
Heart failure patient recovers at home thanks to a Canadian first at HHS
“It felt like an elephant was sitting on my chest.”
That’s how Hamilton resident Peg Kelly describes chest pressure she experienced one night in December, during the holidays. Kelly has been living with heart failure (HF) for 10 years and recognized the seriousness of her symptoms.
“I couldn’t breathe when I tried lying down in bed. I was sitting up all night long, trying to breathe better, and I felt dizzy and faint. I knew something was very wrong, because these were the same symptoms I had 10 years ago when my heart problems started,” she said.
Kelly visited the emergency department at Hamilton Health Sciences (HHS) Hamilton General Hospital and was admitted for three days, until she was well enough to return home. While in the hospital, she was invited to take part in a new remote home monitoring program launched by HHS for patients living with HF and chronic obstructive pulmonary disease (COPD).
Innovative HHS symptom monitoring program
Thousands of HHS surgical patients recovering at home from their operations have benefited from remote home monitoring since this form of virtual care was introduced several years ago and expanded during the pandemic.
Recently, HHS launched a remote symptom monitoring program specifically for patients living with HF and COPD. This new program includes nurse practitioners, and is supported by MyChart Care Companion, a feature in Epic, the state-of-the-art, fully digital hospital information system launched at HHS in 2022.
“It’s great because I’m constantly being monitored and if something doesn’t look right a nurse contacts me right away.” — Peg Kelly, patient
Epic is considered among the best hospital information systems in the world and is used internationally by many top-ranked hospitals. MyChart is Epic’s patient portal that allows patients with a computer, tablet or mobile phone to connect with HHS and access their lab and test results, appointment information, doctors’ consult notes and more.
If this program proves successful, it could be expanded to include patients with other health conditions. The clinical pathways developed through this model could also be shared with other Epic hospitals in Canada resulting in improved patient and health system outcomes. An area of efficiency could be the elimination of some costs associated with home monitoring equipment while also streamlining the data collection process.
Developing custom remote monitoring protocols

Kelly O’Halloran, Jennifer Lounsbury, and Prathiba Harsha were instrumental in launching this remote symptom monitoring program for patients discharged from hospital and living with heart failure and chronic obstructive pulmonary disease.
“MyChart provides integrated clinical pathways for patients with HF and COPD who are discharged from HHS,” says Jennifer Lounsbury, chief nursing information officer for HHS. “This created an opportunity for HHS teams to develop MyChart Care Companion custom remote monitoring protocols and to test drive this approach to care starting in November 2024 with HF and COPD patient populations.”
Patients are remotely monitored from the comfort of their homes by a team of HHS virtual care nurses and nurse practitioners through a custom program created by HHS and made possible through the Care Companion platform.
HHS is the first Epic hospital system in Canada to develop a streamlined remote monitoring system integrated Care Companion model. Potential benefits include:
- Improved patient care. For example, patients with HF and COPD rely on their primary care physicians, specialists, home care and other community providers when they return home after being in hospital. Remote symptom monitoring can enhance their care from their home with Care Companion, since with early intervention it’s possible to avoid the worsening of HF and COPD conditions. This can improve patients’ health outcomes, well-being, as well as system outcomes such as reducing emergency department visits and readmissions.
- Health equity and cost savings. By providing patients with hospital-owned kits containing home monitoring equipment, all patients have access to technology and there’s no need to rent this equipment from outside providers.
- A better provider experience for HHS virtual nursing staff and other team members. Since HHS-owned monitoring equipment is integrated with Epic, nurses will not have to manually input data from another source into the Epic system.
Seamless integration between home and hospital
Eligible patients with HF and COPD are identified by HHS teams and receive a home monitoring kit consisting of an HHS-owned iPad so they can log into MyChart’s health tracking application, says Prathiba Harsha, HHS interim director of clinical informatics and solutions delivery.
Kits also include an HHS-owned blood pressure cuff, a weight scale, a pulse oximeter for measuring blood oxygen levels and pulse, and a thermometer, with results for all the devices automatically entered into the patient’s electronic health record in the Epic system via MyChart.
“I had never used an iPad before,” says Kelly, who received support from the HHS team in learning how to use the equipment. Each morning, Kelly logs into Epic’s MyChart to input her vital signs. “It’s great because I’m constantly being monitored and if something doesn’t look right a nurse contacts me right away,” says Kelly. “They really keep an eye on me, and it’s easy.”
Kelly also enjoys weekly video conferences with a member of the program’s nursing team. “The nurses are very agreeable, supportive and kind.”
Care Companion also provides medication reminders, education, questionnaires, links to community resources and on-demand video visits with a member of the HHS virtual care nursing team and nurse practitioners.
Patients’ vital signs seamlessly integrate into Epic, where HHS clinical informatics teams, clinical experts and operational leaders have worked together to create specific care pathways that empower patients to monitor their vital signs at home, respond to questions related to HF and COPD, and connect with virtual nursing and nurse practitioners to obtain required support.
Improving patient care
Kelly O’Halloran, director of community and population health services for HHS, came up with the idea to offer remote home monitoring to HF and COPD patients, and partnered with the HHS informatics team on the development of custom MyChart Care Companion protocols.
“I believe patients discharged from hospital can really benefit from remote symptom monitoring overseen by registered nurses and nurse practitioners,” says O’Halloran, who elicited funding support from Ontario Health West/Ontario Health to develop and implement the custom Care Companion protocols.
“We have been fortunate to have the expertise of Dr. Catherine Demers, HHS director of heart function services, Dr. Natya Raghavan, HHS head of the service for respirology, and other clinicians to develop the clinical pathways,” says O’Halloran.
Inspired by HHS PROTECT Lab
O’Halloran says she was inspired by the HHS PROTECT Lab and its Continuus Health program, based at HHS Juravinski Hospital and Cancer Centre (JHCC).
The PROTECT Lab is a leading-edge HHS and McMaster University research lab that studies virtual care and remote home monitoring of hospital patients through its Continuus Health program. Care Companion is a satellite model build around the hub PROTECT Lab virtual care model, which has traditionally focused on post-surgery care, with plans to include JHCC cancer patients receiving treatments such as chemotherapy, radiation, and immunotherapy as outpatients.
The virtual nursing team supports pediatric and adult surgical patient populations. This further expansion to support patients with chronic medical conditions like COPD and HF continues to build on a virtual care model supporting person-centred integrated care for the people of Hamilton and surrounding regions.