Case Studies in Telehealth Adoption
January 2013
Partners HealthCare: Connecting
Heart Failure Patients to Providers
Through Remote Monitoring
Andrew Broderick
ABSTRACT: Partners HealthCare’s programs in home telehealth have been driven by its
Fund is to promote a high performance
Center for Connected Health, which has pilot-tested and implemented telemedicine and
health care system. The Fund carries
remote monitoring solutions. The center focuses on practical innovations that can change
out this mandate by supporting
patient behaviors to realize better clinical outcomes. The center’s Connected Cardiac Care
independent research on health care
issues and making grants to improve
Program has enrolled more than 1,200 patients since its introduction in 2006 and has expe-
health care practice and policy. Support
rienced an approximate 50 percent reduction in heart failure hospital readmission rates
for this research was provided by
overall for enrolled patients. The center estimates the program has generated total cost
The Commonwealth Fund. The views
savings of more than $10 million since 2006. Human factors and social processes have
presented here are those of the author
been important in successfully introducing telehealth technology solutions into work-
and not necessarily those of The
flow and patient care. Technology has also had a positive impact on patient activation and
Commonwealth Fund or its directors,
officers, or staff.
engagement in self-care, helping to demonstrate to providers that this new program sup-
ports behavior changes that lead to improved care and quality outcomes.
For more information about this study,
OVERVIEW
please contact:
Partners HealthCare (Partners), an integrated health system in Boston, is under-
Andrew Broderick, M.A., M.B.A.
going a mission-driven, system-level transformation by aligning the organization
Codirector, Center for Innovation
and Technology in Public Health
with external forces shaping the future organization, financing, and delivery of
Public Health Institute
health care. Its strategic initiatives center on making patient care more affordable
and accountable through providing integrated, evidence-based, patient-centered
care. Partners’ strategy implementation group has been looking at performance
improvement in a number of priority conditions. These initially included diabe-
To learn more about new publications
tes, acute myocardial infarction, coronary artery bypass graft surgery, stroke, and
when they become available, visit the
colorectal cancer, but other conditions will be added to the initial care redesign
portfolio over time. Care redesign initiatives are working to move the organiza-
Commonwealth Fund pub. 1656
Vol. 3
tion from an episodic and specialty approach to a longitudinal, condition-based,
2
The Commonwealth Fund
and patient-focused orientation. These include deter-
BACKGROUND
mining how technology can contribute toward improv-
Boston-based Partners HealthCare is an integrated
ing care quality and cost-effectiveness and identifying
health system. In addition to the two academic
strategies for their successful introduction into practice.
medical centers, Brigham and Women’s Hospital and
A key strategic priority at Partners has been
Massachusetts General Hospital, the Partners’ system
to reduce 30-day readmissions to improve quality of
includes community and specialty hospitals, commu-
care and patient satisfaction, and to minimize Partners’
nity health centers, a physician network, home health
financial risk for potential reductions in Medicare pay-
and long-term care services, and other health-related
ments. Initiatives that work toward meeting those goals
entities. The spectrum of care offered at Partners
include: providing patients with critical information at
includes prevention and primary care, hospital and
discharge to promote safer transitions, using transitions
specialty care, rehabilitation, and home care services.
teams and health coaches, participating in the Center
As one of the nation’s leading medical research orga-
for Medicare and Medicaid Services’ care coordina-
nizations and a principal teaching affiliate of Harvard
tion pilot demonstrations, and programs that connect
Medical School, the nonprofit organization employs
chronic care patients with specialized outpatient care
more than 50,000 physicians, nurses, scientists, and
services.1 Health information technologies, including
caregivers.
patient-centered telehealth technologies, serve as a
Partners’ mission includes a commitment to its
strategic tool across many of these process improve-
community and the recognition that increasing value
ment initiatives. In the future, widespread use of con-
and continuously improving quality are essential to
nected health solutions at Partners will be driven by
maintaining operational excellence. Partners is also
structural changes like new reimbursement models and
dedicated to enhancing patient care, teaching, and
the introduction of patient-centered medical homes.
research and to taking a leadership role as an integrated
Partners’ Center for Connected Health (CCH)2
health care system. The organization also prizes tech-
leads the development of patient-centered telehealth
nology adoption and innovation to drive improvements
solutions and remote health services for a variety
in operations, productivity, and patient care. Its success
of chronic health conditions, potentially leading to
to date in the large-scale adoption of electronic health
reductions in preventable readmissions. The shared
record (EHR) and computerized physician order entry
goal of these telehealth solutions is to improve outpa-
(CPOE) systems attests to the organizational culture of
tient care management. Partners’ experience with the
openness, preparedness, and ability to adapt to change.
implementation of technology into workflow and care
Such attributes have helped to ensure that the rollout of
management practices indicates that the technology
new technologies is minimally disruptive and seamless
has a positive impact on patient activation and engage-
to workflow.
ment in self-care and plays a critical role in realizing
Partners has launched efficient care redesign
better clinical outcomes. This evidence is critical in
efforts for five conditions—diabetes, acute myocardial
demonstrating to providers that this new program sup-
infarction, coronary artery bypass graft surgery, stroke,
ports behavior changes that lead to improved care and
and colorectal cancer—that reflect its shift toward
quality outcomes. However, Partners’ experience indi-
longitudinal, condition-, and patient-focused orienta-
cates that organizations must be prepared for potential
tion in care. The care redesign initiative is being led by
implementation delays imposed by the current fee-for-
Partners Community HealthCare (PCH), the manage-
service environment’s adverse impact on staff behav-
ment services organization for the Partners’ network of
ior. To overcome workforce resistance, organizations
physicians and hospitals. PCH encompasses more than
must demonstrate to clinicians and other staff that new
5,500 employed and affiliated physicians and seven
programs will support care and quality outcomes.
acute care hospitals within the system. If opportunities
Partners HealthCare: Connecting Heart Failure Patients to Providers Through Remote Monitoring
3
for using technology-enabled strategies to aid in rede-
exchange during care transitions across settings and
signed care have been identified, Partners’ Center for
caregivers.
Connected Health will lead the design and develop-
ment of patient-centered telehealth solutions and
THE CENTER FOR CONNECTED HEALTH’S
remote health services. PCH will help introduce them
ROLE IN ADVANCING PATIENT-CENTERED
into practice across the Partners’ network.
TECHNOLOGY
In 1995, Partners established Partners Telemedicine
PERFORMANCE IMPROVEMENT
to use consumer-ready technologies to enhance the
INITIATIVES THAT REDUCE PREVENTABLE
patient-physician relationship and deliver remote
READMISSIONS
care. This entity later evolved to become the Center
A top strategic priority at Partners is to reduce 30-day
for Connected Health. “Connected health” signifies
readmissions to improve the quality of patient care and
new patient-centered technology strategies and care
patient satisfaction and minimize risk for reductions in
models that use information and communications tech-
Medicare payments. In a survey of Massachusetts hos-
nology—cell phones, computers, networked devices,
pitals, more than 10 percent of patients were reported
and simple remote monitoring tools—to support the
to have been readmitted for the same or unrelated com-
health care needs of patients in community-based set-
plaints within 30 days.3 Processes that ensure seam-
tings without disrupting their day-to-day lives. CCH
less transitions from hospital to other care settings are
solutions help providers and patients manage chronic
essential. These include improvements in educating
conditions, maintain health and wellness, and improve
patients and caregivers, reconciling medications care-
adherence, engagement, and clinical outcomes. To
fully before and after discharge, communicating with
date, CCH has generated more than 100 scholarly
receiving clinicians, and ensuring prompt outpatient
publications and helped more than 30,000 patients. In
follow-up. Exhibit 1 illustrates 30-day readmission
2011, CCH collected its one millionth vital life sign
rates for heart failure, acute myocardial infarction, and
from program participants.8
pneumonia at selected Partners’ hospitals.4 Partners
CCH’s programs use a combination of remote
is currently pilot-testing several programs addressing
monitoring, social media, and data management appli-
patient safety,5 experience,6 and quality,7 with a goal of
cations to enhance patient adherence and engagement
reducing 30-day readmission rates for patients at high
to realize improvements in care quality and cost out-
risk of readmission. These include programs that tar-
comes. The center also supports mobile health initia-
get critical failures in communication and information
tives, including a prenatal care text-messaging program
Exhibit 1. 30-Day Readmission Rates at Selected Partners Hospitals
for Acute Myocardial Infarction, Heart Failure, and Pneumonia
Brigham &
Mass.
Newton-
North Shore
U.S.
Women’s
Faulkner
General
Wellesley
Medical
National
Hospital
Hospital
Hospital
Hospital
Center
Rate
Acute myocardial infarction
21.1%
21.1%
22.1%
20.8%
18.6%
19.8%
Heart failure
23.7
27.0
23.7
23.8
22.8
24.8
Pneumonia
20.4
20.0
19.0
17.1
18.6
18.4
Partners HealthCare Data Period: July 1, 2007-June 30, 2010.
Partners HealthCare Source: Hospital Compare.
Reference Point Source: U.S. National Rate for Heart Failure, Acute Myocardial Infarction, and Pneumonia for Medicare Patients.
4
The Commonwealth Fund
for expectant mothers, and wellness programs, such
readmissions provides the heart failure program with
as Step It Up and Virtual Coach, that emphasize activ-
a clear business case in terms of the negative financial
ity and exercise among elementary school children
implications from poor care outcomes. For manage-
and overweight people, respectively. The center offers
ment of diabetes, HbA1c is a well-accepted clinical
video-based, real-time consultations and an online
marker used to measure success. One program that has
second-opinion service, Partners Online Specialty
been successfully piloted and implemented at scale
Consultations. CCH recently spun off a health service
across Partners is the Connected Cardiac Care Program
company, Healthrageous, to provide self-management
(CCCP). It provides home telemonitoring and patient
tools that offer personalized support and motivation in
education over a four-month period to enable patients
health and lifestyle management.
to collect frequent readings and become more engaged
CCH focuses on applying technologies to con-
in their care.
ditions that have standard clinical measures of success
Exhibit 2 outlines two connected models of
or offer a clear business case in terms of the potential
care that are currently being deployed at Partners to
cost savings or return on investment. For example, the
address congestive heart failure, as well as diabetes
Medicare payment reductions associated with 30-day
and hypertension.
Exhibit 2. Connected Health Models of Care at Partners
The Diabetes Connect and Blood Pressure Connect programs offer patients and their care providers a way to
track their blood sugar or blood pressure readings and to collaborate on establishing a shared care plan between
office visits. These programs differ from the Connected Cardiac Care Program (CCCP), which uses a centralized
telemonitoring model. Diabetes Connect and Blood Pressure Connect operate on a distributed model where each
practice comes up with its own structure and protocols for managing patients. Nurses, certified diabetes educators,
pharmacists, or primary care physicians can monitor patients’ data. The driver to adopt is greater provider efficiency
and quality outcomes, and less focus on cost savings. The programs help manage patients by providing structured
data frequently and engaging patients actively in their care management. Both programs are available at several
primary care practices affiliated with Massachusetts General and Brigham and Women’s Hospitals, and through the
Partners Community HealthCare network of physicians and hospitals.
Connected Health Program
Summary Description
A centralized telemonitoring and self-management and preventive care program for heart
failure patients that combines telemonitoring capabilities with nurse intervention and
care coordination, coaching, and education. The daily transmission of weight, heart rate,
Connected Cardiac Care Program
pulse, and blood pressure data by patients enables providers to more effectively assess
patient status and provide "just-in-time" care and patient education. The program has led
to an approximate 50 percent reduction in heart failure-related hospital readmissions for
participants.
Provide practices with tools for the self-management and monitoring of patients with
Diabetes Connect
diabetes and hypertension. A recent clinical study with 75 enrolled patients found that
participants in Diabetes Connect achieved an average drop in HbA1c of 1.5 percent, while
Blood Pressure Connect
22.3 percent of participants enrolled in Blood Pressure Connect achieved a 10mmHg or
greater drop in systolic blood pressure, compared with 16.7 percent among nonparticipants.
Source: Center for Connected Health.
Partners HealthCare: Connecting Heart Failure Patients to Providers Through Remote Monitoring
5
Care Outcomes
that introducing telemonitoring not only affected care
Remote monitoring improves the health of ambula-
outcomes but also indicated a trend toward a decreas-
tory patients who have been recently hospitalized
ing need for nurse visits. The studies did not have a
for heart failure and leads to reductions in hospital
large enough sample to definitively demonstrate cost
readmissions. A 2006 pilot study of CCCP with 150
savings, nor did they indicate that telemonitoring
heart failure patients, with an average age of 70, who
would replace home visits. However, telemonitoring
had been admitted to Massachusetts General Hospital
was seen as providing a critical adjunct to patient care
and received six months of follow-up care did not
and workload efficiency for nurses. The impact was
reach statistical significance. However, the results
significant enough to support adoption of telemonitor-
indicated a positive trend in reducing readmissions
ing as part of the care plan for heart failure patients.
(Exhibit 3). Sixty-eight patients received usual care for
This led Partners in 2007 to fund the program’s expan-
heart failure; the remaining 82 patients were offered
sion systemwide for all heart failure patients that met
remote monitoring. Forty-two patients accepted and 40
the inclusion criteria. To date, more than 1,200 patients
declined to participate. The remote monitoring group
have been enrolled. Exhibit 4 shows that the proportion
had a lower rate of all-cause readmissions compared
of enrollees in CCCP with one or more heart failure
with usual-care patients and nonparticipants. Patients
hospitalizations in the year following disenrollment
in the remote monitoring group also had fewer heart
was 13.3 percent compared with 39.8 percent one year
failure-related readmissions. However, all-cause emer-
prior to enrollment.
gency room (ER) visits were higher among the remote-
monitoring group than for usual care and nonpartici-
User Satisfaction
pating patients. This higher frequency of reporting to
Eleven research studies were conducted at Partners-
the ER may be a result of closer monitoring.
affiliated hospitals to measure patient perceptions of
connected health technologies; namely, if patients feel
Process Efficiencies
empowered to better manage their care, if they have
Initial studies of CCCP that involved patients receiving
increased satisfaction with care, and if their overall
skilled nursing care from a home care provider found
health is improved.9 Patients in CCCP reported the
Exhibit 3. Remote Monitoring CCCP Pilot Results at Six-Month Follow-Up
Control
Intervention
Nonparticipant
(n=68)
(n=42)
(n=40)
Mean rate
Mean rate
Mean rate
(± standard
(± standard
(± standard
deviation)
deviation)
deviation)
P-value
Hospital readmissions
l All-cause
0.73 (±1.51)
0.64 (±0.87)
0.75 (±1.05)
.75
l Heart failure-related
0.38 (±1.06)
0.19 (±0.45)
0.42 (±0.93)
.56
Emergency room visits
l All-cause
0.57 (±1.43)
0.83 (±1.08)
0.65 (±1.0)
.10
l Heart failure-related
0.25 (±1.02)
0.26 (±0.49)
0.35 (±0.80)
.31
Length of stay
l All-cause
10.64 (±9.7)
9.16 (±9.00)
13.2 (±13.4)
.85
l Heart failure-related
8.52 (±8.3)
10.57 (±12.5)
10.78 (±9.1)
.78
Telemedicine and Applications, published online May 19, 2010.
6
The Commonwealth Fund
Exhibit 4. Proportion of Connected Cardiac Care Program Enrollees
with One or More Hospitalizations
100.0%
100%
Proportion of enrollees with
90%
1 or more heart failure
hospitalizations
80%
Proportion of enrollees with
70%
1 all-cause hospitalization
60%
58.1%
50%
39.8%
40%
30%
20%
13.3%
10%
0%
One year prior to CCCP enrollment
One year following CCCP disenrollment
(point estimate and 95% C.I.)
(point estimate and 95% C.I.)
Data include 332 CCCP enrollments among 301 unique patients discharged from the CCCP program prior to July 1, 2009. Results are
similar within more recent cohorts of enrollees discharged from the program prior to October 1, 2009, and prior to January 1, 2010.
program increased their confidence and improved their
confidence to self-manage, and helped them stay out
understanding of heart failure and helped them avoid
of the hospital. In general, once patients are enrolled
hospitalizations (Exhibit 5). Of the 20 participants in
in the program, less than 10 percent opt out of the
the pilot’s remote monitoring group who returned the
program. Those that do drop out usually do so because
satisfaction survey, high levels of program satisfac-
of personal factors, such as preferences, and not as
tion were recorded (93%). All patients reported that
a result of problems with the technology. Diabetic
the equipment was easy to use, resulted in greater
patients report that blood sugar monitoring was most
Exhibit 5. Results of Connected Cardiac Care Program Patient Satisfaction Survey
•
98% of patients reported learning more information about heart failure because of being enrolled in the CCCP
•
85% reported they felt in control of their health because of the program
•
85% reported they were able to gain control over their heart failure while in the program
•
82% reported they were able to stay out of the hospital because of the program
•
82% reported they were able to avoid the emergency room because of the program
•
77% reported they will continue to check their weight daily
•
64% reported they are confident that they can independently manage their heart failure
•
77% reported they would like their treatment providers to offer this program to other heart failure patients
Note: A subset of CCCP participants returned the satisfaction survey (n=93).
Source: Center for Connected Health.
Partners HealthCare: Connecting Heart Failure Patients to Providers Through Remote Monitoring
7
valuable when they were newly diagnosed or trying
high costs involved in caring for heart failure patients
to regain control of their diabetes. Electronic com-
and the potential savings from preventing unnecessary
munication between providers and patients outside of
admissions to hospitals. The support of Partners’ senior
scheduled office visits was perceived as important in
leadership was critical to the program’s expansion. In
improving diabetes management.
particular, the leadership’s interest in connected health
solutions as a way to augment care delivery system-
THE CONNECTED CARDIAC CARE
wide and its commitment of funds to support the devel-
PROGRAM
opment of the program have been critical to scaling
CCCP is developing new ways to help patients at risk
CCCP across Partners’ network.
for hospitalization to manage their heart disease, by
CCCP allows patients to monitor their physi-
integrating technology into remote patient care and
ological health on a daily basis and provides a virtual
supporting self-monitoring. Contract changes to the
link to their health care team from their home. Daily
Medicare payment structure for the home care indus-
monitoring, “just-in-time” teaching—based on the
try—in which Medicare provided a prospective pay-
immediacy of interventions in response to monitored
ment rate for up to 60 days of service—presented an
patient data—and weekly structured education sessions
impetus to create CCCP. Partners HealthCare at Home
help patients become aware of their daily behaviors.
(PCAH), one of the region’s largest home care provid-
This impact leads to changes in behavior and the devel-
ers, partnered with the Center for Connected Health to
opment of new self-management skills. The CCCP
develop CCCP, and provides all of the telemonitoring
team provides the technology, support, and training. It
nurses and clinical support for the program. PCAH,
also installs equipment in patients’ homes and shows
which is recognized as a top-performing agency by the
them how to use it. PCAH and other clinical partners
Centers for Medicare and Medicaid Services, offers
provide the expertise for successfully designing and
medical, therapeutic, and supportive home-based ser-
implementing the technology for use in care practices.
vices for patients who are recovering from a hospital-
There is no cost to patients to enroll or for use
ization, managing chronic illness, or those who need
of the equipment. The program is open to all patients
assistance to remain in their own homes.
with a Partners’ affiliated primary care physician or
CCCP’s core components are care coordina-
cardiologist. Patients are referred by hospital case
tion, education, and development of self-management
managers, nurse practitioners, primary care physicians,
skills through telemonitoring. Patients use equip-
cardiologists, and other clinicians. Since the inception
ment—a home monitoring device with peripherals
of CCCP in 2006, the program has included eligible
to collect weight, blood pressure, and heart rate mea-
patients from across the Partners HealthCare system on
surements, and a touch-screen computer to answer
an opt-out basis.
questions about symptoms—on a daily basis for four
Evaluations of CCCP have been limited to
months. Telemonitoring nurses monitor these vitals,
before and after evaluations rather than randomized
respond to out-of-parameter alerts, and guide patients
controlled trials. Such assessments have shown a posi-
through structured biweekly heart failure educa-
tive, sizable effect in reducing readmissions, which
tion (Exhibit 6). This concentrated effort is effec-
increased the comfort level among Partners senior
tive in meeting the primary goal of reducing hospital
leadership with the intervention. There has also been
readmissions.
ongoing iterative research using small groups of people
PCAH was initially interested in using tele-
to assess the intervention and identify the need for
health under the new Medicare reimbursement model
modifications. CCH has also been working with PCH to
to leverage staff across more patients. Heart failure
test effective adoption and the role of financial incen-
was targeted as a priority condition because of the
tive mechanisms to facilitate spread. CCH’s in-house
8
The Commonwealth Fund
analysis estimates that the program has generated total
the workflow to enable providers to more effectively
cost savings of more than $10 million since 2006 for
assess patient status and provide just-in-time care and
the more than 1,200 enrolled patients (Exhibit 7).
education, and using personal health data to help edu-
cate and motivate patients to make necessary lifestyle
LESSONS LEARNED IN TAKING CCCP
changes. Even though it has not always been met with
FROM PILOT TO SCALE
immediate success, the organization has persevered
Partners’ experience with connected health technolo-
to introduce telehealth-enabled care management
gies and with successfully implementing telehealth-
solutions, to generate evidence of impact, and to use
enabled programs across the provider network high-
that evidence to advocate for broader deployment
lights the significant potential value of transforming
across the provider network. This experience imparts
care delivery, improving care outcomes, and lowering
important lessons for the successful planning, imple-
costs. Social processes are as important in ensuring
mentation and deployment of telehealth-enabled care
program success as are the technical factors. Key social
management programs at scale and for identifying
factors include leadership support and the champion-
future opportunities for continued program advances in
ing of technology, the integration of patient data into
patient care management.
Exhibit 6. Key Features of the Connected Cardiac Care Program
üü
Four-month home telemonitoring of congestive heart failure patients by a telemonitoring nurse
üü
Intervention by telemonitoring nurse based on physician orders
üü
Interactive patient education and lifestyle management
üü
Reports posted in electronic health record with email alerts to physicians and nurse practitioners
üü
No cost to the patient
üü
Open to patients with a Partners’ affiliated primary care physician or cardiologist
Who is eligible?
Who is not eligible?
•
Patients age 18 and older with a diagnosis of heart failure
• Patients currently receiving skilled home care services***
•
Patients considered to be at high risk for hospitalization
• Patients with end-stage renal disease on dialysis
•
Patients who have a Partners’ affiliated primary care physician
• Patients with organ transplant
or cardiologist
• Patients in hospice
•
Patients covered by Medicare, Medicaid, or certain patients in
• Patients with an active cancer diagnosis
the safety net*
• Patients who reside in nursing homes
•
Patients able to speak and read English**
• Patients who do not have a stable environment to conduct
•
Patients mentally competent and willing**
the monitoring
•
Patients with a traditional phone line
• Patients with any physical disability that precludes use of
telemonitoring equipment
* Limited funding available for some patients with commercial insurance.
** Or those with a primary caregiver willing to assume responsibility for telemonitoring.
*** Exception: Partners' Health at Home skilled Medicaid and commercial patients.
Partners HealthCare: Connecting Heart Failure Patients to Providers Through Remote Monitoring
9
Exhibit 7. Reducing Hospital Readmissions with the Connected Cardiac Care Program
Program outcomes
üü
51% reduction in heart failure hospital readmissions*
üü
44% reduction in non-heart failure hospital readmissions*
üü
Improved patient understanding of heart failure and self-management skills
üü
High levels of clinician and patient acceptance and satisfaction
Savings**
A case study prepared by the Center for Connected Health outlines the following cost savings:
Cost of CCCP:
$1,500 per patient
Total savings from reduction in hospitalizations:
$9,655 per patient
Total net savings:
$8,155 per patient
Total savings:
$10,316,075 for 1,265 monitored patients since 2006
* N=332 patients
** This program targeted reductions in unplanned heart failure and non-heart failure related admissions. The savings realized factor involves the cost of running the
program, including marketing, referral management, telemonitoring nurse support, and technology.
Source: Center for Connected Health.
Patient Activation and Engagement Are
need to be aware that the provider is engaged in order
Critical to Program Success
for them to regularly use the technology as a self-man-
With the decision by PCAH to use telehealth to lever-
agement tool.
age staff across more patients in response to Medicare
reimbursement changes, CCH became a strategic
Automatic Enrollment of Patients
partner to PCAH. CCH and PCAH collaborated in the
Improves Clinician Involvement and
design of the technology-enabled clinical program,
Satisfaction
the selection of the technology, and the staffing of the
As the program was extended beyond home care
operational model. Both parties market and perform
throughout the Partners system, pushback came from
outreach of CCCP to patient referral sources. There
other sources, primarily primary care physicians and
was a low level of adoption in the initial phase of the
cardiologists, such that physician referrals and enroll-
program. Nurses at first saw CCCP as driving a wedge
ment into the program were challenged. The program
between them and their patients. They resisted the
struggled initially but the key watershed point came
introduction of the program and the replacement of
with the decision to change patient enrollment to an
the more traditional high-touch approach to care. An
opt-out process. Once a patient is identified for enroll-
important factor in overcoming that initial pushback
ment in CCCP, clinicians are responsible for notifying
from staff—and an important lesson for the adoption of
CCCP that they do not want the patient in the program.
patient-centered technology in general—is the positive
As a result, enrollment has increased, readmission
impact the technology has once it’s placed in patients’
rates have declined, and satisfaction levels among doc-
hands. With CCCP, patients felt more connected and
tors have increased as benefits in patient care became
nurses learned to develop relationships with patients
evident. The refusal rate to participate among doctors
accordingly with the help of technology. Another
went from 10 percent to less than 1 percent.
important insight in terms of adoption is that patients
10
The Commonwealth Fund
Data Can Motivate and Empower
IMPLICATIONS FOR U.S. HEALTH CARE
Clinicians and Patients
ORGANIZATIONS
Outcomes in controlled trials, as well as in before-
Being in an integrated delivery network that owns a
and-after studies, have consistently demonstrated an
home care service business has allowed Partners to be
approximate 50 percent drop in cardiac-related read-
ahead on the adoption curve with telehealth relative
missions for patients enrolled in CCCP. One drive of
to other health systems. Organizations—particularly
that outcome is patients learning self-management
ones lower on the adoption curve—that are considering
skills and receiving constant feedback about how life-
technology-enabled solutions will need to address the
style factors affect health outcomes. Another is just-in-
following issues: establishing acceptance that the tech-
time care, whereby remote monitoring and intervention
nology can clinically make a difference, identifying the
by nurses sends a strong message to patients that they
method by which the organization will implement and
are accountable. CCH’s commitment to research allows
integrate the technology, determining whether a one-
the organization access to the data and studies to coun-
size-fits-all approach will be feasible across the net-
ter resistance and arguments from clinicians about the
work or system, and evaluating whether the prevailing
impact on quality and patient experience. CCH is also
financial system can support an economical approach
able to prepare the business case and concomitant cost-
to scaling.
savings argument. But the traditional business case
From an organizational readiness perspec-
approach cannot convey the full impact that other fac-
tive, it is critical to recognize the role of champions
tors, such as patient experience and staff satisfaction,
who understand workflow and also to understand the
have on improved health outcomes and higher quality
requirements for successfully integrating solutions into
of care.
practice. To gain buy-in from staff, it is important to
put the data in the hands of motivated individuals, like
New Technology-Enabled Solutions Do Not
clinicians who want to help their patients. It is also
Fit Old Policy Frameworks
important to aggregate external data, integrate it with
CCH faces challenges in optimizing the impact of
clinical health information systems, and communicate
connected health programs on care outcomes. The cur-
it to patients and providers alike. Data cannot be main-
rent fee-for-service environment can present a mental
tained in separate data silos and must be placed in the
barrier for clinicians, and pilots involving financial
EHR to be meaningful and useful in clinical decision
incentives that reward provider engagement have not
support. Patients need access to the patient portal, with
led to significant behavior change. Many doctors view
the ability to retrieve clinical information and perform
the move toward a patient-centered medical home as
administrative functions. CCH has invested significant
requiring more staff, such as nurses and pharmacists,
resources in developing a platform to support the inte-
rather than an opportunity for leveraging technology
gration and management of data, which will also serve
in support of fewer staff. While the widespread use
as a platform for the development and implementation
of connected health solutions will require structural
of other applications.
changes in the form of reimbursement and new care
However, recognizing that not all systems are
models like the patient-centered medical home, a sig-
equal in the U.S. health care delivery system, CCH’s
nificant amount of work remains to be done in promot-
experience also points to common pitfalls to avoid
ing the use of technology to leverage existing staff
rather than just best practices to adopt. A common
across more patients.
mistake is attempting to shoehorn a connected health
program into the traditional care model. Technologies
such as telemonitoring can be disruptive to workflow
and represent a change in the way care is delivered.
Partners HealthCare: Connecting Heart Failure Patients to Providers Through Remote Monitoring
11
Organizations often tend to view connected health
sometimes fail. But often, many technology-enabled
solutions as simply requiring a technical interface to
solutions in health care fail to recognize the need for
existing programs rather than a redesign of the care
solutions that are social in nature rather than solely
delivery model. Partners’ experience indicates that con-
technological. In the current fee-for-service envi-
nected health requires a different mind-set to program
ronment, organizations have to also be prepared for
design and execution. Otherwise, there is a low likeli-
the delays that payment system can impose on staff
hood that it will change practice and lead to desired
behavior. Organizations must show clinicians that con-
outcomes. Looking forward, Partners is developing a
nected health programs will support care and quality
predictive algorithm as a screening strategy of a hos-
outcomes, while planning workflow changes very care-
pitalized patient’s risk for readmission. This will help
fully and taking the time and making the effort to work
contribute toward a more aggressive segmentation of
methodically and systematically through issues that
the population and tiering of the program to meet the
may arise. Finally, it takes time to integrate technology
needs of more acute patients on discharge and to man-
into health delivery and to allow staff to adapt to the
age them so they can exit the program.
new work model. As a result, structure, coordination,
Dedicating staff members to the implementa-
planning, and setting goals, as well as expectations, for
tion and oversight of the program is more critical than
the program are critical preparatory steps for success.
the technology itself in understanding why programs
How This Case Study Was Conducted
This case study was developed through interviews with staff from Partners HealthCare and the Center for
Connected Health and a review of both organizations’ websites. From the Center for Connected Health, we
would like to acknowledge Dr. Joseph Kvedar, director; Rob Havasy, project specialist; Regina Nieves, con-
nected cardiac care coordinator; and Khinlei Myint-U, corporate manager, product development and communica-
tions; At Partners HealthCare, we would also like to acknowledge the contributions of Alex Baker, former chief
operating officer, Partners Community HealthCare. Partners’ quality, safety, and efficiency measures are avail-
The other organizations profiled in our Case Studies in Telehealth Adoption series are the Veterans Health
program. To read them, along with a synthesis of findings from all three case studies, visit our website at
12
The Commonwealth Fund
Notes
1
Partners HealthCare System, Quality, Safety and
2
Partners HealthCare System, Center for Connected
3
Partners HealthCare System, Annual Report 2010,
4
Partners HealthCare System, Efficiency: 30-Day
Readmission Rate to Discharging Hospital for AMI/
5
Partners HealthCare System, Report Card: Patient
6
Partners HealthCare System, Report Card: Patient
7
Partners HealthCare System, Report Card: Quality
8
“Center for Connected Health Reaches Milestone
of One Million Vital Signs Collected from Patients
via Remote Monitoring,” Partners HealthCare press
9
“Center for Connected Health Presents Growing
Evidence of the Benefits of Technology to Improve
Patient Satisfaction and Empowerment,” Partners
Partners HealthCare: Connecting Heart Failure Patients to Providers Through Remote Monitoring
13
About the Author
Andrew Broderick, M.A., M.B.A., is codirector, Center for Innovation and Technology in Public Health, at the
Public Health Institute. Mr. Broderick’s research focuses on the adoption and appropriate use of technology to
address vital and pressing challenges in public health, including efforts to enhance linkages between the public
health and health care delivery systems. Mr. Broderick previously managed research activity at HealthTech, including
work in cardiovascular disease, remote health services, and technologies for independent living. Mr. Broderick
holds a master of arts in economics and geography from Trinity College, in Dublin, Ireland, and a master of
business administration from San Francisco State University. He can be emailed at abroderick@phi.org .
Editorial support was provided by Deborah Lorber.
These case studies were based on publicly available information and self-reported data provided by the case study institutions. The
Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case study
series is not an endorsement by the Fund for receipt of health care from the institution.
