September 2, 2016
Build Your Own: Northwell's App for Patient Monitoring
Northwell Health, formerly North Shore-LIJ Health System, is participating in three new Medicare bundled payments programs that are making its 21 hospitals responsible for patients' outcomes from the time they enter the hospital through 90 days after discharge.
Managing a patient throughout this period, dubbed the “episode of care” in the Comprehensive Care for Joint Replacement Model, the Cardiac Rehabilitation Incentive Payment Model and the Bundled Payments for Care Improvement Initiative, will be a significant undertaking, especially because of the system's size.
This year, Northwell is overseeing episodes of care for about 3,500 Medicare fee-for-service patients, who have either received a hip or knee replacement or cardiothoracic surgery. That number is likely to grow to about 5,000 in 2017 when Northwell begins working with patients recovering from heart attacks, coronary bypasses and hip and femur fractures.
Northwell's strategy for handling each episode is pretty straightforward. It involves intensive social work and developing new technology to monitor and engage patients after discharge.
“Hospitals have traditionally had this very paternalistic view that every solutions sits within the intensive care unit,” said Dr. Zenobia Brown, medical director for advanced illness management at Northwell Health Solutions. The episodic payment models force health systems to acknowledge that people are “much more complex.”
For elective joint cases, Northwell starts with a pre-operative phone call from a social worker trained in motivational coaching. The call is designed to gain patients trust and identify social factors that could inhibit their recovery, such as being afraid to use home health care because of the physical condition of their home or holding tight to what Brown describes as falsely held beliefs.
“A patient may chose a rehabilitation center because they want to hold onto their independence and not ask a family member for help,” said Brown. A social worker could explain that they could maintain more of their independence, plus lower their risk of infections, if they were discharged straight home.
Medicare fee-for-service patients can chose where to go after they are discharged and often pick post-acute care facilities like a skilled nursing facility or rehabilitation hospital. But that model drives up costs with, very often, little bearing on outcomes or the overall quality of care. Low quality post-acute care providers can be significant drivers of readmissions while mounting up half the cost of an episode of care.
In the hospital, nurse practitioners, who act as care navigators, follow up with patients, making face-to-face contact. This ideally creates a relationship that will be critical during the post discharge period.
“It's one of the lessons learned,” said Brown, adding that about 40% of patients had turned away health workers pursuing a home visit because they had never met them before.
Once a patient is discharged, care navigators call patients within 24 hours and make house visits within 72 hours. At this point they can reassess risk and reconcile any medication issues.
Medication reconciliation is a big issue. Patients can have medication from before they went to hospital, new medications at the hospital and then a separate list of medication from a rehabilitation center. Navigators are nurse practitioners and can prescribe any missing medication, spot drug-drug interactions or identify other medication errors.
Two types of tech
For elective surgeries social workers and physicians can work with patients pre-operatively and plan their care path before they are even admitted into the hospital. But many patients who qualify for the episodic programs, especially the cardiovascular program, are likely to be admitted through the emergency department, creating another issue: how does the hospital identify patients who qualify for episodic programs as soon as possible.
“If someone comes to emergency department with shortness of breath, it could be COPD (chronic obstructive pulmonary disease), pneumonia, heart failure or influenza,” said Brown, adding that a hospital could lose days waiting for the DRG to drop.” (A DRG is the diagnostic code that hospitals use for billing and that Medicare uses to determine who qualifies for the new programs.) By that time a patient could be discharged or ready to leave.
To find these patients, Northwell built a system called Care Tool, a platform that coalesces information from multiple sources: admissions, surgical scheduling, electronic medical records, and (within the next year) pharmaceutical databases.
“We needed to have some sort of technology that could anticipate the most likely DRG,” she said.
After discharge, care navigators and physicians use Care Tool to see updated list of medications, track patients through different post acute care facilities or even if they show up in emergency room of another hospital in the region.
With the overarching systems in place, Northwell is now piloting a new application designed for orthopedic patients, called Force Therapeutics. The pilot, which began in January, currently involves eight physicians, three hospitals and 660 cases, though that is expected to grow by the end of the year.
The app, which is designed to be intuitive, provides updates that ensure patients have essentials like transportation to the hospital on the day of surgery. It also allows patients to watch a video instructional featuring their orthopedist or nurse running through topics like pre-surgical or post-surgical routines and exercises.
During the hospital stay patients are encouraged to continue to use the app, reporting items like pain level. This helps maintain continuity and reinforces the apps relevance. Once a patient is discharged the app again provides instructional videos, updates and asks questions that enable clinicians to monitor the patient's progress.
The app can also be used to text questions to the care navigator or physician, depending on the physician's preference. Some physician offices are equipped to monitor alerts from the app directly while other chose to use Northwell's care navigator team.
For example, one patient concerned about her wound sent a picture to the doctor, who quickly determined it was fine and kept her regularly scheduled appointment. “The interaction took less than five minutes,” said Brown, adding that without the technology the same interaction would have taken a lot longer.
The pilot saw 88% of its Medicare fee-for-service patients to sign up for the app; About 70% of those patients completed tasks like answering a survey prior to surgery; 30% used it to send electronic messages. About 3% of patients generated a post-operative alert.
Northwell is looking at other applications to serve patients with chronic conditions like heart failure, who have very different needs and may require an intervention that is structured differently. Brown is unconcerned about trying different companies since the technology is so new she expects it to evolve very quickly.
“Year over year, the apps are getting better, faster and easier to integrate,” she said.
September 2, 2016
Identify Metrics When Piloting Patient Monitoring Apps
Hospitals frequently use information technology services and products from large, blue-chip corporations like Epic Systems Corp. or McKesson Corp. But as they hunt for apps that can help them monitor and engage patients in the months following discharge, they are dealing with a whole new world comprised of many, small startups.
Many of these companies' wares have a limited track record. And the firms themselves sometimes lack stable funding.
And, the gee-whiz techies behind the app usually haven't developed valid metrics for evaluating its capabilities. Measures like readmission rates or cost-per-patient are too broad for determining the value of a post-discharge monitoring tool.
“We need to prove what works” before scaling it across the entire system, said Dr. Zenobia Brown, a medical director at NorthWell Care Solutions in Great Neck, N.Y.
Hospitals are looking for post-discharging monitoring technology so they can remain financially viable in the services being thrown into Medicare's new bundled payment programs. Nearly 800 hospitals are now responsible for patients' clinical and financial outcome 90 days after being discharged for a hip or knee replacement. If they fail to hit a target price set by the CMS, they will lose money on the entire episode of care.
In July, the CMS expanded the program to include bundled payments for episodes involving heart attacks, coronary bypasses operations, and hip and femur fractures. The cardiac care bundles alone represent about $11 billion in annual Medicare payments, based on a CMS analysis of historical episode spending between 2012 and 2014.
Many of the startup companies trying to help hospital systems prepare for this brave new world of bundled payments do not have solid financial backing and that can undermine a project. Froedtert Health, for instance, partnered with a company that offered a congestive heart failure application for patients.
The hospital received data from electronic scales, blood pressure cuffs and pulse oximeters in people's homes and used the company's analytic system, which incorporated machine learning, to identify early sign of risks and intervention.
After five months, even though the application performed well, the company lost its venture capital funding and the project folded.
Large advisory firms are very familiar with hospital's workflow. But this is less true for startup companies, who might be eager to do a pilot, free of charge, just to get some more data points on how the application performs in the real world.
“There are a lot of solutions without clear problems,” said Matthew Fenty, director of innovation and strategic partnerships at St. Luke's University Health Network in Bethlehem, Pa., explaining that often vendors have trouble articulating the value of their product and require operational insight from the hospital, which can take extra resources and time to vet.
But the startup vendor and the hospital system need to be very clear what new capabilities the technology brings to the table and if that capability is a “need or a nice to have,” Fenty said. To determine an app's usefulness, key players like physicians, nurses and administrators need to be involved from the onset.
But it is important to consider the less obvious players like the information technology department. Startup companies sometimes expect an unreasonable amount of man-hours from the IT department to deploy their technology, which takes time away from other priorities, said Fenty.
Most importantly, hospitals need to figure out the best metrics for measuring a pilot project's success. These metrics are not always obvious because the field is so new. Until recently many hospitals didn't track what happened to patients once they left the premises.
Reducing readmission rates and preventing possible complications are key reasons for hospitals to engage and monitor patients during the post discharge period. But these can be murky indicators.
“How do you attribute a decline in readmission rates to a specific intervention? It might have had no effect, it may have been the sum total or somewhere in between,” Brown said.
Indeed, many academic researchers are still trying to pinpoint the key variables that cause readmission. Hospitals should look at more quantifiable factors like engagement rates, possibly broken down by age group since there is some concern that older people won't respond well to apps.
Engagement rates can also be broken down by length of time to see if patients interact with the app through the entire episode of care. Or it can be broken down by specific task. Did the patient use the app to send messages, watch videos, complete daily check-ins?
Hospitals are also investigating the possibility of using apps to gather patient-reported outcomes. These surveys are a component of a hospital's overall quality score, which helps determine if they receive a bonus for meeting the quality standards set by Medicare.
And it's not just about Medicare's penalties and rewards. A hospital's reputation ultimately is at stake. “We want to know what percent of our patients are thrilled with the experience. Then how many post public reviews online,” said Jodi Rosen, director of innovation at Northwestern Memorial HealthCare in Chicago.
Other key metrics include: reductions in-bound phone calls to specialty clinics or providers and the ability for nurse navigators to see more patients.
A big part of setting up a pilot is usually defining how it can be expanded into other departments or across a system. This can mean thinking about cost or logistics of expansion before the technology is deployed.
While claiming to handle every condition may be a selling point for would-be vendors, there are obvious situations where different methodologies are needed because they involve different types of patients. For example, an interface designed for a patient undergoing an elective surgery may be very different than one designed for someone who is chronically ill.
For now, even a successful pilot won't offer a clear path to a systemwide technical solution to post-discharge monitoring. “It's too early to pick winners and losers,” Brown said.