Re­mote Con­trol

IoT de­vices of­fer rad­i­cal new ways to mon­i­tor con­di­tions.

Health Data Management - - INSIDE - By Linda Wil­son

The IoT brings new ways to mon­i­tor and man­age pa­tient con­di­tions.

To im­prove the health of pa­tients with chronic med­i­cal con­di­tions, Och­sner Health Sys­tem tapped into the In­ter­net of Things. The health sys­tem, based in Jef­fer­son, La., has used IoT, specif­i­cally re­mote mon­i­tor­ing, to help pa­tients with un­con­trolled hy­per­ten­sion lower their blood pres­sure to healthy lev­els. Its Hy­per­ten­sion Dig­i­tal Medicine Pro­gram of­fers par­tic­i­pants a com­bi­na­tion of ed­u­ca­tion on the dis­ease and life­style changes, as well as dig­i­tal de­vices to reg­u­larly mon­i­tor blood pres­sure and fine-tune med­i­ca­tion to op­ti­mize dis­ease man­age­ment.

To en­roll in the hy­per­ten­sion pro­gram, which be­gan in 2015, pa­tients need an order from their physi­cian and a smart­phone. They then visit one of four O Bars, which are the health sys­tem’s stores that sell and pro­vide sup­port for a va­ri­ety of health-re­lated apps, wear­ables and de­vices. Pa­tients buy a wire­less blood pres­sure cuff that is de­signed to work with their smart­phone, which can be ei­ther an An­droid or iOS de­vice. Once at home, they log in to the pa­tient por­tal, MyChart from Epic, to fill out a ques­tion­naire about their other chronic con­di­tions, so­cial cir­cum­stances, med­i­ca­tions and life­style habits.

Pa­tients work with a health coach and phar­ma­cist to de­velop care reg­i­mens that

in­clude both med­i­ca­tion and life­style goals. Pa­tients mea­sure their blood pres­sure be­tween one and five times per week, and the re­sults are trans­mit­ted au­to­mat­i­cally from the cuff to the EHR via the smart­phone. That in­for­ma­tion is pre­sented in dash­boards for health coaches and phar­ma­cists, en­abling bet­ter track­ing of pa­tient con­di­tions.

The pro­gram works: More than 70 per­cent of the pa­tients en­rolled in it get their blood pres­sure un­der con­trol within 90 days.

Och­sner is one of nu­mer­ous providers cur­rently us­ing apps and con­nected de­vices. A 2016 sur­vey by IDC of 101 providers and 100 pay­ers ex­em­pli­fies the on­go­ing shift. Some 39 per­cent of providers and 52 per­cent of pay­ers said they are pi­lot­ing or us­ing IoT—the most com­mon uses were for se­cu­rity sys­tems and re­mote health mon­i­tor­ing.

As health sys­tems and in­te­grated de­liv­ery net­works as­sume fi­nan­cial risk for their pa­tients’ health out­comes, they’ve be­gun de­vel­op­ing in­ter­ac­tive pro­grams that in­clude re­mote pa­tient mon­i­tor­ing to man­age pa­tients’ chronic med­i­cal con­di­tions or tran­si­tions from a hos­pi­tal to home.

That cer­tainly has been a driver at Och­sner, which par­tic­i­pates in a va­ri­ety of re­im­burse­ment con­tracts based, at least in part, on per­for­mance, in­clud­ing met­rics for the con­trol of blood pres­sure and blood glu­cose lev­els.

“We have to think about new models of care de­liv­ery if we are go­ing to have both an in­ter­me­di­ate- and long-term im­pact on pa­tients with chronic dis­ease,” says Richard Mi­lani, MD, chief clin­i­cal trans­for­ma­tion of­fi­cer at Och­sner Health Sys­tem.

Ac­cord­ing to an on­line sur­vey con­ducted in 2016 by Ac­cen­ture, 76 per­cent of providers and 77 per­cent of pay­ers used re­mote pa­tient mon­i­tor­ing for heart con­di­tions, in­clud­ing con­ges­tive heart fail­ure. Res­pi­ra­tory con­di­tions, in­clud­ing chronic ob­struc­tive pul­monary dis­ease (COPD) and asthma, scored high, too, as 61 per­cent of providers and 49 per­cent of pay­ers said they de­vel­oped re­mote pa­tient mon­i­tor­ing projects for those dis­eases. Other chronic con­di­tions in which sur­vey par­tic­i­pants use re­mote pa­tient mon­i­tor­ing in­clude can­cer, men­tal health, di­a­betes, obe­sity and ortho­pe­dic care.

Re­mote mon­i­tor­ing works bet­ter than of­fice vis­its alone in con­trol­ling chronic dis­eases be­cause of the in­creased fre­quency with which providers re­ceive—and can re­act to—bi­o­logic data from pa­tients, Mi­lani be­lieves. “How can we pos­si­bly catch things be­fore they get out of hand if we are see­ing you two or three times a year?” he says.

John Cas­sar, CEO of Su­perCare Health, a Downey, Calif.-based provider of home care for pa­tients with res­pi­ra­tory dis­eases, agrees with Mi­lani’s assess­ment of the need for new de­liv­ery models to en­gage pa­tients in manag­ing their health.

For ex­am­ple, Su­perCare de­signed a “high-tech, high-touch” home-care ser­vice for high-risk COPD pa­tients re­turn­ing home af­ter a hos­pi­tal stay. That 30-day pro­gram in­cludes an ini­tial visit by a res­pi­ra­tory ther­a­pist, who per­forms a clin­i­cal assess­ment and teaches pa­tients how to take med­i­ca­tions, such as short- and long-act­ing in­halers, and use di­ag­nos­tic tools, such as peak flow me­ters and pulse oxime­ters.

The ther­a­pists also give pa­tients an iPad and show them how to use an iBreathe app, which con­nects pa­tients to an elec­tronic por­tal on Su­perCare Health’s home­grown care man­age­ment sys­tem. Us­ing the app, pa­tients also en­ter data about med­i­ca­tions and read­ings from peak flow me­ters, watch ed­u­ca­tional videos, com­plete cus­tom sur­veys and par­tic­i­pate in tele­health vis­its with Su­perCare Health’s providers. The app, which also is in­te­grated with Blue­tooth-en­abled pulse oxime­ters, trans­mits in­for­ma­tion about blood oxy­gen lev­els di­rectly into Su­perCare Health’s care man­age­ment soft­ware.

The iBreathe app is a cus­tom­ized ver­sion of COPD Nav­i­ga­tor, an Ap­ple HealthKit-com­pli­ant app de­vel­oped by LifeMap So­lu­tions, San Jose, Calif.

Su­perCare Health con­ducted an 18-month trial of the 30-day COPD pro­gram, be­gin­ning in late 2015. A to­tal of 100 pa­tients were en­rolled in the new in­ter­ven­tion, and 100 were as­signed to a con­trol group.

Su­perCare es­ti­mates that it saved $1.6 mil­lion on avoided hos­pi­tal read­mis­sion costs for pa­tients in the 30-day pro­gram. Those pa­tients also logged a COPD read­mis­sion rate of 2.94 per­cent, com­pared with a na­tional av­er­age of 17.1, while their all-cause read­mis­sion rate was 7.35 per­cent, com­pared with a na­tional av­er­age of 21.2 per­cent.

Other ap­proaches

Sharp Rees-Stealy Med­i­cal Group, San Diego, uses a va­ri­ety of de­vices to mon­i­tor and ed­u­cate pa­tients with chronic con­di­tions.

Of the 240,000 pa­tients at Sharp’s 22 out­pa­tient lo­ca­tions, about 6,000 are as­signed to case man­agers, and 1,000 of those use IoT de­vices and apps. “We try to use tech­nol­ogy in many dif­fer­ent forms to meet the needs of our pa­tients and our pro­grams,” says Janet Ap­pel, direc­tor of in­for­mat­ics and pop­u­la­tion health at Sharp Rees-Stealy.

For ex­am­ple, Sharp uses Medtronic’s wire­less blood pres­sure cuffs to keep tabs on pa­tients with hy­per­ten­sion, and the ven­dor’s wire­less scales for pa­tients with

“We have to think about new models of care de­liv­ery.”

—Richard Mi­lani

con­ges­tive heart fail­ure (CHF) and chronic kid­ney dis­ease. Nurses mon­i­tor data and re­ceive au­to­mated alerts, con­tact­ing physi­cians when nec­es­sary for changes in med­i­ca­tions.

Sharp’s pa­tients with CHF who are en­rolled in the pro­gram have 50 per­cent fewer hos­pi­tal ad­mis­sions than CHF pa­tients not in the pro­gram, ac­cord­ing to Ap­pel. Sim­i­larly, pa­tients with hy­per­ten­sion typ­i­cally get their blood pres­sure un­der con­trol within 30 days of en­rolling in the re­mote mon­i­tor­ing pro­gram, she adds.

Sharp also has logged pos­i­tive re­sults from text mes­sag­ing pro­grams that it pur­chased from Agile Health, Nashville. For ex­am­ple, pa­tients dis­charged from the hos­pi­tal who opt to par­tic­i­pate in a 90day coach­ing pro­gram, called Wel­come Home, are less likely to be read­mit­ted than those who don’t sign up for it, Ap­pel says.

Sharp de­ploys other IoT de­vices to help pa­tients learn about their dis­ease and how to man­age it. The med­i­cal group uses a pro­gram from Pro­peller Health, based in Madi­son, Wis., to teach pa­tients about asthma.

Af­ter pa­tients down­load the Pro­peller Health app, they re­ceive a Blue­tooth-en­abled sen­sor in the mail, which they at­tach to their res­cue in­haler. In­for­ma­tion about the time and place they use their in­haler is trans­mit­ted to the user’s smart­phone app. Pa­tients can then tap into their us­age in­for­ma­tion to gain in­sights about when and where they use their in­haler, which helps them learn about what trig­gers their asthma at­tacks and, thus, how to pre­vent them.

“It’s kind of a wake-up call for the pa­tients be­cause they may not think they are us­ing their in­haler that much,” Ap­pel says of the ap­prox­i­mately 50 pa­tients who are en­rolled in the pro­gram at any given time.

While pa­tients learn more about their dis­ease by par­tic­i­pat­ing in the asthma pro­gram, Ap­pel says Sharp has not no­ticed a sig­nif­i­cant in­crease in pa­tients’ ad­her­ence to med­i­ca­tion reg­i­mens re­quir­ing daily use of con­trollers, which dis­pense long-act­ing med­i­ca­tion to help pre­vent asthma at­tacks.

Pa­tient en­gage­ment and ed­u­ca­tion also are goals for Su­perCare Health. That’s why it uses gam­i­fi­ca­tion tech­niques in its iBreathe app. Pa­tients earn points for ac­tiv­i­ties such as watch­ing treat­ment-re­lated videos and tak­ing their med­i­ca­tions.

Pa­tients cur­rently earn a happy or sad emoji based on the num­ber of points they score, but Su­perCare is de­vel­op­ing a pro­gram that would en­able pa­tients to trade points for items with monetary value, such as gift cards, Cas­sar says.

Not all that easy

De­ploy­ing new care models in­volv­ing con­nected de­vices and apps isn’t with­out chal­lenges, how­ever. In the IDC sur­vey, both providers and pay­ers said pri­vacy and se­cu­rity is­sues were among the top bar­ri­ers to im­ple­ment­ing IoT pro­grams.

And there’s good rea­son to worry. Across all in­dus­tries, nearly half of U.S.based com­pa­nies us­ing an IoT net­work have ex­pe­ri­enced a se­cu­rity breach, ac­cord­ing to a 2017 sur­vey re­leased by Alt­man Vi­lan­drie & Com­pany, a strat­egy con­sult­ing firm.

The prob­lem of pro­tect­ing net­works from the se­cu­rity vul­ner­a­bil­i­ties posed by de­vices is mag­ni­fied af­ter you move out­side the walls of an in­sti­tu­tion, says Jon Con­net, se­nior cor­po­rate direc­tor of strat­egy at ForeS­cout, a ven­dor that fo­cuses on track­ing on­site de­vices. For ex­am­ple, it is more dif­fi­cult to de­tect and iden­tify off­site de­vices be­cause tra­di­tional tech­niques, such as pub­lic key in­fra­struc­tures, do not work as well, he says.

There are other tech­ni­cal hur­dles as well, such as IT in­fras­truc­ture devel­op­ment. For ex­am­ple, Och­sner’s IT team de­signed ex­ten­sive cus­tom pro­gram­ming in the health sys­tem’s Epic EHR to cre­ate cus­tom sur­veys, an­a­lyze the sur­veys, as­sign pa­tients to risk groups, and present in­for­ma­tion in dash­boards for health coaches and phar­ma­cists, in­clud­ing daily task lists. “You have to be able to or­ga­nize the work,” Mi­lani says.

The sys­tem’s IT staff also de­vel­oped al­go­rithms to pre­dict which pa­tients are headed to­ward an episode of un­con­trolled hy­per­ten­sion based on their re­cent blood pres­sure read­ings.

Cur­rently, there are about 1,400 pa­tients in Och­sner’s hy­per­ten­sion pro­gram, and Mi­lani says the sys­tem hopes to re­cruit a to­tal of 5,000 pa­tients in the next 12 to 18 months. The typ­i­cal pa­tient does not leave the pro­gram, he adds, be­cause many of them ex­pe­ri­ence mul­ti­ple episodes of un­con­trolled blood pres­sure through­out the course of the dis­ease.

In ad­di­tion to in­creas­ing the num­ber of pa­tients in­volved in hy­per­ten­sion mon­i­tor­ing, Och­sner also plans to ex­pand into other dis­eases. The health sys­tem’s ex­ec­u­tives plan to launch re­mote pa­tient mon­i­tor­ing for di­a­betes this sum­mer, en­rolling from 50 to 100 pa­tients ini­tially and ex­pand­ing over time. Och­sner also may launch a COPD pro­gram this year, Mi­lani says.

Och­sner’s IT staff used the ex­pe­ri­ence it gained build­ing the hy­per­ten­sion pro­gram as the ba­sis for the di­a­betes ef­fort, says Mi­lani, ad­ding that the health sys­tem had al­ways planned to ex­pand re­mote pa­tient mon­i­tor­ing to mul­ti­ple chronic dis­eases. First, “you have to build the train tracks—the in­fras­truc­ture, if you will—to do that,” he says.

“It’s kind of a wake-up call for the pa­tients.” —Janet Ap­pel

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