPM) movement began roughly three decades ago, alongside the consumer health movement. Spurred by an interest in self-help health and wellness, consumers were showing an interest in improving their lifestyles through better diets, exercise, and healthy habits, and they were spurred on by a growing market in self-help resources, including technology such as activity bands, smartwatches, and online resources. Those with chronic conditions, such as diabetes, COPD, asthma, and congestive heart failure, were especially targeted with devices and resources that could help them manage their care at home, in between visits to the doctor.
Healthcare only gradually found interest in this. Early technology was designed to attract the consumer, rather than meet clinical care needs. The devices were stylish, but they weren't accurate enough to appeal to care providers, who wanted specific and reliable data that they could use to make clinical care decisions.
That changed, though, as a few forward-thinking providers and health systems realized that charting activity at home could help them influence patients to become more mindful of care management. Having someone living with diabetes measure their activity, for example, could lead to a healthier lifestyle that reduces negative health events, improves clinical outcomes, and curbs unnecessary health expenses; could help those with Alzheimer's or Parkinson's track the progression of their disease at home and improve functionality; or could help those living with cancer stay active during chemotherapy and boost their chances at recovery.
As time has passed, the technology is getting more sophisticated, with devices that can accurately measure vital signs and other biometric data at home or elsewhere and, through mHealth apps and online portals, send that information directly to care providers.
Health systems are now designing programs around these tools and capabilities. They're identifying populations that would benefit from RPM, giving them the devices they need and creating workflows that allow care providers to track them, gather data, communicate, and change care management plans when necessary. More sophisticated programs are adding smart devices in the home, charting factors such as home and family life, diet, and cultural influences; some programs are even combining virtual care with in-person visits from home health programs, specially trained paramedics, or care teams dispatched by the health system.
Easing into an RPM workflow
Less than 10% of the nation's health systems were using RPM prior to the COVID-19 pandemic, according to studies sponsored by the Brookings Institution, McKinsey & Company, and others. Many were small deployments, focused on specific populations or aiming to tackle a certain data point, such as reducing rehospitalizations in patients discharged after an inpatient stay.
That all changed with the pandemic, which pushed virtual care into overdrive. Everyone moved to reduce in-person care to decrease surging hospital traffic and lower the chances of spreading the virus, particularly to care providers and those at risk of serious complications. Many health systems tried out RPM platforms to care for COVID-19-infected patients at home, then modified their platforms to target other groups of patients who could benefit from remote monitoring.
At Heart of Florida Health Center, a federally qualified health center serving about 28,000 patients through seven clinics in rural Ocala, executives launched an RPM program in 2021 targeting uncontrolled hypertension with the help of a three-year grant from the Health and Human Services Department's Health Resources and Services Administration. The goal was to use the platform to help community members, many of whom face barriers to accessing in-person care, monitor and control their blood pressure, thus improving their health and reducing the chances of a heart attack, stroke, or other serious health issue.
"For us, this was getting our toes in the water," says Carali McLean, LCSW, Heart of Florida's director of quality, risk management, and compliance, noting the health center had tried an RPM program for diabetes care management without much success. "We wanted to have the ability to empower the patient to monitor their own health."
With the program, Heart of Florida is tackling a real health concern, one that kills more than half a million Americans a year. According to the Centers for Disease Control and Prevention, roughly 47% of American adults are diagnosed with hypertension, and yet only one in four have their blood pressure under control.
Through RPM, a patient takes blood pressure readings at least once a day (the frequency and times can be set by the provider if needed) and sends that data to Heart of Florida, where nurses review the readings and determine whether follow-up care is needed. If those readings go above or below a certain threshold established by the care team, an alert is triggered and a physician is called in. This could lead to an immediate intervention if serious, or a scheduled visit with a doctor.
Yasmin Ramasco, MSN, APRN, a nurse practitioner and support educator, says the platform allows Heart of Florida clinicians to regulate a patient's medications on the fly, adjusting them as needed to address changes in blood pressure. Previously, care providers would have had to wait to review data when the patient visited the doctor for a scheduled visit, sometimes weeks or months distant, and then modify the medications.
"We can better manage them and have them involved in that management," she says. "Our patients have been motivated and willing to participate."
McLean says Heart of Florida has seen a roughly 28% reduction in the number of patients with unchecked hypertension through the program, which translates to patients better managing their blood pressure and a reduced chance of adverse health events, including hospitalizations. With that success, the center has hired a nutritionist to work with patients to improve their eating habits.
"This is where we can make a difference," she says. "Preventive care's not a thing you go to a doctor for, like if a limb's broken," she points out. By using an RPM program, care providers can connect with patients when and where they're most comfortable talking about their health and life, and they can help patients make changes and forge new habits that take effect over time.
McLean expects that Heart of Florida will build on this success and branch out to other populations, including those living with diabetes.
Scaling up to manage more complex patients
While RPM programs often target patients who need help managing their care at home, some programs are springing up to handle those with critical care needs, including patients who would otherwise be in a hospital.
Much of the growth in what's being called the "hospital at home" movement is tied to the pandemic, and to a federal program aimed at supporting hospitals for caring for patients at home. The Centers for Medicare & Medicaid Services (CMS) launched its Acute Hospital Care at Home program in 2020, building off the agency's Hospitals Without Walls program, unveiled earlier that year to support the use of RPM and other services to offset the COVID-19 surge in hospitals.
The new program incentivizes health systems to create care programs for patients who would otherwise require hospitalization, combining in-person care with RPM devices and telehealth platforms for daily care management. And it inspired many health systems (more than 200 are part of the program as of the beginning of 2022) to rethink how they care for patients both inside and outside the walls of the hospital.
"The home hospital approach has repeatedly demonstrated its enormous benefit and value as an important treatment option for patients," past Massachusetts General Hospital President Peter Slavin, MD, said in a press release issued by CMS highlighting the first six health systems approved by CMS to join the program. "This innovative model has made available safe, cost-effective hospital-level care to patients at home—a reassuring environment that is comfortable, familiar, and healing. CMS' decision to cover home hospital care will not only make this program more viable but will also enable more patients and families to experience this high-quality high level of care in their own homes in their own communities."
California-based Adventist Health launched its Hospital@Home program in May 2020, focusing on eight specific diagnoses. Hospital executives say the CMS program gave them the support they needed to move forward, but they'd long been talking about reimagining healthcare delivery.
"We are moving from a healthcare organization to a health organization," says Lesa McArdle, RN, director of operations for the program, who notes the program is part of a strategy that maps out the health system's growth through 2030. "We are looking to increase our virtual and digital presence, and this fits right into that plan. It's a unique care model."
Adventist Health exemplifies the evolution of the RPM model, with a care plan in place for patients with more complex needs. In this format, patients are evaluated after they've been admitted to the hospital and sent back home with the appropriate devices and training if they meet the criteria for home-based care.
The program includes regular home visits by care providers, as well as virtual visits and RPM monitoring, depending on the care plan. And patients have four channels through which to contact their care team: through an iPad® (a care provider responds within an average of 17 seconds), through a dedicated phone number to an assigned nurse, through a waterproof PERS (personal emergency response) device, or through a biometric screening tool connected to the iPad that alerts care team members if the patient is in distress.
McArdle says safety and redundancy are crucial in a program like this. Wi-Fi and cellular connectivity are both included, in case one platform fails, and backup power is also on standby (a necessity in California, where weather-related power outages have been known to happen).
"When the patient is outside the walls of the hospital, how can you be sure?" she says, noting the program's goal is to replicate the in-person model of care as much as possible. "It's important that we have all this in place because we need to be able to know what the patient is doing at any time," just as if there were a nurse down the hall who could pop into a hospital room for a quick checkup.
Aside from a minimum five "vital touches" and two clinician visits per 24 hours, the service manages medications and even plans out meals. Home visits are scheduled through the telehealth vendor (in this case Medicity) or a home health service in California, while Adventist's Oregon facilities make use of a community paramedicine program.
The success of this program—or any hospital at home program—depends on the outcomes, and because the Acute Hospital Care at Home model was introduced roughly three years ago, a lot of that data hasn't been collected and put into reports just yet.
Some of the early CMS participants, such as Brigham and Women's Hospital in Boston, have published studies. A cardiac care pilot launched by David Levine, MD, MPH, MA, a physician and researcher in the Division of General Internal Medicine and Primary Care, found that the program reduced overall medical costs by 38% compared to in-person care, due in large part to fewer consults, imaging, and tests.
"This work cements the idea that, for the right patients, we can deliver hospital-level care outside of the four walls of the traditional hospital and provide more of the data we need to make home hospital care the standard of care in our country," Levine said in a 2019 press release issued by the hospital. "It opens up so many exciting possibilities—it's exciting for patients because it gives them the opportunity to be in a familiar setting, and it's exciting for clinicians because we get to be with a patient in that person's own surroundings. As a community-minded hospital, this is a way for us to bring excellent care to our community."
Adventist's program is seeing those results and proving popular with both clinicians and patients.
Per Danielsson, MD, the program's medical director, says the Hospital@Home program has reduced the health system's admission rate by 43% and all but eliminated infections and pressure ulcers in patients.
"Even though the patient is at home, there are so many touch points we have with them, and they're able to connect easily with us," he says.
Danielsson sees the program expanding as the health system builds out the infrastructure to support it, and as new RPM technology improves data capture at home. The program recently saw its first home dialysis patient, and future programs will be built around oncology, post-surgery, chronic care management, and hospice care.
"People are forecasting that the hospital of the future will be one large ICU," he says. "We'll be taking care of only the sickest patients in the hospital, and everything else can be done in the home. [The Hospital@Home program] is a step in that direction. It's beneficial to so many stakeholders."
But it isn't there yet. Danielsson also notes the concept is in its early stages, hindered by a healthcare industry that's slow to adapt to change. Some of the technology is still clunky, and federal and state regulations limit the use of telehealth and other digital health technologies at home. And payers must support the strategy, beginning with CMS.
"Things will change immensely over the next three or four years," he says.
Taking two steps forward, and one step back
In many cases, the success of RPM and hospital at home programs (especially those involved in CMS' Acute Hospital Care at Home program) has been due to the COVID-19 pandemic, which led to a surge in telehealth adoption across the country and emergency federal and state directives aimed at expanding access to and coverage of telehealth and digital health services. With the barriers dropped, RPM and hospital at home programs were launched in a matter of weeks, if not days, with the goal of separating healthcare workers and potentially infected patients and reducing the stress on crowded hospitals.
Some programs may have been launched on the idea that they'd last only as long as the public health emergency kept those state and federal emergency rules in place. But many healthcare executives saw the crisis as an opportunity to push innovation that would last well past the pandemic, and they developed strategies that would have taken years, perhaps decades, in more normal circumstances.
Executives at South Shore Health in southeastern Massachusetts had already launched a mobile integrated health (MIH) program that used specially trained paramedics to deliver care to targeted patients in the community. And they had an eye on the struggles faced by skilled nursing facilities (SNF), which were grappling with staffing shortages and high rates of rehospitalizations.
The health system launched its SNF at Home program in March 2021, with a goal of providing care at home for patients who would otherwise be living in those SNFs. The program was enhanced by the MIH platform, launched a year earlier.
Kelly Lannutti, DO, South Shore Health's director of clinical transformation and co-medical director of MIH, and program development and clinical innovation physician, says the program was designed to reduce stress on both the hospital and SNFs by giving more patients with complex care needs an opportunity to receive that care at home. It included round-the-clock real-time monitoring and in-person visits at least five times a week.
"It's really a shift in the acuity of the patients themselves who can be cared for at home," she says. "It's definitely a different mindset."
In many cases, programs like SNF at Home may be the next step in the RPM journey, as health systems develop the technology and workflows to care for more complex patients at home. But that step isn't without controversy, with critics wondering if home-based care is appropriate and safe enough for some patients with advanced care needs—especially those who would otherwise be in a structured healthcare setting like a hospital or SNF.
Lannutti says the program was structured to carefully review patients in the hospital before sending them home. It was also designed and launched during the height of the pandemic, when hospitals and SNFs were struggling to handle an excess of patients and saw home-based care as a good opportunity to cut traffic and curb the chance of infection.
"In the home setting it's very, very different," says Lannutti, noting that while the program was designed to replicate clinical care at home, it didn't equal the round-the-clock monitoring and care that a hospital or SNF offers.
South Shore Health has since dropped its SNF at Home program and adopted a platform that hews toward a hospital at home program. Lannutti says the decision was due in part to a lack of payer reimbursement for those services, which required a lot of time and effort from the health system, and some technological challenges around continuous monitoring.
"There's a difference between acute and critical care," she says, "and certain things we can't do at the home right now. We eased back."
The shift has given South Shore Health an opportunity to look more closely at what goes into home-based care, and to better define which patients are best suited for the program. They're now tailoring the RPM technology to the needs of the patient and creating workflows that benefit not only patients and caregivers, but also the nurses and doctors who keep tabs on them from the hospital.
"The home is a very different setting from the hospital," says Lannutti. "It forces care providers to think differently. You can't just take a nurse from the clinical setting and put them into [the program] and expect things to work out."
And nurses are a crucial part of the program.
"We would love to include more nurses," she says. "Everyone needs more nurses," and RPM and hospital at home programs fit snugly into nursing workloads, giving them the time and space to gather data, interact with patients, and call in doctors or specialists only when the situation demands it.
(Across the country at Adventist Health, the platform has been a welcome relief for nurses as well. McArdle points out that several nurses were pregnant when the program launched, and the health system saw this as an ideal way to keep them away from inpatient care and the heightened threat of catching the virus.)
It's evident that South Shore's program will evolve much differently than Adventist's, and that Adventist's is moving in a different direction than others. Healthcare executives are intrigued by the idea that these programs can be taken apart and put back together in many ways to meet the individual needs of the patient and the health system. One program might lean heavily on RPM tools to monitor vital signs on demand, while another could skew toward telehealth platforms that allow patients to check in with their care providers when they want or need to. Some programs may require daily visits from clinicians, while others may spread those visits out over the week or per a patient's specific needs.
South Shore is one of a handful of health systems that uses its own MIH program, a relatively new concept that falls into the community paramedicine mold. And that may grow in popularity as health systems look to acquire their own EMS services or partner with local ambulance companies and community health organizations to improve home-based care and reduce unnecessary 911 calls.
MIH "is an absolute game-changer," says Lannutti, who notes the paramedics "are thrilled to be able to do something other than taking people to the hospital."
Lannutti expects South Shore's program to expand, perhaps even going back to the SNF at Home model, as the health system explores its options. This includes talking to accountable care organizations and other risk-bearing programs, many of whom have a significant interest in the postacute care space and want to see alternatives to expensive clinical care.
"We've learned a lot of lessons, all of them positive," she says. "We have a better understanding of what the patient wants now, and they now realize that they can receive care from their home."
That may be a more important factor than anyone realizes. With all the talk of patient-centered care, it's the patient who may dictate how RPM and hospital at home programs evolve. Patients will ask for more care at home, and perhaps base their future healthcare interactions on who can provide those services. Savvy health systems will offer more of these programs to additional populations, taking advantage of newer devices, even wearables and smart home technology.
"We all go into healthcare to make a difference in people's lives," says McArdle, of Adventist Health. "And with this model, we have nurses and doctors in the patient's home virtually, sometimes even physically. We become a part of their lives. We truly have a more holistic view."
A remote patient monitoring program launched by Penn Medicine to treat COVID-19 patients at home is working fine and proving its value. Adding technology didn't make it any better.
New technology doesn’t always add value to a good remote patient monitoring program.
That’s the take-away from a study of a COVID-19 RPM program managed by Penn Medicine and recently published in the New England Journal of Medicine. The study of more than 2,000 patients enrolled in the health system’s COVID Watch program in 2020 and 2021 found that patients who used a pulse oximeter at home didn’t have better outcomes than patients who simply contacted their care providers when they had breathing problems.
“Compared to remotely monitoring shortness of breath with simple automated check-ins, we showed that the addition of pulse oximetry did not save more lives or keep more people out of the hospital,” Anna Morgan, MD, medical director of the COVID Watch program, an assistant professor of General Internal Medicine and the study’s co-author, said in a Penn Medicine press release. “And having a pulse oximeter didn’t even make patients feel less anxious.”
To be sure, the program – which has treated more than 28,500 patients - still proves that an RPM platform can be an important tool in monitoring patients outside the hospital, reducing hospital traffic, and improving clinical outcomes.
“The program made it easy to identify the sickest patients who needed the hospital, and keep the others at home safely,” David Asch, MD, executive director of the Center for Health Care Innovation and a professor of Medicine, Medical Ethics and Health Policy, said in the press release. “The program was associated with a 68 percent reduction in mortality, saving a life approximately every three days during peak enrollment early in the pandemic.”
But that doesn’t mean it needs more technology.
Launched in March 2020, the program uses a text messaging platform to keep track of patients diagnosed with COVID-19 who were well enough to stay at home. The automated system sends text messages to those patients twice a day for two weeks, asking how they feel and if they’re having difficulty breathing. If patients indicate they are having problems, a nurse will call them and either suggest continued monitoring, schedule an urgent telemedicine appointment or direct the patient to the hospital’s Emergency Department.
Penn Medicine then decided to see if more technology would make the program better. Acting on research from the Perelman School of Medicine that patients might not notice when their blood oxygen levels are dropping to dangerous levels, the RPM program sent some patients home with a pulse oximeter.
“Several health systems, and even states like Vermont and countries like the United Kingdom, have integrated pulse oximetry into the routine home management of patients with COVID-19, but there’s been scant evidence to show this strategy makes a difference,” M. Kit Delgado, MD, an assistant professor of Emergency Medicine and Epidemiology and the research project’s principal investigator, said in the press release.
With support from the Patient-Centered Outcomes Research Institute (PCORI), Delgado and her colleagues then studied outcomes from roughly 2,000 patients enrolled between March 2020 and February 2021, randomly divided between those using pulse oximeters and those not using the device. And they found no difference in outcomes.
“Overall, these findings suggest that a low-tech approach for remote monitoring systems based on symptoms is just as good as a more expensive one using additional devices,” Krisda Chaiyachati, MD, an assistant professor of Internal Medicine and the research project’s co-principal investigator, said in the press release. “Automated text messaging is a great way for health systems to enable a small team of on-call nurses to manage large populations of patients with COVID-19,”
The study offers a lesson for any health system looking to launch a new technology platform or use an new tool: Don’t just assume it will make things better.
“There are a lot of other medical conditions where the same kind of approach might really help,” he added.
The Medical University of South Carolina and The Citadel have agreed to a partnership that will allow cadets at the Charleston military college to access healthcare services, including via virtual care, through the health system
Virtual care is coming to The Citadel
The famed military college in Charleston has forged a partnership with the Medical University of South Carolina (MUSC) to provide healthcare services for its roughly 3,300 cadets.
The multi-phased program includes access to MUSC’s 24/7 Virtual Urgent Care program, which enables staff at the college’s infirmary to connect with healthcare providers at MUSC through a telemedicine platform. Students will also be able to manage their healthcare interaction through the health system’s digital health portal.
“Some of the many benefits this affiliation provides include integrated health care access for cadets who can use the MUSC digital medical records portal to manage their care, prescriptions and appointments, and will now have 24-hour access to their medical records and appointments as well as continuing to have 24-hour access to medical care,” Charles Cansler, vice president for finance and business at The Citadel, said in a press release. “Additionally, cadets will be treated with the latest medical technology both on campus and at other MUSC facilities as needed. And over time, upgrades will be made to the infirmary equipment, processes and the building itself.”
As part of the agreement, MUSC Health will bill insurers for care provided at the college and the college will cover co-pays for cadets.
“Health care is undergoing a major transformation right now – from digitization and automation of certain services to how and when individuals access in-person care,” Eugene Hong, MD, MUSC Health’s chief physician executive, said in the release. “As the needs of the community change with the times, we look forward to doing our part to help The Citadel ensure the health and well-being of the Corps.”
One of six senior military colleges in the US, The Citadel was founded in 1842, 18 years after MUSC, also in Charleston, was opened. Its students are called the South Carolina Corps of Cadets, and come from 45 states and 23 other countries.
