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Partners HealthCare Integrates Home Monitoring Data into Hospital EHRs

Posted Jul 02 2013 12:00am

Home monitoring  under the supervision of hospital-based professionals will become an increasingly important component of our healthcare delivery system. It is more economical than care in an ambulatory care facility and can also prevent hospital readmissions. However, there is a need for timely and accurate documentation of the professional services that are delivered in this manner. Such documentation is necessary for compensation purposes. A recent article addresses the efforts of Partners HealthCare in Boston to move in this direction (see: Partners Integrates Home Monitoring Data With EHR ), Here is an excerpt from that article:

The Center for Connected Health (CCH) , a division of Partners Healthcare in Boston, has integrated its home monitoring systems with Partners' homegrown electronic health record (EHR). Patient data collected at home, including blood pressure, weight and blood glucose, is transmitted electronically to...the EHR. While the information was previously available to providers and patients on a Partners website, the integration with the EHR makes it accessible within the clinical workflow. That makes it easier for clinicians to use the data because they don't have to interrupt their work to go a website, said Joseph Kvedar, MD, director of CCH....CCH's home monitoring program began several years ago. At that time...Partners decided not to integrate the data with its core clinical system because there was not yet good evidence that home monitoring could improve the outcomes of patients with serious chronic conditions. When positive results began to come in, physicians saw the value of the monitoring data in disease management...But they'd tell CCH that they couldn't refer any more patients to the program because it wasn't integrated with their workflow and took too much time. That was when Partners gave the go-ahead for CCH to send the data into the EHR, he said....CCH has published studies showing that its program can reduce readmissions of CHF patients by 50%; can result in a 1.5 percentage point drop in the HbA1c of patients with diabetes; and in patients with hypertension, can lead to a significant drop in systolic and diastolic blood pressure after six months. Kvedar attributes much of the success of home monitoring to its ability to engage patients in their own healthcare. In addition, he said, the availability of near-real-time vital signs data allows providers to intervene when a patient is not doing well and help that person get their condition under control.

Pressure is building for hospitals to reduce the readmission rate for discharged patients (see: Hospital at Full Census; Surgery Patients Discharged Too Early?Addressing the Hospital Readmission Problem ). A key element in any such program is adequate attention to patient and family education at the time of discharge (see: Reducing ED Visits, Readmissions with Patient Education ). As of October 2012, CMS began penalizing hospitals for excess readmission rates, starting with those related to heart failure, acute myocardial infarction, and pneumonia. In Indiana alone, the readmission rate for hospitalized patients is between 16.8% and 19% across the state (see:  Lowering Readmission Rates with Post Discharge Plans ).

Another obvious step, as only one example of home monitoring, is continuous home monitoring of congestive heart failure (CHF) patients as emphasized in the excerpt above. A critical element of this type of monitoring is the integration of home monitoring data into the normal workflow of the nurses and physicians who have responsibility for these patients. In practical terms, this means integrating the data into some relevant section of the EHR and perhaps ultimately one dedicated to this activity.

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