Prisma Health is the largest healthcare provider organization in South Carolina. It had encountered a problem while trying to gather patient biometrics and manage their clinical needs: fragmentation.

THE PROBLEM

The logistical challenge of distributing remote patient monitoring equipment to patients across the initial focus of approximately 50 physicians' offices proved overwhelming with the organization's internal resources alone.

"From the patient's perspective, imagine being responsible for recording blood pressure readings multiple times a day, only to have to remember to bring that information to their doctor's visit," said Angela Orsky, senior vice president of value-based care and clinical integration at Prisma Health. "It's understandable this process would lead to gaps in data collection, especially for patients facing visual impairment or literacy challenges.

"Despite efforts to educate patients on when to contact their doctor, it was common for them to overlook reaching out when their readings were abnormal," she continued. "For physicians, attempting to make sense of multiple readings scattered across various documents to determine the appropriate medical interventions, including medication adjustments, only compounded the sense of fragmentation in the process."

PROPOSAL

Prisma Health looked to vendor HealthSnap for help.

"The solution wasn't just about the technology; it was a well-defined program addressing logistics, patient engagement, and full electronic health record integration for optimized clinician workflow," Orsky explained. "The value of having a program where the vendor manages patient outreach, coordinates equipment delivery and ensures proper functioning addresses the coordination challenges for our health system.

"Patient engagement is equally vital for program success," she continued. "The convenience for both patients and clinicians, where patients take their readings with home equipment and data immediately integrates into their health record, is a game changer."

If patients forget their readings, care managers step in with reminders and monitor alerts, calling patients and escalating abnormal results in collaboration with the physician practice. This comprehensive program offers Prisma Health a quicker speed-to-market system that is scalable compared to internally building all components of a program, Orsky added.

MEETING THE CHALLENGE

The initial rollout began in primary care practices, targeting patients who met billable chronic diagnosis criteria for remote patient monitoring and/or chronic care management and had visited their primary care provider within the last 12 months.

"To prepare for the rollout, we collaborated closely with a large internal medicine practice to establish standard workflows and live Epic EHR interfaces for various functions including outbound orders, outbound admit discharge treat, inbound flowsheet, inbound notes, charge interface and outbound notes," Orsky explained. "Educational sessions were conducted for clinicians to familiarize them with these workflows within Epic, including the process of reviewing charges before submission for billing."

The integration also includes a summary of biometric readings over time, enabling physicians to assess and treat the clinical status of the patient more accurately.

RESULTS

Clinical outcomes have shown 82% of patients experienced lowered blood pressure (n = 757 with a minimum 30 days of monitoring). Severely hypertensive patients saw a decrease from a baseline systolic BP of 152.31 to 92.74 after 90 days on the program, while diastolic BP reduced from 133.63 to 82.23.

At baseline, 279 patients were classified as stage 2 hypertension, which reduced to 74 patients following an average of 124 days on the program.

ADVICE FOR OTHERS

"Without exception, the value proposition necessitates a comprehensive program," Orsky said. "While the advancements in technology and the ease of coordination to deploy equipment are critical components of a robust remote patient monitoring program, the integration with EHR and high-touch clinical oversight in collaboration with the attending physician cannot be overlooked.

"Despite significant planning and the identification of robust technology, achieving scale and timeliness of interventions to significantly improve clinical outcomes was not feasible without a complete interface with our EHR," she concluded. "Partnering with a vendor or company willing and capable of supporting integration should be a primary consideration."

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