Connected Health Case Study: Montefiore Health System


Montefiore is a premier academic health system and the University Hospital for Albert Einstein College of Medicine. For almost 20 years, Montefiore has invested in, developed and refined a care model that enables it to take meaningful responsibility for the communities it serves – and make them healthier. At the same time, Montefiore has grown to become an integrated healthcare delivery system that provides primary and specialty care through its eight hospitals, an extended care facility, a School of Nursing, and more than 150 primary and specialty care locations across the region. This includes the largest school health program in the nation and a home health program.

As a Pioneer ACO, Montefiore has embraced a high tech strategy that is based on technology, data, targeted care management and innovations that improve care for patients and supports operational efficiencies for providers. Increasingly, Montefiore has also transitioned to a capitated model, assuming responsibility for the quality and cost of patient care. As a Payer & Provider, Montefiore leverages approximately 1,000 care managers to care for more than 500,000 patients. In year two of the Pioneer ACO program, Montefiore saved the government $24 million in Medicare spending.

“Our mandate is to grow the managed population to one million patients over the next 12 to 18 months. Innovation, technology and mobile solutions are critical to helping us reach this goal.Mony Weschler, Chief App Strategist

IT Governance

“Montefiore Information Technology” is a separate for-profit entity structured to provide full IT solutions--- managed services, hosting infrastructure, consulting and project management--- for hospitals in the metro New York area. This provides revenue that helps offset IT costs, while at the same time, reducing the costs for the Customer. Internally, Montefiore IT partners with clinical and business units, where technological needs and solutions are discussed.

One notable Montefiore development effort is Clinical Looking Glass.

Information Technology creates a bridge to care access.  Clinical Looking Glass, a unique decision support tool developed at Montefiore and in use since 2002, is just one example of how the institution is integrating health IT into its daily strategic vision and operational use for managing population health. CLG was commercialized in 2013 in an agreement between Streamline Health and Montefiore.

Clinical Looking Glass (CLG) is a unique decision support tool that:

· Turbo-charges QI through its unprecedented ability to analyze healthcare data;

· Democratizes the analytic process by allowing the clinical team to navigate clinical databases when and how they want without IT staff involvement; and

· Transforms the culture, excites the staff, and enables award winning changes in care delivery

· Unique temporal operators permit rapid on the fly longitudinal analyses

CLG is an integral tool at Montefiore by monitoring each patient’s temporal trajectory experience.

More than 800 users have been trained in CLG and it has supported over 230 Quality Improvement initiatives, 50 IRB projects, resident education and physician continuing medical education. CLG has also led to the publication of 40 peer reviewed papers including, “Best Clinical Practice Article,” Journal of the American College of Radiology, 2010. In addition to the 800 users, it is part of the curriculum at Albert Einstein College of Medicine for all residents.

"Organizations are starting to understand the value of technology and its role in improving care, reducing costs and supporting the business. At Montefiore, there are no areas in our organization that I can think of that are technology-free. Our strength is that we have leadership who understand the importance of investing in innovation so that we can continue to improve our patients’ experiences and have better outcomes within a financially sustainable model. Recently, we’ve been introducing more technologies to help us better manage patients when they are not in the hospital; tele-health and mobile solutions are key to achieving this goal and overall improving population health.” Jack Wolf, CIO Montefiore

A strategy and process for incorporating innovation and new technologies:
Montefiore has a long-standing process where IT is reviewed by clinical, technical and financial experts to determine if technology solutions align with operational and strategic needs of the health system.  What’s unique is that this Innovations Team assesses each technology, interfaces with incubators, accelerators, and has quickly become the entry point for technology into the health system.

Identifying, evaluating and adopting the latest innovative technologies is critical to ensuring that Montefiore continues to grow and succeed as an integrated healthcare delivery system. Each technology will be evaluated for the ability to:
·Improve outcomes

·Improve quality

·Improve patient satisfaction

·Improve provider efficacies

·Reduce unnecessary admissions

·Reduce costs

·Function as a sustainable model

Montefiore cycle

The goal is that once a technology is successfully vetted through the process and returns with positive findings, the solution will be funded and implemented throughout the organization.

The process when applied to mobility and apps has helped Montefiore decide when to acquire an existing solution and when to develop.  Montefiore has built apps internally, and when necessary, partners with vendors and development firms.  Patient focused apps undergo a marketing and branding review for continuity across platforms and use cases.

Current apps commissioned and co-developed by Montefiore include:

·Barcode medication administration and charting

·Remote phlebotomy

·CLG Mobile viewer

·Radiation oncology nutrition

·Mobile media capture

Montefiore IT supports approximately 4,000 Bring Your Own Devices and 1,500 corporate issued devices – The organization employs a mobile device management system (MDM) to monitor and secure these devices.  The MDM solution also plays a key role in broadly distributing applications to providers and staff.  Montefiore employs an enterprise mobile management solution, to better manage devices and apps, so that corporate apps and PHI are protected while not limiting the user’s personal experience with their device. A geo fence is also in place so that certain apps only function when the device is on campus and connected to the secure wireless network.

Technology in Place and Pilots

One can see a shift to mobile Oriented Technology’s employed across the Organization. We are investing in IOS and Android based solutions:

Cardiocom for heart-failure programStinger
Enterprise PACS with Remote Viewing Capabilities on mobile devices
Airstrip-OB for mobile access to fetal strips
Airstrip One – mobile EKG access
Smart pumps
Smart beds
Wireless vitals

Philips Intellivue  MX40 Intelevue
Stinger Enovate workstations on wheels with batteries that can be swapped.
Mobile Phlebotomy – Real-time draws and labels printed at the bed side

Pilots & Technologies being evaluated:

Cureatr secure & structured provider communications
Alvio spirometry gameified changing the way COPD is identified and treated
Sense Health engaging patients to improve medication and appointment adherence
Zephyr studying the pressure ulcers

Tele-medicine robotics for inter-campus consults
Tele-health combining video visits and physician guided remote diagnosis to reduce ED visits and unnecessary readmissions. Tyto Health:

Mobile Phlebotomy 2

Changes in Care Models and Role of Technology

Mobile technology creates the opportunity for new care models and new workflows.“Mobile devices/mobile apps are the future terminal; both IT and vendors have to get on board with supporting these form factors as user demand is only increasing.”  --- Marc Grayson, Montefiore IT, Product Manager, Apple Product Support and Development    

Montefiore’s partnership with AirStrip has been fundamental to how we have used technology to improve access to clinical data. The deployment of Airstrip OB enables the OB teams to review all fetal monitoring data on a tablet, even though the delivery rooms are miles apart. As one of the first sites to deploy the Airstrip One platform we had to review and redesign the entire EKG workflow. This started with the carts that had to be upgraded with wireless capabilities to the mobile devices the clinicians required. The new workflow provides access to the EKG’s on average in 90 seconds.  The care team can now review current and historical EKG from anywhere which helps the STEMI patient get to the cath lab faster.

Future assessments of the platform include:

·EHR integration
·Lab integration
·Clinical Decision Support (CDS) for ST segment elevation resulting from myocardial infarction (STEMI).  Early warning broadcast alerts provide the ability for the     cardiologist team to be informed of a STEMI arriving.
·Assessment of “door to balloon times” for monitored patients
·Assessment of patients monitored with or without AirStrip ONE®
·Integration of early STEMI with emergency responders for CDS

Much of Montefiore’s patient population lives within one of the poorest counties of the country, and access to smart phones or Internet can be a challenge. Therefore, Montefiore is looking to provide tele-health solutions to supplement home health, specifically for heart failure and post discharge patients. We are looking to partner with a solution provider that can manage the technology while feeding us the data in a common format. Typical kits would include blood pressure, glucometers, scales, smart pillbox, temperature and a smart device to transfer the data and enable a video visit. 

Improving Outcomes

Montefiore is participating in the Centers for Medicare and Medicaid Ambient Warning and Response Evaluation (AWARE) Pilot during a three-year period, Mayo Clinic will train 1,440 existing ICU caregivers in four diverse hospital systems to use new health information technologies to manage ICU patient care.  Montefiore is working with Philips and Mayo to transmit physiological data, lab results and other clinical data to the secure cloud based system.  More than 100 iPads were distributed to ICU faculty to ensure easy access to AWARE. Adding the apps that provide access to the EMR, PACS, EKG’s and analytics is in progress. The opportunity is in creating a better user experience by sharing the patient context between apps and building a common user interface for mobility.

As a member and grant recipient of PILOT health tech NYC, we partnered with Sense Health on a text message clinical trial. Sense Health provides the ability to capture all patients in the system by providing a month of pre-populated communication with patients, from a pre-approved database of messages. These messages are delivered through SMS technology, relieving providers from having to generate new content. It also provides a workflow for case managers to follow-up with needed actions like scheduling follow-up appointments and medication refills. HIPAA compliance is enforced on behalf of providers.

In a pilot study, we saw a 40% increase in appointment adherence and a 12% increase in medication adherence among high-need patients. Combined with our care management support; these high-utilizers were also 21% more motivated, 26% more confident, and 22% more knowledgeable about the lifestyle changes recommended for their health. An IRB study will be conducted over the next year to monitor the success of this platform and to evaluate its sustainability.

Sample patient testimonial “The texting program helped me feel like people cared about me.  I didn’t feel as lonely.  It reminded me what was important and why I was working towards my goals.”

Barriers & Resolution

A significant barrier to improving population health is the fact that New York is an opt-in state with regard to health information exchanges. There is a need for a tiered approach to a master patient index, which integrates with a RHIO and then up to national level exchange. 

Another challenge is the lack of a unique patient identifier.  Having a unique ID would make certain that we are sourcing information for the right patients. This would significantly improve healthcare system efficiencies as well as bring significant financial stability to the healthcare system.

Today, Weschler steers a multidisciplinary Innovation Committee that reviews and identifies innovations to solve existing challenges.  The Innovations Committee is the first step towards Montefiore’s goal to launch its own Innovation Center, which would review opportunities for creating new healthcare solutions by taking equity in companies looking to test and pilot new technologies. This presents an opportunity for Montefiore to continue to use the latest technology to better care for our patients, while diversifying revenue streams that will help sustain operations and drive efficiencies.

Acknowledgements: Dr. David Scher, Isaac Altschuller, Mony Weschler, Steve Berman, Marc Grayson, Jack Wolf, Tracy Gurrisi, and Sue Cipolla

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