Cardiac Initiatives: Telehome Monitoring

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Cardiac Initiatives Telehome Monitoring
Interactive Voice Response

• Christine Struthers
• APN Cardiac Telehealth

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University of Ottawa Heart Institute

• Provides a full range of cardiac services to over
  76,000 inpatients and 6,000 outpatients annually
• Over 50 of our patients come from outside the
  Ottawa area (Eastern Northern Ontario Western
  Quebec)

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Technology Framework

• Strategies using technology to improve the care
  delivered to patients
• Enhances care
• Improves access
• Assists patients to stay in their communities
• Telemedicine, Telehome Monitoring (THM), and
  Interactive Voice Response (IVR) programs

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Technology Framework
Three Programs
Broadband connection in the region
Monitoring of patients in their home
Interactive voice response using automated
calling to care for patients
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Goals

• Provide specialized cardiac care to patients as
  they transition from hospital to community
• Provide health promotion and illness prevention
  strategies to cardiac patients living in their
  communities
• Facilitate timely consultation services for
  patients waiting for cardiac intervention
• Discuss potential management issues with local
  physicians

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Goals

• Supports chronic disease management
• Connects providers and patients
• Educate health care providers
• Support cardiac patients their families living
  at a distance from the University of Ottawa Heart
  Institute
• Knowledge transfer to providers and patients in
  the community

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What is Telehome Monitoring?

• Point of care delivery system
• Uses POTS lines for data transmission
• Uses peripheral devices based on patient need
  ECG, weight scale, glucometer cables, INR monitor
• Providers use protocols and medical directives
• Incorporates a clinical database (EHR)

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What Is Innovative?

• Non-physician physician referrals are accepted
• Promotes a collaborative approach to care
• No billing involved - scheduled medical visits
  occur as booked
• No home visits. User demo training occurs at
  Cardiac Telehealth unit or patient room.
  Patients install monitor in their home. No
  distance barriers!

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Telehome Monitoring Technology
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Telehome Care Study 2000-2002

• To determine whether telehome monitoring of
  cardiac patients at high risk of readmission
  reduces hospital readmissions and improves
  quality of life

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Telehome Care Study-Methods

• RCT n249
• Inclusion Criteria
• CHF
• NYHA class II-IV
• Angina
• CCS class I or greater angina scheduled to
  return for revascularization
• CCS class II or greater angina discharged on
  medical treatment
• Able to read write English or French
• Live within 100 km by road

• Intervention
• 3 months of home monitoring post-discharge
• Regularly transmitted their weight, vital signs,
  and electrocardiograms
• Video-conferences were held at least weekly
• assessment of the patient's progress
• self-care education

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Telehome Care Findings

• Telehome monitoring significantly reduced the
  number of hospital readmissions by 51 at 3
  months 45 at 1 year in a cohort of patients
• Telehome monitoring improved QOL and functional
  status in both HF and angina patients
• Patients found technology easy to use and
  expressed high levels of satisfaction with this
  approach to care
• Patients preferred to speak to the nurse using
  telephone instead of videoconference
• Woodend, K. et al. (2007). H L. In press .

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Who Should Be Monitored?

• HF patients with 1 readmission/1 month or 2/in 6
  months
• Patients with new HF diagnosis
• Patients recovering from cardiac surgery
• Patients requiring VS, arrhythmia monitoring
• Any cardiac patient requiring frequent monitoring
  or trending of information to facilitate optimal
  clinical management

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Operations

• 1FTE at central station/ 40 active patients
• Monitoring duration 1-3 months
• Data reviewed Monday-Friday 0800-1600 hrs next
  regular working day
• Patients given 24/7 One number to call for
  off-hours and stats
• Reports sent to referring and primary care
  physicians and specialists on regular basis on
  demand.

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Cardiac Clinical Applications

• Monitoring of fluid status
• Medication management
• Vital sign arrhythmia monitoring
• Risk factor education
• Self-care education
• Caregiver support

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Heart Failure Cohort 2006

• 78 patients followed for an average of 117 days
• Interventions Medication optimization (49),
  vital sign alerts (44), diuretic titration (39)
• Average of 10.6 calls per patients
• 48 readmissions (31 non-cardiac, 17 cardiac 5
  non-avoidable CHF, 3 CHF medication
  noncompliance)
• No readmissions due to unrecognized precipitating
  causes of heart failure

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Lessons Learned

• Using regular phone lines is easy cost
  effective
• Patients are success at connecting equipment in
  their homes. Equipment return by bus is
  feasible. No distance barriers.
• The technology is reliable, producing valid
  patient data EHR
• The technology can be adapted to meet individual
  patient needs volume, language, frequency of
  transmissions, clinical questions
• Infrastructure promotes collaborative care model

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Limitations Challenges

• Programming the question on medication changes
  every Monday allows for medication reconciliation
  
• Data is just data. Patients instructed to call
  with symptoms
• Manual dexterity important for pocket ECG, and BP
  cuff
• Psychosocial home environment assessment
  important
• Remote programming now available

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Scope of Telehome Monitoring

• Self-care
• Health promotion
• IIness prevention
• Disease management
• Caregiver support education

• Monitoring VS
• Audio/video triage
• Teleconsultation with
• specialist
• Compliance monitoring
• Remote diagnosis
• Remote treatment

Health Applications
Administrative Management Applications
Patient Information Education

• Electronic case
• management
• Electronic record
• Database
• Remote access
• to records
• Care integration
• Coordination

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Future Plans Regional Cardiac Telehome
Monitoring Program
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What is IVR?

• Interactive Voice Response
• A technology which uses the telephone system.
  It delivers a set of automated questions to which
  a patient can respond using voice instead of key
  pads. This interaction identifies the patient by
  name and collects the responses in a database.

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How It Works

• Enter name of patient, contact number and
  discharge date
• System dials patient on scheduled dates
• Text to speech engine personalizes the call
• System asks questions in the algorithm
• Patient responses are dropped into a database
• System highlights issues that require management
  by health care provider

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IVR Applications
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Heart Failure Algorithm

• Q Do you weigh yourself daily before breakfast?
• If Yes, continue
• If No, Weighing yourself daily is an
  important habit. More than 2 lbs could mean you
  are retaining fluid. Weigh yourself every morning
  after emptying your bladder before breakfast.
  Use the same scale record your weight to show
  your physician.
• Q In the last two weeks has your weight increased
  more than two lbs in one day or more than 5 lbs
  in a week?
• If No, continue
• If Yes, callback

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Q8. Has the patient stopped or changed any of
their heart failure medications
Q14. Does the patient want information about how
to understand food labels?
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Remember your sodium target is 2000mg/day!
What the Label Really Means If labels say It
means Sodium free/ Less than 5mg
sodium/serving, Salt-free remember to check
the serving size. Reduced Sodium
At least 25 less sodium than
the original product (may still
be too high in sodium). Unsalted/ No
salt added during No added salt processing
(not necessarily sodium-free).

• HOW TO READ A FOOD LABEL FOR SODIUM
• Reading food labels is the only way to be sure
  of the sodium
• content of foods. The sodium content must be
  listed on the
• package check the Nutrition Facts panel.
• Food manufacturers change ingredients all the
  time make it a
• habit to read the label.

Follow these 3 easy steps to read the label
Step 1 Serving Size. Always compare the serving
size on the package to the amount that you eat.
The label lists the amount of sodium per serving
of food (not the package or container).

• Step 3 Ingredients are listed in decreasing
  order by weight if salt or sodium appears on
  the ingredient list at all, make sure it is near
  the end.
• Ingredients that shout HIGH IN SODIUM!
• Baking soda
• Brine
• Disodium phosphate
• Garlic, onion or celery salt
• Kosher salt
• Monosodium glutamate (MSG)
• Salt
• Sea salt
• Any other ingredient with the word sodium, such
  as sodium citrate or sodium nitrate.

• Step 2 Sodium. Low sodium choices for most foods
  are
• 200 mg sodium or less/serving or
• 8 Daily Value (DV) or less/serving.

INGREDIENTS CORN, WATER, SALT FOR TASTE
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Benefits

• Empowers patients in their own care
• Fills the gap from discharge to when the
  patients can access primary care provider
• Improves medication safety
• Meets patient individual needs self select
  information required
• Cost effective method for patient teaching
• Mechanism to maintain patients on best practice
  guidelines

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Lessons Learned

• Dont reinvent the wheel
• Algorithm is the key feature
• Use experts to develop
• Use focus groups to understand customer
• Refine continuously, based on feedback
• Ensure patients aware they will be called by the
  system
• Integrate with existing work practices
• Ensure expert responds to call
• Reports

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Study in Progress Preliminary Results n47

• 125 total calls made by IVR
• 47 callbacks requiring assessments
• 58 requests made to system to hear information on
  heart failure medications
• Patient satisfaction with IVR n35 (74 response
  rate 74 found IVR helpful very helpful, 94
  would use service again believe it is a good
  way to follow patients in the community
• 7 medication adverse events or potential events
  captured
• No avoidable readmissions to date

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Summary

• Patient-centered model
• Follow natural history
• Decisions made based on service youre providing
  to the patient
• Mild HF IVR
• Moderate to severe HF Telehome
• Technology allows you to leverage providers
• Promotes collaboration communication
• Fills a void where there are no primary care
  providers

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Key Issues

• Biggest learning spend your technology dollars
  wisely
• Adds value for the patient
• Match program to regional needs
• Service provided in the most optimal location

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