HealthVault Experience at Cleveland Clinic Monitoring Patients with Hypertension

I believe that tethered personal health records (PHRs) will provide a means to enlist healthcare consumers into taking a more active role in the management of their chronic diseases. There is much that can be learned from the experience of hospitals such as the Cleveland Clinic as they deploy PHRs like Microsoft's HealthVault for patient use. I have published previous notes about this product. This topic of home physiologic monitoring was addressed in a recent article (see: Experiences at Cleveland Clinic with HealthVault). Below is an excerpt from it with boldface emphasis mine:

The local Cleveland paper published a good article today that highlights the work between Cleveland Clinic and Microsoft HealthVault....Cleveland Clinic [patients] who are managing a chronic condition, e.g., hypertension, take periodic measurements that are fed, by way of the HealthVault repository to Cleveland Clinic’s EPIC EMR.  Once in EPIC, the physician can track and trend readings and make adjustments to treatment plan as warranted.

(1) Does the use of such systems impact payment/reimbursement schedules?  Is payment reform required to insure that a physician/hospital is reimbursed for such services that typically fall outside the domain of most payment schedules?

(2) How does this type of system fit into the workflow of what is already a hectic schedule for most practicing physicians? Is it primarily the responsibility of the nursing staff to do the day to day monitoring and reporting and bring the physician in when readings exceed certain pre-defined limits, or is it left to the physician to oversee all aspects?

(3) In addition to chronic care cases, what about episodic care?  Such a telehealth system may dramatically drop re-admissions after a given procedure if a patient is monitored post-discharge.  Yes, we all know how important it is to address chronic care and compliance as these are huge cost drivers to healthcare today, but re-admissions is also a significant cost and should not be overlooked.

As usual, John Moore of Chilmark Research is asking all the right questions about a timely topic. Hopefully, the Cleveland Clinic experience will pave the way for other similar initiatives involving patients with chronic diseases who are coached about how to monitor their conditions at home. They then upload the data for review by a healthcare professional at a remote site. This allows earlier intervention and avoidance of both expensive inpatient admissions and added mortality and morbidity. Below I comment on some of the questions raised by John.

• Should health systems or clinics be compensated for the monitoring of patient-generated physiologic data from home settings? Of course. This process differs little from, say, taking a blood pressure reading in a physician's office.
• Is payment reform necessary to allow such payment? For me, the economic value of such a home monitoring program is self-evident. However, I also understand that as soon as payment is permitted for the review of home-generated physiologic data, some unscrupulous providers will immediately try to "game" the system for personal gain. Rules governing such programs obviously need to be put into place.
• What type of professionals need to be involved in such monitoring programs? The answer is undoubtedly specially trained nurses or physician assistants with some physician oversight if a serious problem is encountered. Some of the monitoring obviously can be accomplished using computer rules with alerts integrated into the system for broader coverage.
• It has been already determined that the readmission rate for older patients after various surgical procedures or treatment of medical conditions is high, resulting in substantial additional costs. The rate is about one in five within a month of discharge for Medicare patients (see: 1 in 5 Medicare patients readmitted within month). I suspect that the program for monitoring hypertension was relatively easy to develop and deploy but that other programs will follow in short order.

Comments

[Brian Jackson]

Bruce,

I just finished the Innovator's Prescription (which I received from my LabInfoTech registration). Regarding your post above, I suspect Hwang and Christensen would say that "cramming" (their term) an innovation such as this into the existing value network will doom it to failure. So instead of asking how to make health insurers pay fee-for-service for use of EHR's, we should be asking why prepaid plans such as Kaiser and Group Health Cooperative aren't moving faster with these innovations. My personal suspicion is that despite their HMO components, Kaiser, Intermountain and other integrated systems do enough Medicare business that it locks them into the same old health care business models that everyone else is in -- so they may innovate around the edges, but they miss the opportunity to create radically higher value.