Our Connected Cardiac Care program passed a big milestone recently. This program is designed to use remote monitoring technology (weight scale, blood pressure cuff, pulse oximeter and a table top computer) to deliver care to sick heart failure (CHF) patients in their home. The most exciting thing about it is that the technolgy becomes a teaching and adherence tool for the patients. They literally start to manage their own condition.
To help these patients stay healthy at home, their condition is being monitored daily by our telemonitoring nursing staff, who can reach out on a moments notice and coach a patient through any given illness issue. In fact, these nurses are often armed with standing orders from our doctors so that if a patient begins to deteriorate, the nurse can make some basic therapeutic changes over the phone and check in later in the day to see if the patient is doing better.
The milestone we achieved was that the program went to ‘opt out’ status in the Partners HealthCare system. That means we will proactively identify patients that we feel are good candidates for remote monitoring (basically at risk for readmission) and inform their doctor that unless we hear an objection from them in a few days the patient will automatically be enrolled in our Connected Cardiac Care program. This little bit of choice architecture has made a huge difference. Heart failure patients are often most vulnerable to decompensation right after discharge and we believe there is significant benefit to start monitoring them as soon as they leave the hospital.
As I write about the current state of our Connected Cardiac Care program, it all sounds logical and straight forward, but I promise you it did not get from conception to success on a straight path. There were dips and turns, good days and bad. We still have a ways to go and many improvements we see that need to be made (more on that in a minute). But I can confidently say that there were a number of points along the journey that an impatient group might have moved on, discontinued the program or turned to something that had a new/fresh appeal. It is universally easier to come up with novel ideas than to execute them.
My sense, having been involved in the implementation of this and other similar Connected Health programs is that they go through predictable adoption phases. Anyone out there who is starting the journey on Connected Health implementation will probably find comfort and solace in knowing a bit about these phases.
Provider Skepticism. The antidote to this is, initially, evidence base. Literature is a start, but many provider groups insist on studies in their own system, and will criticize all but the most rigorous. Don’t fight this, but play into it. Get the skeptics involved as your advisors and build the study design to answer their questions. We’ve shown twice how CHF telemonitoring reduces readmissions at Partners-affiliate, Massachusetts General Hospital. The credibility that quality research brings can’t be underestimated.
Provider Acceptance. After establishing the evidence base, a period of low volume often follows. During this time, various brave souls are trying the program out. They chat with colleagues and if the program lives up to your promises they’ll share positive feedback. They’ll refer patients and other colleagues will follow their lead. There is no way to speed this process. It is inherently slow in healthcare and will frustrate you to no end. Executives will question your volumes and the program’s value and you’ll feel embarrased. This is the phase where tenacity is critical. Happily, if you ride this out and provide a high quality service experience for both patients and providers, volume will pick up and skepticism will drop in classic s-shaped curve fashion.
Workflow changes. Connected health is a new care model. It requires new work flow that is different than the workflow of providers in traditional care models. If you don’t prepare (particularly ancillary staff) for this, they will stiffle adoption and chafe while you are out evangelizing to doctors. Get a nurse evangelist on board and make sure that person is equipped to sell the benefits to non-pysician staff. It can break the program’s success if you don’t.
Integrated operations and care management. Connected Health is a tool set best applied to an overall approach to care coordination. The best example of that comes from our friends at the Veterans Administration. Resist the temptation to run the program as a skunk works (which you will need to do in the very beginning) and establish the relationships with folks interested in care management, disaese management and the like. You will know you are truly successful when the disease management guru talks about your Connected Health intervention in the context of the organization’s overall care management strategy.
Connected Cardiac Care has achieved all of this at Partners and survived these predictable challenges as well. What’s next for us? It’s all about improved efficiency. Better, lower cost, more modular technology. Improved software tools to allow nursing staff and tech support to cover more patients and dogged attention to ways to improve quality. We are not the only people with innovative ideas for care improvement and we have to make sure we are lean, effective and that we fit in to the big picture.
Dr. Joseph C. Kvedar is the director of the Center for Connected Health (www.connected-health.org), a division of Partners HealthCare in Boston. Connected Health is focused on developing new methods of delivering quality patient care outside traditional medical settings.
