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 the IoT, specifically remote monitoring, to help patients with uncontrolled hypertension lower their blood pressure to healthy levels.
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 their 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, according to a 2016 article published in The American Journal of Medicine.
Ochsner is one of numerous providers currently using apps and connected devices, according to a 2016 survey of 101 providers and 100 payers from IDC. In the survey, 39 percent of providers and 52 percent of payers said they were piloting or in production in a department, business unit or the entire enterprise with an IoT project—the most common uses were for physical 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.
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,” Janet Appel, director of informatics and population health at Sharp Rees-Stealy, says.
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 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 90-day 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 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 wakeup 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 myriad activities, such as watching videos and taking medications.
Patients currently earn a happy or sad emoji based on the number of points they earn, but SuperCare is developing a program that would enable patients to trade points for items with monetary value, such as gift cards, Cassar says.
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 towards 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.