Boston Medical Center is a not-for-profit academic medical center and the largest safety-net hospital in New England. It provides medical care for infants, children, teens and adults.

Dr. Christina Yarrington is chief of maternal fetal medicine at Boston Medical Center. As a leader in obstetrics at the medical center, her focus is on ensuring the facility's population has the resources needed to monitor patients at high risk of postpartum hypertension to reduce overall health risks in a way that doesn't disrupt the important early days of infant bonding at home.

THE PROBLEM

Postpartum hypertension is a leading cause of postpartum hospital readmissions and severe maternal morbidity, since it can lead to heart attacks and strokes, which makes it vital to monitor blood pressure closely and then be able to leverage data from blood pressure readings.

There are challenges in getting timely blood pressure data if dependent on a visiting nurse or if coming into the doctor's office with an infant is sometimes impossible. The pandemic magnified these challenges.

"Fortunately, we already had started to explore remote patient monitoring solutions that integrated with our Epic EHR, were easily accessible and required minimal effort by the patient," Yarrington noted.

PROPOSAL

Boston Medical Center serves a population largely reliant on Medicaid to support healthcare access. Reflecting on the economic access of the patients, Yarrington and staff sought a remote patient monitoring system that could work without dependence on WiFi, Bluetooth or an individual mobile data plan.

"We ultimately chose Rimidi because their clinical management platform integrates with cellular-enabled connected blood pressure cuffs, which meant the only ask of our patients was to put on the cuff and press a single button and the data would come to us regardless of their WiFi, broadband, etc.," she explained.

"When looking to implement a remote monitoring program, it's important to keep your unique patient experiences top of mind."

Dr. Christina Yarrington, Boston Medical Center

"We heard from many of our patients that telemedicine video visits drained their personal data plans, so the reassurance that this part of their care was independent from their own digital environment enabled participation," she continued.

The data from the blood pressure readings taken from the cuffs is transmitted directly to Rimidi, which was integrated with the Epic EHR, enabling clinicians to see the blood pressure data within their existing workflow.

"The goal of implementing the remote patient monitoring solution was to give patients the tools they need to monitor their blood pressure at home while knowing their care team is looking out for them as well to catch any out-of-range blood pressures that could lead to a stroke," Yarrington explained.

"We also hoped to keep our postpartum patients at home with their families and new infants, thus we built out a protocol for managing new hypertension remotely whenever possible," she added.

MARKETPLACE

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MEETING THE CHALLENGE

Patients at high risk of postpartum hypertension, such as those with hypertensive disorders of pregnancy, chronic hypertension or hypertension during hospitalization for delivery, are given cellular-enabled blood pressure cuffs and provided instructions to take their blood pressure daily for six weeks following delivery.

They receive written instructions available in English, Spanish and Haitian Creole (the three most common languages in the area), as well as a QR code that links to an instructional video on home blood pressure monitoring in that language.

"The blood pressure measurements are transmitted to Rimidi's secure web portal and combined with other relevant, patient-specific clinical information pulled from Epic," Yarrington said. "This gives us the opportunity to see not just the trend of the individual's blood pressure, which commonly informs next steps, but also the context of their hypertension in their overall cardiometabolic health.

"For this program, Rimidi also set up configurable clinical decision support cards, which flag when a patient was missing a reading, or when readings were outside a certain threshold," she continued. "In addition, the system provides discharge alerts when the patient has been monitored for six weeks if their blood pressure looks good."

The alerts were designed with the Boston Medical team to improve triage, patient and provider communication, and the clinical workflow, she added.

"It's not just the data from Epic and the blood pressure cuffs that are integrated, it's the experience for clinicians; the technology launches and provides decision support within their Epic workflow," Yarrington explained.

"Overall, by setting up this program and utilizing the remote patient monitoring technology, we've been able to intervene faster to prevent adverse outcomes," she said. "Patients have stated that through this program they felt well cared for, and they felt like someone was paying attention, even after they left the hospital."

RESULTS

Boston Medical recently published results of the remote patient monitoring program in the American Heart Association journal Circulation.

Out of the 1,000 patients monitored during the time period of April 2020 and September 2021, 98.7% submitted at least one blood pressure measurement, with an average of 17 unique measurements from enrolled patients during the six weeks after delivery. This has led to the early detection and management of stroke-risk blood pressure.

ADVICE FOR OTHERS

"When looking to implement a remote monitoring program, it's important to keep your unique patient experiences top of mind," Yarrington advised. "It's not enough to give a person a device – the amount of work they are able to do to provide data, the way they interact with it, and their particular digital environment will vary, and these are the critical components of success.

"The other half of the equation is making sure the solution integrates well into your current EHR and clinical workflow," she concluded. "Changing workflows always is hard, but taking the time to properly train a small number of the staff and making sure they are comfortable with the new processes, then disseminating it to the rest of the staff, makes the new processes and procedures easier to implement."

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