The largest gaps in patient care today exist in transitioning from the hospital and managing chronic diseases in the home. The New Care Model section gives an overview of opportunities and barriers for the implementation of mobile technologies in these settings. While references will be made to the healthcare landscape in the U.S., most of the issues discussed are also common to other countries of the developed world.
The active collection of personal health data including sleep patterns, physiologic values including blood glucose, blood oxygen saturation, blood pressure, and studies such as electrocardiogram tracings is currently possible1. The data can be measured, stored, and used either as feedback for the patient to improve their own health or delivered to appropriate providers for evaluation and management of patients. Despite the regulatory environment, it is reasonable to expect that the trend towards exploiting ubiquitous computing capabilities will continue while more powerful and sophisticated tools will be placed in the hands of both patients, and providers.
It should be noted that a distinction should be made between objective data and subjective data that can be collected from mobile devices. Objective data is passively collected from monitoring and subjective data is collected by active input from the consumer or patient. The extent of monitoring that is now possible and the degree of participation through self-management are both drivers in the adoption of mobile apps in preventive medicine and disease management.
Transitional Care: Decreasing Hospital Readmissions
Decreasing readmission rates is one of the highest priorities for hospitals today. The US federal government says that one in five elderly patients is readmitted within 30 days of leaving a hospital2. Hospitals are now penalized for patients readmitted within 30 days of discharge3. Regulations now dictate that Medicare financially penalizes hospitals for patients readmitted within 30 days for three conditions: congestive heart failure, heart attack and pneumonia. That list is expected to expand by 2014 to include chronic obstructive pulmonary disease (COPD) and coronary bypass surgery. In addition, it is anticipated that the readmission window will expand to 90 days and include other diagnoses.
The explosion of the number of post-acute care facilities such as rehabilitation centers, assisted living centers, skilled nursing homes as well as patient residences represents a shift of care of the chronically ill away from the acute-care setting. According to the AARP, “Nearly 90 percent of seniors want to stay in their own homes as they age, often referred to as “aging in place.” Even if they begin to need day-to-day assistance or ongoing health care during retirement, most (82 percent) would prefer to stay in their homes. Only a few express a preference for moving to a facility where care is provided (9 percent) or for moving to a relative’s home (4 percent).” Aging in place in combination with a shift in healthcare from the hospital to home for non-critical illnesses, is the focus of technologies that will aim to keep people in their homes while observed remotely4.
Remote Patient Monitoring
Remote patient monitoring (RPM) is beginning to play a preeminent role in many healthcare settings. It may be defined as the use of electronic communication and information technologies to allow interaction between patients and providers.
RPM may be implemented in several areas including chronic disease management, transitional care (nursing, long-term acute care and rehabilitation) and aging at in place. Potential benefits of remote monitoring include: 1) continuous surveillance of the patient’s condition (as compared to episodic snapshots seen during a clinical visit), 2) efficiencies translating into decreased costs (both direct and indirect) and 3) improved convenience for patients, caregivers and providers.
The first widely used remote monitoring technologies were wireless implantable defibrillators. These tools have the ability to alert physicians automatically to significant heart rhythm abnormalities or malfunctions of critical components of the implantable defibrillator system. RPM has since expanded to include complete vital signs monitoring, medication adherence tools, diabetes management (uploaded glucose measurements, patient activity and dietary diaries), implantable and wearable sensors and home sensors.
Results of studies evaluating cost-effectiveness and outcomes of RPM have been hindered by factors including heterogeneity of technology, limited numbers of study subjects as well as incomplete analyses. According to a recent survey of Accountable Care Organizations (ACO), one of the biggest concerns of providers is the lack of adequate support for analytics and clinical decision support tools5. As such, online tools are being developed for organizations such as the ability to calculate the ROI for RPM for congestive heart failure6.
One term coined “situational awareness” is now playing a role in healthcare. “Situational awareness can be defined as being aware of events that are happening and how information and actions impact the [provider’s] objectives. The concept of situa tional awareness has been used in the aviation industry for decades to improve airline safety and performance by promoting adherence to three core principles: perception, comprehension, and projection.” In highly critical patient care areas such as the emergency room, perioperative arena, intensive care and telemetry units, mobile devices can be used to deliver situational awareness for points of care when the provider may be in a different location. The technology essentially enables the provider to “be” in more than one location simultaneously such as the delivery of ICU vital signs to a patient-worn touch-screen device7.
Such interactions will improve communication. It should be kept in mind that mobile devices will not totally replace the physician who, despite built-in algorithms provided by some technologies, will need to orchestrate and deliver care based on actionable data. However, they do enhance the physician workflow, reaction time, proactive decision-making and oversight with the ultimate goal of improving patient care and safety. Particularly important in areas of high data flow where poor decisions may rapidly result in bad outcomes, critical patient care areas may benefit most from situational awareness and decrease the chance of human error. In general, RPM requires interoperability between systems utilizing near real-time interfaces and data to multiple provider types to augment, but not replace, the vigilant care that already exists in these critical patient areas.
Lower acuity care locations, such as a patient’s home certainly could benefit from near real-time data delivery to improve safety and care. RPM has the potential to aid with significant events as they occur or when conditions exist that could lead to a significant event. And if these events are proactively addressed, they could potentially be mitigated or avoided all together.
The examples below highlight some of the many types of RPM devices and tools widely available today including:
- Implantable sensors: Sensors associated with some pacemakers and implantable defibrillators can detect changes in chest wall impedance measurements which can correlate to the accumulation of fluid seen in congestive heart failure. Another type of implantable sensor consists of implantable MEMS (microelectromechanical systems) technology unassociated with a pacemaker or defibrillator for the monitoring of heart failure. MEMS technology will play an increasing role in healthcare. These will be utilized in new methods of early cancer detection and drug delivery. They are the basis of physiologic monitoring whether it is injectable, wearable, or device-based8.
- Wearable Sensors: Fitness, aging in place, remote patient monitoring, and point of care sectors, make up the largest portion of the wearable sensor market. Specific examples of wearable sensors for fitness include those by Fitbit and Body Media. Aging at home sensors might include motion sensors, door sensors and bed and chair sensors. Additional examples include sensors incorporated in shoe inner soles for detection of abnormal gait, which via algorithmic analysis can predict falls in Parkinson patients and location detectors for patients with dementia. External shoe ultrasonic sensors are in development for people with visual impairment to better sense their environment. Wearable sensors are being incorporated into clothing which presents minimal obtrusion and therefore might potentially increase patient acceptance. Sensors in development which are placed on the skin in the form of tattoos will be able to sense not only vital signs but abnormalities in body chemistries.
- Diabetes Monitors: There are multiple mobile technologies that allow for glucose level monitoring. Some have clinical decision support incorporated into the device and advise patients (based on algorithms) how to proceed with medical management, while some incorporate patient diaries that track activity levels and dietary intake to glucose levels. An app currently on the market which accommodates all FDA-approved glucometers is called Glooko.
- Lung Disease App: One hugely successful mobile tool for the management of chronic lung disease comes from Propeller Health. It allows patients to keep track of their symptoms, triggers and use of medications.
- Other mobile sensors: New sensors currently under development can be embedded into the casing of smart phones, eliminating the need for physically attached accessory sensing devices. Another significant development in the sensing market is Angel, a multisensory consumer-oriented device which is unique in its open platform model and able to support multiple applications, like a smartphone.
Mobile medication adherence tools. It is estimated that problems with medication adherence cost the U.S. over $600M annually in the management of chronic diseases. A recent study published in the Journal of the American Pharmacists Association identified and ranked 160 medication adherence mobile apps. “These apps were most prevalent for the Android OS. Adherence apps with advanced functionality were more prevalent on the Apple iPhone OS. Among all apps, MyMedSchedule, MyMeds, and RxmindMe rated the highest because of their basic medication reminder features coupled with their enhanced levels of functionality.” Other mobile solutions include sensors on bottle caps (GloCaps) and probably the most intriguing is the ingestible/wearable sensor combination by Proteus Digital Health. Proteus’ solution consists of an ingestible sensor which is placed on a pill during the pill’s manufacturing process. It is activated upon ingestion and transmits data to a wearable patch, which, when combined with the pill ID, time and other physiologic sensor-derived data, furnishes a more complete picture than just an adherence log9.
RPM in these settings would fill gaps in clinical care due to limited on-site human and technical resources. Patients in these settings may experience health problems discoverable only with RPM before severe clinical problems manifest. The HHS cites analysis by the Medicare Payment Advisory Commission which indicates that nearly 14 percent of individuals on Medicare discharged from a hospital to a skilled nursing setting are readmitted to the hospital for conditions that could potentially have been avoided. Early detection through RPM and subsequent treatment of such abnormalities could prevent readmission to acute care facilities. In addition, sensor technologies andassociated apps in healthy persons will aim to maintain health and promote healthy life-styles and other preventive medical guidance. Care models of the use of mobile technologies in transitional care settings might involve direct monitoring of patients by the provider, or involve third party monitoring entities which employ technicians and/or clinicians who would interact with the patient and give guidance directed by the provider via algorithms. One example of telemonitoring in association with an interactive voice response system by the Geisinger Health System decreased hospital readmission rates by 44%10.
Chronic Disease Management
It is estimated that 75% of healthcare spending goes to managing chronic diseases11. Diabetes, chronic lung disease, and heart disease are the focus of much of the sector because of the numbers of these patients (with their associated economic impact), their associated high hospital readmission rates and the economic impact of care. Chronic disease management can truly benefit the most from RPM and this has begun to play an important role especially for communication between patients and their providers. In the future, innovative methods like microelectromechanical systems (MEMS) and mobile medical apps will be playing a significant role in healthcare as consumers become more conscious and engaged in their proactive healthcare. Wearable sensors and different patient tracking devices for symptoms, triggers and use of medications with multisensory and unique open platforms will increase the usability and acceptance from the patients living with chronic illnesses.
Adoption Challenges for New Care Models
While some mHealth technologies have demonstrated positive ROI and patient acceptance, there exist challenges which need to be addressed in order to facilitate successful implementation. Firstly, effective analytics tools and clinical workflow need to be designed around the monitoring, or in many cases, the monitoring solution should be designed to tie into existing workflows. Data collection itself will not lead to better outcomes. Clinical decision support tools collecting and managing individual, local population and institutional disease specific data will prove most useful. Messaging needs to involve the patient and caregiver to optimize communication and adherence. Federal and private reimbursement is often cited by providers as a barrier to adoption of remote monitoring.
The investment in monitoring needs to be considered from the context of decreasing financial penalties for readmissions, improved patient satisfaction, and an improvement of communication workflows. The perceived image by providers of a deluge of useless data by remote monitoring or transmission of fitness data represents a common pushback of mobile technology. Having local providers contribute to establishing alert thresholds or algorithms layered on top of predetermined evidence-based guidelines will improve buy-in and adoption. Older patients have expressed resistance to sensor technologies, being concerned about potential privacy breaches. Sensors which are less bulky and/or obtrusive might also improve adherence. (For more, see section on Reimbursement and ROI).
With regards to fitness and other preventive medical apps, gamification (the application of game design to non-game applications) with incentives is important, as adherence to consumer apps is typically poor. All apps require optimized user experience including health and educational literacy, cultural diversity, human behavior, peer involvement and simplified interfaces.
Despite the fact mHealth technologies have been quite promising with positive return on investment (ROI) and patient acceptance, a number of challenges exist. Several studies have been explicitly examining the cost-effectiveness, usability, and outcomes of implementation of RPM tools. Some of the major concerns are a lack of interoperability, barriers between systems utilizing real-time interfaces, inadequate support of clinical analytical data and lack of functionality of existing decisions support tools to evaluate ROI for such implementations.
These challenges need to be addressed to facilitate the successful implementation of new care models. Advancements in health information technology such as mobile devices and remote patient monitoring have expanded the arena of telehealth beyond the hospital and into the hands of consumers. It’s reasonable to expect that proposed changes in the current care models with enhanced usability, security and reliability will continue to grow. As technology becomes more sophisticated, user-friendly and easy to use, it will improve sound decision making for data delivery interfaces as well as costumers acceptance, experience and care outcome.
RPM Solutions: Examples in Use
There are several current RPM Solutions being used in today’s society with interesting results. The examples listed below cover solutions from within and outside of the operating room (OR) as well as telehealth.
Inside the OR: One example of an app being successfully used inside the OR is the perioperative mobile application VigiVUTM , an iOS application developed by the Perioperative Informatics development team at Vanderbilt University School of Medicine. This is not a commercially available product, but one that has been developed in house which has provided for improved workflow efficiencies. The app securely delivers digitally accessible situational awareness to attending anesthesiologists performing medical direction to up to four care locations. It was built upon Vanderbilt’s Perioperative Information Management System, VPIMS, which is a VB.NET application. As part of the application’s standard implementation the following standards were included:
- Cameras installed to deliver video (never stored)
- Vital signs collected through monitors
- Serving as the perioperative electronic medical record
- Facilitating the documentation of care by anesthesia providers and nursing in the perioperative arena
The application provides mobile access to the operating room case board to facilitate operational management of individual rooms, groups of rooms or the entire suite. At the patient level, digital preoperative histories and prior anesthetic records may be accessed, and VigiVUTM graphically displays near real-time physiologic data as well as medications and fluids that have been administered. It also displays additional ventilator and monitor data, which can be useful in certain care scenarios. A notification engine uses automatically collected, documented data to apprise a room subscriber that a value is out of range or to configure value range limits on a global and individual patient basis through a push notification service. This is an added benefit since providers are still required to carry institutional pagers for communication purposes.
Communication is one of the more noted features and is used frequently by the providers. Upon launch, it loads the most current phone and pager list, creates a favorites list based on subscribed rooms, allows preset message creation for quick message entry and a pager/notification log to view a history of messages received.
It is important to note that the mobile application does not replace the necessary communication between the attending physician and the qualified anesthesia provider, who is present throughout anesthetic care. Nor does it replace the physical presence of the attending physician during key portions of a case.
The application has been identified anecdotally as invaluable. While complication rates in anesthesia are too low to develop a sufficiently powered study showing a proven benefit in either efficiency or an improvement in outcomes, use of the application may “enhance physician workflow, reaction time, proactive decision-making, and oversight, with the ultimate goal of improving patient care and safety12”.
Outside the OR: There are various examples of RPM that use WAN (mobile) which are commercially available to include Air-strip, Alere, IdealLife, and others. Disease specific RPM solutions include those such as Propeller, AliveCor, and Telcare. One example of an app being used outside the OR, is Airstrip ONE, which uses wireless WAN and WLAN. This is a commercially available product that presents a “virtual bedside” for selected care areas. It displays a customizable, secure, rolling 24-hour view of vital signs data and waveforms in a unified view and may also include pertinent patient health and demographic information13.
A second example is ViSi Mobile. This commercially available device delivers vital signs and positioning information wirelessly to providers and is worn as a wrist watch. This again allows the patient to move, or be moved, freely and still deliver continuous information to mobile devices and an EHR through existing hospital infrastructures14. In September 2012, the FCC allocated spectrum for Medical Body Area Networks (MBANs)15. As a result, the U.S. is the first country in the world to make spectrum available for this purpose. Per the FCC’s mHealth Task Force recommendations report, “MBANs are networks of wireless sensors, often no bigger than a Band-Aid, which can transmit data on a patient’s vital health indicators to their doctor or hospital. The FCC’s International Bureau will work with FCC counterparts in other countries to encourage them to make spectrum available for Medical Body Area Networks (MBANs) and to discuss possible spectrum harmonization efforts to allow for medically safe cross-border patient travel and better economies of scale for device makers.”Telehealth: A broad category of health information technology solutions including live video, audio, and electronic health record access where providers communicate, educate, and in some instances guide the treatment of patients from a remote location. Telehealth’s focus has been how to serve geographically isolated individuals. It is most utilized in the areas of mental health, and remote stroke management. Hospitals with shortages of intensive care physicians use ICU robots that enable direct visualization and communication between the patient, hospital personnel, and remote intensivists. One example is InTouch Health’s RP-VITA16. There have also been instances of using similar technology to guide advanced surgeries remotely. Investigators are now using Google glass as a tele-health tool on an investigational basis.