Connected Health as a Population Management Tool

Last week, I posted a brief, general overview of how the health reform bill offers connected health providers a great opportunity to move our concept mainstream.  Following on that theme, I’m going to spend some time talking about the value of connected health as a tool for population health management.

One of the goals of healthcare payment reform is to extend the care of more individuals across the same number of providers.  Although this is not specifically stated, it is clearly required.  Extending access to all of those new citizens will strain health care resources (we saw this in Massachusetts) unless we employ a different care model.

Success will necessarily be defined by the management of populations of patients, and the implementation of programs that enable providers to reach individuals in need of care in the moment (rather than seeing them when an appointment is scheduled) while providing guidance and support to those who do not need immediate intervention so they can remain as healthy as possible.

Connected health tools provide great resources for population health management.  My favorite example in our own system, is our Connected Cardiac Care program, a collaboration between the Center for Connected Health, Partners Home Care and our High Performance Medicine Disease Management Team.  Heart failure patients thought to be at risk of readmission are given a set of technologies (hub, weight scale, blood pressure and oximietry) and asked to upload their vital signs daily.  We now have 250 patients on the program at any given time.  3-4 nurses manage the dashboards and reach out to patients whose readings are out of parameter.  This enables preventative and proactive care and encourages patient self-care.  The result has been a ~ 50% drop in readmissions in the cohort we’ve followed over a year or so.  The multiplier effect has two components.  Nurses who previously got in their car and saw 5 patients in a day can now manage 250 at a time.  Doctors have reported that they see these patients in the office less frequently and thus have more spaces in their appointment book for others.  We’re applying the same principles now to the management of diabetes and hypertension and having great success with these as well.

Another great example of this phenomenon is the innovative work being done by American Well.  Their system also breaks down the need for scheduled visits and allows patients who need help in the moment to reach out and find providers who are available.  Widespread use of this type of online consultation will undoubtedly improve care efficiency.

Lastly, I’ll mention the good work of Pharos Innovations.  Their super-simple interactive voice system prompts patients to self report their vital signs and engages them in a different way.  They’ve had good early success.

Of course, some folks aren’t truthful when self-reporting, especially when it comes to weight.  One of the things we need to do as an industry is build more robust selection tools so we can predict who will do well with a system such as Pharos and who might need the more intense accountability that an automatic vital sign upload system provides.

There is no doubt that the next several years will see a variety of experiments coming out of the government on payment models that encourage population health management.  Connected health is an approach that can add great value in these settings.  We need to prepare.  That means increasing the efficiency of our operations, striving to use technologies that work virtually all of the time, and investing in better patient selection methodologies so we can target programs effectively.