mHealth Tackles Readmissions

Healthcare leaders are finding that consumer-ready technologies can help patients right where they are.

This article first appeared in the July/August 2014 issue of HealthLeaders magazine.

Health technology advances are beginning to reduce hospital readmissions. The smartphone itself is becoming a way of keeping tabs on recently discharged patients. Smartphone apps are engaging patients. Sensors are providing the kind of mobile monitoring that only recently graduated from the ICU to the general hospital bed, and now is able to be used wherever patients resume their normal lives.

Other mobile technology helps patients arrange for rides or reminds them to take their medications, weigh themselves, or perform other necessary daily activities to stay out of the hospital.

"We have one practice that we follow closely" that is applying consumer-ready technologies, such as cell phones, the Internet, and digital cameras, to enhance the patient-physician relationship, says Joseph Kvedar, MD, founder and director of the Center for Connected Health, a division of Partners HealthCare, a Boston-based integrated healthcare system with nearly 60,000 employees and a research budget of $1.4 billion. He is also an associate professor at Harvard Medical School.

"I call this practice our canary in a coal mine practice, because [the patients] are in a relatively poor town adjacent to Boston, and many of them speak English as a second language, and we survey them for a number of things routinely," he says. "A couple of months ago, we found that 65% of them were carrying smartphones."

Within a year, Partners expects to be routinely asking any patient entering a chronic illness management program if they own a smartphone, know how to download an app, and are able to work with those apps, Kvedar says.

If patients can use their own devices to run these apps or mobile health sensors marketed to consumers, costs could be split between consumers and healthcare systems, and consumers would be partly responsible for the device maintenance, Kvedar says.

"We're looking forward to the time when we can do it that way. This will allow us to spread our resources among many more patients who are in need of this service if the patient can own not just the hub, which is the phone, but the data charges and all of the technology costs that we now pay," he says.

Mobile device management, however, is one challenge. Working with an mHealth startup, the Center for Connected Health gave discharged patients a Withings scale, a blood pressure cuff, and a tablet. The startup's idea was to avoid the potential hassle of a patient having to connect the tablet to a home WiFi network, but instead provide 3G networking in the tablet and a data plan.

"The cheapest data plan is 50 megabytes," Kvedar says. "We convinced them that that was too little, so they went to the 2 gigabytes, and most of these patients ate up the 2 gigabytes watching YouTube videos, and then in the middle of the month they couldn't transmit their data anymore. So little details like that haven't been worked out yet, and it's still viewed as cutting-edge to use consumer mobile devices in the space of managing chronically ill patients."

At Mercy, a St. Louis-based system with 2013 operating revenue of $4.48 billion, smartphones are being paired with special sensor hardware to collect and transmit a variety of vital signs to hospitals.

"It's a medical class 2 device, so I can put it in the chart," says Wendy Deibert, RN, BSN, vice president of telehealth services at the 34-hospital system, which includes 300 outpatient facilities. "It gets heart rate, temperature, respiratory rate, single-line ECG, and then it also shows mobility and motion. If I'm turned right, left, back; if I'm sitting up in a chair; if I'm down on the floor; or if I go from here to here," and it will alert the provider if the patient takes a dramatic change in position—for example, a fall.

"That's real data that I can trust. It can be used as an app on a phone. It's not consumer-grade, but it could be used that way."

Mercy is piloting the reusable BioModule device, made by Zephyr Technology Corp., a division of Covidien. Nicknamed the puck, the device weighs 1-1/8 ounces and mounts on a one-use patch worn on the patient's chest. The device also integrates standard EKG patches already in widespread use in hospitals.

"You come into the ED," Deibert says. "You're fairly healthy. You've got an infection. It might be infection enough that you need antibiotics. Well, let's put you on a puck. Let's send you home and have a nurse monitor you at home where you're comfortable. You never get to the hospital. And now it's a much better outcome. And if you start to get in trouble, we're seeing the data in real time and will act on the early warning signs."

Battery life of the device is 24–36 hours, depending on the number of alerts it sends via Bluetooth or ZigBee to a paired Samsung Galaxy device, which relays data to the hospital, along with data from other paired devices such as weight scales. Each patient gets two of the puck devices, one to wear and one to keep charging.

Part of the process of evaluating the puck involved bringing it into a Mercy ICU during a three-week trial that helped the manufacturer gather data for its FDA approval for the temperature side and confirmed the accuracy of the puck's various measurements, Deibert says.

Also important to Deibert, the puck is completely sealed and easy to clean. "We have found a tool for which nobody has to go around and manually collect vital sign data," Deibert says, noting that the patient simply needs to replace it once a day with the fully charged unit.

While Deibert expects to see substantial corroborating data about the mobile device's efficacy at reducing readmissions, not yet having that data is not stopping Mercy from deploying the puck in more scenarios, such as reducing sepsis.

A big challenge for providers is going to be how to prepare their clinicians for even more information about how patients are doing outside of the clinic, says Linda Reed, RN, MBA, vice president and CIO of Atlantic Health, a Morristown, New Jersey–based system with multiple hospitals and more than 1,300 licensed beds.

"Are you going to leave it as raw transactions?" Reed says. "Are you going to need to feed it into some kind of an analytics engine, and then how do you use it? Do you use it for alerts and reminders? I'm not sure."

With the right permissions, other family caregivers could also be more active participants, Reed says. "Your mom might be in California," she says. "You could be in a different state. If your mom gives you permission, you can have that stuff at your fingertips. How do we keep tabs on our aging parents? You don't want to be on the phone. A mobile app is probably a great way to do that."

Providers still primarily running fee-for-service businesses could trail in their adoption of mHealth for preventing readmissions, but Reed believes that the penalties now being levied by the Centers for Medicare & Medicaid Services "will add up quickly."

Atlantic Health is involved in two CMS Medicare Shared Savings Program accountable care organizations at risk for 75,000 Medicare lives.

mHealth can move providers beyond earlier practices such as interactive voice response calls, Reed says. "What happens if you're not home? You're still playing telephone tag, whereas if you've got this mobile app, you're always connected," she says.

Mobile apps are becoming a remote control for a variety of other applications ranging from automated pillboxes to video communications with providers, Reed says.

Another way mHealth applications can help patients is in preparation prior to surgery, says Bradley P. Graw, MD, an orthopedic surgeon at Sports, Orthopedic and Rehabilitation Medicine Associates in Redwood City, California. For the past two years, Graw has been a beta tester for HealthLoop, a mobile application to prepare patients for joint replacements and follow-up after procedures. Graw has tested the app with more than 100 patients during that time.

"In joint replacements in particular, the name of the game is prevention and planning in terms of decreasing the risk of complications and readmissions," Graw says. "The major complications are infections, lower-extremity blood clots, stiffness, and other medical complications such as cardiac events, so the way I used HealthLoop was with existing protocols that I had been using."

Graw entered the critical portions of those protocols into HealthLoop, so if patients are getting ready for surgery, they go through a checklist of reminders to make sure that they're getting all the appropriate work done, he says.

Postsurgery, the HealthLoop app reminds patients to take medications, get needed physical therapy, and stay in touch if they have any questions, Graw says. The app can catch patients who may be failing to thrive due to uncontrolled pain or inability to move.

"Patients do like the HealthLoop interface so that they can communicate their concerns and get them answered relatively quickly, especially nonurgent ones, because it's when questions start to pile up and people's anxiety level rises that they tend to go to the emergency room as a last resort," Graw says.

Perhaps because Graw practices in Silicon Valley, less than 5% of the patients he sees are uncomfortable using a mobile app. Graw says it is important to remind patients that the mobile app is not a substitute for live patient visits or conversation when needed. "It's an adjunct to these tools to help with patient communication in a world where patients and doctors are busy alike," he says.

Also important is that the entire care team, including medical assistants and nurse practitioners, is comfortable with and actively using the app, Graw says.

In Graw's case, the patients' primary care physicians are not yet part of the care team that uses HealthLoop. "That is certainly a possibility of the interface," he says.

The national rate for joint replacement readmissions is about 5%, but at Redwood City–based Sequoia Hospital, the Dignity Health hospital where Graw practices, that number is already less than 1%, he says.

In 2012, Beth Israel Deaconess Medical Center, a 649-licensed-bed facility in Boston, received $4.9 million from the Centers for Medicare & Medicaid Services to improve patient outcomes within a 30-day discharge window. One component of that program uses iPads, says John Halamka, MD, the CIO.

The program, administered by Julius Yang, MD, medical director of inpatient quality at BIDMC, "has been quite effective identifying patients who are at risk for readmission. These various interventions, especially on patients with congestive heart failure using mobile devices, help to reduce readmissions to the hospital,"
Halamka says.

BIDMC's program, known as PACT, which stands for Post-Acute Care Transitions, deploys nurse care transition specialist care coordinators and dedicated clinical pharmacists dually-sited between the hospital and primary care practice to reliably deliver a "bundle" of postacute care interventions designed to address observed readmission risk.

Halamka says improvements in mobile health will continue to enhance the delivery of care.

"I absolutely believe that in the next two years, as hospitals are paid differently, we will, instead of just providing more care, provide right care, especially gathering data from telemetry and patient homes as part of keeping people continuously well, instead of treating them while they're episodically sick," says Halamka.

Reprint HLR0814-7