Eden Internal Medicine in Eden, North Carolina, believed it could up its game on treating diabetes and hypertension patients.

THE PROBLEM

For diabetes patients, first there was diabetes control and monitoring in between visits. Patients with uncontrolled diabetes with elevated A1c did not have any close monitoring between visits to bring the sugars down.

For example, if the patient has extremely high blood sugar in the three-months-average A1c test during the visit today, staff will not have a way of closely monitoring the patient in between the visits until the patient comes for the next visit in three months. 

That means the patient has been uncontrolled or partially controlled for three months. Uncontrolled diabetes leads to many complications for the patient. CMS and other HEDIS star rating and quality metrics require better A1c control.

"There are limitations with Bluetooth technology," said Dr. Dhruv B. Vyas, owner and partner at Eden Internal Medicine. "Bluetooth is not convenient for the patients who are not technologically savvy and do not have a smartphone, which makes it difficult to monitor them for glucose control in between the visits.

"Bluetooth devices lead to failure to transmit sometimes and a problem with syncing the devices that results with more time spent by the staff and the patient to fix the device connectivity issues," he continued. "Many patients do not have smartphones or have aversion to technology, which limits the use of such devices."

Then there is patient accountability and compliance monitoring. It was difficult to manage patients' accountability and compliance without having instant blood glucose monitoring between the visits while they were at home.

"Some patients may need close monitoring of the blood sugar readings and monitoring to follow the diet and exercise program," Vyas explained. "Without the instant access to the blood sugar readings daily for the doctor's office, it is difficult to advise such patients to improve their lifestyle and/or make medication changes."

Then comes hypertension. First, there was monitoring of blood pressure in between the visits.

"Monitoring blood pressure in between visits and adjusting the medication to get the blood pressure to the goal is key," said Vyas. "Patients with uncontrolled blood pressure and recent medication changes require frequent office visits, which is difficult for many patients.

"And then there is managing the patient with white coat hypertension," he continued. "It is difficult to treat the patient with labile hypertension or white coat hypertension based on the readings in the office. Patients may have extremely high blood pressure in the office, but reportedly normal blood pressure at home."

Treating such patients aggressively may lead to a hypotensive episode and syncope, he added. Monitoring such patients with reliable devices would give accurate data in their home settings when they are comfortable and not anxious, he said.

Lack of reliability of the current cellular blood pressure devices also was an issue. Some of the existing cellular blood pressure devices were not as accurate, and it was difficult to treat patients based on those numbers. There was a need for reliable cellular blood pressure monitor devices that produce consistent readings based on which medication could be adjusted.

And again, limitations with Bluetooth technology.

"Bluetooth BP devices work for people with smartphones and who are technologically savvy, but do not work for people with a regular phone in a rural area and who have a phobia of technology," Vyas said.

PROPOSAL

Eden Internal Medicine turned to technology from Smart Meter. The technology offers cellular-connected devices like blood sugar and blood pressure machines that would instantly transmit the readings to a patient's records or to a dashboard.

"By using cellular technology, the patient barriers of technology reliance are removed," said Vyas. "Diabetic supplies and test strips can be automatically shipped to the patient's home when they run out of the strips by the intuitive data platform on Smart Meter technology. Unlimited amounts of test strips are supplied with the Smart Start program. The technology has excellent support staff for troubleshooting, which reduces patient and staff time.

"Smart Meter devices are reliable and accurate, and produce consistent results of the blood pressure and blood sugar readings, which are in acceptable norms of standard deviation," he added. "The technology enables flexible device distribution, including direct-to-patient delivery, and manages all device and data logistics. It also provides training and support for providers, patients and caregivers."

MARKETPLACE

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MEETING THE CHALLENGE

Eden Internal Medicine integrated the Smart Meter technology with its AstuteDoc care management platform.

"The intuitive software from AstuteDoc provides dashboards, care plans, interventions, data graphs, time management, billing exports and many more features, along with dedicated care team members embedded in the medical practice," Vyas explained. 

"AstuteDoc's complete care management solutions include chronic care management, remote patient monitoring, transition-to-care management, annual wellness, ACO quality metrics, incident-to-visit, and principal care management.

"This platform has been used by many ACO medical practices, PharmD, physicians, cardiologists, endocrinologists, primary care practices, nurse practitioners, care coordinators and medical assistants," he continued. "AstuteDoc embeds the PharmD or medical assistant into the doctor's offices to achieve care management goals and quality metrics."

Implementing the Smart Meter technology resulted in better workflow, seamless integration, and staff and patient satisfaction, Vyas reported.

"AstuteDoc's care management providers, staff and PharmD were able to deliver better outcomes for the patients' blood pressure and blood sugar control," he said. "This has translated into better HEDIS Star rating quality metrics.

"And patient compliance has significantly improved," he continued. "Care coordinators' intervention in between visits led to improvement in the patient lifestyle and accountability toward exercise and dietary choices. Patients were more knowledgeable about their health issues and more motivated to take care of their health."

Enrolling patients in remote monitoring was much easier for care coordinators using Smart Meter devices, he added. Instant transmission of the data and integration to the software was seamless and reduced enrollment time, he said.

"Monitoring of data was much easier for staff via specific alerts for each patient to achieve their goals," said Vyas. "During the pandemic, tele-visits were surging, and use of the Smart Meter devices nicely complemented with such visits to provide more data to the providers for the meaningful disease management. Home BP readings transmitted were used for certain visits like annual wellness, which is a required element for CMS."

RESULTS

On the diabetes metrics front, Eden Internal Medicine saw improvement in A1c readings, reducing hospitalizations via improved patient compliance.

"Improvement in A1c was noted on an average of 1.6 with patients at the next visit in three months," Vyas reported. "And there was significant improvement in postprandial hyperglycemia due to close monitoring and intervention between visits. This has translated into weight loss due to patient accountability and lifestyle change.

"By creating critical alert triggers for different glucose readings, we were able to reduce the hospitalizations for hypoglycemia and diabetic ketoacidosis," he continued. "In the long run, we expect this A1c control to reduce diabetes-induced complications."

Eden Internal Medicine achieved a 4.95 HEDIS Star Rating for United Healthcare Medicare.

On the hypertension metrics front, patients' blood pressure was reduced by intervention in between visits.

"Patients with labile hypertension or white coat hypertension had somewhat normal readings at home, which has been documented in the EHR," Vyas explained. "Remote patient monitoring blood pressure readings can be used one time a year during in-office visits for the CMS quality metrics goal of BP Control.

"There were two patients with syncopal episodes, which appeared to be due to low blood pressure readings at home with the same medications, while these patients were showing high BP readings in the office," he continued. "The number of medications was reduced now based on the home blood pressure readings to correct the problems of overmedication. Patients started having more energy, and had no syncopal episode and less medication expense."

ADVICE FOR OTHERS

"Any healthcare provider organization considering using similar technology needs to investigate cellular technology platforms that integrate with the care management software or EHR," Vyas advised. "Reliability of the device and consistent support from the vendor will be equally important for this program to be successful."

Vyas strongly advises against using Bluetooth technology unless patients are technologically savvy and have a smartphone. Providers should use remote patient monitoring technology for high-risk patients, set specific critical alerts and decide intervention/care plans to bring them to the desired goals, he added.

"For better implementation of the remote monitoring program, it needs to be intertwined with the other care management programs like CCM, TCM, AWV, PCM, etc., to maximize the benefit for the value-based patient care, which translates into better quality scores and outcomes," he said. 

"Implementation for such programs is extremely difficult if you do not have dedicated staff or a care management company handling day-to-day needs of the program and critical alerts interventions as providers will not have time to handle the workload.

"And having a PharmD-supported program also provides significant value to the practice, patient, ACO and Medicare advantage plans," he concluded. "The highest performing practices achieve their goals from the most coordinated care team efforts, workflows and smart technology."

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
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