Clinical Review & Education
Surgical Innovation
Using Telehealth to Enable Patient-Centered Care for Liver Transplantation Audrey E. Ertel, MD; Tiffany Kaiser, PharmD; Shimul A. Shah, MD, MHCM
What Is the Innovation? Liver transplantation is a highly complex and resource-intense intervention. Patients are often significantly debilitated, have a poor nutritional state, and incur the comorbidities of chronic immunosuppression. These realities leave recipients at high risk for complications and subsequent rehospitalization. At our institution, the 30day readmission rate following liver transplantation is 42% and increases to 69% at 1 year.1 This rate is similar to national 30-day readmission rates of 40%, and more than 20% of these patients are readmitted multiple times, with readmissions accounting for more than 10% of combined 90-day direct costs.2 Clearly, this is an area in which we as a community must improve. To address this issue, we are currently piloting a patientcentric model of acute posttransplantation surgical and medical care. Through a tablet-based monitoring and feedback infrastructure, telehealth will be used to support patients and caregivers and to improve their communication with health care professionals. Although use of telehealth has gained momentum in the medical community, it has not yet been well adopted in the surgical community. During the developmental stage, a survey was conducted among transplantation candidates to assess technological literacy and willingness to adopt a tablet monitoring system into their postoperative care. In total, 159 surveys were collected, with most patients reporting use of the Internet (70.8%) and email (73.8%), while almost half of the patients (45.6%) reported having used a smartphone or tablet computer. Almost 90% of patients reported being comfortable using electronic monitoring and communication during the post-
transplantation period. In addition, 77.1% of patients thought that it would be helpful for postoperative care. Eligible patients are enrolled at the time of transplant surgery admission. On discharge, patients receive a tablet containing automatedtextmessagesspecifictotheirpostoperativestatus,dailyhealth questions, and a configured vital sign tracking program from remote devices to include temperature, blood pressure, blood glucose level, and weight measurements. The tablets are also equipped with videoconferencing ability to allow for patient and health care professional interface (Figure). Objective measures, including alerts, timeliness of responses, and data inputs, are tracked by the transplant team. This protocol is designed to address acute postoperative needs after transplantation, and patients will participate for 90 days. Using thesedata,thetransplantteamwillbeabletocloselymonitortheprogress of the recipients during their initial at-home days. In addition to reported patient data, health services utilization is tracked, including calls, clinic visits, and health care professional satisfaction. This information will be used to evaluate the impact that such a program will have on resource utilization and patient and caregiver satisfaction. Long-term end points of analysis will include 30day and 90-day readmission rates, outpatient clinic visits, and recipient health metrics such as blood glucose level, blood pressure control, medication adherence, weight loss or gain, and activity goals. The pilot study has successfully enrolled 20 of 23 eligible patients. Three patients were not enrolled due to death, refusal, or lack of long-term evolution coverage at the place of residence. Because of the ongoing nature of this pilot study, preliminary data are not yet available but are expected by the fall of 2015.
Figure. Sample Patient and Health Care Professional Interface and Remote Monitoring Devices
Home
Transplant center Phone line Internet Wireless
Transplant physician Transplant coordinator
Patient information and education
Adapted with permission from Intel–GE Care Innovations LLC. 674
JAMA Surgery July 2015 Volume 150, Number 7 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Northwestern University User on 10/03/2016
jamasurgery.com
Telehealth to Enable Patient-Centered Care for Liver Transplantation
What Are the Key Advantages Over Existing Approaches? First, this model has the capacity to improve clinical outcomes by affording the opportunity to increase early involvement and communication between patients and transplant surgery health care professionals. With more vigilant monitoring between clinic appointments, we may provide improved mechanisms to better understand the factors that lead to readmission and compromised health status following liver transplantation. Second, this model makes care more patient centered. The current practice guidelines in liver transplantation do not account for patient preferences, needs, and expectations. Consequently, patient care remains inefficient and limited and is not designed to meet the perceived needs and challenges of transplant recipients.
How Will This Model Impact Clinical Care? This innovative health care delivery model has the potential to optimize the quality, outcome, and efficiency of postdischarge care. The telehealth model will provide insight to clinicians, health care systems, and transplant centers regarding how to improve patient care, especially among patients who are currently underserved and have poor outcomes. The direct oversight in this model will enable health care professionals to recognize concerning trends requiring evaluation and will reduce unnecessary hospital visits due to patient or caregiver concerns.
Is There Evidence Supporting the Benefits of the Innovation? Use of a patient-centered medical home has been well described in chronic medical illnesses such as congestive heart failure, diabetes mellitus, and pulmonary conditions, but similar programs remain undefined in complex surgical care models, such as liver transplantation.3,4 The utilization of telehealth technology has been
Surgical Innovation Clinical Review & Education
met with mixed success in primary care settings. The resource tools, remote monitoring, and expenses associated with these instruments do not seem to justify the acuity of illness or care required by the primary care population. In liver transplantation, this stipulation is not the case.
What Are the Barriers to Implementing This Innovation More Broadly? To our knowledge, a real-time patient-centered telehealth model has not been implemented in a dynamic setting, such as postoperative care. This scenario raises several practical issues. Our current fulltime-equivalent support in transplant surgery may be affected by this implementation because telehealth may increase if the education and workload associated with telehealth are deemed to be more extensive than the traditional model. This increase in cost and resource utilization may be prohibitive for many health systems. In addition, the literacy associated with such devices is dependent on exposure. Some areas of the country may have difficulty implementing such a program among a population unfamiliar with these devices.
In What Time Frame Will This Innovation Likely Be Applied Routinely? Our pilot study is under way. It will provide the basis for a larger cohort study that randomizes patients to either a traditional care model (as currently practiced) or a telehealth model that will begin in the fall of 2015. With this program, we expect to implement a system that can produce a significant decrease in readmissions and hospital utilization, coupled with an increase in patient satisfaction and protocol adherence. This program will become the driving clinical program by which to foster more telehealth-related programs for complex surgical and medical care.
ARTICLE INFORMATION
Accepted for Publication: February 23, 2015.
Author Affiliations: Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio (Ertel, Shah); Department of Internal Medicine, University of Cincinnati School of Medicine, Cincinnati, Ohio (Kaiser).
Published Online: May 13, 2015. doi:10.1001/jamasurg.2015.0676.
Corresponding Author: Shimul A. Shah, MD, MHCM, Department of Surgery, University of Cincinnati School of Medicine, 231 Albert Sabin Way, Mailbox 0558, Medical Science Bldg 2006C, Cincinnati, OH 45267-0558 ([email protected]).
REFERENCES
Section Editor: Justin B. Dimick, MD, MPH.
2. Wilson GC, Hoehn RS, Ertel A, et al. Variation by center and economic burden of readmissions after
jamasurgery.com
Conflict of Interest Disclosures: None reported. Submissions: Authors should contact Justin B. Dimick, MD, MPH, at [email protected] if they wish to submit Surgical Innovation papers.
1. Paterno F, Wilson GC, Wima K, et al. Hospital utilization and consequences of readmissions after liver transplantation. Surgery. 2014;156(4):871-878.
liver transplantation [published online March 13, 2015]. Liver Transpl. doi:10.1002/lt.24112. 3. Bikdeli B, Wayda B, Bao H, et al. Place of residence and outcomes of patients with heart failure: analysis from the Telemonitoring to Improve Heart Failure Outcomes trial. Circ Cardiovasc Qual Outcomes. 2014;7(5):749-756. 4. Mammas CS, Geropoulos S, Markou G, Saatsakis G, Lemonidou C, Tentolouris N. Mobile Tele-Medicine Systems in the multidisciplinary approach of diabetes management: the remote prevention of diabetes complications. Stud Health Technol Inform. 2014;202:307-310.
(Reprinted) JAMA Surgery July 2015 Volume 150, Number 7
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Northwestern University User on 10/03/2016
675
Surgical Innovation
Using Telehealth to Enable Patient-Centered Care for Liver Transplantation Audrey E. Ertel, MD; Tiffany Kaiser, PharmD; Shimul A. Shah, MD, MHCM
What Is the Innovation? Liver transplantation is a highly complex and resource-intense intervention. Patients are often significantly debilitated, have a poor nutritional state, and incur the comorbidities of chronic immunosuppression. These realities leave recipients at high risk for complications and subsequent rehospitalization. At our institution, the 30day readmission rate following liver transplantation is 42% and increases to 69% at 1 year.1 This rate is similar to national 30-day readmission rates of 40%, and more than 20% of these patients are readmitted multiple times, with readmissions accounting for more than 10% of combined 90-day direct costs.2 Clearly, this is an area in which we as a community must improve. To address this issue, we are currently piloting a patientcentric model of acute posttransplantation surgical and medical care. Through a tablet-based monitoring and feedback infrastructure, telehealth will be used to support patients and caregivers and to improve their communication with health care professionals. Although use of telehealth has gained momentum in the medical community, it has not yet been well adopted in the surgical community. During the developmental stage, a survey was conducted among transplantation candidates to assess technological literacy and willingness to adopt a tablet monitoring system into their postoperative care. In total, 159 surveys were collected, with most patients reporting use of the Internet (70.8%) and email (73.8%), while almost half of the patients (45.6%) reported having used a smartphone or tablet computer. Almost 90% of patients reported being comfortable using electronic monitoring and communication during the post-
transplantation period. In addition, 77.1% of patients thought that it would be helpful for postoperative care. Eligible patients are enrolled at the time of transplant surgery admission. On discharge, patients receive a tablet containing automatedtextmessagesspecifictotheirpostoperativestatus,dailyhealth questions, and a configured vital sign tracking program from remote devices to include temperature, blood pressure, blood glucose level, and weight measurements. The tablets are also equipped with videoconferencing ability to allow for patient and health care professional interface (Figure). Objective measures, including alerts, timeliness of responses, and data inputs, are tracked by the transplant team. This protocol is designed to address acute postoperative needs after transplantation, and patients will participate for 90 days. Using thesedata,thetransplantteamwillbeabletocloselymonitortheprogress of the recipients during their initial at-home days. In addition to reported patient data, health services utilization is tracked, including calls, clinic visits, and health care professional satisfaction. This information will be used to evaluate the impact that such a program will have on resource utilization and patient and caregiver satisfaction. Long-term end points of analysis will include 30day and 90-day readmission rates, outpatient clinic visits, and recipient health metrics such as blood glucose level, blood pressure control, medication adherence, weight loss or gain, and activity goals. The pilot study has successfully enrolled 20 of 23 eligible patients. Three patients were not enrolled due to death, refusal, or lack of long-term evolution coverage at the place of residence. Because of the ongoing nature of this pilot study, preliminary data are not yet available but are expected by the fall of 2015.
Figure. Sample Patient and Health Care Professional Interface and Remote Monitoring Devices
Home
Transplant center Phone line Internet Wireless
Transplant physician Transplant coordinator
Patient information and education
Adapted with permission from Intel–GE Care Innovations LLC. 674
JAMA Surgery July 2015 Volume 150, Number 7 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Northwestern University User on 10/03/2016
jamasurgery.com
Telehealth to Enable Patient-Centered Care for Liver Transplantation
What Are the Key Advantages Over Existing Approaches? First, this model has the capacity to improve clinical outcomes by affording the opportunity to increase early involvement and communication between patients and transplant surgery health care professionals. With more vigilant monitoring between clinic appointments, we may provide improved mechanisms to better understand the factors that lead to readmission and compromised health status following liver transplantation. Second, this model makes care more patient centered. The current practice guidelines in liver transplantation do not account for patient preferences, needs, and expectations. Consequently, patient care remains inefficient and limited and is not designed to meet the perceived needs and challenges of transplant recipients.
How Will This Model Impact Clinical Care? This innovative health care delivery model has the potential to optimize the quality, outcome, and efficiency of postdischarge care. The telehealth model will provide insight to clinicians, health care systems, and transplant centers regarding how to improve patient care, especially among patients who are currently underserved and have poor outcomes. The direct oversight in this model will enable health care professionals to recognize concerning trends requiring evaluation and will reduce unnecessary hospital visits due to patient or caregiver concerns.
Is There Evidence Supporting the Benefits of the Innovation? Use of a patient-centered medical home has been well described in chronic medical illnesses such as congestive heart failure, diabetes mellitus, and pulmonary conditions, but similar programs remain undefined in complex surgical care models, such as liver transplantation.3,4 The utilization of telehealth technology has been
Surgical Innovation Clinical Review & Education
met with mixed success in primary care settings. The resource tools, remote monitoring, and expenses associated with these instruments do not seem to justify the acuity of illness or care required by the primary care population. In liver transplantation, this stipulation is not the case.
What Are the Barriers to Implementing This Innovation More Broadly? To our knowledge, a real-time patient-centered telehealth model has not been implemented in a dynamic setting, such as postoperative care. This scenario raises several practical issues. Our current fulltime-equivalent support in transplant surgery may be affected by this implementation because telehealth may increase if the education and workload associated with telehealth are deemed to be more extensive than the traditional model. This increase in cost and resource utilization may be prohibitive for many health systems. In addition, the literacy associated with such devices is dependent on exposure. Some areas of the country may have difficulty implementing such a program among a population unfamiliar with these devices.
In What Time Frame Will This Innovation Likely Be Applied Routinely? Our pilot study is under way. It will provide the basis for a larger cohort study that randomizes patients to either a traditional care model (as currently practiced) or a telehealth model that will begin in the fall of 2015. With this program, we expect to implement a system that can produce a significant decrease in readmissions and hospital utilization, coupled with an increase in patient satisfaction and protocol adherence. This program will become the driving clinical program by which to foster more telehealth-related programs for complex surgical and medical care.
ARTICLE INFORMATION
Accepted for Publication: February 23, 2015.
Author Affiliations: Cincinnati Research in Outcomes and Safety in Surgery, Department of Surgery, University of Cincinnati School of Medicine, Cincinnati, Ohio (Ertel, Shah); Department of Internal Medicine, University of Cincinnati School of Medicine, Cincinnati, Ohio (Kaiser).
Published Online: May 13, 2015. doi:10.1001/jamasurg.2015.0676.
Corresponding Author: Shimul A. Shah, MD, MHCM, Department of Surgery, University of Cincinnati School of Medicine, 231 Albert Sabin Way, Mailbox 0558, Medical Science Bldg 2006C, Cincinnati, OH 45267-0558 ([email protected]).
REFERENCES
Section Editor: Justin B. Dimick, MD, MPH.
2. Wilson GC, Hoehn RS, Ertel A, et al. Variation by center and economic burden of readmissions after
jamasurgery.com
Conflict of Interest Disclosures: None reported. Submissions: Authors should contact Justin B. Dimick, MD, MPH, at [email protected] if they wish to submit Surgical Innovation papers.
1. Paterno F, Wilson GC, Wima K, et al. Hospital utilization and consequences of readmissions after liver transplantation. Surgery. 2014;156(4):871-878.
liver transplantation [published online March 13, 2015]. Liver Transpl. doi:10.1002/lt.24112. 3. Bikdeli B, Wayda B, Bao H, et al. Place of residence and outcomes of patients with heart failure: analysis from the Telemonitoring to Improve Heart Failure Outcomes trial. Circ Cardiovasc Qual Outcomes. 2014;7(5):749-756. 4. Mammas CS, Geropoulos S, Markou G, Saatsakis G, Lemonidou C, Tentolouris N. Mobile Tele-Medicine Systems in the multidisciplinary approach of diabetes management: the remote prevention of diabetes complications. Stud Health Technol Inform. 2014;202:307-310.
(Reprinted) JAMA Surgery July 2015 Volume 150, Number 7
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Northwestern University User on 10/03/2016
675
