What is remote patient monitoring? In this episode, we talk with Axis Community Health about launching a digital health solution that captures and records a patient's blood pressure data in the comfort of their own home — all in the middle of the pandemic. Our hope is by sharing the highs and of this pilot project, safety net organizations can apply these lessons learned to their own challenges.
What is remote patient monitoring? In this episode, we talk with Axis Community Health about launching a digital health solution that captures and records a patient's blood pressure data in the comfort of their own home — all in the middle of the pandemic. Our hope is by sharing the highs and of this pilot project, safety net organizations can apply these lessons learned to their own challenges.
Here’s where you can learn more about the people, places, and ideas in this episode:
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Jessica Ortiz:
Hello. I'm Jessica Ortiz with the Center For Care Innovations. Today we're talking about one of the exciting projects that Axis Community Health has been working on for the past seven to eight months. Our hope is by sharing the highs and of this particular digital health solution, safety net organizations can apply our lessons learned to their own challenges. I am here with Amit Pabla, member of our Tech Hub learning network, 14 tech forward California based community health centers, clinic coalitions, and primary care departments in county health systems that are working to accelerate the adoption of innovative technology.
Jessica Ortiz:
We partner with our Tech Hub members to vet, pilot, evaluate and spread innovative digital health solutions targeting Medicaid markets and historically underinvested communities. We're excited to bring you this story today.
Amit Pabla:
Thank you, Jessica. Hello listeners. My name is Amit Pabla. I am the chief quality and transformation officer for Axis Community Health. Axis Community Health is a community based healthcare center or otherwise known as a federally qualified healthcare center in Eastern Alameda County. We see about 15,000 patients a year with close to 100,000 visits. Our patients are, like Jessica said, underserved and marginalized.
Amit Pabla:
They have a lot of social determinants of health environment and social factors that kind of prevent them from achieving optimal health outcomes. Our job is to put them in a position to achieve those health outcomes by leveraging technology. In my role as Chief Quality and Transformation officer, my team and I help oversee IT data and analytics, as well as our epic EMR system, which houses that patient health information for our patients.
Jessica Ortiz:
We're so happy to have you. Tell us more about your project. Where did you start?
Amit Pabla:
Hypertension in itself has been a big focus point for our patient population. One in four patients come in with a diagnosis of hypertension and many of them are uncontrolled, and or also have a comorbidity of diabetes. Our big problem area, the problem in itself exacerbated during the pandemic when patients stress levels increased. When COVID hit and the shelter-in-place took place, we had to think fast in terms of how we could address chronic conditions remotely. And that is where our project coming came in place in terms of starting to think about remote patient monitoring.
Jessica Ortiz:
And in thinking about your solution to that problem, could you share with us a bit more about the digital health solution that you chose to address this issue?
Amit Pabla:
Yeah, so we chose to go with CareSignal. What we wanted to do was to have some type of platform to try to replicate a dashboard. We knew that we have over 2000 patients with a diagnosis of hypertension. We wanted to use a platform that allowed us to scale up once our pilot showed that we met our key performance indicators. CareSignal was something that we had started to take a look into.
Amit Pabla:
Another item that we wanted to focus on was the device list remote patient monitoring, meaning non-integrated non-connected devices. I think technology and the tech literacy rate, it's something that we need to evaluate within our patient population. At a time when we didn't have too much time to implement something, we wanted to go with a solution that people from all age groups, people from all different backgrounds could easily use and for us to get that information, meaning those patient values back into our EMR system.
Jessica Ortiz:
And at CCI, we suggest the framework of making sure during that vetting process with the digital health solution that there's a mission fit and operational fit and sustainability. And I know you touched on some of this in your description of the solution. Did this framework play into your decision making?
Amit Pabla:
We have a change management process at Axis Community Health, a committee that meets weekly. First and foremost, we needed to get buy-in from different departments, including our chief medical officer, our chief operations officer, our team that also deals with different languages as well too. At the end of the day, the tool needed to be appropriate for our patient population. It needed to be at the 5th and 6th grade reading level. It needed to be essentially very user friendly on the patient end and also user friendly on the staff end, knowing that we didn't have too much staffing that could partake in operationalizing this tool for us.
Amit Pabla:
Another important thing when it came to the vetting process was taking a look at the partner that we're looking, the vendor that we're going to create a partnership with. In order for us to make this model sustainable. We knew that we needed data. Data to eventually showcase to our funders, the health plans and so forth. We partnered with CareSignal. And one of the contributing factors was that CareSignal was willing to work with us on getting us the data that we needed to showcase that the ROI was favorable for us and for the entire healthcare system in general.
Jessica Ortiz:
What were the key performance indicators that proved success for you, and how long did you run the pilot project with them?
Amit Pabla:
Very good question. Our pilot ran from March 9th through September 9th. We were in the process of doing an in-depth analysis, both requesting information from CareSignal, getting information out of our EHR system. And then also taking a look at claims data with our health plan partners. We're looking at both process and clinical outcome measures. We're looking at enrollment rate and engagement rate of the patients that enrolled and stayed engaged for at least three months.
Amit Pabla:
Of course, we're going to take a look at hypertension control rate, but also just general improvement in their systolic blood pressure values, taking a look at ER visits and hospital rate visits before the intervention and after the intervention. As well as medical home engagement to see how engaged they were prior to the remote patient program and post. Taking a look at patient and provider satisfaction as well. I think the provider piece is really crucial.
Amit Pabla:
The primary care scope has been increasing and providers kind of feel burnt out, so the more tools, technology, and resources and different programs that we could provide our providers to help them manage their panel, I think the more beneficial or the higher satisfaction we'll have. And the coolest part is that we're going to look at all these measures from a health equity lens as well too. Specifically focusing on our African-American Black population.
Jessica Ortiz:
And how many patients did you have in the pilot?
Amit Pabla:
We have 250 patients in the pilot.
Jessica Ortiz:
And kind of going a little bit deeper into your experience with the project. Can you share with the listeners, your top highlight for your project thus far.
Amit Pabla:
The top highlight actually stemming away from what hopefully, we hope to see in on the data side is just the patient satisfaction and the anecdotes that we've heard back from our care manager that has been managing the program. A lot of patients I feel like are thankful. This program in itself, and I talk a lot in data, so forgive me even as I say I'm not going to talk about data, is we've been able to intervene in 125 times when it comes to alerts. Meaning that patients had a very high blood pressure value or very low blood pressure value where we intervene at the right time to get them in for an appointment or call 911 or go to see an urgent care provider.
Amit Pabla:
Essentially, hopefully saving their lives or doing some degree of that level of work. That is probably the highlight in terms of we're always looking at ROI in terms of what was this beneficial, but when it comes to patient lives and hearing those type of stories, I think that is what makes a lot of this work worth it.
Jessica Ortiz:
Yeah, of course sometimes in healthcare we're often thinking high level strategy, but then when you get down to the patient level, that's where it's really fulfilling.
Amit Pabla:
Absolutely.
Jessica Ortiz:
Thanks for sharing that. And following up from the highlight of the project, can you share with the listeners the biggest challenge associated with this project?
Amit Pabla:
In terms of challenges we thankfully, thus far, and I think I could say this with confidence, haven't had too much challenges with the platform in itself. I will say that CareSignal has been a valuable partner in terms of helping us work out workflow issues. There hasn't been any performance issues in terms of slowness with the platform or things of that nature. Our biggest challenge has been to get blood pressure cuffs for patients. We can't really ask patients to provide blood pressure values when one, they don't have blood pressure cuffs, and if they don't know how to use it.
Amit Pabla:
Taking the time out to really focus on the education piece was a commitment that we have to make with the resources that we have on staff. Staffing will always be an issue with a lot of these programs that aren't technically reimbursable. We did dedicate one FTE to this program, but with COVID and the pandemic, that nurse had to be pulled out to do COVID testing or COVID vaccines and things of that nature,. That is one of the reasons why we haven't had an aggressive scale up thus far, and why we stopped at a panel of 250 patients.
Amit Pabla:
I do think that with full FTE and consistent staffing, we could get to a panel of 1000, which would be awesome. The other thing when it comes to non-connected devices, is a lot of the reason why we do this is to focus on our quality measures. And a patient reported vitals, unfortunately, do not count when it comes to HEDIS and UDS performance data. At the end of the day, we still need to get these patients in and it still get them engaged into within the Primary Care Medical Home. Those I think are two of the things or three of the things that kind of posed as challenges or something that we needed to think through during our process.
Jessica Ortiz:
And you mentioned COVID-19 as being a part of that challenge. Thinking about that a little bit more broadly, what has it been like to innovate in the middle of a pandemic?
Amit Pabla:
One thing that I will say, and I'm not sure if it's popular belief, but I can only speak for access here is the pandemic catalyzed a lot of innovations when it comes to telehealth, when it comes to outdoor services and leveraging technology or new technology to reach more patients. COVID-19 is probably the main reason why we did this project. I always had dreams of implementing remote patient monitoring in the primary care setting and doing telehealth, never did we think that we had to do these things in a span of two weeks to a month.
Amit Pabla:
COVID-19, I don't want another pandemic. And I want these surges with COVID 19 to definitely be mitigated, but I will say that COVID 19 served as a catalyst for a lot of our innovative work. It kind of showed us how things should be done outside of some of the regulations that are placed on community health centers and FQHCs. It created a sense of urgency. Whereas we still took systematic approach, but whereas you normally have two months to brainstorm and get buy-in and assess how you're going to measure this and go through the workflows. It really took a team effort since there was so much urgency in terms of implementing it at rapid speed.
Jessica Ortiz:
Yeah, I totally agree with that. The pandemic really opened our eyes to what was possible, and for folks who have been, like you, who have been wanting to do this type of work for a long time but face so many barriers, all of the different players involved needing to make this work happen all were aligned with responding to the pandemic and really creating a window through which this work was possible.
Amit Pabla:
Absolutely.
Jessica Ortiz:
And lastly, I'm focusing on the challenges during the pandemic with this project using RPM for maybe the first time, how difficult was it to integrate this new data coming in into the clinical and operational workflow?
Amit Pabla:
One thing that we did not do at the onset was integrate CareSignal into our epic EMR system. We understood that that data would appear what we call a flow sheet and the flow sheet isn't always visible for the provider. In terms of integrating it, one of our other challenges or things that we have to think about was the information is going into a standalone platform. How is that information going to get into the EMR system? When is it going to get into the EMR system and does every single piece of information need to be in the patient's chart? That is where we met with our providers to get their input.
Amit Pabla:
And what we ended up doing was the information gets requested three times a week; Monday, Wednesdays, and Fridays from our patients through an automated text messaging system, or voice message. A patient responds back, it gets put into three separate buckets; green, yellow, and red. If it's above red, it ends up being an alert trigger. And we have standard operating procedures behind each of those buckets that lets our RN know what protocol to follow. Patients that appear in the red or have a much higher blood pressure or very low blood pressure, the RN is going to intervene immediately and also involve the provider and the care and the advice that's administered out.
Amit Pabla:
Thankfully, in a panel of 250 patients, we probably get patients fall in the red or alert trigger status, maybe one or two patients a day. Very manageable so you could tell how many triggers or how much intervention we would need to do if you scale up to past 1000 patients. That is one way operationally providers get that information back. Other than that, we upload a trend summary, a blood pressure summary. That's part of the CareSignal platform once a month. And we drop the highest and the lowest values and average the rest of blood pressure and input that into the vital section. And input a comment under there that says, patient reported vitals. That lets us know that the blood pressure was not taken in the clinic.
Amit Pabla:
We tried that a couple of times, got feedback from our providers and it's been working really well for us. Some providers want that information more often, in which case, the care manager takes note of that and provides that information maybe on a weekly or biweekly basis. But a lot of providers are content with having that information during the pre-visit planning process so that they have the tools in place to administer to the appropriate level of intervention when the patients come in for their office visit or their telehealth visit.
Jessica Ortiz:
I'm sure that's very valuable information that folks are considering how to approach RPM and workflows and that incoming data. And to that with this learning network you're a part of, the Tech Hubs, we're big believers in collaboration, and not reinventing the wheel. How did your peers in the Tech Hubs program support and help you push this project forward?
Amit Pabla:
Being part of the Tech Hubs was very beneficial. One, you end up developing this rapport with a bunch of intelligent people really forward thinking, innovative people that want the same things that you do. We actually had one of our peers, Tiburcio Vasquez Health Center, pilot the same tool with us as well at the same time. And they went in the route of diabetes and we went in the route of hypertension. It was very cool as we progressed with different milestones, we compared and contrasted with in terms of how CareSignal was working for us.
Amit Pabla:
Workflows were a little bit different, but it's good to compare best practices. One of the larger benefits of working with hubs is if you do get a couple of other health centers that want to go in with you on a contract, you're able to negotiate as well too. That gave us negotiating power with us and TVHC going in at the same time. Tech Hubs also, through the different meetings that we have, gave us feedback on some of the key performance indicators and how to look at data to evaluate ROI, which was helpful as well.
Jessica Ortiz:
And in the spirit of sharing and not reinventing the wheel, what would you advise others to do to make sure that the changes you had to make remain as a viable option for the future?
Amit Pabla:
My general rule for contracting with vendors and tech solutions is to always go for one-year terms for the contract. Treat tech solutions as a pilot because there's so many things that could go right, and there's so many things that could go wrong as well too. Having a year to reassess whether this tool meets your current needs, as they have evolved is always good. I think SOPs, the Standard Operating Procedures, in terms of when to intervene and what to do in different situations depending on the blood pressure reading that you get back, depending on the patient's diagnoses, shouldn't be reinvented. We're always happy to share our Standard Operating Procedures.
Amit Pabla:
You want to get consensus from your providers and your care teams on those SOPs as well too, prior to getting started. And then workflows in general, engaging the providers in terms of knowing how often they want this information. Not all providers could be involved in the planning process, but they could always know when, how often they would like to have feedback as part of the process as well too.
Jessica Ortiz:
And what's next for you? What's next with the CareSignal project? What can we look forward to hearing from you?
Amit Pabla:
Yeah, I feel like there's a lot of eyes on this project in terms of our in-depth analysis. Currently, our Analytics team is running reports, doing data dumps and taking a look at the data that's coming in to assess our key performance indicators. We'll be sharing that data with our stakeholders, our Leadership team, our Board of Directors, our health plans in Alameda county, as well as our Tech Hubs friends as well too, to share lessons learned and to assess the ROI.
Amit Pabla:
The next thing that we are piloting with CareSignal that we're happy about is diabetes. The difficulty with the hypertension program was we found out that a lot of our patients didn't have blood pressure cuffs or difficult to obtain through their health insurance. That was one thing, an extra barrier that we had to come through. With diabetes we're learning that a lot of our patients had already have glucometers and have ways to monitor it. I'm hoping it'll be a little bit simpler in terms of just requesting that information, inputting that information, providing that information back over to our care team. It'll be exciting to compare and contrast the diabetes module with hypertension, but hopefully we similar results and all positive.
Jessica Ortiz:
Before we wrap up here, is there any last words that you have for our audience and members of the broader Safety Net Community on stepping into that journey of exploring RPM?
Amit Pabla:
Definitely. with Remote Patient Monitoring I think it has hopefully become a tool, especially as a lot of our organizations prepare for alternative payment methodology and healthcare reform in California. And that it could be a tool that could be associated with alternative touches. Treat every technology as a PDSA, as an opportunity to learn and test it out with a small group. And if you take it in that approach, I think you'll be able to systematically see how beneficial technology is, as well as different models of care including Remote Patient Monitoring.
Jessica Ortiz:
That's great advice. Thank you so much, Amit, for spending the time to talk with us, to share your knowledge and expertise in this area as you're exploring RPM with our broader Safety Net Community. Thank you for being a valuable member of the learning community.
Amit Pabla:
Definitely. Thank you so much for, for having me, Jessica.