Innovative HHS remote symptom monitoring program is a Canadian first
Potential benefits include cost savings and better patient, provider experience
Thousands of Hamilton Health Sciences (HHS) patients recovering at home from surgery 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 for patients living with heart failure (HF) and chronic obstructive pulmonary disease (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.
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 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
“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.
“I believe patients discharged from hospital can really benefit from remote symptom monitoring overseen by registered nurses and nurse practitioners.” — Kelly O’Halloran, HHS director of community and population health services
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.
How it works
Eligible patients with HF and COPD are identified by HHS teams and provided with 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.
HHS home monitoring kit
Kits also include an HHS-owned blood pressure cuff, weight scale, pulse oximeter for measuring blood oxygen levels and pulse, and a thermometer, with results automatically entered into the Epic system via MyChart.
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.
