Proactive Care Management at Mahaska Health through Remote Patient Monitoring
By Bob Berbeco, CIO, Mahaska Health
Healthcare technology is constantly evolving and driving numerous advancements in delivering patient care. Remote patient monitoring (RPM) is a subset of technologies that fall under the telehealth umbrella and a type of telemedicine where care for patients is not done with the provider and patient being physically present. Its focus is on collecting patient health information (PHI) either manually via remote systems or via biosensors, fitness trackers, blood pressure (BP) monitors, heart monitors, and other devices configured to gather PHI automatically or continuously. All that collected information is then aggregated within a singular dataset to facilitate the healthcare team’s ability to evaluate trends and changes. That singular dataset is typically the primary electronic medical record (EMR) the healthcare organization uses. From a higher-level perspective, RPM can all be done via interfaces between aggregating systems and EMR, third-party management providers, or through manual transmission.
Our Remote Patient Management program is designed to improve outcomes, reduce hospitalizations, and provide continuous, supportive care from a distance.
As the technology landscape continues to transform within healthcare, the use of RPM is advancing as a method of using digital technology to collect PHI outside the hospital setting. The true value realized is it is a proactive, low-cost, and empowering method to engage with patients in keeping line of sight on potential issues, increasing access to care, reducing Emergency Room (ER) visits, reducing hospital readmissions, and improving patient outcomes. It is particularly important for patients with chronic diseases such as hypertension, diabetes, and heart disease, as it enables continuous monitoring without being onerous or requiring frequent in-person visits. It also empowers and engages the patients by enabling them to actively participate in their care through self-monitoring their vitals.
Mahaska Health leverages RPM as a program to enhance care for patients with chronic conditions such as hypertension, diabetes, and heart failure. The program focuses on having easy-to-use devices available for patients to monitor vital signs like BP, weight, blood glucose levels, and oxygen saturation within their home. The real-time data is automatically transmitted to our care team, and the Epic EMR is included in the patient’s chart to enable a line of sight on the patient’s condition and early intervention if a health issue is seen. The program is available for eligible patients and designed to offer a simple and safe way to empower patients share their health information with their providers. Mahaska Health’s care team monitors these readings and provides personalized support, medication management, and regular check-ins to help patients stay on track with their health goals.
From a patient perspective, they request enrollment within the program with one of our healthcare providers. Once enrolled into the program, an internal process is initiated with multiple steps to facilitate remote monitoring and enable data transmission to the EMR. The devices themselves are provided to the patient. The patient receives a BP monitor, weight scale, oxygen monitor, or glucose meter, which requires no setup and automatically shares the readings with our care team. The devices do not require a smartphone, Wi-fi, or application. They are preconfigured devices that are out of the box with included batteries and are ready to take initial readings without setup.
The patient would have access to a personal nurse navigator who helps them achieve their health goals while they are at home. They receive personalized support, education, and care plan management; 24/7 access to clinical staff to help them with their healthcare questions related to their chronic conditions; assistance with medication reconciliation and appointment scheduling; enhanced collaboration with their doctor to prevent unnecessary hospitalizations and ER visits; and active monitoring of their health status by their care team. Based on the care plan, reading results are monitored daily, and the care team reaches out to the patient if any changes in trends or readings are out of healthy ranges. A personal nurse navigator provides monthly consultations to check in with the patient to touch base on the current state of the care plan and to engage them within their care process.
Telehealth and artificial intelligence (AI) are where the future of healthcare technology is headed. The pairing of the two has shown a lot of promise to date, and they continue to show increasing value as they are used to optimize the patient care process while also reducing waste. RPM enhances the way chronic conditions are managed, adding patient convenience and engagement, and reducing the cost of care. Integrating real and near-real-time data transmission enables a more holistic and personalized treatment with the added benefit of home monitoring. With RPM, healthcare providers can deliver proactive interventions, optimize care, and foster better patient outcomes. The key to realizing this promise for healthcare is thoughtfulness in the approach by developing specific strategies around its use. Those strategies should be decomposed into plans which are thought out into how the technologies would be mapped within the care delivery process from end to end.
