CM enhances telemedicine program

Embedding prompts considered a key to success

Many healthcare professionals have touted the benefits of telemedicine in improving quality of care, and there is no doubt the technology can enhance care delivery, but as Wenatchee Valley Medical Center in Wenatchee, WA, has demonstrated, the processes implemented by the human component of such programs are at least as important as the telemedicine itself.

Wenatchee Valley was one of the participants in a Medicare demonstration project that employed Bosch Healthcare's Health Buddy System; the center says it not only improved quality of life for chronically ill patients, but it reduced ED visits, hospitalizations, and mortality — as well as producing up to 13% savings in costs.

"The demonstration project involved patients with diabetes, COPD, heart failure, and co-morbidities," says Lori Smet, MN, RN, CCM, the head case manager. "The goal was to decrease costs by decreasing hospitalizations, and we used a telephonic health component of that program to help manage the large numbers of patients we have."

Patients at home would respond to standardized questions, says Peter Rutherford, MD, chief executive officer of Wenatchee Valley Medical Center and medical director of the program. "The patient has a box with a computer chip, with an on-off button basically in the telephone. There is a video screen and they can answer questions on the screen," he says. Those answers, he adds, are stored in a memory chip, and each night the unit makes an automatic phone call to a server for the facility's computer system, where they are stored until they are retrieved in the morning.

"The questions are individualized to the chronic condition each patient has," says Rutherford. "They are basically objective questions for each disease felt to be reasonable metrics to assess if the condition is exacerbating." So, for example, diabetes questions focus on blood sugar, infections, and weight, while congestive heart failure questions would ask about shortness of breath, difficulty sleeping, or swelling in the feet.

The case managers review the answers when they first come in each morning, adds Smet. "The program risk-stratifies the responses based on parameters, and they are color-coded either green, yellow, or red," she says. So for example, if the code is red the case manager will call the patient and find out what's going on. "If appropriate, we will escalate up to the physician, but we have some standing orders we can use to start changing meds to get the patient more stabilized before the doctor has to become involved," says Smet. If it is thought the patient needs to be seen that day, she adds, they can usually arrange an appointment with the patient's primary care provider or a mid-level provider.

"A lot of people with chronic diseases can wake up and be OK one day, then the next day they're a little short of breath and think they'll be better, but they get worse again and then they're in such distress they go to the ED," says Rutherford. "Our statistics suggests if they end up in the ED with a chronic problem, they have a 50% chance of being admitted to the hospital. The idea is to get people to answer the questions and catch them a day or two before they really start down this slide — and we were successful in that."

The machine, he adds, also has an educational benefit as there are teaching points embedded for the patient to read each day.

Process, people are critical

No matter how good a telehealth system is, Rutherford insists, success is not guaranteed unless you have effective processes in place and the people to implement them. "I think you create the success," he says. "It's a whole system you build; if you acquire data but do not do anything with it, you've not done anything different."

Telehealth, he points out, leverages the time of the case manager. "They spend time working with people who have trouble today; the device takes care of people who are OK and they just deal with the exceptions."

However, notes Smet, "there have been a lot of studies with telehealth that have not been as successful as we have. [According to Rutherford, admissions to the ED and the hospital were reduced by about 20%, and mortality was reduced by 50%.] The piece we've got that's different is we have a case management program within the clinic that is part of the healthcare team. In other systems, you might not know what the labs are, or the current plan of care, and just call in and say the patient's not feeling well today and that's where it stops."

Rutherford notes that another factor that set Wenatchee Valley apart was the development of specific treatment protocols for this program. "We developed them for the case managers," he explains. "So, for example, if someone with CHF has gained 'X' pounds, this is what you can do — i.e., they either need to be seen, or you can adjust the meds and have them seen tomorrow." These protocols, he adds, make sure the physician and the case manager are on the same page.

Another key difference, adds Smet, is the center's electronic medical record (EMR). "It enables real-time communication with the [patients'] physicians," she says. "There are a variety of ways we can communicate. With the EMR they get real-time notification in their 'In' basket that I have e-mailed them. Or I can call the staff nurse and tell them I need to talk to a physician or the patient needs to get in today. I also have the capability from the responses to the Health Buddy to print up a trend report, make a note on that and fax it off to the physician."

Success continues

Rutherford notes that the program is now more than five years old "and the positive trends are continuing."

However, he adds, there have been struggles. "For one thing, not all patients want to participate; we were at best able to get somewhere in the 40% range," he says. "The second thing is this is new for physicians as well, so we had to develop trust between the physician and the case manager — to trust that the case manager is adding value, and is not just stirring the pot. It took probably a year to start seeing successes and wins — and that improved physician acceptance."

"Developing a relationship with the patients was also a real critical part of this," says Smet. "We want the patients to call us when they have issues, and the Health Buddy is just one of the tools. We make referrals to community resources, arrange for transportation, for how they will pay for their care — so we do more than just chronic care and disease management; we care for the patients holistically."

[For additional information, contact: Peter Rutherford, MD, Chief Executive Officer, Wenatchee Valley Medical Center, Wenatchee, WA. Phone: (509) 664-4868, ext. 5484.]