Medical Monitoring Goes Mobile

Healthcare providers are seeing great potential in portable and miniature devices that enable the measurement of vital health data in acute and non-acute environments.

This article appears in the July/August issue of HealthLeaders magazine.

Thanks to mobile technology, the line between acute and nonacute care is blurring, reaping benefits for providers and patients.

Using technology ranging from newly miniaturized vital signs monitors to FDA-approved portable devices for measuring asthma symptoms, providers are seeing improved outcomes today—and great potential as the mobile monitoring trend just starts up its adoption curve.

Away from the ICUs, on the regular nursing floors, patients in postacute care can benefit from portable monitors such as Sotera Wireless' ViSi Mobile, according to Lisa Graydon, chief nursing officer of five Salt Lake City–area hospitals of Intermountain Healthcare: Intermountain Medical Center, LDS Hospital, the Orthopedic Specialty Hospital, Riverton Hospital, and Alta View Hospital.

ViSi Mobile, which straps to a patient's wrist, monitors and displays ECG, heart-pulse rate, respiratory rate, blood pressure, blood oxygenation level, and skin temperature. "Those patients are much more mobile," Graydon says. "We expect them walking in the halls. If we can monitor them, their vital signs, more closely, wirelessly, or in some way not invasive to them, then we could probably provide a safer environment, and we're all about patient safety at Intermountain."

To evaluate ViSi Mobile, Graydon and nurse administrators from two of the five hospitals—the 460-bed Intermountain Medical Center and the 200-bed LDS Hospital—selected a floor in each facility with patients recovering from orthopedic surgery. To formalize its study of the device, Intermountain went through its institutional review board, Graydon says.

Out of that came a three-phase trial approach. In phase one, Intermountain nurses and patients simply wore the ViSi Mobile device during rounds. "The patients got to wear it just for a little while to see how comfortable this is," Graydon says. "We didn't monitor anything. We didn't use the data. We just wanted to see if it was comfortable, and then we took a survey to see how people felt about it."

Then, in April 2013, Intermountain began getting patients' consent to begin having them wear the devices. About 20 patients in each facility agreed to be monitored, Graydon says. At first, the number of alarms being generated by the ViSi Mobile devices due to sensitivity to vital sign changes was a nuisance. Sotera Wireless took the initial data collected, deidentified it, and ran it through a software simulator to troubleshoot the device's software to reduce the number of nuisance alarms.

Monitors in ICUs are troubling to patients, as well, so it's critical that false alarms be minimized so as not to disturb patients trying to relax or sleep. As the testing progresses, nursing staff are becoming more confident that the device is issuing alarms only when patents really need attention, Graydon says. "It's a great technology that we're just learning about," she says.

"The nursing staff is excited about this new technology that gives them more information about their patient without requiring them to do more work, or adding some sort of data collection along with it," Graydon says. "Nurses are here to take care of people, not to take care of equipment. It's a great way to keep your patients safe and know what's going on at a distance, if you will."

A benefit of using ViSi Mobile in a postorthopedic surgical setting is to monitor patients' oxygen saturation while they are being administered opioid medications for pain, because such medicine suppresses the respiratory system. Continuous mobile monitoring can spot trends in respiration or blood pressure over a 24- to 48-hour period that intermittent vital sign collection can miss, Graydon says.

In phase 3 of the trial, now in the planning stages, data from ViSi Mobile devices will flow directly into Intermountain's electronic medical records, Graydon says. "I think this type of monitoring could become a standard of care," she says.

Three categories of mobile monitoring are emerging in healthcare and wellness, according to John Mattison, MD, CMIO of Kaiser Permanente, which serves more than 9 million members and employs more than 16,000 physicians.

Mattison says the first category encompasses super-athletes and warriors. Special military forces are intensively tracking their personnel's vital signs with mobile technology in cases where the health of the soldier is vital to completing the mission. Athletes are trying to squeeze "every last erg of energy" out for highly competitive events. "In five years, it will be standard practice for even high school athletes to be wearing this stuff periodically to ensure they don't have any risk indicators for sudden death or adverse consequences," Mattison says.

Category 2 is patients recovering from a hospital discharge or serious illness, Mattison says. Category 3 is "the rest of us," where mobile devices can play a "powerful role" in the initiation and reinforcement of healthy behaviors, he says.

"As the price comes down and the data science grows, it's going to become more and more routine," Mattison says. "The problem is, we don't have a lot of data to know where the thresholds are.

"Until we calibrate all of these devices and all those streaming data for different contexts, we're going to have a lot of false alarms."

There was even a Mayo Clinic study a few years ago that found that monitored patients had higher mortality than unmonitored patients, Mattison says. "What happens when you put a monitoring device on someone who's ill and you don't give them any encouragement that this is going to help them?" asks Mattison. "They are constantly aware that they're sick. What it does is it raises anxiety levels and fear, and fear raises your cortisone or it raises your adrenaline, and both of those are known to be acute phase stress reactants. That increases your mortality. That's been known for 50 years."

The solution, Mattison says, is to convert mobile monitors from "worry devices" to "reassuring and supportive and healthy devices for that category of people."

Kaiser is about to begin testing the AliveCor, an FDA-approved case for the iPhone that lets the phone collect ECG data by resting the case's electronics on the fingers of each hand. "There's a very high percentage of people with atrial fibrillation who go for quite a period of time before it's diagnosed simply because if it's intermittent, it might not be detected at those rare moments when they're actually in a clinician's office," Mattison says. "[If] we can detect atrial fibrillation earlier, we can prevent a significant number of catastrophic events by diagnosing and anticoagulating those folks as appropriate."

The clinical need exists and efforts to develop and deliver the technology continue.

"Real-time data delivered to patients and physicians is going to be an essential component to providing 21st century care and achieving the goals of the triple aim," says Rich Roth, vice president of strategic innovation at Dignity Health, one of the nation's five largest health systems, an 18-state network of nearly 10,000 physicians and 56,000 employees with more than 300 care centers. "While it may take a few routes, and we need to make sure to address the digital divide effectively, it's hard to imagine it not being a standard of care in the next three to five years."

According to Roth, accelerating that progress will be a $1 billion Center for Medicare & Medicaid Innovation initiative announced in May 2013. CMS is seeking proposals for models that are designed to rapidly reduce Medicare, Medicaid, or Children's Health Insurance Program costs in outpatient or postacute settings.

"It's a great opportunity to improve quality and ensure that patient preference and patient choice in the postacute care realm is preserved, but that you can add in these efficiencies that allow for better care coordination," Roth says.

Dignity Health "has a very purposeful strategy" for mobility technology, working with three to five companies at any given time, Roth says. One example is AirStrip OB, which offers an app that runs on iPads and enables nurses to share heart rhythm waveforms collected by traditional ICU monitoring equipment with obstetricians who call up those waveforms in the AirStrip OB app running remotely on their iPads.

This takes the place of trying to describe the waveform over a phone call, which, Roth says, is "like describing a sunset to somebody." The AirStrip OB app instead ensures that "caregivers can make appropriate and right decisions at a very critical moment with all the information that they need to ensure the health and safety of the mother and the child," Roth says.

So far, Dignity Health has monitored 15,000 babies with the AirStrip OB app. As part of the Hospital Engagement Network, a joint effort with the Centers for Medicare & Medicaid Services and CMMI, Dignity Health has put in significant processes incorporating AirStrip OB to lower costs and save lives.

"The country has got to make these great improvements in quality and safety," Roth says. "We've got to figure out ways to take advantage of technology as a healthcare system to improve our own operations, become more efficient, and ultimately achieve the clinical goals and the cost-reduction goals that the system needs to achieve."

Mobile monitoring of asthma symptoms is another technology being tested now at Dignity Health. Patients use an inhaler paired with the Asthmapolis sensor device, which records the type and amount of medication dispensed, as well as date, time, and GPS-enabled location of the self-treatment. "If patients are using their inhaler too often, or not using it, we can ping them and get them into the clinic and adjust their medication or help with patient education so they can better self-manage," Roth says.

The cost of controlled asthma conditions versus uncontrolled asthma is a difference of $3,000 per Dignity Health member per year, and early stage data of the trial has been significant enough to prompt Dignity Health to expand the technology's use in the greater Sacramento, Calif. area, Roth says.

"If you can interject something with mobility that allows for simplicity, and really just does the work to support the patient, rather than making the patient do 10,000 other things that are just not intuitive to them, I think there's a real win there that really gets at the promise of what mobility will offer," Roth says.

One last example of mobile health saving lives is at Health Quest, an alliance of three hospitals in the Hudson Valley region of New York. In the past year, Health Quest has seen a steady decline of 20% to 30% in the time required to open arteries for emergency patients, says Daniel O'Dea, MD, Health Quest director of cardiovascular services.

In part, Health Quest achieved this by deploying the AirStrip system to ambulances within its service area, O'Dea says. EKGs, taken by paramedics and transmitted to the AirStrip app, "can be looked at by the emergency room doctors even before the patient arrives at the hospital," O'Dea says. "This allows us then to activate the team before the patient arrives at the hospital. So while the patient is coming to the hospital, the team is also coming to the hospital, so those two things occur in parallel rather than in series."

As for postacute and home monitoring, O'Dea says the technology has a role to play, even if the monitoring itself has the potential downside of unnerving patients, as Mattison described.

"If you have a reminder that you do have a chronic disease that needs to be managed on an ongoing basis, such as heart failure, where there are specific things that you need to do to take care of yourself—you need to weigh yourself, you need to watch your fluid intake, you need to watch your salt intake—it's easy for patients, once they leave the acute care center and go into the home setting, to forget and to revert to their old ways and go back to eating the same things that they always ate and doing the same things they always did," O'Dea says.

"If there's something around us reminding you that you do have a chronic illness, that may actually increase adherence to medications, diet. Things like that that are going to have a positive effect, so you have to weigh the two of them, and you have to know your patient, really, to understand that."

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This article appears in the July/August issue of HealthLeaders magazine.