For many health centers and clinics, educating a diverse patient population about digital tracking tools to monitor blood pressure is a challenge. However, learning to adapt based on patient needs is vital to ensure both continuity of care and staff bandwidth. Asian Health Services (AHS) in Oakland, California, leverages health coaches and digital health advocates to support these evolving needs. They work closely with community members with varying levels of digital literacy as well as hypertension requiring different levels of management. For the care team, this allows them to move from a labor-intensive and sometimes inconsistent approach to hypertension, to the lighter-touch practice of remote blood pressure monitoring. In our conversation with George Lee, he shares Asian Health Services' multi-phase journey in patient education for remote care and where they've had to pivot along the way in order to better integrate IT into their existing operations.
For many health centers and clinics, educating a diverse patient population about digital tracking tools to monitor blood pressure is a challenge. However, learning to adapt based on patient needs is vital to ensure both continuity of care and staff bandwidth. Asian Health Services (AHS) in Oakland, California, leverages health coaches and digital health advocates to support these evolving needs. They work closely with community members with varying levels of digital literacy as well as hypertension requiring different levels of management. For the care team, this allows them to move from a labor-intensive and sometimes inconsistent approach to hypertension, to the lighter-touch practice of remote blood pressure monitoring.
In our conversation with George Lee, he shares Asian Health Services' multi-phase journey in patient education for remote care and where they've had to pivot along the way in order to better integrate IT into their existing operations.
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Episode Teaser // George Lee, Asian Health Services (guest):
...At this point, we're running this as part of the innovation aspect of things, but we really want this... Because this is how care is going to be delivered going forward. It will no longer be an innovation a few years down the line, it'll just be standard of care. So, how do we put all of those processes and integrate those into existing operations? So, when we, for instance, hired the digital health advocates, we hired them under each site, and we tried to have them being managed by the usual management infrastructure of the sites, so that hopefully when the time comes for it to just become standard of care, all of that will just happen a little bit more seamlessly.
Health Pilots podcast intro:
Welcome to the Health Pilots podcast presented by the Center for Care Innovations. This podcast is about strengthening the health and wellbeing of historically underinvested communities. Every episode offers new ideas and practical advice that you can apply today!
Jessica Ortiz, Center for Care Innovations (CCI):
Hello, everyone. I'm Jessica Ortiz with the Center for Care Innovations. And today we're talking about one of the exciting projects that Asian Health Services has been working on for the past nearly two years. Our hope is that by sharing the highs and lows of this digital health solution, safety net organizations can apply the lessons learned to their own challenges. I'm here with Dr. George Lee, member of our Tech Hub learning network, which is comprised of 14 tech-forward, California-based community health centers, clinic coalitions, and primary care departments and county health systems, that are working to accelerate the adoption of innovative technologies. We partner with our Tech Hub members to vet, pilot, evaluate, and spread innovative digital health solutions, serving Medicaid markets and historically underinvested communities. And we are excited to bring you this story today. Dr. Lee, could you introduce yourself to our listeners and share a little bit about you and your organization?
Dr. George Lee, Asian Health Services (AHS):
Yeah, so my name's George Lee and I'm the Chief Innovation Officer at Asian Health Services. We're a community health center that has been around since 1974. We provide primary care services in 14 different languages, and we are located in the Bay Area in Oakland primarily, but we have multiple sites all around the Bay Area. We have specialty mental health services, as well as dental services, and we also have care in Oakland within a high school.
Jessica Ortiz, CCI:
Welcome. We're so happy to have you, Dr. Lee. Let's just jump right in. Tell us about your project. How did you get started? What was the challenge that you were facing?
George Lee, AHS:
Yeah, so we really started during the pandemic when people were in shelter-in-place, and we weren't able to reach our patients. So, we needed a way to really keep track of how our hypertensive patients were doing. That was the main challenge. We had also been thinking about how to provide continuous care for our patients as well. So, for instance, patients were only coming in... We would see them for three or four visits a year, but it's hard to make behavioral change when you are only interacting with them for those three or four times a year. So, we're hoping by having a more continuous contact with them that we will be able to affect a greater change.
The other thing that we were faced with was really the technology challenges of our patient population. We serve about 50,000 patients. We have about 130,000 visits. About a third of those patients are elderly, or over 65, so that's definitely a challenge for that particular population. Also, about 90% of our patients are limited English proficient, so we also had to figure out a way to serve them in a different language. So those were all the different challenges that we were trying to figure out at the beginning of the pandemic.
Jessica Ortiz, CCI:
And what did you end up doing to try to solve that problem?
George Lee, AHS:
Okay, so this is a rather long journey. We've probably gone through about three different versions of what we're trying to do, so I guess I'll just go through the different versions. So, I would say version 1.0 -- this was at the beginning of the pandemic, and there were literally patients that we had not seen or touched for a while, and we didn't know what was going on with them. We were able to secure a grant where they actually supplied iPhones along with cellular service for one year. So, what we did was we identified our patients that did not have a telehealth visit, and they had hypertension that was uncontrolled, because we were most worried about them, and they also could not speak English, because we wanted to take care of our neediest patients. So, what we did was we gave those phones to them. We also gave them an iHealth blood pressure cuff.
This was a challenge because they had to learn how to use the iPhone, because they've never had an iPhone before. So, we actually had our nurses teach them how to use the iPhone. They have to download the app for the iHealth cuff, and then we have to teach them how to use the blood pressure cuff. It has to sync to the iPhone, and then that had to sync to our Epic patient portal. So that was essentially the process. We would send them home with this sort of setup. They would sync their blood pressure readings to us, and we had a system where we would monitor their blood pressures, and we would have health coaches call them to check in on them, to help manage their blood pressure. So, for instance, if it was mildly elevated, they might give them diet and exercise advice. If it was more elevated, it would get escalated to one of our providers, or to the nurse, in order to actually do some medication management.
So that was version one. And then version two, we needed to expand it to a greater proportion of patients. So, we went ahead and did the same situation with any patient who had their own iPhone. So that was version two. And what we did was we also expanded it to the rest of our sites. We started off with one site, and we also just started with Chinese. So, our version two, we spread it to all of our sites and also availability in all different languages, which meant that we had to recruit our health coaches that spoke in different languages in order to provide the coaching.
And now we're on version three, which is that we wanted to be able to expand beyond iPhones, to be almost what we're calling, “phone agnostic.” Because our solution now that we're working on is one which has the embedded SIM card in it. So, it doesn't matter if you have a smartphone or not, because the SIM card is embedded in there. It's a wireless connection. It's easier to use for the patient. So currently we have both systems running, because we're still piloting this particular wireless connection device. So that's where we're at.
Jessica Ortiz, CCI:
Thanks for sharing that. I'm really curious about the initial two phases and the decision to start with the iPhone. Was that a strategic decision to prove that this works by using this particular subset? I'm just curious what your thinking was around that.
George Lee, AHS:
Yeah, I think it was an opportunity that came up that we could provide these iPhones along with this particular device. I would say that the main driving factor, though, was that there was an interface with our electronic health record (EHR), because we had pretty high priority - the fact that the blood pressure data had to come back into our electronic health record, so that number one, it counts for UDS (Uniform Data System), because that was one of the issues we were faced with, that if it was only a reported blood pressure, it wouldn't actually count towards our UDS numbers, but if it was inside our EHR, then it would. And we also thought that we'd be able to manage it more easily if it was within our electronic health record.
Jessica Ortiz, CCI:
Have there been any interesting challenges in the uptake of technology when you think about age, language, family situations, and things like that?
George Lee, AHS:
Yeah. Let's see. Where do I start? (laughs) It's been very eye-opening. The level of difficulty it is to teach patients how to use it. What we did was we initially started with having health coaches do some of the device teaching, but that was taking way too much time. So, we actually had to hire what we're calling digital health advocates in order to teach them how to use the phone. But what we realized was that we needed to do more than just the initial teaching. We actually needed to do a lot of troubleshooting afterwards, because we realized that we taught them how to do it. We actually said to them before they came in, "You have to know your Apple ID,” because nobody remembers their Apple ID. So, then they would come in and we can't download anything. So, there were certain things we had to put in place.
But even after we taught them how to use everything, they would go home and we get feedback like, "I forgot what to do now." Or "I did something to the screen and now I can't see anything." Or, "The phone just updated and now I can't log back in." So, there were always these persistent problems beyond the initial device-teaching. So, at this point, I think probably with version two, we decided that we would actually have them demonstrate that they have sent five readings over, within a period of a week, before we graduated them into our health coaching phase. So, what that meant was that they demonstrated that they could send the readings fairly consistently before we moved them onto the next phase. Otherwise, the health coaches would've been doing too much troubleshooting
Jessica Ortiz, CCI:
Yeah. And doing something like that within a short amount of time consecutively, so that we've had the opportunity to learn it and develop that skill-
George Lee, AHS:
That's right.
Jessica Ortiz, CCI:
Through repetition, yeah.
George Lee, AHS:
Yes.
A few more thoughts related to teaching of elderly patients in particular. We did try to enlist the help of relatives, and that definitely helps if we can get a caregiver in the visit during our device teaching visit. We also actually try to do some group device teaching, because we thought, "Oh, maybe, since we're saying the same thing over and over again, maybe we could do it as a group." But that didn't really work out, because everyone was kind of bored while they were trying to fiddle with their machines. The only time that it worked is if there was a couple, so a husband and wife or something like that. And then that case it kind of worked well, because they would help each other a little bit more readily. So anyway, those are some of the different, actually PDSA (plan-do-study-act) cycles that we did, in terms of trying to do better in teaching them how to use it.
Jessica Ortiz, CCI:
And did you get a good number of people that actually showed up? Even if it wasn't the outcome that you had hoped for, like if some people were bored, but did people actually come in good numbers?
George Lee, AHS:
Yeah, I would say that people did come. One of the challenges is that with iPhone in particular, or the iHealth, is that it's a pretty complicated process. So, we actually had some people who we recruited, or the physicians recruited, but after a full explanation of everything that it requires, they said, “I'll just pass." So we actually had a fair number. It was like 20-25% of people after a full explanation of everything that it entailed, they decided not to go into the program. Which is actually what got us thinking about switching to this wireless solution for this version three. We had also done a lot of different things. We created videos instructing them how to do it. We also had materials and language for people, but it was still quite a bit of work for folks to learn how to use it.
Jessica Ortiz, CCI:
Technology's such a challenge, and finding the right fit for different groups of people. And I'm wondering, you might have touched on this a little bit, but did you have any differing onboarding processes and procedures for different individuals based on age and language? I'm thinking about the class that you had and maybe the outreach might have been tailored to folks that were of a certain age group, etc. How did you approach that?
George Lee, AHS:
Yeah, I think we generally did most of our device teachings one-on-one, and so I would say that it was basically dependent upon how quickly the patients were able to pick things up. So, if they were younger and they can figure it out, then that definitely went by faster. We are considering age differences and tech savviness in determining who gets our wireless solution, versus who is getting our Bluetooth solution, because there are differences between the two that will probably push us one way or the other.
Jessica Ortiz, CCI:
I'm assuming the tech-savvy individual is more likely to get the iPhone.
George Lee, AHS:
Yeah, correct, correct. So, yeah, one of the issues with the newer solution for the one that's wireless, with the cellular enabled chip, is that number one, it's not actually integrated with our EHR (electronic health record), so we actually had to work with our vendor to create an interface, and that's actually in the works right now. The other is that it's a subscription model. It's fairly inexpensive after the first year, it becomes something like $3 a month, but it is some bit of expense. Yeah, so we'll probably end up with the people who can handle it using the iPhone one, the iHealth, and then our older ones who really need the simplicity, with the Smart Meter ones.
We're also realizing and understanding that the younger patients tend to take their blood pressures for a while, and then they kind of forget about it. They don't take it as consistently as our older patients. Our older patients tend to keep checking it. And so that actually works pretty well for that subscription model, because at least we know that they're using it. Whereas the younger patients, it would be a one-time cost, they can pick it up whenever - that kind of thing. We are trying to say to our elderly patients on the other one where it's a subscription service, that "we want you to send in a reading at least once a month at this point, because if not, then we're going to take back the meter, because we want to make sure that you really are engaged, an active part in this program."
Jessica Ortiz, CCI:
Right. Yeah, that also makes sense because it's on a subscription, and so you want to make sure it's being used, or then the subscription's not really useful anymore.
George Lee, AHS:
Right, right.
Jessica Ortiz, CCI:
I'm curious to go back to the digital advocates that you have now. What type of background and training do these folks need to be successful in this work?
George Lee, AHS:
Yeah, I think the good thing is that they actually don't need a whole lot of training. You can get a tech-savvy person who's interested in working with patients. So, we have one main person who actually used to be an interpreter, because language for us is a primary need, and so she anchors the group. Over the summer, we had two college students who came to us, who volunteered for the summer. They helped us do a lot of recruitment and teaching. Yeah, it's really just a willingness to work with other people, with patients. And there are actually a lot of people who are interested in that kind of stuff.
Jessica Ortiz, CCI:
That's great. Especially some of the younger generation, they grew up with technology. They really know how to use it.
George Lee, AHS:
Yeah. It's really just second nature.
Jessica Ortiz, CCI:
It's so easy.
George Lee, AHS:
Yeah, it's just second nature to them. And so, the main piece of training that we have to provide for them is how to use the blood pressure cuff, and the rest of it is just downloading apps. All of those things are quite easy for them.
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Jessica Ortiz, CCI:
I'm curious about the different phases of the programs, or I guess of this project overall, what those numbers were looking like as that evolved with phase one, two, and three. About how many patients were you touching through these different phases of the program?
George Lee, AHS:
Yeah, so version one, or phase one, it was 50 patients. That was basically our pilot. Version two was our expansion, and we probably got to about 350 or so, for that one. And now for version three, we're essentially piloting this new one, and we have about 30 patients in that particular one. So I would say in total, we're probably getting close to 400 or so patients that's been in this program.
Jessica Ortiz, CCI:
Great. And so, the phase one and two would've been the iPhone and iTech? Is that correct?
George Lee, AHS:
Yeah, iHealth.
Jessica Ortiz, CCI:
iHealth, thank you. And then the second one, so the add on the 30 is now the Smart Meter for a total of almost 400. Wow.
George Lee, AHS:
Right.
Jessica Ortiz, CCI:
Great. And they're both still running side by side?
George Lee, AHS:
Yeah, they're both still running side by side. Now, not everyone is getting the full suite of services, because the other thing that we did as we thought about this was that we wanted to be able to just support people where they were at. And not everyone needed the full suite of services because that's also very time intensive. So, the 400 people are the people that have gone through our most intensive plan, and the idea is that they then graduate to what we're calling the “engaged phase,” where they would be sending in the readings on their own, but they would not have the health coaching component of it.
So, we actually have multiple tiers at this point and that's the way we're thinking about it. We have the people with our most intensive, and that's what we're calling our SHIP program, which is the Smart Hypertension Improvement Program, which includes the health coaches. And then we have the engaged tier, where they're just sending in the readings, it's showing up in our electronic health record and being managed by the usual care team. And then we have usual care where they're basically... They might be checking their blood pressures at home, maybe they're writing it down and bringing it into the visit. So, they're just being seen at the time of the visit. The first two components, the first two tiers, they're actually sending in readings in real-time. So, we could actually do the vision of doing continuous care, where we can actually see what's happening in real time with them.
Jessica Ortiz, CCI:
And so, you have these three different kinds of buckets. And so, one, I see the continuous subscription model for maybe high risk, is that correct?
George Lee, AHS:
Yeah.
Jessica Ortiz, CCI:
For more high risk intensive care. And then you have your medium and low.
George Lee, AHS:
Mm-hmm.
Jessica Ortiz, CCI:
So medium is a little bit more periodic, checking in with your provider, but not necessarily on a subscription service. And then you have that lower tier of risk where it's just you're keeping track of it on your own, and then when you end up going to a provider, you share that information with them.
George Lee, AHS:
Yeah, it's probably a combination of risk and patient engagement. Because a lot of it is also what the patient is willing to do, or what stage they're at in terms of engaging with their disease.
Jessica Ortiz, CCI:
Right. So, someone who doesn't want to engage in a subscription model, who still may be high risk, might be in one of the other tiers by preference?
George Lee, AHS:
Correct. Yeah, exactly. Exactly.
Jessica Ortiz, CCI:
Nice.
George Lee, AHS:
And what we're trying to really work on is... We might be talking about this later, but this kind of flows with our conversation, is that we're trying to see whether or not we can make that middle tier a little bit more automated so that it's less time intensive. At this point, with our electronic health record, we do get various alerts that pop into the provider inbox based on certain readings. So, if the blood pressure readings are very high, or if their pulse is extremely high, the provider would get notified by it. Which is nice, because that is part of continuous care. It's happening outside the visit, I'm getting this thing that, "Oh, my patient's blood pressure is actually 180 over 110 for some reason." So those are actually helpful pieces of information, and we've actually had some anecdotes of when that has actually been helpful for us.
Jessica Ortiz, CCI:
Yeah. I wonder if you could... This might actually I think be a good time to go into that a little bit more. I'm curious what that middle tier really looks like in practice. How would you determine that a patient should be in that middle tier and what would a patient in that middle tier experience?
George Lee, AHS:
Yeah. Okay, so there are multiple ways in which people get into that tier. Probably the main way is graduation from our high-risk tier. We have within our management system, we've created a series of flags for the health coaches to know when they could potentially be graduated. So, for instance, if a patient has had a blood pressure reading under control for the last 30 days, then there's a flag that's placed so that it alerts the health coach that maybe this person could be graduated. The other flag that we have is if somebody's been in the coaching program for three months, then there's a flag of like, "Hey, let's reassess whether or not this patient should continue to be in coaching or not. Maybe we've done as much as we could with them, or maybe not, and we can keep them on a little bit longer, but just let's just do a little bit of an assessment after three months, regardless of what their blood pressure value is.” So those are the flags.
And so usually there's a conversation really with the patient about, "You're now under control for the last month, so what we're going to do is we'll stop calling you, because you're doing so great, but we'll continue to monitor you." So, for somebody who's there, they would just continue to do exactly as they have before, checking their blood pressures, linking it with our system, and they just won't get these calls from the health coaches. We found that they actually love it, because they know that somebody's on the other end looking at their blood pressure. So that's actually been a very high source of patient satisfaction. They feel much more connected with the care team. So that's the patient experience.
And when they come into a visit, our EHR has a smart phrase, that pulls in the average blood pressures, for instance. So every time I see a patient who's in my engaged phase, or in one of these monitors, I can just type in a little thing and I can get the average blood pressure at home for the last 30 days. And I don't have to ask them anything, they don't have to tell me anything. It's all there. It makes the visit go a lot easier. And I can say to them, it's like, "Oh, I see that you checked your blood pressure five times in the last 30 days, and this was your average, so you're doing well," or something. So there's really this comfort, I think, for the patient to know that this is actually happening. So that's that on their end.
And then on our end, as I said, we're trying to develop a few more flags and systems to engage the patient. So, for instance, if a patient... And we haven't done this yet, we're thinking about how to do it, is if a patient doesn't have a reading for 30 days that's been sent in, can we send them a text to say, "Hey, is anything going on? How can we help you?" At this point, it's actually one of our digital health advocates that's doing that particular engagement with them. And so, what we're finding from that is that sometimes it's a technical issue. We've had people running out of batteries, or the other thing is that sometimes the app updates and that causes a problem. So just little things like that.
Some people are just tired of doing it, and as I said, we found that the young people are the ones that are like, "I got better things to do in my life." Which, that's their choice, but we want to make sure that the people who want to do it, can do it. So, we're hoping to be able to automate some of those processes, sending them that text, or continuing to have a better alert system I think for our care team, because right now it only alerts for one-time elevations that are very severe. We want to be able to create alerts for an ongoing trend of more mild elevations above their goal. So that's probably part of the next phase.
Jessica Ortiz, CCI:
Wow. Yeah, I was just thinking the other day about how many health-related apps there are, and a lot of them are really exciting to use. I think about young people and the engagement piece. And it's really exciting at first, and then you're like, "I don't want to track this anymore. I don't want to enter this thing in anymore." Just because of the information overload, app overload, etc., etc. But I could see how someone maybe in the older population, who is just really acutely aware of their health and the situations that they're facing with maybe their chronic diseases and elevated blood pressure, that this feels like a really good way to monitor that. And also like you're saying, the engagement, the constant engagement, knowing that there's someone on the other end that cares for you, I think is really, really important.
George Lee, AHS:
Although sometimes we have had to tell some of our patients to not check it so many times, "Don't check it 15 times a day. You don't need to do it that often." Yeah, so we do get people on both sides of the spectrum.
Jessica Ortiz, CCI:
That's really nice to know though, that even those patients that are checking constantly are really wanting to be engaged with their health. And so that's really promising to think about.
George Lee, AHS:
Yeah. Yeah.
Jessica Ortiz, CCI:
I'm wondering, from the patient perspective, do the patients know about your roadmap, or engagement, when they are maybe flagged to start with either the SHIP program or being involved in these remote patient monitoring programs? Are they shared the path of three months engagement, if you're under control, then you go to this next phase? How does that work with patient education?
George Lee, AHS:
Oh, that's interesting. I don't know that we've been explicit in explaining exactly what happens, it seems like there's a lot to talk about already in the beginning. But definitely the people who... Remember I mentioned that some people hear about all the different things they have to do with the iHealth, iPhone one, and they say, "Oh, no thanks." We do tell them about... We do keep them on the list for possible engagement later on. So that's actually who we're working off of for our Smart Meter list, because they've shown that they are interested, it's just that the technology has been the barrier. But back to your question of whether or not they know the full extent, I think we talk about it more during the graduation phase of like, "Oh okay, these are the different options. And you can choose however you want to maintain your engagement in the program."
Jessica Ortiz, CCI:
And if someone wanted to continue to be engaged at a high level, do they have that option?
George Lee, AHS:
Yeah, that's interesting. I don't know that we forced anyone off before, but I think that most people tend to see what's happening and they agree with it, and that kind of thing. So, I think some people have asked for, "Maybe don't call me every two weeks, but can you call me once a month?” or something like that. So, we have, I think, kept people on for a lighter touch of the health coach. But I do think that over time they start feeling more comfortable in realizing that even without the health coach, they're still getting care. And so, it's really working with them to have that same understanding and reassurance. So I think it's worked out. I don't think we've kicked anyone off, but also, I don't think we've had any issues. But I actually do remember somebody wanting to have a slower ramp down, as opposed to fully off the program right away.
Jessica Ortiz, CCI:
Like they got used to a certain level of check-in?
George Lee, AHS:
Yeah.
Jessica Ortiz, CCI:
Yeah.
George Lee, AHS:
The other side benefit really is that they know them. So, for instance, the patients on my program, it's my health coach who's calling them. So, when they come in to see me, it's like they have an instant bond, it's like, "Oh, this is Cindy who's been talking to me all this time." And they can go off and it's really quite nice.
Jessica Ortiz, CCI:
Yeah, it's nice to hear. I could see some challenges with those who want to continue to stay engaged when you're trying to graduate and maybe have other folks enroll in the program. But it sounds like even those that are most engaged see that they're still getting care, that having a reduced level of engagement is okay while still getting the care and the follow-up that's needed to manage their condition. It helps build confidence.
George Lee, AHS:
Yeah, because I think sometimes when you just realize that somebody's there for you, then you're not as worried about it, so then you end up not needing to make the appointment, because you know that, "Oh, if I need to, they're available."
Jessica Ortiz, CCI:
It's there.
George Lee, AHS:
Yeah.
Jessica Ortiz, CCI:
Great. I'm just curious if there's anything that you feel like we need to know about the technology itself that you're using, so iHealth and Smart Meter. I know that they use two different technologies, I wonder if you want to share just quickly the pros and cons of those too.
George Lee, AHS:
Yeah. So iHealth to us works only with iPhones, and I say “to us,” because it technically can work with Android phones, but I believe it involves a download of three different apps or something like that, and multiple sync processes, which just seemed like that was going to be too onerous. So, for us, it really only works with iPhones. It does have the connection with Epic EHR. So, the data does come through as a regular feed. It shows up in a particular program, basically a particular section where you can read all of the different blood pressure readings. There will be alerts that are preset within Epic for when it will go into the inbox. So those features are certainly nice.
For Smart Meter, the cost is I suppose variable, depending on how it's negotiated. So, for us it's about $100 per device for the first year, and then it's $36 per year thereafter. I would say that they're still a new company, so they're really trying to figure out how to scale. They're fiddling around with their portal. And so, we have been having some customer service issues with them, or things are changing very rapidly with them, but their device seems to work fairly well for the patients. It's just a single button that they touch and that's it, there's no other thing they need to do. So, the single button gives them their blood pressure and it sends it off into the cloud where we can then access it via a portal. And then, as I said, we're working on an integration so that we can bring that data into our EHR. We have to do a scope of work in order to do that.
Oh, one feature of the Smart Meter, which we're getting some negative feedback on, is that the blood pressure reading disappears from the device after it is uploaded to the cloud. So, depending on how fast that is, sometimes it disappears in 10 seconds or something like that, and so for some of our elderly patients, they're like, "Oh, what just happened?" So that's just one idiosyncrasy of the device at this point, but it may be something that can be worked on. But that was just some feedback that we were hearing from patients. And we try to get the patient feedback as quickly as possible so we can make changes.
Jessica Ortiz, CCI:
Yeah, that's interesting. I also wonder if, even though the information is being sent directly to the health system, if patients are also tracking that still for themselves and writing it down. If it's gone, then you can't do it.
George Lee, AHS:
Yes.
Jessica Ortiz, CCI:
I could totally see my grandmother doing that if she had a blood pressure cuff.
George Lee, AHS:
Yes, exactly.
Jessica Ortiz, CCI:
And being really concerned that she can't write it down in the notebook.
George Lee, AHS:
Yes, exactly.
Jessica Ortiz, CCI:
Yeah. Great. Well, it's nice to hear about the two differences, and you're still doing those side by side so you can learn and understand how different patients are engaging with each of those technologies. I wonder if you have any key results that you'd like to share from this project so far?
George Lee, AHS:
Yeah, I would say that the main result that we're looking at is just whether or not people improve with their blood pressure through the program, and that's actually been quite spectacular. I would say it's probably close to 90% of people that go through the program will actually improve their blood pressure, or they get to goal. So that's probably the main one.
We also look at patient feedback as well. And so, it's been generally quite positive, in terms of the services that they're provided and how close they feel to us. There are some really cool points, at least for me as a provider or for us as a health system. They're more anecdotal, but we had somebody who was in our program and the blood pressure ended higher than his usual, and actually our health coach called him to find out what was going on, and it turned out that he was having a gout attack. And so, his gout attack was the thing that was causing his blood pressure to go high, and so then they referred him to get a drop-in visit and took care of that. And he was like, "Wow, this is great." Because it was like proact[ive]... he didn't even call us for the gout. He was just like, "Oh, I guess this hurts." But then, because it was affecting his blood pressure, we caught that off of this.
That was one of my patients, I had another one of my patients who... I got a notification from Epic that his heart rate was 30-something and was like, "Oh, that's really low." And I looked at his med list and there was nothing in there that could have caused that low blood pressure. So, I called him, and it turns out that he actually got a prescription for a beta blocker, which is a medicine that can lower your heart rate, from another provider, and I didn't know about it. And so, we had him stop that medicine and that sort of thing.
So, you find things that you wouldn't otherwise, and you can catch things a lot earlier. So those are definitely some highlights and some results of this particular project. Some of the issues, as I said, the sort of dropout after recruitment, we have to find a way to make it easier for patients to participate. And we're still trying to figure out this whole engaged cohort in trying to see how engaged people truly are and what's that percentage for our staff, or for our patients.
Jessica Ortiz, CCI:
I love you sharing those stories of using technology to help us be more proactive. There's a lot going on in people's lives, and you can't know all of that by meeting with a patient or a quick visit. And patients don't always reach out when they need care. So, it is nice if we're able to extend that hand and say, "Hey, how are you doing?" and check in with folks. So really nice to hear that story. You did mention some of the challenges with engagement with the program. I wonder if there are anything else, any specific challenges, with this project overall that others can learn from?
George Lee, AHS:
Yeah, I think aside from the ones I mentioned, certainly the digital divide is a huge one and this whole troubleshooting issue, but the other two things I would say that we're running into, is one is workforce. Because it's hard to hire people, and it's tough to hire health coaches, and MA’s (medical assistants) and things like that. So, we had to build the program off of what was available time for MAs or health coaches. For instance, instead of enrolling a bunch of people and trying to figure out how many health coaches it would take to support that, we figured out, "Okay, how much health coach time can we spend on this particular program for each particular site?"
So, for instance, if the particular site can devote 0.2 FTE of a health coach time for this program, then we would say, "Okay, it takes about half an hour per patient for these health coaching calls." And so, we could figure out what panel size for the health coaches, and let's say they call an average of every two weeks, something like that. So, we can determine what kind of a panel or load that each of these health coaches can have. And that determines our capacity for this most intense tier. So that was how we created that, so that was a way of making sure that we didn't overburden our workforce. And even still, there's always some back and forth, because there's always somebody who's out sick and who needs to be pulled in, that kind of thing. So, I would say workforce is a challenge.
And the second thing is probably eventually this integration into existing operations, because at this point, we're running this as part of the innovation aspect of things, but we really want this... Because this is how care is going to be delivered going forward. It will no longer be an innovation a few years down the line, it'll just be standard of care. So how do we put all of those processes and integrate those into existing operations? So when we, for instance, hired the digital health advocates, we hired them under each site, and we tried to have them being managed by the usual management infrastructure of the sites, so that hopefully when the time comes for it to just become standard of care, all of that will just happen a little bit more seamlessly. Now, I don't know if this is actually going to work, but that was the theory of doing it that way, because we think that eventually this has to go back into the regular flow.
Jessica Ortiz, CCI:
Yeah, I love the way that you're thinking about that, Dr. Lee. A lot of these innovation projects are being tested in a small space, like you said, in an innovation team within an organization. But in the long term, a lot of telehealth changes, policy changes around just virtual and remote care, is going to be the standard for the future. And so, thinking about that ahead of time is going to be really helpful, so that you're not trying to do that while everyone else is already doing it as a part of their regular existing model.
George Lee, AHS:
Yeah, that's part of the message that we're trying to deliver as well to our staff, it's like, "This is happening, but you know it's becoming standard of care." It's like how EHR used to be a thing, and maybe there's a team to implement the EHR, but now it's everywhere and everyone learns it as they come in. So that's the analogy I try to use for people, so that they're prepared for that particular reality.
Jessica Ortiz, CCI:
Yeah, that's great thinking. As we wrap up here, I have two final questions for you, and one is just around the learning network that you're a part of. And here at CCI, we're big believers in collaboration and not reinventing the wheel. Have there been any peers, resources, or other sources of support, that you've accessed to help you do this work?
George Lee, AHS:
Yeah. I think CCI has actually been great, because it's put us in touch with different people doing this work, and I would say that it really helps to understand different approaches from different people. And within our system, hearing how Rimidi works and CareSignal, and some of the other vendors, I think that's really helpful in terms of helping us figure out what would work for our patients in particular. We also are part of CHCN, Community Health Center Network, within the Alameda County clinics. There's eight clinics within that. And so, we share information about that as well. Because they're actually our MSO (management services organization), we're starting to talk about how we can do some of these things and maybe incorporate those into our pay-for-performance measures as well. So, it's a little bit more integrated approach into how we do these projects.
Jessica Ortiz, CCI:
CHCN is also a member of Tech Hubs. And so, it's nice to see how it's kind of a small, tight-knit innovation group that we have, and it's nice to be able to bounce ideas off of each other. And just like with you, Dr. Lee, doing really innovative work over at Asian Health Services, everyone would now have the opportunity to learn from the way that you're thinking about things. And so, with this final question, what is next for this project and for your innovation work at AHS? What can we look forward to hear from you in the future?
George Lee, AHS:
Ooh, okay. Let me try to do this in one minute, no...(laughs) Yeah, I think I alluded to it a little bit. Kind of build out a platform for our engaged patients, how we can use automation really, to make it more feasible for us and decrease the amount of staff time, because it has to be sustainable going forward. So that's definitely one of the key features that we're looking at. We generally look at different processes from the lens of desirability, feasibility, viability – that sort of thing. So that's definitely what we're looking toward. How do we maintain engagement for our patients, trying to see what level that is. Are we really going to keep this two-device system? So I guess those are a lot of questions that we're not quite sure what's going to happen.
We'll probably look forward to expanding to other chronic conditions. At this point in our timeframe, we're hoping that within the next six months or something like that, we can get things all worked out so that it can be integrated - the blood pressure situation - integrated into existing operations. And then for our next period, we'll start piloting other chronic conditions, so that we'll be ready for expansion once the blood pressure gets more offloaded into regular operations. So, we have a timeline for the different things that we're going to bring up.
Jessica Ortiz, CCI:
And I know that your next phase of the project is targeted towards congestive heart failure, right? I think you talked about it before.
George Lee, AHS:
Yeah. Yeah, we think congestive heart failure and possibly diabetes. Yeah, so we're in the midst of exploring both of those options at this point.
Jessica Ortiz, CCI:
Great. Thank you so much for your time today, Dr. Lee, for sharing your expertise and experience with the broader safety net community. It was really great to talk with you today.
George Lee, AHS:
Yeah, it was nice to talk to you too. You make it easy.
Health Pilots podcast outro:
Thanks for tuning into Health Pilots hosted by the Center for Care Innovations, with podcast production services by Wayfare Recording Company. If you like what you heard, please spread the word and be sure to subscribe where you listen to podcasts. For more information about the Center for Care Innovations or for upcoming programming, events, and funding opportunities, please visit our website - careinnovations.org - and connect with us on LinkedIn and Twitter. We’ll catch you here on the next episode of Health Pilots!