by Nesim Bildirici
Winter 2013 – Although we’ve seen the widespread adoption of HIT throughout the healthcare system led by the dramatic increase in the use of EHRs/EMRs by physicians and hospitals, true patient-centered, coordinated care is still an unrealized goal. EHRs/EMRs do an outstanding job of enabling vast amounts of patient data to be captured, stored, accessed, and, increasingly, analyzed. Yet it’s widely known that despite the incentives and mandates to accelerate health information exchanges (HIEs), we have a long way to go to get disparate systems to talk to each other. The irony, however, is that after that is accomplished, it still won’t get us to our goal of lower utilization for populations with chronic illness.
Even in a perfect world with seamless interoperability between systems, this connectivity is still insufficient. Why? Because there exists a critical gap in the health data required to effectively manage a patient with chronic illness between care settings (say, between hospital and home, or between outpatient treatment and home). That gap is real-time and near-real-time information from the home.
Although these patients may frequent inpatient and clinic settings, the vast majority of the chronic disease experience is played out at home. EMRs are excellent – and are getting better at – summarizing and analyzing what was done to a patient. They are even getting better at incorporating care management pathways. But they are far from being able to shed light on what is happening to a patient when they aren’t being observed by a pair of clinical eyes.
It is precisely these intervals that provide opportunities to steer patients away from hospital readmissions, with the ultimate goal of helping them modify behavior and actively manage their health at home. Are treatment plans being followed? Does the patient have sufficient help at home? Is there adequate transportation to get to a follow-up appointment? Is there an adverse trend in biometric readings or symptoms that would otherwise go unnoticed until the patient arrived at the emergency department (ED)? Waiting until a full-blown medical problem surfaces does not bring the change we need. Only by detecting pre-acute patterns far enough upstream of emergent events can we steer the patient to less costly care venues, and that will only happen with real-time data.
The special case of post-hospital care
Discharge from the hospital is where the ball often gets dropped. Nurses, with too much to do and not enough time, tend to go through the steps quickly. Patients (and their families) are more focused on getting out the door than on listening and asking questions, so they’ll do whatever it takes, and sign the required paperwork, to make it happen. Both sides assume the written instructions are sufficient. Sadly, they often are not.
Patients often don’t comprehend or they ignore follow-up care recommendations once they arrive home. For example, half of all patients don’t comply with instructions for taking prescription medications—they may not fill the prescription, stop taking a medication when they feel better or have difficulty understanding the directions. Patients forget (or choose not to) make follow-up appointments and don’t track key indicators such as blood pressure, blood glucose levels or weight. It’s no wonder that these gaps in care can result in preventable and costly ED visits and readmissions, which can lead to financial penalties under the Affordable Care Act (ACA), as more than 2,200 hospitals discovered in 2012.
Eliminating the gaps
One solution to avoid readmissions is for healthcare providers to follow up directly with every patient to ensure they’re doing everything they’re supposed to do. But that would be costly, time-consuming and ultimately unworkable.
Instead, we can apply techniques we rely on in other areas of our lives to healthcare. We can use EHRs and evidence-based databases to identify patients at the highest risk of readmission or preventable medical complications, and provide them with remote monitoring solutions and targeted, timely interventions to prevent problems and help them stay as healthy as possible. We already rely on our cars to notify us when to schedule a maintenance “check-up” or texts to remind us to make a payment to avoid a late charge—it’s time for healthcare to adopt similar consumer/patient-driven approaches such as:
• Automated biometric readings that are immediately uploaded and analyzed using sophisticated analytics that flag problematic readings or trends and alert healthcare providers to look into the situation more thoroughly to determine if they need to intervene
• The ability to integrate data and other information such as self-reported symptoms directly into a patient’s EHR if desired or to augment the EHR with intuitive, easy-to-use documents such as dashboards
• Personalized educational information that reflects a patient’s language preference, health literacy level, co-morbidities, and ethnic and cultural preferences
• Automatically sending reminders to patients to schedule/attend follow-up appointments
• Automatic medication dispensers that provide the right medication at the right time
• Managing all the steps to ensure the treatment plan is followed, actions are taken and gaps are eliminated
Comprehensive remote patient monitoring programs can also include personalized coaching and video visits with a clinician. The ultimate goal is to engage, educate and empower patients to become active participants in managing their health.
The good news is that there is a growing body of rigorous research findings that demonstrate the benefits of remote patient monitoring, such as:
• A study in Medical Care found that a post-discharge interactive voice response (IVR) remote patient monitoring solution paired with case management helped the Geisinger Health Plan lower 30-day all-cause readmissions among Medicare beneficiaries by 19.5%.
• A study of a New York City Health and Hospitals Corporation diabetes remote patient monitoring program in the Journal of Managed Care Medicine showed a 1.8% reduction in the hemoglobin A1c levels of Medicaid patients with diabetes. This is significant because just a 1% percent drop in HbA1c cuts the risk of stroke by 12%, heart attacks by 14%, heart failure by 16%, diabetes-related complications and mortality by 21%, and peripheral vascular diseases–including amputations–by 43%.
• A HealthPartners of Minnesota study published in the Journal of the American Medical Association demonstrated that adding telemonitoring plus pharmacist management to usual care procedures significantly lowers blood pressure over a prolonged period of time. After 12 months, 71.2% of the telemonitoring patients had their blood pressure well controlled, compared to 52.8% of the control group.
Telehealth technologies, working in concert with EHRs/EMRs, can fill current gaps in care resulting in better short- and long-term patient outcomes. As the transition to value-based care gains momentum fueling the growth of ACOs, PCMHs and other risk-sharing arrangements, EHR/EMR vendors are likely to partner with telehealth companies to gain a competitive advantage and help their hospital and physician clients offer more coordinated, collaborative care.
About the Author
Nesim Bildirici is President and CEO of AMC Health, a New York-based provider of customized, scalable, cost-effective telehealth solutions that assist organizations serving at-risk populations and those conducting clinical trials. A proven combination of technology and end-to-end support services enables safe, dependable patient monitoring at home that identifies potential problems before they become serious and triggers appropriate interventions. AMC Health’s remote patient monitoring programs deliver clinically actionable information that enhances care coordination, improves patient outcomes, improves the quality and reduces the cost of clinical trials, and reduces the overall cost of healthcare.
Mr. Bildirici founded AMC Health in 2002 to honor the memory of his father, Gabriel. He was convinced that his father would have lived longer, with a better quality of life, if remote patient monitoring had been a part of his care, and made a decision to take action to help others with chronic conditions. Prior to founding AMC Health, Mr. Bildirici was co-founder of RSL Communications, Ltd., and a Managing Director for R. S. Lauder, Gaspar & Co., a venture capital fund formed by the Estee Lauder family, where he was responsible for managing the initial investment in RSL Communications. He was also an investment banker with Morgan Stanley and holds an MBA from Harvard Business School and a BA from Columbia University.