Mount Sinai Health System, based in New York City, has been having a problem with digital health inequities.

THE PROBLEM

In a report examining New York's digital divide based on 2019 American Community Survey data, several key data points were established that continue to describe households in the communities Mount Sinai serves today.:

• Almost 25% of New Yorkers lacked the infrastructure for basic internet connectivity to see their healthcare clinicians, and approximately 1.6 million did not have access to a personal laptop or desktop during the pandemic.

• Furthermore, 40% of New Yorkers aged 65 and older did not have access to wireless internet, and one-third did not own a computer.

These disparities are rooted in structural and social determinants of health, with Black and Hispanic groups more likely to face resource barriers:

• Older Black people were one-fifth as likely to own a computer as European Americans.

• Hispanic Americans were one-half as likely to have access to the internet.

Uncontrolled chronic disease is another issue, said Dr. Robert Fields, executive vice president and chief population health officer.

"Hypertension is a chronic condition that increases the risk of developing cardiovascular disease," he said. "In 2019, more than half a million deaths in the United States had HTN as a primary or contributing cause.

"The mission focuses on patient-centered clinical services using innovative technologies that improve access to care, positively impacting social needs and improving overall clinical outcomes."

Dr. Robert Fields, Mount Sinai Health System

"Despite available pharmacologic and nonpharmacologic therapies, the current office-based approach for HTN management has led to suboptimal results, as only an estimated one in four adults with HTN have their condition under control," he continued.

Potential contributing factors include:

• Suboptimal medication doses.

• Limited clinic readings and time to provide adequate patient education.

• Unidentified white coat HTN (office-based readings are elevated and out-of-office readings are normal) and/or masked HTN (office-based readings are normal and out-of-office readings are elevated).

"There are significant differences in blood pressure prevalence and control rates based on race and ethnicity," Fields noted. "In an NHANES survey, HTN control rates among non-Hispanic white adults (55.7%) were significantly higher than non-Hispanic Blacks (48.5%), non-Hispanic Asians (43.5%) and Hispanic (47.4%) adults.

"The Mount Sinai Health System supports populations disproportionately affected by uncontrolled chronic conditions and reduced access to technology," he added.

PROPOSAL

Mount Sinai's Condition Management remote patient monitoring (RPM) program leverages the support of a clinical team to help patients titrate medications in between office visits and get patients to goal sooner.

"By design, this program broadens access to care by providing devices that do not require the patient to have any additional technology or WiFi and by servicing patients in their homes," Fields explained.

"Created in June 2020, this program aims to improve cardiovascular health for those with uncontrolled conditions, while also addressing the challenges of healthcare access through technology," he continued. 

"The holistic care model integrates RPM and timely pharmacologic treatment designed and led by ambulatory care clinical pharmacists, and offers comprehensive education and customized care plans delivered by registered dietitians in collaboration with referring providers."

Care plans include nutrition and physical activity strategies and care coordination services to onboard patients to the program, and in-home devices.

"Patients use tablets to aid vitals measurement, better interpret results and communicate more easily with providers."

Kristin Myers, Mount Sinai Health System

"The program provides enhanced access to comprehensive medical care, patient-centered education, and linkage to community-based health and social support resources as identified," Fields said. 

"The mission focuses on patient-centered clinical services using innovative technologies that improve access to care, positively impacting social needs and improving overall clinical outcomes.

"Through services such as RPM, therapeutic optimization and clinical coaching, the program strives to help patients monitor, manage and maintain their conditions," he continued.

The Condition Management Program provides a novel offering, he added, by focusing on the following aspects:

• Technology and services. Person-centered clinical care using RPM technology and services to increase healthcare access and empower patients to engage in self-management for improved health outcomes.

• Individualized care. Model of prioritized healthcare access that meets each patient where they are and provides enhanced disease management efforts through digital care delivery, allowing therapeutic optimization and seamless communication between patients and providers.

• Interdisciplinary. Care team members include an ambulatory care clinical pharmacist and registered dietician who work synergistically with the referring physicians to provide whole-person care through medication management and clinical coaching to improve clinical outcomes and reduce utilization.

• Equity focused. Provides connected devices and broadband connectivity to all its participants to support technology-insecure patients. RPM care coordinators address critical social needs by overseeing and encouraging retention in routine care and completion of referrals. The program provides assessment of clinical and social needs and coordination of real-time care plan management that allows for earlier identification, timely intervention and prevention of unnecessary use of emergent hospital care and morbidity.

"In response to the immense need of our patients, we created the Condition Management Program to meet people where they are," Fields said.

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MEETING THE CHALLENGE

Offering a digital-first program that provides value to customers and is tailored to their needs whenever and wherever they are is the overall technical objective, said Kristin Myers, executive vice president, CIO and dean for digital and information technology at Mount Sinai Health System.

The RPM infrastructure helps improve quality of life and access to care by enabling timely patient information, remote monitoring and real-time analytics, she said.

"The technology consists of a wearable device producing continuous data, several connected devices producing intermittent data, as well as tablets, wireless communication and logistics/shipping support," she explained. "The continuous wearable devices offer detection of pulse rate, oxygen saturation, skin temperature, mobility, step count and respiration rate.

"The patient leverages MyMountSinai, an Epic-based patient portal custom developed by Mount Sinai, to view their vitals, better understand their care plan and to interact with Mount Sinai providers."

Darryl Hollar, Mount Sinai Health System

"The intermittent connected devices detect vitals such as weight, blood pressure, oxygen saturation, glucose, spirometry, etc.," she continued. "Patients use tablets to aid vitals measurement, better interpret results and communicate more easily with providers."

Device shipping and logistics support enables a completely remote experience from start to finish. Patients can begin the enrollment process via a virtual visit with a clinical pharmacist. Custom device kits are preconfigured, pre-paired to a tablet, and shipped with an active wireless connection so that only minimal setup activities need to be completed by the patient at home.

"Both patients and providers use the RPM technologies," Myers said. "Patients use connected devices to measure their vitals continuously or at specific times of the day, and to obtain a better understanding of their overall health.

"The Condition Management team is the primary provider user, consisting of pharmacists, dieticians and program coordinators," she continued. "They use the RPM infrastructure to review vitals, respond to alerts generated by out-of-range vitals, conduct virtual visits, and for overall management of patient care."

Each connected device has one or more sensors that can measure patient vitals. Vitals are captured at the patient's remote location, stored on the connected device and then, transmitted via the internet to Mount Sinai's Epic EHR.

"The Condition Management team uses the EHR to manage patient vitals and device alerts," said Darryl Hollar, director of digital health at Mount Sinai Health System. "Mount Sinai collaborates with RPM vendor specialists such as Current Health and Omron to transmit the patient vitals from the connected device to the EHR, and to provide logistics, shipping and program support.

"The patient leverages MyMountSinai, an Epic-based patient portal custom developed by Mount Sinai, to view their vitals, better understand their care plan and to interact with Mount Sinai providers," he continued.

By leveraging digital capabilities and device-enabled workflows, Myers said, RPM has enhanced the patient experience by:

• Offering convenient care at home.

• Improving provider effectiveness through automated data collection and patient interactions.

• Enabling quicker and more intelligent interventions that improve patients' health outcomes, preventing avoidable emergency and inpatient utilization, thus reducing costs.

RESULTS

"We have found that by addressing digital health equity, we can support the achievement of clinical and utilization outcomes through the engagement of a clinical team and remote monitoring," said Cathleen Mathew, PharmD, director of condition management and population health at Mount Sinai Health Partners.

"There is a clearly demonstrated value to patients – with more effective achievement of clinical outcomes than compared with a matched cohort controlling for age, sex, race and diagnosis," she continued. "We conducted an internal quality-improvement-matched cohort analysis of 218 patients, examining the effects of RPM on blood pressure control and healthcare utilization versus usual care in-clinic."

"Patients using RPM were found to have lower rates of emergency department and inpatient visits over 12 months – significant to the population health goals of our organization."

Cathleen Mathew, PharmD, Mount Sinai Health Partners

Demographic breakdowns showed the following:

• 35% of patients examined identified as Black, and 30% as Hispanic.

• 89% were 65 years or older.

• Median household income was less than $50,000.

Results from the evaluation found that 61% of patients in the RPM group achieved blood pressure control (defined as less than 140/90 mm Hg) from baseline at three months, compared with 43% of patients in the usual care group (p=0.010), Mathew reported.

At six months, 72% of patients in the RPM group achieved blood pressure control, compared with 53% of the usual care group (p=0.005), she continued. On average, Black RPM patients saw a 10-point decrease and RPM patients aged 65 and older saw an 8-point decrease in systolic blood pressure at three months.

"RPM patients experienced on average a 7-point decrease in systolic blood pressure from baseline to three months post-enrollment," Mathew said. "90.2% were able to sustain the seven-point difference for an additional three consecutive months.

"Patients using RPM were found to have lower rates of emergency department and inpatient visits over 12 months – significant to the population health goals of our organization," she continued. "RPM patients experienced 25 all-cause-related ED visits compared with 33 ED visits by usual care patients (p=0.396)."

Staff observed an overall reduced total cost of care for patients enrolled with RPM as compared with usual care. RPM patients experienced 19 hospitalizations, compared with 56 for usual care patients (p<0.001). This equated to approximately $21,976 and $814,000 estimated cost savings for ED visits and hospitalizations, respectively, for RPM patients over 12 months.

"We noted that at the time of enrollment, 40.6% of enrollees did not have a smartphone and 26.3% did not have a cellular connection or Wi-Fi in their homes," she observed. "Providing connected devices to 100% of patients participating in the Condition Management program continues to effectively address the need to improve access to technology among certain demographics, which resulted in measurable improvements in clinical outcomes."

USING FCC AWARD FUNDS

Mount Sinai Health System received $920,000 from the FCC telehealth/RPM grant program.

"The FCC funds have been used as the Condition Management Program has grown to support various patient groups over the past two years, including our high-risk obstetric population and geriatric population with uncontrolled conditions," said Ruchi Tiwari, PharmD, executive director of ambulatory pharmacy and population health at Mount Sinai Health System.

"Our goal for the funds is to support those who need it the most, across multiple conditions."

Ruchi Tiwari, PharmD, Mount Sinai Health System

"Our goal for the funds is to support those who need it the most, across multiple conditions," said Tiwari. "In the second half of 2022 and in 2023, our program will expand to cover additional conditions, including diabetes, pulmonary arterial hypertension and lung transplant."

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