Like many other health systems, University Hospitals in Cleveland advanced hospital-at-home technology and programs in rapid response to the COVID-19 pandemic.
A few days after the World Health Organization declared COVID-19 a pandemic in March 2020, Dr. Peter Pronovost, chief clinical transformation officer at University Hospitals, got on the phone with a remote patient monitoring company to pair the company’s technology with a pulse oximeter to track patients’ oxygen levels remotely. Within days of the initial call with the vendor, Pronovost received emergency use authorization approval from the U.S. Food and Drug Administration, and a few days they rolled it out with patients.
“Patients would show up to the emergency department and we’d connect them through the device with their phone so there was no extra hardware needed,” Pronovost said. “It saved us on personal protection equipment, the patients loved it because they’re in their home. They’d get calls from nurses twice per day, which helped them maintain that human connection. We’ve monitored about 4,000 patients with this. We’ve expanded it to patients with COPD (chronic obstructive pulmonary disease), pneumonia, heart disease and urinary tract infection.”
During the first year of the pandemic, University Hospitals took advantage of the Centers for Medicare and Medicaid Services’ Hospital Without Walls and the Acute Care at Home programs, which launched in March and November 2020, respectively. The programs provided payment to health systems for remote-based technology and other home-based healthcare services. A few months into COVID-19, the Cleveland-based health system officially rolled out its full hospital-at-home program, which includes virtual and home-based care.
University Hospitals has seen some early successes with its hospital-at-home program and remote patient monitoring technology. From a safety perspective, the technology led to a mortality rate of six per 1,000 patients with COVID-19 compared with 26 per 1,000 patients without at-home monitoring, according to research in JAMA, published by Pronovost and his team. Pronovost said length of stay and hospital readmission rates have also been much better for those using the technology and participating in the program.
Despite these successes, deploying hospital-at-home technology and programs in a short time period is naturally going to come with a certain set of obstacles. Here were the three biggest challenges Pronovost and his team dealt with during rollout and beyond.
Vendor collaboration. Pronovost said the technology developed by the vendor was nowhere near ready for prime time, partly because it wasn’t developed in tandem with clinicians. “We had to tweak some of their products to make sure they were easy for clinicians to use. Then we had to see how it would fit in a workflow, and who would do the work for it,” he said. Between the FDA approval and patient rollout, the company’s engineers and University Hospitals’ team were on frequent conference calls where the health system’s team identified glitches and redesigns that were needed. “They’d come back that afternoon or early the next day with those fixes. It was these intense, rapid learning cycles,” Pronovost said.
Figuring out where it sits in the organization. Fitting the technology into the organization’s structure and the clinician’s workflow was no small task. For one thing the team had to ensure data from the remote patient monitoring devices were getting integrated into the health system’s electronic health record system. Beyond the technology, they had to figure out where within the health system this program would sit. “This is essentially a whole new service line,” Pronovost said. “It could be staffed with hospitalists, emergency care, critical care or a combination of one of those [groups of staff].” Since the operating room was closed, the health system settled on using post-anesthesia care unit nurses, emergency room physicians and hospitalists to care for the patients virtually. Once this was figured out, Pronovost said it was important for University Hospitals to win the clinicians’ trust when leveraging this technology and program. This came through extended conversations and listening sessions with clinicians. It’s imperative, Pronovost said, to name a team that’s responsible for understanding structural and cultural challenges.
Payment uncertainty. The last obstacle remains ongoing. When the public health emergency ends, so do the flexibilities for providing care to patients remotely, as outlined in CMS’ Hospital Without Walls and Acute Hospital Care at Home programs. A recent bill introduced by a bipartisan group of congressional members would extend the hospital-at-home waivers another two years. But without that bill passing, it could be hard to continue these programs, which require technology investments and continuous maintenance. Pronovost said the hospital-at-home waivers have been transformative. He said that if health systems like his can show the effectiveness and cost savings of these programs, CMS will be on board in the long run. Separate from hospital at home, the remote monitoring technology is a little more nuanced in terms of how it’s reimbursed, since it requires billing from the team that puts on the technology on rather than those who are continuously monitoring it.