In a move expected to anger virtual care advocates, the Centers for Medicare & Medicaid Services has proposed dropping Medicare coverage for audio-only telehealth services, including telephone calls, in its 2023 Physician Fee Schedule. The proposed action would take place 151 days after the end of the public health emergency.
The Centers for Medicare & Medicaid Services has proposed dropping Medicare coverage for audio-only telehealth services once the Covid-19 public health emergency is over.
The proposal imperils a service that had become popular during the pandemic, when health systems shifted in-person care to virtual channels to cut down on hospital traffic and reduce the spread of the virus. Thanks to federal and state waivers tied to the pandemic, healthcare providers were allowed to connect with patients on a telephone or other non-video platform for some healthcare services and be reimbursed for those services.
In its proposed 2023 Physician Fee Schedule (PFS), however, CMS aims to eliminate separate Medicare coverage for those services, except for some behavioral health services. That coverage, found in CPT codes 99441-99443, would end 151 days after the end of the PHE, which is expected to take place next year.
The decision won’t sit well with healthcare providers and consumers who see the telephone as a vital channel for healthcare services, especially in rural areas where access to audio-visual telemedicine is limited or even non-existent. Telehealth advocates have been lobbying Congress – and several bills have been introduced – to make audio-only telehealth coverage permanent.
The proposal was highlighted in a blog penned by Foley & Lardner attorneys Nathaniel Lacktman, who chairs the Telemedicine & Digital Health Industry Team and serves on the American Telemedicine Association's Board of Directors; Thomas Ferrante and Rachel Goodman.
"With the exception of certain telemental health services, CMS stated two-way interactive audio-video telecommunications technology will continue to be the Medicare requirement for telehealth services following the PHE," the three attorneys wrote as part of an analysis of all telehealth coverage changes in the proposed 2023 PFS. "This is because Section 1834(m)(2)(A) of the Social Security Act requires telehealth services be analogous to in-person care by being capable of serving as a substitute for the face-to-face encounter."
"In CMS' own language, 'We believe that the statute requires that telehealth services be so analogous to in-person care such that the telehealth service is essentially a substitute for a face-to-face encounter,'" the post continued. "As audio-only telephone is inherently non-face-to-face, CMS determined, that modality fails to meet the statutory standard."
Some states and payers have changed their telehealth guidelines to enable coverage for audio-only telehealth, while others have rolled back those freedoms. Opponents say the telephone isn't a good channel for establishing a doctor-patient relationship or conducting healthcare.
The American Medical Association, meanwhile, has come out in support of permanent coverage.
"Payment for audio-only visits has been a lifeline for patients during the COVID-19 PHE," AMA President James Madara, MD, said in a January 28 letter to Acting CMS Administrator Elizabeth Richter. "The need for these services to be available will not diminish when the PHE ends, and the AMA strongly urges CMS to continue separate payment for the CPT codes in the future."
"While not a high percentage of visits, even during this PHE, access to audio-only services is critical for patients who do not have access to audio-video telehealth services," the letter continued. "Discontinuing payment for these services would exacerbate inequities in healthcare, particularly for those who lack access to audiovideo capable devices such as seniors in minority communities that have been devastated by COVID-19."
As the changes are part of a proposed rule, telehealth advocates point out there is still time to submit comments to CMS. The agency will accept those comments up until 5 p.m. ET on September 6.
Healthcare organizations are turning to remote patient monitoring to improve care management and give patients an on-demand connection to their care teams, but they need to plan carefully to make sure the program is sustainable and scalable.
Healthcare organizations are looking to enhance care management by connecting and collaborating with patients outside the hospital, clinic or doctor's office, and they're often doing this with remote patient monitoring (RPM) platforms. Using digital health technology, they're developing programs that allow a care team to monitor a patient at home, gathering vital signs and other data, communicating with the patient when necessary, and creating treatment plans that can be modified in real-time.
HealthLeaders recently conducted a round-table with three health system executives to talk about their RPM programs and strategies. This panel featured Carrie Stover, MSN, NP-C, national senior director of virtual care for Ascension; Sarah Pletcher, MD, MHCDS, system vice president and executive medical director for strategic innovation at Houston Methodist; and Kathryn King, MD, MHS, associate executive medical director at the Center for Telehealth at the Medical University of South Carolina (MUSC).
Q: Do you have dedicated staff for your RPM program? Do you centralize the platform and allow staff to manage patients from other locations like home? Or is this something that you integrate within the provider population?
Carrie Stover: We have a centralized team of nurses and enrollment specialists. Before COVID, they all sat in a bunker setting and monitored patients. We learned with COVID that they don't need to be in a centralized location. They absolutely can be remote. So all of our staff since COVID have been remote and will stay remote.
One difference between 1.0 and 2.0 is that our nurses are now documenting directly in the EMR. We have multiple EMRs, and we do not have standards or consistency in our technology, which is a huge challenge. But we have our nurses document directly in those EMRs so that they’re functioning as an extension of the practice and building the relationship between the practices and the monitoring nurses.
Carrie Stover, MSN, NP-C, national senior director of virtual care at Ascension. Photo courtesy Ascension.
We have recognized that physicians had no idea who was doing this monitoring. We hadn't built those relationships or a high degree of confidence in those physicians that these are highly skilled, highly qualified nurses doing great assessments on their patients and only escalating when necessary. We now have a centralized team, and we encourage them to develop those relationships.
We also are developing leads, or champions by diagnosis, and so that we don't have all of our nurses monitoring and managing every patient population. We're trying to create pods of primary and secondary areas of specialties, so that they can develop those relationships and expertise with that patient population, and then that relationship with the physician practice.
Sarah Pletcher: That's a must. It's on that dedicated team to implement aspects of the [program], like training ER staff to send patients home with a device or supporting outpatient clinics. All the complexities and nuances really speak to the importance of having a centralized team where you can consolidate that expertise and distribute parts of the care continuum thoughtfully, as opposed to trying to have everybody think they can do it, doing it differently, running into billing, tech, and integration inconsistencies, having redundant staffing models or accesses where every department now thinks they need to hire monitoring tech. I'm a fan of centralizing everything you can, and then providing service not only to the patients but to the providers and other clinical stakeholder groups who are part of the care landscape.
Kathryn King: These programs are really meant to be scaled. Likely the ROI will not be realized unless you are able to scale to populations. The best way to do that is with a centralized team of monitoring nurses. Our first remote patient monitoring programs were monitoring patients for providers at free clinics and [federally qualified health centers], who would never be able to scale and support financially a centralized pool of monitoring nurses. We could monitor all their patients and communicate with the providers. We knew that those populations of patients needed to be as effectively managed as possible.
We [will have] patients with multiple disease states or metrics to be monitored. You could be in a hypertension monitoring program and a diabetic remote patient monitoring program, and having those siloed is not helpful to the patient. That really speaks to centralization so that we can are monitoring patients, not metrics or diseases.
Q: Do you recruit nurses for this program? Do you train them specifically for RPM?
Kathryn King: We have nurses who are specially trained to interact with the technology and the patients. Through that, we've gained a lot of efficiencies in nurses who are really good at monitoring several different metrics at the same time.
Sarah Pletcher: Not every nurse is well-suited for monitoring, just like not every physician is well-suited to be a telemedicine physician. And it goes the other way as well. The nurses monitoring patients in our VICU program have loads of bedside and specialized ICU experience, but they've been picked because of their fit for following a broader patient population and algorithm-based care. Being a good fit to interact with lots of different bedside teams is a special skillset.
Sarah Pletcher, MD, MHCDS, system vice president and executive medical director for strategic innovation at Houston Methodist. Photo courtesy Houston Methodist.
We do carefully select those folks. Not only is this helpful to bedside nursing staff and other care team members, it's another career opportunity for them, whether they're looking to diversify their portfolio, extend a career, or save a career for perhaps a nurse who isn't able to handle the physical demands of floor nursing any more. It can be a great way to keep people in the profession.
Carrie Stover: It definitely has been an evolution. Back in the day, our nurses tended to be more toward the case management side of remote monitoring, especially as we were monitoring chronic conditions and patients who had been discharged from the hospital or identified by their physicians. We were training people who had some experience, oftentimes case managers, on the technology.
As we think about higher acuity use cases, and as we added postpartum hypertension, and as we continue to think about hospital at home and more continuous or near continuous monitoring, we have to think about how and who we're recruiting, their expertise and capabilities. It's going to require a different kind of training on virtual assessment. Not everyone is suited to provide telemedicine, and not every nurse is suited to provide remote monitoring, do that virtual assessment, and interact with people day to day who are at home or wherever they are. What we're doing now is training nurses for specific areas and types of remote monitoring and disease trajectories.
Q: How do you choose the technology for an RPM program, or the vendor that you want to use? What do you look for in tools, in vendors, that would make for a good fit?
Sarah Pletcher: Good common sense carries the day most of the time. When you try out some of these sensors, devices, scales, blood pressure cuffs [and] stickers, it's a lot easier than you think to pick one that is not going to be disruptive to the patient and easy for the care team to use.
With a vendor partnership, that's a whole art to itself. You're not only evaluating their goods, but looking at their leadership team, their mission, and the health and sustainability of their company. What's on their company's roadmap? Where are they in their development cycle? What are some of the integration constraints that you might face? Implementation and account management success?
Some vendors put all their assets into sales, and once you've signed the contract, there's not a lot waiting for you in terms of implementation partnership. I spend a lot of time with the leadership of a company because that relationship really has to work and carry you through the challenges that you know you're going to face throughout the sales and implementation and account management life cycle.
Q: Do you look first at in-house programs, running them yourselves, or is there an interest in outsourcing some of these services?
Sarah Pletcher: It depends on what you're trying to do. It's often going to end up being a blend of build and partner. Particularly when it comes to scale, niche expertise and supply chain constraints, partnership is essential. Where it can be an argument to build it yourself is when it comes to the clinical team that you're putting on the other end of some of the technologies. It depends on where you're at in your journey, [your] investment in innovation, to what degree you're going to take on the tech, maintenance support, etc.
Carrie Stover: We just finished an RFI and RFP at Ascension, and it was incredibly painful because of all of the things that we've talked about.
Add to that the turmoil in the industry. Because of COVID, remote monitoring has really increased in popularity. Several of the vendors that we were working with, that had some good elements and capabilities, were acquired by another company while we were evaluating them.
It becomes complicated, but at the end of the day, identifying those requirements and capabilities that are most important to your organization and your programs is critical. The days of having specific tools that are attached to tablets and kits are gone. We are really interested in an agnostic platform that will allow us to decide what tools we use and how often we use them.
There have been some challenges in the past with pathways, for example, that were FDA-cleared, and so we couldn't make changes. We're now interested in evaluating and developing our own programs.
One of the things that's important from a technology perspective but that we don't often think of is reporting and data analytics. We have so much information that's feeding into these platforms, [and we want to use] that information to drive change and identify patients who are or are not benefiting from the program. There are questions that don't have value, or things that we should have been asking and didn't. Do we really need to check people's blood pressure twice a day, is once a day good enough?
Kathryn King: Traditionally, choosing a telehealth vendor came down to video capability, endpoints and integrations. Remote patient monitoring software is really data gathering, storage, analysis, and display software, more than telehealth 'software.' It's all about how can you, in the easiest way possible, gather only actionable data in huge quantities, store that data, analyze that data such that I can learn from it, and display it in a way that is helpful to certain groups of providers, as well as the patient? What I'm looking for, really, is are you going to easily get the data and make it usable?
Kathryn King, MD, MHS, associate executive medical director at the Center for Telehealth at the Medical University of South Carolina (MUSC). Photo courtesy MUSC.
Q: Do you look to technology with an eye toward the future, where you might use it for another RPM program or more services?
Kathryn King: I am uninterested in niche and condition-specific solutions. The algorithms, or clinical content associated with those, take a lot of work. A lot of companies are developing [products based on] their area of expertise, but we're looking [for solutions] that have potential in different, really usable, actionable ways. We're likely to see these companies start merging and buying each other up anyway.
Q: How do you measure the value of an RPM program? What benchmarks are you looking for to prove that this program is working and that it can continue and that you can build on it to keep it going?
Sarah Pletcher: Ideally, you're going into a program knowing what you want it to achieve, and you've identified some metrics and benchmarks for how you're going to evaluate it. That seems obvious, but is surprisingly rare. If you've done that, then you have a way to evaluate whether it's working. Do your patients like it? Do your providers like it? Do your nurses like it? Are you achieving your clinical outcomes? Are you getting use? Maybe it's an amazing kit that you send home, but it turns out patients don't like to stick their arm in a blood pressure cuff twice a day for a month. If you've done your work on the front end, then you should know what you're trying to achieve and have some metrics in mind for how you're going to pursue it.
I'm not interested in niche options. I'm also not looking for a modular 'here's the 10 things it comes with' toolkit solution because that doesn't allow me the speed to run with whatever the market's bringing me. That being said, I'm excited about what I call ‘hero’ products: multi-parameter sensors that can be helpful for loads of conditions and use cases, and with which I can build in other specialty sensors. I am particularly excited about a sticker that collects several pieces of data continuously. I think that's a great space to get right, because its so easy for the patient and then you can add modular pieces to that, tag other specialty conditions, or parameters, that you need to measure.
Q: Is there a certain data point or benchmark that surprised you at how valuable it was for you, something that you weren't expecting to collect, or you weren't really giving a lot of thought to, but it turned out to be important to the program?
Sarah Pletcher: We’ve done loads of inpatient monitoring and are transitioning to the outpatient space. What I'm looking ahead to is not so much what I'm surprised is valuable, but the opposite- something I assumed was critical to measure but turns out to be overrated. I have a feeling that respiratory rate is going to be a lot more valuable when it's collected correctly and continuously, and I suspect that blood pressure might not be as valuable a vital sign as we've thought. I think we're going to be equally surprised by things that aren't as valuable as we thought as we are about ones that are.
Carrie Stover: We've spent a lot of time optimizing and standardizing our programs and focusing on outcomes and measures because historically, although everyone will tell you that every heart failure program that they've initiated has had tremendous value and great results in terms of preventing readmissions, when you look at it, no one was using the same numerator or denominator, and nobody was defining anything the same way. We are really specific about how we're defining success and what are the outcomes that we're measuring.
We have the Ascension Data Science Institute. I'm not claiming that we did all of this ourselves, but we had some really smart people to help us build those dashboards to ingest all of that information and evaluate it.
In terms of metrics that are surprising, with our postpartum hypertension program, one of the things that impacted us tremendously is postpartum visit adherence. Did this new mom go to her postpartum visit? We've seen an increase, overall, from 56% to 95%. Really impactful, and maybe not something that we would've measured if it wasn't tied to one of our national quality goals.
We also have a clinical quality escalation meeting every week with some of our nurse leaders and physician leaders to look at red alerts, what happened from those red alerts, and what was the escalation path, so that we can identify if there are things that we're doing that don't have value, or are there educational opportunities, both on the nursing side and on the physician side, about how to manage these patients.
Kathryn King: How do you demonstrate the value of the program? That is such a key question. Value is in the eye of the beholder. If you're going to take into account every bit of increased quality, or everything you got out of healthcare, over every cost to your system, it really has to do with who are you providing the value to and what did they get for what they gave.
There are lots of different value cases for remote patient monitoring. Maybe the value case is that monitoring blood glucose works really well for the current fee-for-service model, so we are actually going to have a good defined ROI on that program.
Maybe it's that Medicaid came to us and said, 'We need moms to go to their postpartum well visit.' We're going to ask mom some questions, we're going to text message them and help them get to that visit and their newborn follow up visits. That provides extraordinary value to a large payer in our state, and so on and so forth. It's about defining why are you doing this in the first place. Then, what is the value of that program? How do you add value to why you're doing this? That's where you define your metrics.
As far as what's surprising to me, in our COVID post-discharge program we had a lot of physiologic metrics and a lot of validated questionnaires from other pulmonary diseases. Yet the most helpful thing to ask someone ended up being, 'Are you better today than you were yesterday?'
Q: Do you design RPM programs to have limited lengths? Do they have an endpoint, or are you designing programs that can, as in chronic care management, continue for years?
Carrie Stover: Historically, we would've said that this is our anticipated timeframe and patients may come off before or after. Now we're thinking about this as a new care model, where we're using technology to support the interactions and the engagement. What we'd like to do is move people up and down the spectrum depending on their needs: lower acuity, higher acuity, monitoring, and then patient-reported outcomes. One question a day or one question a week and maybe some of these nudge interactions.
We are recommending an anticipated length of stay on the program just to give people some idea of what we're anticipating. It's easier with higher acuity use cases like hospital at home, or a postsurgical use case, but when you get into chronic disease that becomes more complicated. Where we would like to be is that we're not just like cutting you off; we're moving you up and down this spectrum of connected care based on what you need and where you are in your disease trajectory.
Sarah Pletcher: It's like prescribing a medication or physical therapy. You're always assessing, evaluating, moving forward, reevaluating, reassessing. Can you graduate? Can you change the frequency? Obviously the length of time a patient can tolerate being in one of those [programs] is going to align with how complex and disruptive and burdensome it is.
With regard to benefits and ROI and thinking a little bit outside the box, the ‘placebo effect’ and the ‘Hawthorne effect’ are still effects, therefore effective. Even if all that a remote monitoring program achieves is that the patient feels a little bit more engaged in managing their own chronic condition or their health, that has huge benefit- even if the data doesn't change what the care team does or there's no great predictive algorithm or alert. If all it achieves is that the patient feels like it's helping them or that it engages them more, that’s not to be dismissed. We'd be delighted if many of our medications could achieve that much.
That's an important thing to not overlook. When you're thinking about your metrics at the beginning- consider ways to measure patient perception. It doesn't all have to be around what hard data from the technology are we gathering.
Maybe a patient thinks ‘Hey I'm doing something the will help me with my high blood pressure, I'm going to take my medication, I'm going to pass on the can of Pringles. ‘ The data didn't do that. The tech didn't do that. It was just the patient being more engaged.
Kathryn King: We tend to say OK, I think it's going to last this long because we're building siloed things. But this is just part of caring for patients, and patient care doesn't have a beginning and end. It's a continuum of care. There will be [some] sliding back and forth for all of our patients. At some points it might look like just engagement, and at some points it might look like physiologic monitoring.
But this is all for a therapeutic effect. The length of therapy is determined by that therapeutic effect, just like any other therapy that we would prescribe. That is how we take care of patients, rather than 'Today you are on a remote monitoring program and it will be over in three months.'
Sarah Pletcher: We need more evolved reimbursement codes. For example, if a patient goes home from the hospital after a surgery or illness and we slap a sticker on them and a week of close monitoring later they look great, they should take it off- they're done, they're good. But if the reimbursement code says no, it has to be for 16 or 30 days, now we're locking people into arbitrary lengths of time that aren't aligned with what the patient needs.
Q: How do you emphasize patient engagement, or patient activation, and how do you help the patient take charge of his or her own health?
Sarah Pletcher: You have to think about how you're going to survey patients. Again, it seems obvious, but is often overlooked. Everyone just wants to default to the standard survey that gets sent out to patients [but which] really doesn't reflect these new programs. You have to find a way to engage the patient. Do you like this? Does it help? Do you feel better? Would you recommend this to somebody else? Do you feel cared for? I mean this is basic, basic, basic.
Kathryn King: Remote patient monitoring is very tightly wound to what we call a patient engagement cycle or a cycle of engagement with our patients, whether it's just a brief outreach or hands-on physiologic monitoring. The point of the technology is to collect and display data in an actionable way and, as someone said, 'a way that is helpful to the patient.' That is so important. Can I display back the data to a patient in a way that is engaging to them?
For instance, I'm a general pediatrician. At every well child check, I turn the screen around and show a mom her child's growth chart. That's why she came, just to see the growth chart. She knows her child grew, but it's such a fulfilling thing to look at your child's growth chart. And that is true of most of the data about our health. We like to see it.
For a long time, people were all about developing healthcare apps. With weight loss apps, it is not actually the amount of calories that correlates to weight loss, but that you logged into the app at all. That you interacted at all is more connected to weight loss than what you actually ate. So when you engage with healthcare, you are more likely to be healthier. All we're trying to do is help you engage in a really easy way with healthcare.
Carrie Stover: The idea that I'm supposed to check my blood pressure, so I ought to take my blood pressure medication before I do that, has some intrinsic value. We've [done] a study with our postpartum hypertension pilot, and we learned not just about what our physicians or our monitoring nurses are thinking, but what our patients are thinking and why and how they're participating. We learned that just because they're participating, just because they are checking their blood pressure once or twice a day, doesn't necessarily mean that they are happy with or engaged in the program. Sometimes it's a source of frustration.
We have to do a better job of connecting with our patients, because oftentimes they will do exactly what their physician asks them to do, but it doesn't necessarily mean they understand the value. If we could turn that around, show them how much better their blood pressure is controlled or whatever it is that we're measuring and engage them in not just the measuring but also in the evaluating of the results, we could have a lot more benefit.
About the importance of respiratory rate when it's collected accurately, that made me laugh a little bit because one of the many questions that we were asking our COVID population when we first started monitoring them was to [track] their respiratory rate. Anything over, I think, 24 or 28 would set off an alert to our nurses. I would be willing to say that 99.9% of the time, patients were counting it inaccurately. That taught us that we have to be thoughtful of what we're asking people to do, and just because it seems easy for us as clinicians or as people who work in hospitals and health systems, it doesn't necessarily apply to the general population.
We have struggled, as I think everyone has, with all of these disease-specific applications. It's easy to monitor someone or create an app that helps somebody monitor one thing, but so many patient populations don't just have diabetes or hypertension. Having all of these one-off applications that do just a couple of things is not helpful. We have to get to the point where we're making these things not only tech-friendly for patients, but making sense clinically and helping people manage their overall health.
Kathryn King: One other benefit that we were surprised about was in interviewing patients. They said it made me feel like I wasn't alone. There is a huge benefit in that, and it's difficult to quantify that benefit. In our program for postpartum discharge we'll be working with both moms and babies. While there are a lot of metrics, the bottom line is it's a period of time when a lot of people feel very alone, and if we can help people not feel so alone, I think there's great benefit in that.
Sarah Pletcher: That 'I'm not alone' comes from the patients, but if done right it also comes from the bedside team. If you're doing inpatient monitoring, someone else is watching, there's another safety net. The physician [feels that] I'm not alone in managing my patient's chronic conditions. I have some of these partnerships. Reduced isolation is a big thing.
The other reality, particularly when you're talking about longer term monitoring, is that behavior change is hard. It's hard to get long-term utilization and traction. One of the things that excites me about the consolidation and disruptors coming onto the market is that some of those partnerships will yield more people who study how to get people to engage sliding into health. Maybe the same science that knows what YouTube video I just have to watch at midnight is hopefully also going to help me craft some of the sticky solutions to keep patients engaged in optimizing their care.
Q: How do you see our RPM evolving? And is there one government policy or action or something that would really help RPM to evolve?
Kathryn King: The ultimate goal, for most of us, is that it becomes just a normal way of how we take care of patients. One day telemedicine will just be medicine. I think there's a lot of fear about overuse when it comes to reimbursement of remote patient monitoring. Hopefully this might be a little Polyanna of me, but we're to a point where we realize that, overall, everyone wants to take better care of their patients. From a policy standpoint, whenever we can look at supporting the healthcare system and taking better care of patients, we will be closer to that goal.
Sarah Pletcher: I think the technology solutions are going to get smaller, faster, smarter, cheaper, better, easier, stickier, and more integrated. I hope that we'll continue to see more utilization, more engagement, more AI, and therefore more predictive insight so that we can be a lot more tailored and personalized with the healthcare that we deliver. We need the regulatory and payment models to try to keep up or give health systems and providers latitude to figure out how to leverage these models in their care.
Carrie Stover: As we continue to create these solutions that are extensible across the whole care continuum, these don't have to be program-specific or platform-specific uses that have a beginning and an end. They become part of the tools that we use to help patients get better. Just like we use the laboratory and imaging and all of those things to help us evaluate how a patient is doing related to their disease and how we can help them be better, these will just be tools, not very specific programmatic platforms that have this beginning and an end and are only applicable in certain circumstances.
Health system executives at a recent HealthLeaders round-table explained how to create an effective remote patient monitoring strategy, from selecting the right patient population and technology to securing staff buy-in.
Healthcare organizations are looking to enhance care management by connecting and collaborating with patients outside the hospital, clinic or doctor's office, and they're often doing this with remote patient monitoring (RPM) platforms. Using digital health technology, they're developing programs that allow a care team to monitor a patient at home, gathering vital signs and other data, communicating with the patient when necessary, and creating treatment plans that can be modified in real-time.
HealthLeaders recently conducted a round-table with three health system executives to talk about their RPM programs and strategies. This panel featured Carrie Stover, MSN, NP-C, national senior director of virtual care for Ascension; Sarah Pletcher, MD, MHCDS, system vice president and executive medical director for strategic innovation at Houston Methodist; and Kathryn King, MD, MHS, associate executive medical director at the Center for Telehealth at the Medical University of South Carolina (MUSC).
Q. Could you please define remote patient monitoring and how you've used it in your health system?
Carrie Stover: We've had remote monitoring in place for chronic disease since 2014, but those programs were developed market-by-market and physician practice-by-physician practice - or organically, as I like to say. Historically we defined remote monitoring the same way that [the Centers for Medicare & Medicaid Services] does: Using a connected device and being monitored by a team of nurses.
Over the last few years, and particularly with COVID, we've seen that we don't always need to have a connected device. We've started to think about this in terms of a connected care spectrum, from patient nudges, wearables and patient-reported outcomes through traditional remote patient monitoring, and then onto higher acuity monitoring in terms of hospital at home and even some in-facility monitoring.
Sarah Pletcher: It can be any solution where you have a remote care team looking after a patient, informed by some data about the patient. There’s a wide variety - we’ve seen an evolution in how continuous that monitoring might be, or how synchronous, and how robust, and how automated, the depth and scope of data, degree of artificial intelligence, the timeline to intervene [and] what that care team is and can do. And are you using AI and algorithms? There needs to be a continuum, but at the highest level remote patient monitoring can be anytime we are using data to look after a patient, the care following the patient closer to where they are.
At Houston Methodist, we are using virtual care and monitoring technologies to care for patients in hospitals across the health system, as with our VICU program and telesitting service and to offer access to care to the patients wherever they are, as with our Virtual Urgent care, and we use virtual platforms to allow our primary care and specialty care providers to see and monitor patients at home.
Kathryn King: It's difficult to not have payers define remote patient monitoring for us. Certainly, I think it is helpful in that it gives us a common language. But at the end of the day, this is really about how can we take better care of our patients.
It comes down to, if you could wipe the slate clean from what we were taught in medical school, which is you treat chronic disease in 15 minutes every three months, and instead say, "What's the one question I could ask my patient every day that would help me better manage their health?" What is the one piece of information we need every day to make a better decision about this patient's care.
Q: What are the biggest benefits of an RPM program?
Kathryn King: It is about more efficient, effective care for our patients. Whenever you're talking about a digital transformation or a change in healthcare, that's what it should come down to: That patients feel like they are getting better access to better care and providers feel like they are delivering higher quality care. Remote patient monitoring is a great example of exactly how to do that.
Sarah Pletcher: It can be much more efficient, allowing us to better use hospital, nurse and doctor resources, and there's more freedom, convenience, independence, and wellness for the patient, and the technology can allow us to be more proactive. We're identifying things earlier so that we can impact better outcomes for the patient. Better care delivered more efficiently? that's the ideal. You're looking to serve the patient and move the needle forward on the value continuum, so ideally you tick all the boxes.
Sarah Pletcher, MD, MHCDS, system vice president and executive medical director for strategic innovation at Houston Methodist. Photo courtesy Houston Methodist.
We're trying to take increments of time and effort and distribute those for maximum gain. If technology helps me know who I need to spend time [with] in a moment or a day or a five-minute increment, I'd far rather do that than spend it on the people who don't need me and miss the one that does. If I am the patient, I don’t want to be bothered if everything is OK. I think we're all trying to get the most bang for our buck.
RPM is the most powerful tool we have available to us, to use data to elevate where we should be leaning in to use more resources, and then being able to pull away and not waste resources that are often disruptive to the patient. If we don't have to wake that patient up three times a night to check their vitals; but can instead watch them from a wearable patch while they sleep … not only am I not wasting hospital resource time, but I'm also creating a more healing-friendly environment for the patient and catching problems earlier.
Carrie Stover: With traditional benefits, which is why everyone started thinking about remote monitoring years ago, [we're] reducing readmission rates and improving stickiness to your system. It [also] helps to fill in gaps, what we call the white spaces between physician visits, to help us better understand our patients. There are so many challenges that patients face that we don't know anything about because they happen in that white space in between visits.
Understanding what's happening to them clinically, but also socially, is so important. I think we've seen some unintended consequences related to improvements in visit adherence by having that relationship with that monitoring team, and decreasing calls to the practice. [We're] making sure that when we're escalating something to a physician, that it really requires a physician and that it couldn't have been handled by somebody else.
Q: What are the biggest challenges to launching an RPM program and how do you address them?
Sarah Pletcher: The challenges are different depending on your RPM journey. At the beginning, it's ‘What should I do?’, ‘Where's the ROI?’, and ‘How do I get started?’ Then, [it's] making sense of a complex and rapidly moving technology market - software, hardware, and considering form factors as well as the potential service partner landscape, and then it's trying to make sense of the operations.
It often isn't the fun, sexy things the launch innovative technology but the boring, essential workflows, algorithms, protocols, and change management meetings. The challenges are different depending on where you are on the journey and [they're] absolutely surmountable, but pack your tool belt before you set out.
Q: Are there challenges that you didn't expect to have that cropped up?
Sarah Pletcher: Trying to make sense and keep up with the vendor market. I knew that it was complex. I don't think I fully appreciated all the different niche areas, not of the devices and sensors and gadgets and cameras per se, but all that middle stuff. Data aggregation and data storage and data visualization. And the management software for people using data and how quickly you can build algorithms within the data and when and where EMR integration is essential and where you should avoid it like the plague.
There were a lot more nuances in what I'll call middleware than I appreciated. It's been fun to navigate that and come up with a strategy for a very diverse and complex market. But in particular, that middle area required a little more lean-in than I mentally budgeted for.
Kathryn King: Whenever we talk about something disruptive in healthcare, and certainly most telehealth is meant to be such, we talk about culture change. It is a cultural shift, thinking about how you manage patients, particularly large populations. There are a lot of things that go along with that, from provider acceptance to digital literacy. Payment is probably the largest barrier to widespread implementation.
We have seen during the pandemic that when payment and reimbursement restrictions were lifted, a lot of barriers fell away with other modalities. We're starting to see the same thing with remote patient monitoring.
Kathryn King, MD, MHS, associate executive medical director at the Center for Telehealth at the Medical University of South Carolina (MUSC). Photo courtesy MUSC.
If we're only willing to do it within the strict guidelines of what is reimbursed through a fee-for-service architecture, we're going to limit ourselves and, in some ways, make things less efficient and broaden disparity gaps. For instance, when I ask a physician, "What is one piece of information you need to make a clinical decision?" That might not be a physiologic metric uploaded directly from a device for 16 days during the month, but I have teams that want to make it that because that's what we will be reimbursed for. That is pushing us in the wrong direction.
Q: Is there one challenge or one barrier or something that came up that really surprised you?
Kathryn King: When I think about this, I think about building programs to increase efficiencies. And I realize that we also need to think about the direct ROI, which looks like dollar signs, but sometimes value can be calculated downstream and in a different way than straight reimbursement.
Getting people on board for that was something I did not anticipate. When we were so excited about these known fee-for-service billing codes, in fact it would threaten to widen disparities by really self-selecting patients, and that would potentially lead us in the wrong direction from an efficiency standpoint. I am happy that we have these codes to put to the test, but I think that what we are learning is that other payment models are needed and we need to keep pushing on that.
Sarah Pletcher: The reimbursement models we have for remote patient monitoring. The billing codes select patients and care teams who can comply with a rigidly defined frequency and cadence of data collection. That's what worries me, that 'magical thinking' that seems to keep cropping up in the RPM space.
People get excited about the technology, and a payment model that can support meeting the needs of the patient, and they think it's reasonable that a super busy primary care doc whose in-basket is bursting, who's booked seven months out for just a follow-up visit, somehow they're going to be able to handle all these incoming alerts, escalations, and alarms and review all this data.
Similarly, for a patient who's struggling to manage their own care, because they're elderly or they've got comorbidities or dual diagnoses, suddenly we think they're going to be up for climbing on a scale and attaching their blood pressure cuff and doing several actions every day to deliver enough data.
Then there are the care teams. We forget about the existing burden on our nursing staff and hospital providers and think, ‘Oh, well, it should be no problem for them to do, A, B, C, D, E.'
I find that I'm constantly [playing] whack-a-mole on [that] magical thinking that crops up in the design of these programs. I agree that limited billing codes is one piece of it, and I hope that with more optimized payment examples it'll be easier to overcome some of these other challenges.
Carrie Stover: One challenge that I was unprepared for was that we have lots of programs that meet every one of the stringent CMS criteria, and it should be so easy to bill for that. It's 16 days, it's a connected device, all of those things, but we've discovered that we are leaving lots of money on the table because it's very hard to bill for something in a practice that, number one, is time-based, and number two, is not tied to an encounter.
We have these massive workflow documents and diagrams that detail what we need the remote monitoring team to do and provide to the practice, and then what somebody at the practice has to do in order to turn that into a bill. It's really complicated. Developing that value, even when you can bill in a fee-for-service world, most of the time we are not because it is so incredibly complicated and complex. It has created so many tasks.
Carrie Stover, MSN, NP-C, national senior director of virtual care at Ascension. Photo courtesy Ascension.
With the program, the challenge is related to logistics and support. As we think about all of these devices and who needs what, I call it the virtual care Clue game. Who's where with what device being looked at by whom?
With logistics, the best way to enroll someone and get engagement is when they need it. It's coming from their physician or their discharge nurse in the hospital, and that sounds simple. We're going to give this patient a kit and they're going to go home and turn it on. But it's not simple. Managing lots of locations with lots of variations of those kits is challenging, and sending those kits to the patient's house, you've now created this 24-, 48-, 72-hour gap between when everybody agreed that they need this thing and when they actually get this thing. Are we going to enroll them face to face? Via video? All of those things need to be solved. It's further evidence that sometimes we, with all of the best intentions, end up with a lot of technology in the closet collecting dust, because we haven't really thought through the workflow.
With support, you have people who are trying to utilize these Bluetooth connected devices, {but] they may not have the expertise. The vendors all say that everything will work right out of the box, and that may be true for the first two weeks or four weeks or 70 times, but at some point that device is going to come disconnected. How that gets reconnected and who helps them can be an issue. Are they calling the nurses or are they calling the enrollment specialists? If you haven't really thought it through in the beginning, you have a good chance of having an awesome program fail for all the wrong reasons.
Q: How do you identify patients or the population that you want to monitor at home? And how do you prepare patients for this program? What do you look for in the home setting that will make them good candidates for an RPM program?
Carrie Stover: That's been part of our journey from 1.0 RPM to 2.0 RPM. 1.0 was a little bit of a free for all. We'd take anybody who wants to participate. In 2.0, we're more thoughtful and specific about inclusion and exclusion criteria. How do we identify patients that are appropriate clinically? How do we identify people who are at the right trajectory in their disease progression to participate? Then, understanding who's going to benefit the most from these programs from a clinical perspective, because we can't monitor everybody all the time.
When we think about assessing a patient from their ability or interest in participating, that engagement is so much better when that discussion is initiated by their physician. There's no substitute for that conversation.
We also think about the home environment. Even though these devices are cellularly connected, we have regions where patients have zero cell coverage. That's part of our assessment. We have a team of enrollment specialists to determine whether a patient should be kitted or unkitted, whether they can use an app or an unconnected device vs. a connected device or a tablet. They assess their interest in the program, their willingness to participate, and help walk through that enrollment process.
It creates a scenario where we're [eliminating] the patients who may need our help the most and may have the worst access to other forms of care. We've been really specific about creating equity solutions, but it doesn't solve the problem by any stretch of the imagination.
Kathryn King: From a population-based approach, at one end we're talking about high-touch, technologically based remote physiologic monitoring, which poses a lot of barriers. At the other end, where folks are starting to explore, is the lower-touch, not-as-specific, technology-based monitoring of patient-reported outcomes – asynchronous engagement and therapeutic monitoring. That's what we're tending towards from a standpoint of equity: What is the lowest tech solution to reach our clinical goals.
At that point you're looking at what population can I engage in this way. We're piloting a lot of programs. One that has been particularly successful is in perinatal behavioral health, [targeting] anxiety, depression, and substance use during pregnancy, because we know those are tied to the highest causes of maternal mortality in our country. That tends to be a time when people are very engaged in their healthcare. We're trying a lot of programs, both for mothers and newborn babies, that look like a low-tech, text message-based monitoring programs.
If we're debating the right population for this, we need to ask ourselves if this is a population that we need to engage in a different way. They're not a great population for X, Y, or Z. Well, then maybe we need to do A, B, or C to better monitor and engage this population.
Sarah Pletcher: It’s trying to fit the program to the population that you're trying to reach, and then choosing the most minimalistic and successful tools to achieve the goals that you're aiming for. For sending a patient home with a kit, for example, you need the ‘just plug-it-in’ level of simplicity, whether that's a cell or a WiFi, or even just using their own device. And in terms of sensors, it can be as simple as a sticker that they wear home from the hospital or a whole suite or a toolkit when truly needed.
One thing that is underconsidered is it doesn't always have to be the patient managing these tools themselves in their home. It can also be leveraging a partnership. Are they getting visiting nursing? Is there a family member who can assist? For patients who may not have cell or WiFi connectivity, are there places that they can go, [such as a] church, grocery store, community or senior center, soup kitchen, that can be data hubs, that can be a partner if the patient's going there anyway? Can those be our distribution centers rather than always trying to make it work in the patient's home environment?
Selection and enrollment are critical, but if there's a population that we're struggling to reach, we've got to think outside the box to bring that program to them, even if it means redefining where that is.
Q: How do you develop support among your staff for these programs? What are their most common concerns about RPM, and how do you address them?
Kathryn King: When you start the conversation, wipe the slate clean. Why do we think we need to manage things in 15-minute increments every three months? Most providers are really on board [and] know what they would ask their patient every day. Where we run into some hiccups is in the algorithmic management of patients by a centralized team of nurses. We hear from providers who say, 'Well, I really manage my patients individually, and there are certain things that I need to consider on an individual basis for each one of my patients.'
We direct the conversation toward gold standard treatment guidelines, and we want to work with them to develop an algorithm that will help them adhere to the highest quality guidelines for the majority of the population that really fits into that algorithm. Once we have an algorithm that they feel comfortable with, we will use it to take care of a large percentage of the population in a way that they would want them taken care of. There will be some patients who do not fall into those guidelines, and it will be very clear through remote patient monitoring that those patients need to be escalated to the provider for individualized treatment that only they can provide.
Basically, you frame it as 'How about I take all of the patients that are really easy for you to manage and make sure the patients that you really need to see get to you.' Usually they say, 'Oh yeah, that does make sense. That would make my life easier.' Again, we're not taking patients away from their provider; we are helping to [identify] the patients that they have to spend a larger amount of time with.
Sarah Pletcher: We have a buy-in matrix for providers with three core pillars. They are time, money, and tech. It can't be a huge waste of the provider's time or an intrusion into their off-time. It can't cost the provider or have them lose out on reimbursement to participate. It doesn't have to be a huge windfall or save them loads of time, but can't be a big loser on either of those dimensions. In terms of the tech, it has to be basically decent. It doesn't need to be earth-shattering. It just needs to be reliable and do what it's meant to do with modest support.
If you get those things, then providers can be motivated for lots of different reasons- maybe to look after a chronic condition by value metrics, or because it's cool or because they get to be the first person in their practice to try something or to create convenience and peace of mind for their surgical patients. There are all sorts of ways you can amplify buy-in, but I haven't seen a program succeed if it doesn't have solid foundation in those first three pillars.
Carrie Stover: With providers, that has been a challenge. It reminds me of the early days of the EMR when people thought there was no way that we could ever come up with consistent order sets by disease process because every physician treated their patients differently and individually. We have spent a lot of time and energy undoing some of the organic growth of remote monitoring.
With RPM, historically there have been centralized monitoring nurses whose job was to take that alert and pass it on to the physician. We've spent some time thinking about the job of that remote monitoring nurse. Just as a patient in the hospital is evaluated by a nurse before anyone calls a physician, we do the same thing. And as we start to monitor higher acuity patients, we have a team of very highly skilled nurses who have lots of clinical experience. We've developed very clear assessment protocols and escalation paths.
We’re finding that 60% to 70% of the time, nurses can resolve that alert. The rest of the time they may be initiating a patient case and sending a note to the physician. Very rarely, about 1.5% of the time, they are actually escalating to a physician. And then that's resulting either in a medication change, a virtual visit, or perhaps a trip to the emergency room.
The message that we're creating for physicians to get buy-in is that we're not looking to inundate you with additional data points and information. We're trying to create a valuable set of information for you to better interact with and treat your patient population.
Independence Blue Cross is backing three programs developed in Penn Medicine's Center for Health Care Innovation with $200,000 grants aimed at helping the programs address gaps in care for underserved populations.
The Clinical Care Innovation Grants aim to help the three programs, which address barriers to healthcare access for underserved populations, scale up their services. Philadelphia-based Independence Blue Cross is among the nation's most forward-thinking health plans in identifying and supporting new technologies and strategies that target gaps in care.
The grants will support:
Healing at Home, a program led by Kirstin Leitner, MD, an assistant professor of Clinical Obstetrics and Gynecology; Lori Christ, MD, an assistant professor of Pediatrics; Laura Scalise, MSN, RN, a nurse manager; and Emily Seltzer, a senior innovation manager at the Center for Digital Health that uses an AI-guided chatbot to provide on-demand assistance and resources, including mental health services, to new mothers during the vulnerable "fourth trimester;"
The Pregnancy Early Access Center (PEACE), a program led by Courtney Schreiber, MD, professor of Obstetrics and Gynecology and chief of Family Planning, which provides resources for pregnant women, including and especially services both before and after birth for women who experience miscarriages; and
A program led by Jeanmarie Perrone, MD, a professor of Emergency Medicine and director of the Penn Medicine Center for Addiction Medicine and Policy, that improves access to buprenorphine and other substance abuse treatment services, including telehealth outreach and navigation services, for people of color.
“The funded projects this year also address areas in which some of our most vulnerable patients may see the greatest benefits,” Elissa Klinger, director of health equity for Penn Medicine’s Center for Digital Health, said in a press release. “For example, black women in Philadelphia experience higher rates of severe pregnancy related health problems, particularly in the postpartum period, so programs like Healing at Home can enhance critical postpartum support that may ultimately help drive down rates of maternal morbidity. PEACE provides urgent and timely pregnancy care while promoting health equity. And increasing access to buprenorphine and other substance use treatment services targets the burdens of substance use and overdose striking in communities of color in Philadelphia.”
"Independence Blue Cross looks for novel interventions with strong early evidence and high potential to improve value-based care, so winning three awards is meaningful validation of Penn innovation programs,” added Roy Rosin, chief innovation officer of the University of Pennsylvania Health System and interim executive director of the Center for Health Care Innovation. “Our teams have shown they can make a difference in areas of care and patient populations that could benefit most from change, and with Independence’s partnership, we can advance and scale this work.”
Three Penn Medicine programs were also chosen last year for grants from Independence Blue Cross. Each of those programs has either expanded to serve more patients or launched a new study.
A recent survey finds that health systems see patient self-scheduling tools as vital, but they aren't using them because clinicians aren't buying into the strategy.
The transition to consumer-centered healthcare can sometimes create conflicts between patients and their doctors, especially as patients seek more of a say in matters that doctors have traditionally—and stubbornly—managed. An ideal example is scheduling.
Patients want the ability to schedule their own appointments with doctors, and healthcare organizations recognize that this is a vital tool in fostering patient engagement and improving care management and adherence. But while a recent survey from the Center for Connected Medicine (CCM) finds that 88% of health systems see patient self-scheduling as their top target for investment, only about 3% currently have that capability, and few are actually acting on those plans.
That's because doctors don't want to give up control of their schedules.
"Many physicians believe that by allowing patients to self-schedule appointments they are giving up control of their own calendar," Joon S. Lee, MD, executive vice president of UPMC, which supports CCM, said in a press release accompanying the study. "Self-scheduling is a big part of improving patients' access to care. It is up to organizational leaders to work with physicians to find solutions that address their concerns while still meeting the demands and expectations of our patients."
According to the CCM report, 78% of the health systems surveyed do have some self-scheduling technology in place, but four out of five health systems are seeing less than 20% of their appointments booked through those tools. Not only are those patients not making use of the technology, but the health system isn't making them aware of that capability.
When asked for reasons for those delays, only 8% said patient adoption is an issue, while 22% cited physician buy-in, and another 16% cited staff concerns.
Lee, who's also president of UPMC Physician Services and vice dean for clinical affairs at the University of Pittsburgh School of Medicine, told HealthLeaders that it's up to healthcare leadership to change that dynamic by convincing physicians that patient self-scheduling is a good thing.
"We often think this is a technological problem, but it's not," he says. "It's a cultural problem and an organizational problem, and that needs to be changed. Organizations have to be committed to making this happen."
The Benefits of Patient Self-Scheduling Technology
Self-scheduling tools have the potential to improve not only the patient experience, but clinician workloads as well. While giving patients the ability to schedule appointments that fit into their lifestyles, the platform also makes sure the patient is seeing the appropriate care provider. This reduces no-shows and other delays, and ensures that the visit is valuable to both patient and care provider, thus enriching care management and offering a better chance of improving clinical outcomes.
Lee notes the technology makes the scheduling process much more efficient, reducing phone calls and cutting down on time spent by staff and clinicians fiddling around with schedules and calendars. It also ensures that clinicians are seeing the right patient, someone who needs to be seen by that particular care provider, rather than one who should have been seen by someone else or someone who could have been treated via telehealth or some other pathway.
"Patients want to be seen by the doctor who can help them the most," he says. "This should be a much better experience."
And it's what the consumer wants. Encouraged by the use of digital tools in everything from banking to travel to retail shopping, consumers want that ability in their healthcare experience as well, and they'll change providers if those desires aren't met. Add to that the influx of competition in the healthcare market from telehealth companies, retail giants like Amazon and Walmart, and nearby health systems who are adopting new technology, and the traditional hospital or health system has to embrace these new services or risk losing business.
"We do have to tell physicians to adapt or lose out," Lee says. "They have to realize that."
Lee says a health system should lay out the groundwork for adopting patient-self-scheduling by first targeting provider concerns. Management should sit down with clinicians and explain the benefits of the technology for both sides, tackling the worries that clinicians will be losing control of their schedules or workflows. As with most new technology, the platform is designed to assist healthcare providers in mapping out and improving their workflows, not replacing providers or staff or interfering with them.
Getting the Technology Right
Preparing for a patient self-scheduling platform also means understanding the technology, Lee says, and it's important that a health system research the various types of platforms available on the market and choose the best option. This isn't a one-size-fits-all technology, nor is it plug-and-play or something that just falls into place and works on the first try.
According to the CCM survey, roughly a quarter of those surveyed say they're still looking for the right platform, while 22% are working to standardize templates and schedules. Some 17% were focused on installing the technology and 14% were looking to expand the platform to outlying sites. Just 6% were focused on patient education and support.
Clinicians and other staff should be part of this process, Lee says, so they know what the technology can and can't do. In addition, leadership should design the platform "with a human touch," so that a patient can opt out and speak with a live person at any time, or switch from a virtual visit to the scheduled in-person visit if that's more comfortable for them.
Lee says the technology should be seen as another tool in the care provider's toolbox, much like the virtual visit. Many health systems set telehealth and digital health aside, separating those services from other healthcare services so that they're seen as add-ons or supplementary services rather than a part of the healthcare process. Instead, health systems should be integrating those services, making them a part of the process.
The healthcare industry "has always focused on care inside the hospital," Lee says. "But that is changing. Consumers want a connected healthcare experience." This means connecting with consumers at home and giving them a portal into the hospital that enables them to accomplish any tasks before they meet with a care provider.
Lee says UPMC has been actively integrating patient self-scheduling alongside other services, such as direct-to-consumer telehealth and remote patient monitoring. And they've been careful to include staff and clinicians in every step of the process. A health system, he says, shouldn't give its employees a new tool or platform and tell them to go try it out. They should include them in the planning and installation so that they already know all about it before anything goes live.
With patient self-scheduling, he says, "they have to learn to give up some control … but if you choose the right technology they will see why that has to happen."
The health system has added two new centers, covering musculoskeletal and bariatric health, to its program, giving business leaders a direct link to specialist services and allowing them to better manage employee healthcare costs.
The Cleveland Clinic has expanded its Center of Excellence program, which gives business leaders a direct link to specialty services for their employees.
“By choosing a center of excellence, employers can offer employees specialized healthcare from experienced Cleveland Clinic doctors, nurses, and technicians,” Robert Lorenz, MD, the Cleveland Clinic's executive medical director of market and network services, said in a press release. “The effects of healthcare access inequality are two-fold — it affects how patients are cared for when sick as well as their future health. Our centers of excellence make equitable healthcare not only possible but achievable. We know these types of healthcare solutions are not always available close to home, which is why we help employers find an option that fits their needs as well as the needs of their employees no matter where they are located.”
Businesses are choosing this model not only to reduce the complexity of health plans and cut administrative costs, but to better manage soaring employee healthcare costs and boost health and wellness through more focused, evidence-driven care programs, including preventive care.
"When working with employers we have experienced their need, and their constant work, to address inconsistent healthcare quality and rising costs," Wesley Wolfe, the Cleveland Clinic's executive director of market and network services, said in the press release. “These new innovative centers of excellence aim not only to improve access to care, but help employers add a benefits solution that assists in retaining employees. By offering programs like our centers of excellence, employers give employees access to higher-quality care at a lower cost."
Many of these programs, because they serve large businesses with multiple locations, include digital health and telehealth platforms and tools to improve access to care and help employees and providers with care management.
The study, involving 476 patients recruited through 18 health systems, was done on a completely virtual platform, with researchers communicating with and collecting data from patients through an mHealth app and online portal. It may serve as a model for future clinical studies.
Researchers at Henry Ford Health are celebrating the results of a multi-institutional heart failure study that was conducted entirely on a virtual care platform, saying it could be the model for future clinical studies.
Some 476 patients were enrolled in the study through 18 participating health systems between March 2020 and February 2021 – during the height of the pandemic, when every effort was being made to reduce in-person treatments. Researchers connected with study participants through an mHealth app and online portal, where they communicated with patients and collected data from surveys and Fitbit devices. Medications used in the study were mailed to the participant's home.
“What this study demonstrated is that you can execute a virtual clinical trial with greater efficiency than a traditional, in-person trial,” David Lanfear, MD, an advanced heart failure specialist at Henry Ford Health and one of eight authors of a report on the study recently published in Nature Medicine, said in a press release. “This could lead to more people getting involved in medical research because of the convenience of participating from home and the potential for lower costs and faster results.”
The study sought to test the value of a sodium-glucose co-transporter 2 inhibitor (SGLT2i), a newer class of drugs used in heart failure treatment and shown to improve clinical outcomes. It also looked at how these drugs could be applied to patients at home, how it might affect their quality of life, how patients could report their own data and observations through a connected health channel, and how patient-reported outcomes might affect treatment and results.
"The costs of conducting clinical trials have risen substantially over time, leading to calls for novel study designs to generate the evidence needed to guide care," Lanfear and his colleagues said in the report. "A large component (up to 50%) of these costs is the burden of data collection on sites, which have nearly quadrupled from 1990 to 2010. The ongoing Coronavirus Disease 2019 (COVID-19) global pandemic further highlighted the challenges of traditional study designs that depend on in-person visits and resource-intense data acquisition and verification. In response to the growing demands to make clinical trials more pragmatic, novel study designs have been implemented, from leveraging existing registries for data collection to the use of electronic health records to identify, enroll, randomize and follow-up eligible patients. Although the innovation of eliminating in-person clinical trial visits has been proposed, it has not, to our knowledge, been tested on a large scale."
Lanfear and his colleagues said the virtual study may have been "the first randomized drug study of its kind in cardiology." It could also set the bar for clinical studies by eliminating geographical barriers to patient recruitment, allowing healthcare organizations to find the right participants no matter where they live. And the platform allows researchers to better understand how patients are affected at home, and in their daily lives and routines, while gathering biometric and other data in real time.
“Improving symptom burden is one of our main goals for managing heart failure patients,” he said in the press release. “Clearly, what this study showed is that these agents have meaningful impact on patients within just weeks of starting treatment, which we were able to prove using a virtual research approach.”
The platform also reduces barriers to participation for patients. Lanfear noted enrollment for this study was roughly five times faster that in traditional in-person heart failure clinical trials.
The Illinois-based health system created the innovative program during the pandemic to identify patients infected with COVID-19 and steer them to the right resources. Now it's expanding the platform to help identify underserved populations and the resources they need to improve health and wellness.
OSF Healthcare is expanding an innovative data platform developed during the pandemic to help health clinics, primary care providers and others identify Medicaid members at risk of poor health outcomes and the resources they need to improve their health.
The Peoria, Illinois-based not-for-profit Catholic healthcare system is making OSF Community Connect available to a wider range of providers in an effort to tackle social determinants of health that affect residents in surrounding communities. The tool was developed by the OSF Innovation Data Science and Advanced Informatics Lab to "help the ministry prioritize care and resources for the most affected communities."
“The solution was born out of the pandemic as a way to support OSF community health workers (CHWs) who were digitally connecting with COVID-19 patients to assess their conditions, provide education and refer them to a provider when needed,” Roopa Foulger, OSF's director of the data lab and vice president of digital innovation development, said in a recent press release. “We discovered it could also be a way to reach out and maintain relationships with under-resourced communities.”
The program is representative of the efforts of healthcare organizations across the country to address barriers to healthcare access and outcomes, especially those with non-clinical origins. They include home and family life, job status, food resources, transportation and geography, cultural norms, even digital literacy, which can impact access to telehealth.
The platform not only combs data to identify patients facing these difficulties, but looks for resources that can help them, such as remote patient monitoring, screening programs, local food banks, credit and family counseling, transportation networks and community centers.
“We’ve essentially built an electronic community health record to integrate data from multiple places,” Foulger said in the press release. “With OSF Community Connect, it should be much easier for us as a healthcare system to identify people in most need of our help, monitor progress and intervene when necessary. We shouldn’t have anyone falling through the cracks because of their social or economic status.”
Supported by a state award, OSF OnCall Digital Health has adapted the program to look for more than just COIVID-19 patients and resources, thus making it sustainable beyond the pandemic. It will also be used to support federally qualified health centers (FQHCs), which will work with CHWs to reach out to underserved communities and populations who often don't seek the care they need or follow up after their primary care visit.
“The possibilities are endless,” Nick Heuermann, a strategic program manager with OSF Innovation, said in the press release. “Users can customize workflows in the platform to identify any patient group they want to focus on. From there, they can use the same tool to positively impact an entire population.”
Health system executives taking part in the recent HealthLeaders Healthcare Workforce of the Future event cite the challenges to staffing an IT department and the rewards in advancing new ideas.
Workforce shortages in healthcare aren't limited to the clinical ranks. Healthcare organizations are also seeing challenges in keeping their IT departments staffed.
Due in part to the pandemic, health systems are adopting (and adapting to) much more technology than they have in the past, from complex electronic health record and imaging platforms to digital health and telehealth tools. They're now facing much more competition than they've seen in the past, including stand-alone clinics, telehealth and virtual health vendors, retail giants like Amazon, Google, and Walmart, and other health systems looking to take their patients.
But executives taking part in the recent HealthLeaders HealthCare Workforce of the Future roundtable, noted there are advantages that make working in healthcare IT an attractive career.
"When we look at talent, we look for those who are wanting to have the culture that we offer, are wanting to work in person, or have a hybrid model because no matter what we offer," said William Manzie, administrative director of telehealth and telehealth strategy at the Memorial Healthcare System in Florida. "If a millennial or someone who just came out of college wants to work from home and make over $200,000 a year, then we're just not the organization for you. We're doing everything right in terms of promoting our culture, promoting growth, promoting opportunities to potential applicants, and that has allowed us to bring in additional talent, but also use our existing talent and grow them for the positions that we're hiring for."
Richert pointed out that as the healthcare industry evolves, IT departments have evolved as well, from helping staff with simple installations and downloads to maintaining an integrated technical platform capable of scaling up and out as needed.
"We're … shifting that mindset from order-taker into a solution partner, and really guiding the organization through a digital roadmap that would help them understand how we're going to scale differently and how we're going to be able to provide care without so much labor in the past," he said. "I think we're now setting a vision for what's possible with digital and partnering more with the organization. That's brought different types of people and skill sets into my organization."
Richardville said the pandemic has highlighted the value of being able to work remotely, even from home. This means he can look a lot farther out for IT talent.
"I think it's here to stay," he said of the hybrid work environment. "And I think that provides a great opportunity … because we could even recruit from around the country, and in some cases around the globe, for talent."
But that can work both ways.
"We have to watch it," Richert said. "With all of our Epic expertise, there's a hospital in New York City that found four of my good Epic people and said, 'We'll pay New York City wages and [you can] just sit in your Missouri home and you'll be fine. So that dimension is there, [and] we have to be aware of it, but we also have to make sure that we take advantage of it ourselves."
Richert pointed out that working in healthcare is different than working in retail, and that culture may help in securing IT talent.
"We're a faith-based organization, and I know the impact of walking amongst the caregivers and being in the hospital lobby and seeing neighbors come through," he said. "It really bonds me to the mission of the organization and the fact that a lot of … our IT coworkers came through the healthcare career path. And so, their identity is with the Mercy organization, [even if] there are other places to make more money than in our organization. We've always had a real strong culture."
"For me, it's probably more about being a professional parent and telling people I'm here to grow and develop you," Richardville said. "[I'm going] to give you challenges and if you're with me for a year, two years, three years, I'm here to grow your résumé, to make you more valuable, hopefully to me, but if not to me, to somebody else."
"I've got 12 CIOs or CDOs in the industry that used to work for me, and I'm just privileged that those people have grown," he added. "It's really [about saying] 'I'll give you the challenge, I'll grow your résumé, I'll make you more valuable to the market, and if I'm able to keep you I'll just continue that. But if there are other opportunities somewhere else, I'm here to help you capture those as well so you can fulfill your life goals.'"
Manzie, like the others, also pointed out that the IT department is changing as the healthcare industry moves from testing and adoption of new technology to scaling and sustaining the best platforms and services. And part of the process is in helping clinical staff understand and embrace these new tools.
"We don't just jump right into a new technology or jump right into the next shiny thing that comes out on the market," he said. "Actually, sadly, it takes us a long time to make a change and be innovative. [Adopting] new telehealth and virtual technologies happens at a slower pace, which allows the existing staff to learn that new skill set, drive some of that change, and manage some of the tasks or the people involved with that change."
"To me that feels like a whole different partnership [and] engagement model with the organization," Richert added. "We're finding key challenges and key areas within the healthcare operations that are embracing that, saying 'this is great, let's do more.' I'm excited over the next few years that we're going to be able to bring those kinds of skills."
"I think it continues to mature and evolve," Richardville said. "We are here to serve and those that we serve are those on the business side and the clinical side. From that standpoint, we've got to make sure that we understand that we aren't doing technology because it's cool, and it's fancy, and it's kind of neat, but we actually have measurable outcomes that are happening at the end and we're helping our caregivers provide a higher quality product, a better patient experience, at maybe a more efficient, effective way."
"And that's what we're here to do," he concluded. "I think that part of our job is to continue to educate so that people know that those things are out there and aren't threatened. We need to engage, make that part of us, with more ideas and thought leadership. It can't just come out of technology; it's got to come out of the people that are actually doing the work."
The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Please join the community on LinkedIn. To inquire about attending a HealthLeaders Exchange, email us at exchange@healthleadersmedia.com.
The Association for Community Affiliated Plans, which represents 74 not-for-profit Safety Net Health Plans serving 22 million people across the country, is highlighting innovative research and programs aimed at addressing the non-clinical barriers to healthcare access and outcomes.
The Association for Community Affiliated Plans (ACAP) has launched a new resource aimed at helping not-for-profit Safety Net Health Plans understand and take on non-clinical challenges and barriers to healthcare access and outcomes.
The ACAP Center for Social Determinants of Health Innovation offers resources, including policy reports, research and educational events, to help the nation's 74 health plans, who serve more than 22 million low-income people with complex healthcare needs through Medicare, Medicaid, marketplaces and other health coverage programs.
“Longstanding racial inequities cannot improve without meaningfully addressing the social factors underlying them,” Margaret A. Murray, ACAP's chief executive officer, said in a press release. “Safety Net Health Plans have worked in communities across the United States to address factors that shape their members’ health for decades."
Studies have shown that roughly 60% of health outcomes are caused by non-clinical factors, including physical and social environment, cultural concerns, economic and family issues and access to housing and health food.
"This new center creates unique opportunities to showcase what works, share that knowledge with others, and support a healthier future for people with low incomes, whose wellbeing has too often been held back by their environment,” Murray said.
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