Story contributed by Cleveland Clinic.
Never before has the need to leverage technology for population health management been more apparent. With the outbreak of COVID-19, consistent outreach and prompt intervention are necessary to prevent negative outcomes. Although patients with COVID-19 often experience mild symptoms, deterioration can be rapid, even in patients considered low risk.
That’s why, in March, Cleveland Clinic developed and implemented a COVID-19 home monitoring program with Epic. Patients are tasked with completing a daily symptom questionnaire that allows primary care teams to monitor condition changes and quickly intervene when necessary.
As the number of infected patients increases, this automation of patient engagement supplements existing workflows, extending the reach of clinicians without increasing staffing levels.
Leveraging existing technology
Available since 2018, Epic’s MyChart Care Companion has been used at organizations across the U.S. to monitor patients with chronic conditions. Cleveland Clinic is the first to customize the technology for COVID-19.
More than a symptom-checking app, Care Companion is an interactive, secure tool that enables personalized care in an easy-to-use format. Through both a website and a mobile app, patients are engaged as a member of the care team and empowered to manage their health through the use of daily tasks for education, condition tracking, and treatment.
Rapid design and implementation
Given the urgency of the COVID-19 situation, Cleveland Clinic and Epic joined together to quickly implement a home monitoring solution that can be used by other healthcare organizations. With over 1 million Cleveland Clinic patients already active on MyChart, leveraging the EHR for COVID-19 was an obvious choice.
Clinicians and analysts worked side by side to design and build the technology and clinical workflow components. Normally it takes three months to design and build technology this complex. However, collaboration between the teams enabled implementation in just 10 days.
To start, orders were created to enroll designated patients. Next, COVID-19 questionnaires were developed to assess each patient’s condition. Additionally, educational content was integrated to further support patients as they recover at home.
New or worsening symptoms trigger a real-time notification to an In Basket monitored by a dedicated group of clinicians. Integration with other existing population management tools enables robust reports and a patient registry for tracking outreach encounters.
All information collected through the various touchpoints is stored in the electronic health record for seamless continuity of care. This discrete collection of data enables future research and predictive modeling as we all work to better understand and treat this novel virus.
A comprehensive home monitoring program
Home monitoring is implemented for all Cleveland Clinic confirmed or suspected COVID-19 cases. Upon enrollment, an initial outreach call provides isolation instructions, COVID-19 education, and screening for social support and home safety. At this time, the patient is invited to engage with MyChart Care Companion.
Daily monitoring of patients consists of the following:
- A Care Companion task reminder
- Telephone outreach to high-risk patients from a registered nurse or allied health professional
The clinical team calls low-risk patients only when significant changes are detected.
Monitoring continues for 14 days from the reported onset of symptoms. Patients enrolled after a hospital stay are monitored for seven days from discharge. Throughout the process, the patient’s PCP or primary specialty provider is kept apprised of all patient encounters via the EHR.
Patients are asked whether any of a list of symptoms are present, and whether those symptoms are getting better, getting worse, or staying the same. These symptoms include:
- Dyspnea (Have you been able to perform your usual activities without shortness of breath?)
- Vomiting (Have you been able to keep down fluids?)
- Poor appetite
Patients also are asked to provide pulse oximetry and temperature readings, if available.
Patients reporting new or worsening symptoms are notified that their changing condition will be reviewed by a clinician. After nurse assessment, they then may be escalated for additional care, such as:
- An urgent virtual evaluation with the patient’s PCP or an on-call physician
- Referral to the Emergency Department with direct handoff communication
The provider may order additional medications (e.g., cough suppressant, bronchodilator), arrange for additional diagnostics (such as labs or imaging) in a designated facility, or dispatch a visiting paramedic or allied health professional.
For patients who do not desire escalation of care, the focus is placed on comfort and management of symptoms. In these cases, palliative care is activated through a virtual visit, and services are initiated when symptoms worsen.
Engaging patients in their care
To date, over 1,200 lab-confirmed COVID-19-positive patients have been enrolled in the program. This includes over 240 patients discharged from Cleveland Clinic hospitals after treatment for COVID-19 complications. In addition, approximately 900 suspected cases (i.e., symptomatic patients who do not meet the high-risk criteria for testing) have been referred. Most patients are enrolled after Day 5 of symptom onset.
Overall engagement with the program has risen since the start, from 13% to nearly 20%. The majority of patients display mild to moderate illness that is successfully managed at home. On average, patients who require escalation present with worsening symptoms by Day 8. The most common symptom is shortness of breath.
Since implementing the program, 24 patients have been admitted due to deterioration of symptoms, complications of underlying medical conditions (e.g., uncontrolled diabetes), and physiologic reasons (e.g., an infected mother going into labor).
One patient, a 92-year-old in an assisted living facility, used the home monitoring program to report her COVID-19 symptoms each day. A nurse noted dropping pulse oximetry readings and escalated the patient for a virtual visit. Although the virtualist advised the patient to go to the Emergency Department, the patient did not comply. The following day, a nurse again noted worsening symptoms. Subsequently, the patient was admitted as an inpatient for COVID-related diarrhea and dehydration, which she had earlier denied to the virtualist.
Patients like this are benefiting from the added surveillance this program offers during this fraught and uncertain time.
Anecdotally, clinicians appreciate being able to care for the rest of their panels, knowing that their COVID-19-positive patients are being monitored closely. As one clinician noted, “[The team] has been great with follow up. I’ve been looking at the monitoring notes to know where they are in their course.”
To date, over 700 patients have been discharged from the program.
Real-time optimization and future opportunities
As with the pandemic itself, home monitoring needs are rapidly changing. Optimization of the technology is ongoing.
Since the program’s start, enhancements have included adding screening questions:
- Advanced Directives (Day 2 of monitoring)
- Anxiety and stress (Day 5)
- Depression and coping (Day 10)
- Expressing gratitude (Day 14)
Based on their responses, patients are directed to online or Cleveland Clinic resources. For example, a link to The Conversation Project appears if patients wish to begin planning for end-of-life care.
Specialty groups also are using EHR tools to help manage cohorts of patients. For example, Cleveland Clinic’s Women’s Health team has designed a registry of COVID-19-positive obstetric patients, allowing for improved coordination of care. Virtual care is implemented where appropriate, and facilities are prepared when in-person care is required. Similarly, the Occupational Health team uses the tools to support infected Cleveland Clinic employees and prepare them to return to work.
Opportunities abound for chronic disease populations during the current pandemic and beyond. In the near term, Cleveland Clinic plans to use home monitoring tools to support patients experiencing disruptions in care due to stay-at-home orders. This technology can help identify those in need of care, either virtually or in person.
Engaging patients with technology has great potential for improving overall outcomes. Cleveland Clinic is excited to explore the expansion of these tools as it plan ahead for a “new normal” post-pandemic.
Final considerations for these tools are research and predictive modeling. That work has been initiated this work with Cleveland Clinic’s COVID-19 patient registry, with plans to expand these opportunities for other chronic medical conditions and episodes of care.
Eric Boose, MD, serves as an Associate Chief Medical Information Officer and Family Practice physician at the Cleveland Clinic. Christopher Babiuch, MD, serves as Family Medicine physician and the Medical Director, COVID-19 Disease Home Monitoring Program, for the Cleveland Clinic. Michelle Medina, MD, serves as a Pediatrics physician and the Associate Chief of Clinical Operations for the Cleveland Clinic Community Care. Adrienne Boissy, MD, serves as the Chief Experience Officer at the Cleveland Clinic. Matthew Kull, serves as the Chief Information Officer at the Cleveland Clinic. Amy Merlino, MD, serves as the Chief Medical Information Officer at the Cleveland Clinic.