# Presentation: 346400

## The Connected Health Initiative

**Vision**

- The Connected Health Initiative is extending the care community beyond the traditional walls of healthcare institutions by bringing healthcare to the everyday surroundings of the health consumer and their families.
- Five essential components:
-   Care follows the patient
-   Innovative, patient-centric technologies are enablers
-   Process re-engineering is essential
-   Feedback can change behavior
-   Access, quality, and efficiency are improved

**Accelerating the Agenda**

- The members of the Connected Health Initiative are leading a set of strategic initiatives and operational programs that use communication technologies to transform the traditional paradigm of care delivery in physically bounded facilities.
- Driving the agenda are several pressing needs in today’s complex healthcare environment. The ubiquity of technology in consumer homes, an ageing population, the rise of patients with chronic disease, a shortage of specialists, sharply rising costs, and patient demand for quality and convenience – forces that create the imperative for Connected Health.
- Through innovation of technology and process, new models of care that extend and enhance the physician-patient relationship are emerging.  Those models show measured improvements in access, quality, and efficiency across the entire spectrum of care.

**The Connected Health Initiative**

## Featured Initiatives

**Featured Initiatives**

- _CHF Remote Monitoring_:  CHF patients were remotely-monitored for physiologic data and received feedback and daily remote communications from homecare nurses.  It was determined that these patients required fewer nursing visits to the home and had fewer hospital re-admissions.  The patients also reported improved quality of life.  As a result of this study, CHF remote-monitoring has been rolled out operationally within the Partners HealthCare system.

- _E-visits_:  This pilot will evaluate the clinical outcomes and value of using a web-based communications platform to conduct follow-up dermatologic care.  In addition to the impact on patient care and satisfaction, the study will determine if this will improve clinic workflow and enable urgent cases to be seen earlier.

- _Hypertension adherence_:  The nature of poor adherence to medication is a multi-faceted one.  This initiative examines the effect of unobtrusive, personalized feedback mechanisms in impacting adherence behavior. The aims of this study are to increase drug adherence, to create and use a novel and automated feedback loop and to measure patient satisfaction with this kind of service.

- _Wound care with camera phones_: Past studies showed that a woundcare telehealth system with digital imaging capabilities increased patient access to specialist care.  A current initiative expands this by using camera phones to further improve process and efficiency of care.

## CHF Tele-monitoring

**Research **
**Objectives:**

- This trial examined, using an outcomes-based methodology, the hypothesis that the addition of telemonitoring devices to monitor heart rate, blood pressure, pulse oxymetry and weight in Class 3 and 4 CHF home care patients, coupled with patient communication around issues of medication compliance, diet and functional status will result in an improvement of quality indicators while enhancing medical care efficiency.

**Study **
**Overview:**

- Several trends suggested that telemedicine technologies and thoughtfully implemented disease management programs together play a role in enhancing management of CHF patients.  The trend in telemonitoring technologies is towards small, user-friendly devices that monitor heart rate, blood pressure, pulse oxymetry, and weight.  This technology is relevant in the home care environment as patients continue to become more technology savvy.  This trend is true even among the over 65 age group, the fastest growing segment of Internet users.
- This study was a collaborative initiative between Partners Telemedicine and Partners Home Care.  Homecare agencies are now reimbursed on a prospective system for Medicare patients.  Consequently, they are eager to adopt technologies that can enhance the quality of care while streamlining costs.  Partners Home Care offers opportunities, I.e. geographically dispersed patient population and a vision for the application of technologies in the home care practice to implement solutions that will enable economies of scale.
- The trial began with the first patient enrollment in September 2003 and continued through April 2004.  The trial involved a sample size of eighty-five patients, followed for a 2 month period following hospital discharge. The patient communication component included scripted disease management questions provided by the telemonitoring nurse.  Patients transmitted their weight, blood pressure, and oxygen saturation daily to a telemonitor nurse, who evaluated each patient with a follow-up telephone call.

**Results:**

- This trial found that using telemonitoring devices, coupled with patient communications, had significant impact on efficiency of care and quality of life, while showing decreases in hospitalization rates.
- Telemonitored patients required 40% fewer nursing visits to the home and had a 33% reduction in rehospitalization rates.   These patients also reported improved quality of life and appreciation for increased involvement in their care.
- As a result of this study, Partners Home Care will extend the use of CHF telemonitoring on an agency-wide basis.

## Wound TeleHealth Consultation System

**Research **
**Objectives:**

- This trial evaluated the value and feasibility of implementing a wound telehealth consulting system to wound patients in the home care environment.  In allowing wound care specialists to remotely evaluate patient images and data from their desktops, the study was able to determine whether the system could improve efficiency while improving quicker access to specialist care.

**Study **
**Overview:**

- Early wound diagnosis and treatment increases the quality of care to the patient and decreases overall health care costs. Wound care nursing specialists provide this care,  but unfortunately there are insufficient number of them to meet the growing demands of the home health care patient population.  Only the most serious wounds can be evaluated directly by a wound care specialist.
- Partners Telemedicine, in collaboration with Partners Home Care, developed the Wound Telehealth Consultation System (WTCS), a web-based software application and imaging system that allows the wound care nursing specialists to evaluate wounds from a computer.  Home care nurses could then digitally image the wound and upload pertinent medical information and electronically transmit the data to a wound specialist.  In this system, a wound care nursing specialist can evaluate a wound every 10 minutes, compared to the 1.5-2 hours it takes her to make a house call.
- The trial began in 2002, which included thirty-four patients admitted to Partners Home Care with lower extremity wounds.  Patients were imaged according to a three-image protocol by a home care nurse, who uploaded the images and pertinent information into WTCS.  Efficiency gains, as well as overall usability and workflow impact were evaluated.

**Results:**

- The study demonstrated clearly that using WTCS can be an efficient means of delivering quality wound care to home health patients.  An average time reduction of 2.5 hours per wound care specialist assessment was determined.  The trial also demonstrated differing diagnosis and treatment plans between home care nurses and the wound care nursing specialists.
- In March 2003, Partners Home Care began to roll out WTCS on a branch-by-branch basis for all wounds that required daily care.  Wounds in the following categories are being imaged: statis, traumatic, surgical, and pressure.  Imaging is performed by a commercially available digital camera, although further workflow improvements using a cell phone camera is planned.  Other program improvements, such as better user interface design, is also being evaluated.  The goal is to seamlessly integrate WTCS as part of the Partners Home Care Standard of Practice.

## Partners Online Specialty Consultations

**Summary:**

- Partners Online Specialty Consultations (POSC) is a web-based application that enables consumers and their physicians to have “anytime, anywhere” access to the knowledge base of the 4000+ specialists located at Massachusetts General Hospital, Brigham and Women’s Hospital and Partners/Dana Farber Cancer Care.

**Patient**
**Benefits:**

- When faced with an unusual or life-changing diagnosis, getting an expert second opinion from some of the best specialists in the world gives patients options, answers, and often, peace of mind.  Patients have access to the highest quality care without having to travel or waiting weeks to get an appointment with a specialist.  Patients receive an opinion on their diagnosis or treatment plan which they can then discuss with their local physician.

**Physician**
**Benefits:**

- Partners Online Specialty Consultations service works as a physician-to-physician consultation.  Patients and their local physicians both register for the service and the delivered opinion is sent to the referring physician.  This gives local physicians access to highly specialized resources to help them manage their patient’s care plan.

**Program**
**Overview:**

- Both patient and the referring physician register for the service.  They provide medical history and can upload files, scan documents and images, or fax or mail pertinent materials.   The assembled case is organized and formatted by the Telemedicine Coordinators, who assign the most qualified specialist to the case.  The consulting specialist receives all of the information and delivers a professional opinion within 7 days.
- Consultations typically cost $225 for a radiology or pathology interpretation or $450 for a specialist consultation.
- In our experience, we found that the diagnosis changed in 5% of cases, and that 90% of opinions recommended a change in the treatment plan.

**Employer**
**Benefits:**

- Several innovative employers have offered POSC as an employee benefit.  A recent WSJ study showed that employees would prefer improved health care benefits over a salary increase.  POSC allows employers to give their employees access to the highest quality care without necessarily a loss in productivity that results from travel.

## Dermatology E-Visits

**Research **
**Objectives:**

- This trial will evaluate the clinical outcomes and value of using a web-based clinical workflow prototype to conduct follow-up dermatologic care.  In addition to the impact on patient satisfaction, the study will determine if this will improve clinic workflow and enable urgent cases to be seen earlier.

**Drivers:**

**Study **
**Overview:**

- Patient access to dermatologic care is threatened by the existing dermatologist work-force shortage.  Telemedicine has long been promoted as the answer to our burdening supply and demand problem, though its efficacy as a substitute for in-patient visits has yet to be established.
- A clinical workflow prototype was developed in collaboration with RelayHealth.  The web-based system allows patients with facial acne to have follow-up visits using a customized online questionnaire (‘e-visit’) and by uploading digital images of their faces.  The patients will be trained in how to take clinically-meaningful images and to use the system.
- The system also allows the physician to respond to the online questionnaire, prescribe new medications, and be reimbursed for the visit.   Physicians have up to 4 business days to respond to a patient’s e-visit.
- A randomized control trial will be conducted, assessing the impact and  outcomes of teledermatology management (‘e-visit’) for patients with mild to moderate facial acne.  One hundred and sixty patients from the dermatological practices at Massachusetts General Hospital and Brigham and Women’s Hospital will be recruited. The study will begin in October 2005.

## Hypertension Adherence

**Research **
**Objectives:**

- This trial will evaluate the effect of communications technology, providing real-time information to patients, on adherence to medication. The aims of the trial are to increase drug adherence, to create and use a novel and automated feedback loop and to demonstrate patient satisfaction with this service.

**Study **
**Overview:**

- Of the 65 million Americans with hypertension, almost 70% do not have adequate  blood pressure control.  A recent report by the World Health Organization stated that 50% of patients with chronic disease do not take the medication as prescribed.  Poor adherence has a significant negative economic impact and leads to increasingly poor health outcomes for patients.
- This study will use consumer-grade technology to provide patients with feedback which we hypothesize will positively impact their adherence behavior. The study uses a “smart” pillbox that will send SMS messages to a central server housing the individual patient’s data.  The data repository then signals back to the home device, in this case a simple globe, which gives the patient relevant feedback regarding whether medication has or has not been taken. Our team will examine the effect of unobtrusive and personalized reminders on adherence rates.
- In addition to assessing whether or not the automated feedback system is technically feasible, this study will provide adherence data for the local hypertensive population, and is the first layer of a strategy to develop effective behavioral strategies to improve adherence.
- This randomized controlled trial will begin in Fall 2005 and will recruit 70 patients.

**Desk-top globe glows red to indicate medication overdue**

**Patient responds by taking medication**

**“****Smart”**
**pill bottle sends SMS message to central interface**

**Central Server  sends signal via pager **
**network  to patient’s globe**

**Globe glows green to indicate medication taken**

**Drivers:**

## Hypertension Monitoring

**Research **
**Objectives:**

- This trial will evaluate whether hypertension can be managed more effectively and brought under control more quickly with the use of a remote-monitoring system.  In addition to physiologic monitoring, the study will look at how managing medication and dosage by phone or Internet can reduce patient office visits.

**Study **
**Overview:**

- Of the 65 million Americans with hypertension, almost 70% do not have adequate  blood pressure control.  It is estimated that poor control of hypertension contributes over $40 billion in direct healthcare costs annually, and generates over 17 million physician office visits.
- There is an opportunity to look at how the use of communications technologies can benefit everyone in the system:

- the patient by providing daily feedback of physiologic information and reducing the need to travel to a healthcare facility
- the healthcare provider community by enabling workflow efficiency without compromising quality
- the payer community by offering cost-effective and preventative care

- In addition to the benefits above, it is believed that the use of averaged blood pressure results may be more reliable than single clinic measurements.  Short-cycle medication adjustment protocols may reduce clinical inertia.
- Patients with a hypertension diagnosis and an unachieved blood pressure goal will be recruited for the 12 month randomized controlled trial.  Patients randomized for intervention will use a home blood pressure monitor that stores and transmits daily data directly to the clinic.  A nurse practitioner will assess the averaged BP data and call patients one afternoon each week to make medication adjustments if necessary.
- Other additions may include use of a personalized decision-support feedback system for the patients, integration of diet information, and additional sensor data.
- Approximately 250 patients will be recruited for this trial, which will begin in 2006.
- Study endpoints include: change in blood pressure from baseline, the percentage of patients at goal at six and twelve month intervals, and the number of medication adjustments made over 12 months.

**Drivers:**

## Operation Village Health

**Operation Village Health**

**Summary:**

- Partners Telemedicine joined Sihanouk Hospital Center of HOPE, American Assistance for Cambodia, and Japan Relief for Cambodia to bring improved care to villagers of two remote regions in Cambodia.  Started in January 2001, the project has expanded and is having an impact on the local disease burden.

**Program Overview:**

- Operation Village Health was initiated in the Rovieng region in the village center of Robib, and continues to operate due to committed individuals locally.  Despite the lack of public transportation, a visiting nurse from Phnom Penh makes an arduous nine-hour trip by truck every month to this under-served area.  Here he interviews, examines and digitally photographs patients, then transmits the information by satellite to physicians at Sihanouk Hospital Center of HOPE, Massachusetts General Hospital, and Brigham and Women’s Hospital in Boston using a solar-powered computer.  Within hours these physicians respond with medical opinions and treatment recommendations.
- Built on the success of the Rovieng project, a second telemedicine clinic was launched in April 2003 in Banlung, in northeast Cambodia.  This clinic is based in a regional referral hospital, and although it has greater diagnostic capabilities, it does not have medical specialists.
- Over 500 consultations have been performed since the first clinic opened.  This is remarkable given the many barriers (lack of running water, electricity, telecommunications system, transportation, and money) to transporting medical knowledge and care in the most inaccessible and remotest areas.  This program shows how healthcare knowledge can transcend geographic boundaries to provide effective medical care through simple low-cost technology.

**Lab-in-**
**a-Box:**

- In 2004, the Partners Telemedicine team and the Division of Laboratory Medicine at MGH developed and introduced a basic portable laboratory called "Lab-in-a-Box" to improve local diagnostic capacity with powerful but easy to use point-of-care lab technology.  This lab, along with symptom-specific guidelines, allows local health workers to immediately screen and evaluate patients without depending on referrals to expensive offsite testing facilities.  Together with the telemedicine initiative, this program enhances our ability to improve local care.

**Ongoing Outreach:**

- Partners Telemedicine continues to educate the public about the opportunities to provide access to top quality health care in Cambodia through media and networking events.  We have placed an emphasis on renewing ties between Cambodian communities in the U.S. and their family villages in Cambodia.  We have collaborated with local community health care advocates and have participated in events to raise awareness and much needed funds for Operation Village Health.