Providence, a 52-hospital health system based in Renton, Washington, views digital innovation as an important vehicle to overcoming industrywide challenges and transforming care delivery for the betterment of the communities it serves.

Many of the virtual care and digital health systems in development, as well as those pursued over the past several years, are geared toward addressing three macro challenges healthcare currently faces: workforce shortages and burnout; hospitality capacity and throughput; and care fragmentation or patient access.

The health system's expansion into remote patient monitoring is meant to directly address two of these issues.

THE PROBLEM

"Scheduling in-person appointments with primary care providers as frequently as needed for proper monitoring and follow-ups can be a real challenge for patients with chronic conditions," remarked Dr. Eve Cunningham, chief of virtual care and digital health at Providence. "RPM provides a viable solution to improve patient care and outcomes, leverage team-based care, and maintain neutral workload for PCPs and care teams.

"It significantly eases the way of our patients by extending our clinical team directly into homes, enhancing the quality of care we provide to patients with chronic conditions while streamlining the patient experience," she continued. "RPM has been a game-changer for both our caregivers and patients, and our work with [RPM vendor] Cadence is a tremendous example of how our commitment to embracing this virtual modality of care has translated to better patient outcomes."

PROPOSAL

For large-scale adoption, Providence took a population health approach and looked at how many patients could be eligible for this type of program, the clinical benefits, the increased access and the ability to care for patients in a better way.

"What we discovered was there was a lot of interest in RPM from both a caregiver and patient perspective, thus a huge opportunity to widely implement this technology," Cunningham said. "For years, we had experimented with RPM in smaller pilots, but never had scaled it for a variety of reasons.

"With technology, it's very important to develop simple and frictionless tools that don't add to physician burnout, but instead reduce administrative burdens and make the care delivery process more efficient and energizing."

Dr. Kenneth W. Kooser, Providence Medical Group Family Medicine-Lacey

"When we connected with Cadence, we saw an opportunity to implement RPM across our footprint," she added. "Together, we were able to identify a site where we could prove the concept, demonstrate success and socialize it internally to scale."

At the onset of this work, Providence had four fundamental objectives: to increase patient engagement, strengthen the patient/provider relationship, improve quality of care and ultimately shift the delivery of care from reactive to proactive.

"We knew this would lead to improved clinical outcomes and reduced total health expenditure for patients – and we were right," Cunningham noted.

"The program has since helped us keep chronically ill patients safe at home to achieve the Quintuple Aim of healthcare improvement: Improve the patient experience by tailoring treatments and interventions to patient data; address population health through proactive, preventative care delivery; lower cost by connecting patients to the most appropriate care intervention and reduce avoidable hospitalizations; improve provider well-being by extending their reach via a virtual care team; and provide equitable care by reaching all patients, regardless of their ability to present in-person for treatment."

MEETING THE CHALLENGE

At Providence, patients suffering from congestive heart failure, hypertension and/or type 2 diabetes are provided with equipment that allows Cadence's virtual care team to proactively monitor a patient's condition from their home.

"If there are concerns, the Cadence team reaches out to the patient to assess their wellbeing, manage their medications, and, if necessary, connect them to their Providence clinician to hopefully avoid a trip to the emergency room," said Dr. Kenneth W. Kooser, a family medicine physician at Providence Medical Group Family Medicine-Lacey in Lacey, Washington.

"This team-based approach allows for additional touchpoints with chronically ill patients from the comfort of their home, between patient visits," he continued. "Cadence's services are accessible 24/7 and help triage emergent, urgent and non-urgent issues, which reduces the burden on Providence clinicians."

For team-based care to succeed, it is critical to establish mutually agreed-upon clinical guidelines so everyone on the care team is rowing in the same direction, he added.

"With remote monitoring, for example, that meant we had to set clear and effective clinical guidelines for patients in advance, so everyone on a patient's care team understands when and how to intervene if needed," he explained. "We regularly review and update these clinical guidelines with the latest evidence-based practices.

"We then communicate these new guidelines to everyone on a patient's team in an effort to standardize care and ensure every patient is getting the best care across every clinical touchpoint," he continued. 

"With technology, it's also very important to develop simple and frictionless tools that don't add to physician burnout, but instead reduce administrative burdens and make the care delivery process more efficient and energizing."

In the case of remote monitoring, the value for patients is clear: Patients receive peace of mind knowing someone is monitoring their health consistently, he added.

"What's less commonly discussed is how RPM can improve work-life balance and alleviate burden for clinicians," he noted. "For us, a key aspect was ensuring EHR integration was available from the beginning for our clinicians. With EHR integration, all patient information is available in real time for clinicians.

"They can easily identify patients who would benefit from remote monitoring, based on personalized eligibility criteria established by our clinical team, and then easily place orders for patients in the EHR," he continued. "We also prioritized innovative features, such as a sophisticated alert system and patient communication platform, so RPM is seamless and easy to use for clinicians, staff and patients."

The majority of these alerts, for example, get addressed efficiently by the RPM team, without ever escalating to the primary care provider, he added.

"In fact, less than 1% of alerts require escalation to the Providence care team," he reported. "This results in fewer phone calls and messages coming into the clinic. This means we also can catch potential patient issues in real time instead of waiting for the patient to come in for a traditional appointment, at which point their medical condition may have deteriorated.

"Not to mention, with remote monitoring data readily available, clinicians can better utilize their in-person visits with patients and reduce the need for more frequent visits that can be avoided due to routine concerns," he said.

RESULTS

Providence's remote patient monitoring program went live in the summer of 2022 with two pilots in Washington state. Since then, the health system has seen high growth and adoption.

"We measure across key metrics including utilization, retention, patient and provider satisfaction, and escalations to Providence PCPs, along with clinical metrics such as blood pressure, percentage of patients on guidelines, etc.," Cunningham explained.

To date, she reported, Providence now has more than 1,500 patients currently enrolled in the care model, and "we expect this number to reach 5,000 to 8,000 by the end of 2024."

Meanwhile, 88% are taking their vitals daily and 77% remain enrolled in the program after six months.

Cadence is reducing workload for providers with its clinical care team and successfully managing and triaging patient alerts: Only 0.6% of remote encounters escalate to Providence clinicians.

Clinical outcomes for patients with hypertension and type 2 diabetes are even more notable: Patients starting with systolic BP>160 achieve a median SBP reduction of 21 mmHg by week 12 (in other words, 12.55% reduction in SBP by week 12); and patients with a blood glucose reading above 183 mg/dL achieved a 16.75% reduction in blood glucose by week 12.

With a year of success under its belt, Providence is now live with RPM in Washington, Montana and California, and is green-lighting expansion of the program to Alaska this year.

ADVICE FOR OTHERS

At the highest level, Providence prioritizes executive alignment at the beginning of any key partnership or large-scale initiative, Cunningham noted.

"Pick your technology projects intentionally, with strategic KPIs and implementation plans behind them," she advised. "Make sure they line up to your health system's key objectives and help solve your biggest challenges.

"This has been very effective in determining if our approach is working," she continued. "Be rigorous around bringing stakeholders together, reviewing and making sure you're on track so you can continue to move forward or not."

Piloting and developing a proof of concept is key, she added.

"We are firm believers in piloting technology programs before scaling more widely across the health system," she explained. "That said, we do not want to engage in perpetual pilots, so we are always planning the 'pilot to scale' approach for any solution we bring forward.

"For remote patient monitoring programs, it's important to ensure the flow of communications is working correctly between patients, physicians and your partner," she continued. "Ensure the incoming data is managed properly – where is it going, who is reviewing it, is it adding any extra burdens along the way, who acts on this information, are important questions to ask."

And last, Providence recommends developing a "tiger team" to scale, ensuring one has expertise in change management and workflow redesign on the team, she advised.

"Getting a program like this off the ground is only the beginning – scaling it is really when the rubber meets the road and you need a team internally, across departments, that can champion and encourage adoption at every touchpoint," she concluded. 

"Assigning project managers in different departments across the organization including clinical influencers, IT and operations support, and marketing and communication experts, is critical to the program's success."

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