Chances are, when patients check out of a hospital for home or another health care facility, they will end up back in the hospital within a month if they have not worked out the details and logistics for ongoing care. Too often such planning falls by the wayside, resulting in frequent hospital readmissions.
For the federal government, the cost to Medicare alone totals more than $17 billion each year for return trips to the hospital, to say nothing of the difficulties for the patients themselves. (pdf) The Affordable Care Act’s (ACA) proposed cure for this condition is for hospitals, healthcare workers and patients to make greater use of technologies that monitor health remotely, ensuring patients receive proper medical care to avoid additional hospital visits.
The Obama administration introduced the ACA in 2010 to move health care away from a fee-for-service model to one that promotes preventative care and overall wellness. Beginning this October the ACA will reinforce this approach by penalizing hospitals with chronic readmission problems by cutting Medicare reimbursement payments to those facilities. This policy initially targets patients suffering from three health conditions—heart failure, pneumonia and heart attack—but penalties will apply to additional conditions beginning in 2015.
About one in five Medicare patients return to the hospital within a month after discharge. Although some hospital readmissions are unavoidable—the odds are higher for the elderly and those with chronic conditions—many result from the lack of transitional care and long-term support, says Mary Naylor, a professor at the University of Pennsylvania School of Nursing who has researched the most common reasons for rehospitalization. Among frail, older adults these include stroke, hip fracture, sepsis and urinary tract infection.
Technologies most likely to help hospitals lower readmission rates and limit penalties include so-called “telehealth” systems that connect patients with physicians, nurses or other care managers after checkout, microchipped pills that indicate whether patients take their medicine as prescribed and software that improves the management of electronic health records (EHRs).
Telehealth has matured beyond the ability to simply gather and transmit patient information over the Internet and wireless networks. Newer technologies include touch-screen devices and software that guide ongoing care. Bosch Healthcare’s wireless T400 Telehealth System for discharged patients, for example, addresses dozens of medical conditions, including chronic obstructive pulmonary disease, congestive heart failure and diabetes. Patients enter their vital signs into the T400 daily, and the device transmits that data to their health care provider for review and response.
Other remote health monitoring systems have patients wear sensors that wirelessly collect, store, analyze and transmit health-related data. One of several approaches is the Wearable Wellness System from Italy’s Smartex, essentially an undershirt with embedded sensors and a processor that can monitor heart and respiration rates. Although not as fashionable, the Metria wearable sensor, from Vancive Medical Technologies, a medical division of Avery Dennison, can be adhesively bound to the body to measure heart rate, respiration, sleep duration and activity levels.
One person who sees a great need for use of telehealth technology in patients with chronic conditions is Richard Della Penna, a former physician with Kaiser Permanente and chief medical officer at Independa, a company that sells software and services designed specifically to help the elderly live independently. “If a health device is able to capture data that predicts when a person with, say, heart failure is starting a readmission trajectory, and someone quickly responds appropriately to the incoming data, only then may readmission rates be impacted," he says.
But some warn that sensors and the like, despite their potential for good, could backfire by creating more work for physicians and other health care workers. “A big challenge is addressing the huge amount of data that is obtained through monitoring,” says Mary Rodgers, professor and chair of the Department of Physical Therapy and Rehabilitation Science at the University of Maryland School of Medicine. “It has to be analyzed, points of concern have to be
identified, and communication has to occur.” Other challenges include protecting patient privacy, determining who will pay for the technology and ensuring that different wearable sensors can communicate with the variety of smartphones and computers trying to read the data.
In addition to monitoring the patients themselves, physicians are looking for ways to assure that discharged patients take their medications as instructed. “There are many ways this can be done, but the bottom line is that mobile technology has been shown to improve patient adherence to prescribed treatment plans,” says Marc Mitchell, a pediatrician and lecturer on global health at Harvard School of Public Health. This technology might someday include smart caps for medicine bottles that would automatically inform a clinician when a prescribed medicine is taken (or at least if the bottle was opened), he adds.
In August 2012 the U.S. Food and Drug Administration approved the use of electronic chips in medications, giving Proteus Digital Health the green light to embed ingestible sensors in pills to help doctors, nurses, pharmacists or other health care workers to monitor patients’ medicinal intake. When swallowed, the sensor—a microchip made of copper, magnesium and silicon—transmits a signal to a patch worn on the body, which then sends physiological data such as heart rate, temperature and activity/rest patterns to a patient’s smartphone. Patients control the information the system collects and can choose to share it with their clinicians or caregivers. The microchip ultimately passes through the digestive system.
Electronic health records
For years EHRs have been promising to transform the health care industry by making patient health information available anywhere, anytime—an important part of helping health care workers to stay on top of patients discharged from hospitals. Unfortunately, it has been a slow transition. In addition to being expensive—for starters, creating and managing digital records involves computer and network upgrades to ensure patient privacy—EHRs require doctors and nurses, for in particular, to become more accustomed to interacting via computers and mobile devices with other health care professionals as well as with their patients.
In 2009 the Health Information Technology for Economic and Clinical Health Act (HITECH) gave EHRs a shot in the arm by allocating more than $20 billion to encourage hospitals and health care facilities to digitize patient data and make better use of information technology (pdf). By 2012, 72 percent of office-based physicians were using EHRs, compared with 48 percent in 2009, according to a December report from the U.S. Centers for Disease Control and Prevention. Yet many physicians are not using EHRs to their full potential—such as digitally ordering prescriptions and refills. To help solve these problems the U.S. Department of Health and Human Services recently allocated $18 million in ACA funds to further EHS adoption and use.
The ACA’s looming Medicare payment penalties could induce hospitals and their staff to take fuller advantage of EHRs and a variety of other technologies to keep closer tabs on discharged patients. Says Independa’s Della Penna: "We now have the tools to merge the boundaries between hospital and home.”