By Bill Siwicki
THE PROBLEMS
First, staff recognized a high percentage of patients with diabetes or hypertension, or both, had unhealthy blood pressure (BP) and blood glucose (BG or A1c) metrics. High A1c levels indicate that a person might be at risk for diabetes.
Staff took a measure of all HopeHealth patients in December 2020 with these two problems:
- A1c < or = 9, 70%
- A1c > or = 9 / untested, 27.8%
- BP <130/80, 30.7%
- BP <140/90, 64.9%
“These simple metrics have a ripple effect in rural areas,” said Sean E. Whitfield, system integration analyst at HopeHealth. “Lack of care opportunities due to transportation, limited primary care locations and inadequate income opportunities can send many patients running to the emergency department.
“The need for early intervention through remote patient monitoring is key to saving patient lives and preventing unnecessary ED visits. For this problem, we adopted a remote patient monitoring solution from FORA Telehealth,” Whitfield continued.
Second, HopeHealth’s supply of telehealth hardware was out of date and lacked clinical peripherals. These constraints made it impossible to offer a comprehensive exam remotely.
“In 2019, we could only provide 156 telehealth visits for nutrition education and psychiatry,” Whitfield recalled. “As HopeHealth serves more than 50,000 patients, significant gaps in care in most centers were obvious. For this problem, we chose the vendor IronBow Technologies and specifically their Clinic Telehealth platform.
“Because we were painfully aware of the patient barriers that keep them out of care, each of these problems required funding,” he said. “When an FCC telehealth grant opportunity arose with a pandemic looming, it was high time to enhance and upgrade our services.”
PROPOSAL
For the health system’s RPM solution, the goal was to have patients achieve healthy BP and BG metrics over a set amount of time, using the devices to track progress. This program uses a 3G-enabled blood pressure and blood glucose monitor and a web-based electronic health record.
“Whether through partnerships with hospital systems, school systems and more unique monitoring programs, telehealth is here to stay, and we are looking toward the future.”
Sean E. Whitfield, HopeHealth
“Each patient would be requested to check their BP and BG multiple times a day, such as after a meal, when they wake up and before bed,” Whitfield said. “The RPM device then automatically submits this data to the EHR with a subsequent clinical pharmacist notification. Gathering this much data allows for early intervention of medication dosage, nutrition and lifestyle stressors.”
The bulk of HopeHealth’s investment in telehealth hardware came in the form of carts outfitted with the following equipment:
- High-definition monitor.
- Intuitive touch panel.
- Point-tilt-zoom high-definition camera.
- JedMed Horus with a general view lens and otoscope lens.
- Omnisteth digital stethoscope.
The goal, which focused on the pandemic, was to alleviate the need to reschedule patients due to physician exposures to COVID-19. With physicians out of the office for up to three weeks, a logistical nightmare could develop without telehealth, Whitfield said.
“Each appointment reschedules a backlog of visits. Patients begin to run out of medications, have healthcare events, and add to already overwhelmed EDs,” he explained. “Procuring such specialized equipment also allows exponential advancement in our telehealth offerings. Now physicians can see and hear a patient with a telehealth presenter operating the examination peripherals from any of our centers.”
This qualification on its own allows the completion of comprehensive visits such as annual wellness check-ups for adults and children, he added.
MARKETPLACE
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MEETING THE CHALLENGE
HopeHealth’s remote patient monitoring program started with a bang after acquiring 375 devices with $423,645 in FCC grant funding. The project manager issued instruments to the staff at most care locations and then distributed them to patients.
“The patients we provided devices to were mainly low-income patients who would never usually have access to technology or information like this,” Whitfield noted. “We encouraged each patient to check their metrics multiple times a day, and the clinical pharmacists export the reports to the eClinicalWorks EHR. Most of the results go to the individual patient’s primary care physician for final review.”
When the pharmacist reviews concerning data, they create an alert to have the patients’ clinical team intervene immediately. As this program stabilizes, staff can begin developing programmatic structures for the RPM groups. The plan will include RPM as a part of regular patient visits enhanced by nutrition and lifestyle education.
The carts began service immediately for physicians affected by COVID-19. Dr. Joseph D. Hoyle contracted COVID-19 in the fall of 2020 and had the following experience.
“When I had COVID, my employer offered me the option to continue working,” he explained. “My patients appreciated getting to keep their appointments and see the rest of their medical home team and me. My staff managed the peripherals while I directed the camera. Our shared documentation process did not change.
“I knew I could rely on the in-office vital sign measurement, office processes and nursing interventions,” he said. “The medical assistant and nurse prepare the patient chart with a pre-visit encounter and then usually dedicate a room for the patients to rotate with privacy for these visits.”
In primary care, a personal relationship is essential to disease management and anticipatory guidance, he added.
“Telehealth has maintained my relationship with patients during times of great need or isolation,” he noted. “Over the last year, the fear of COVID-19 has made many patients hesitant toward in-person visits. However, telehealth has allowed us to maintain or even improve patients’ health who have been able to engage with the technologies or access a telephone.
“The necessity of using telehealth over the past year keeps me optimistic for enriching my career,” he continued. “I look forward to blending intuitive telehealth to overcome barriers in healthcare, access and quality. Over time my team and I [have] become more confident in deciding which patients and complaints we can assess comprehensively using telehealth to diagnose certain conditions virtually.”
Dr. Hoyle’s experience is just one example of how HopeHealth used the telehealth carts during the pandemic. Many of the providers had this same experience when they either had a potential exposure or contracted COVID-19, Whitfield noted. A few specialists who were practitioners of telehealth got a nice upgrade from the outdated hardware in circulation, he added.
RESULTS
Preliminary results for the RPM program have seen some positives for the first group of patients. In these five months spanning December 2020 to April 2021, data indicates an average of positive outcomes for all 375 patients:
- A1c < or = 9, December 64%, April 67%, +3%
- A1c > or untested, December 35.1%, April 33%, -2.1%
- BP < 130/80, December 30.5%, April 31.8%, +1.3%
- BP < 140/90, December 65.2%, April 66.5%, +0.3%
“These patients decreased their A1c values and reduced their blood pressure,” Whitfield noted. “Only time will tell if this becomes a trend, but these outcomes are promising. Such data is validation that RPM can be a driver of patients controlling and maintaining their healthcare over time, and information is truly powerful.
“Implementation of the new telehealth carts allowed us to increase our patient visits throughout 2020,” he continued. “In 2019, with our existing hardware, we saw 156 patients via telehealth out of 218,050 total encounters. In 2020, we were able to see 21,013 patients virtually, out of 234,527, successfully. Of the 21,013 encounters, 20% [were] accounted for via telehealth carts, and direct-to-patient software accounted for 80%.”
Each maintained appointment stopped the ripple effect and allowed for prescription refills, labs, procedures and fewer chances of an ED visit.
“As a federally qualified health center, a large part of what we do is keep patients in care so EDs can focus on more significant issues like COVID-19 and non-preventable emergencies,” he added.
USING FCC AWARD FUNDS
In 2020, HopeHealth was awarded $423,645 by the FCC’s telehealth grant program for remote monitoring equipment and telemedicine carts stationed at 10 clinic sites throughout four counties, so providers exposed to COVID-19 who are required to self-isolate can continue seeing patients, and patients that are most vulnerable to the virus can be seen at home via telehealth remote monitoring devices for care coordination and medical tracking.
“The FCC telehealth award funds went to hardware purchases only,” Whitfield explained. “We bought 375 BP/BG monitors and 16 telehealth carts. We successfully expanded our RPM program from around 10 patients to 385 in a matter of months. We are now capable of comprehensive telehealth visits in all 14 care locations, up from only five in 2019.
“Not only are we able to see more patients, we feel that these resources provide a new point of access for them,” he added. “Our ability to provide patients with devices and accommodate travel restrictions levels the playing field for many individuals and overcomes barriers to care.”
For HopeHealth as a whole, the health system now is an accessible telehealth provider in South Carolina, he said.
“Many new conversations and potential partnerships are on the rise,” he concluded. “The hardware, staff training and awareness have us looking at new ways to deliver healthcare. Whether through partnerships with hospital systems, school systems and more unique monitoring programs, telehealth is here to stay, and we are looking toward the future.”
