Atrium Health and UAB Extend Digital Care Journeys Across Multiple Service Lines to Support ERAS, Reduce Readmissions & Lower Costs

As the healthcare industry undergoes transformation, technology has become an integral part of how healthcare providers engage with patients pre, during, and post hospitalization. The right technology can assist with increasing efficiencies, empowering patients, reducing costs, and improving quality and patient safety. Technology such as digital care journeys can improve medication safety, automate delivery of evidence-based education (e.g., ERAS) and enable standardized, high reliability care.

According to a report published in 2021, top health system executives stated improving the patient consumer experience and improving quality and patient outcomes were their top priorities. With this in mind, many health systems initially focused their digital patient experience efforts on making it easier for patients to search and schedule appointments, check in at the hospital, and pay for services, however, with the ongoing shift to value-based case, innovative health systems like Atrium Health and UAB have evolved their digital approach to focus on using digital care journeys to better engage and monitor patients across different episodes of care, such as the surgery to improve quality and patient safety.

Whether a patient is going through a surgery, cancer journey, maternity care journey, a chronic care journey, engaging patients across their individual care journey is critical as 95% of that patient or care journey is on their own at home with limited support. Often patients forget verbal instructions and lose paper instructions or find them hard to follow. Resulting in patients and providers feeling disconnected, and providers feel like they are sending patients into a black hole between visits.

Wouldn't it be great if we could monitor patients outside the four walls of the hospital setting? Imagine that a patient could go home and, on their smartphone, or their tablet, or desktop computer, they could be guided digitally step by step to keep them on track, to monitor them, and catch problems earlier and really achieve the things that healthcare providers want for patients, which is not only a great patient experience, but better quality and better outcomes.

“For our institution, especially with COVID affecting so many processes at the hospital, the throughput of our hospital, the length of stay, has been a high priority. How do you avoid excess lengths of stay and focus on the most optimal postoperative recovery, the best recovery that you can give the patient, so they're not in the hospital seven days, but they can be in the hospital three days and yet still achieve optimal outcomes with no readmissions, no increasing complications? Enhanced recovery has also become a top priority because that is a mechanism through which you can address all these other metrics,” explains Dr. Daniel Chu, Vice-Chair of Health Services Research at UAB Medicine, during our recent the webinar titled How Atrium Health and UAB Medicine Are Using Digital Care Journeys to Improve Quality and Patient Safety.

During a recent poll, we asked 121 healthcare professionals “Which quality and safety initiatives is your organization focused on in 2022?”, 48% indicated they are focused on improving the patient experience, 29% reducing readmissions, and tied in third at 7% shortening length of stay and Enhanced Recovery After Surgery (ERAS).

“I would say with the organization and with our group specifically, improving the patient experience is probably a top priority for us now, especially with value-based care in the way that things are coming down with how you get paid. We have implemented enhanced recovery after surgery and been highly involved in that. We've been doing it for six...almost seven years. From our standpoint, we've already done the reducing readmissions pretty much as much as we can. It's always a constant focus for us. We've done that probably as good as we're going to get that. With hepatobiliary surgery, liver and pancreas surgery, most of these patients 85% of them being cancer-related, we have a 30% readmission rate on these patients, and I don't think that there's any way for us to get less. We've done multiple different things, including with SeamlessMD, to be able to try to reduce that number. I think that's as low as we're going to get, and it's quite a bit lower than what it was seven years ago,” shared Misty Eller, Advanced Nurse Practitioner, Department of Surgery at Atrium Health during our recent webinar.

Eller further explains, “our length of stay is much improved. Seven years ago, a Whipple patient would be in the hospital anywhere from 10 to 15 days was our averages, and now we're anywhere from 5 to 7 days consistently. I think that we've reduced our length of stay as much as we possibly can. Then the opioid use with enhanced recovery goes hand in hand. For us, in 2023, it's going to be a big push to look at the patient experience, and how can we make something that is the worst time in the patient’s life, how can we make this as good as it can be and as easy as it can be for the patients and their families.”

Deploying EHR-Integrated Digital Care Journeys Across Clinical Areas

Let’s take a closer look at how forward-thinking health systems like Atrium Health and UAB are using digital care journeys today across multiple clinical areas to achieve quality initiatives and better outcomes.

Taking a digital approach for the past four years, has enabled Atrium Health to keep patients on track throughout their episode of care, keep documentation up-to-date and always available to patients, support Enhanced Recovery After Surgery (ERAS), and keep patients’ activities documented in their EMR. Atrium Health is using digital care journeys across four service lines - bariatrics, colorectal, pancreas, and liver surgery. Pancreas and liver are together with hepatobiliary surgery. Through the integration of SeamlessMD and Epic, all dashboards and patient reported outcomes are accessible right inside the Epic patient chart making it easy to access the information without leaving the patient’s chart, eliminating the need to open different windows, and the time-consuming task of going back n’forth between applications, switching screens and logging in and out frequently. When time is of the essence in inpatient settings, streamlining processes and access to patient information is critical. Integrating key systems and auto-populating patient records with timely information makes it easier for clinical staff to access key information.

For example, by utilizing SeamlessMD to help with reducing Atrium Health’s readmissions, clinical staff can pull up a dashboard within SeamlessMD, and go through and look at all the surveys that patients who've been discharged are answering. If patients indicate on the survey that they had 10 nauseas, it'll highlight in red, then staff can call that patient and ask clinical questions like, "Hey, do you have some Zofran at home? Do you need me to call you in something else? If you have a G-tube, are you venting it? Are you doing tube feeds? Are you eating? What are you eating?". 80% of the time, the remote monitoring can prevent patients from calling the office and prevent them coming to the emergency department.

Misty Eller explains, “I would say 90% of patients are just scared, and they don't know what to do. So having someone that's like a big brother in there and looking over the questions they're answering and then calling them when something's abnormal has been huge in us preventing patients from coming back to the emergency room. We've seen a reduction in patients that just pop into the ER and basically get seen, examined, CT scan, all these things done, everything looks fine, and they send them home the same day. We don't even admit them or do any treatment because it wasn't necessary. They just needed reassurance. I think that that has been one of the biggest things that we've been able to utilize with SeamlessMD.”

Like Atrium Health, UAB Medicine has a taken a digital-first approach to guiding patients through episodes of care for the past five years initially deploying digital care journeys in their colorectal service lines and then expanding to thoracic, cardiac and gynecology oncology, mainly because these were basically some of the busiest service lines, most complicated patients at UAB. They have also integrated SeamlessMD with Cerner, their EHR system of record.

“It's really been fantastic. Patients truly love this opportunity to be engaged with their journey because surgery is as we all know literally a journey from the beginning to the end and they can really have a customized experience,” stated Dr. Chu.

UAB has also synergized these experiences with their enhanced recovery protocols, especially within colorectal and gynecology. As everyone knows, adherence to components of enhanced recovery is the key to its success. Programs like digital care technologies can really help patients improve and hopefully have better adherence to these components. One of the things that technologies like digital patient engagement apps have also enabled is the ability to go beyond collecting traditional metrics like length of stay, but also patient-reported outcomes which is reflective of the patient’s experience - what do they really think about the various things that they're experiencing with pain, nausea, ability to go back to their normal functions of daily living.

Dr. Chu adds, “the remote patient monitoring is awesome in the sense that it provides, in our minds, really another safety net for patients. Through programs on their phone, it's much easier to basically be able to communicate with your primary team. So, our nurses, for example, will get emails, will get warnings if something were to go awry with a patient's recovery at home and that has prevented readmissions and has prevented some serious events from happening.”

Optimizing Enhanced Recovery After Surgery

There are several different ways that health systems can use technology to support and complement enhanced recovery protocols. Digital technologies like digital care journeys enable health systems to educate patients and their families before surgery, which is critical before enhanced recovery can begin. Packaging all the education components and streamlining the communication in a consistent, high-quality manner to ensure patients have a clear understanding of expectations, processes, and preparations is important to ensure that they have a good recovery.

Dr Chu explains, “to deliver it into the real world, to implement it, give it to someone and do it in a way that's of high quality and consistent, that's the tough part. So that's when you need tools to do that. That's what enhanced recovery is. I think it's a great tool to basically deliver all that. Digital healthcare technologies, like SeamlessMD, is a great tool to be able to package things and deliver things more consistently and in high quality. Where technologies like SeamlessMD can be incredibly impactful is in education because we all check the box, "Oh, we educated a patient." But doing it in a way that is aligned with everyone's different levels of health literacy. Doing it in a visual, simple easy to understand interactive way is critical.``

For Atrium Health, interactive digital care journeys have helped deliver the documentation, automate patient reported outcomes, as well as monitor and track patient activity. Misty Eller explains “Before we deployed SeamlessMD, we had timers on the doors like literally kitchen timers that we put on the doors and patients would hit the timer, they would go for their walk, they would hit the timer, the CNAs would have to document it on a sheet that was on the door. At the end of a 24-hour period, we'd have to have the nurses go and get those sheets with the CNA, and then they would have to go through and document 24 hours of the patients’ mobility and stuff. It did fail a lot. But we didn't really have a better way to be able to track it. So, I think, that has been one huge thing for us as SeamlessMD allows us to be able to do that in an easier fashion.”

Providing patients with evidence-based materials that they can go through in the app on their device especially during their recovery when they can’t think about opening a paper booklet, or don’t feel like flipping through a booklet every day enables the patient easy access to pertinent information that can enhance their recovery.  

The widespread adoption of smartphones has hit an inflection point. Analysts today put smartphone adoption in the U.S. at 88%, with almost 75% adoption in the 65 and older demographic. One study stated the average person touches their phone 1,500 times a week. There are no comparable physical technologies that we interact with more. So, whether it’s a smartphone or an iPad, it’s easy for patients and their caregivers to access their personalized digital care journey anywhere, anytime.

No longer is it necessary to make patients come into hospitals to show providers their incisions. Patients can now snap a photo with their smartphone and submit the incision photo through the digital care journey app. Making it easier for providers to monitor patients during recovery and follow-up. Especially for rural patients who live hours away from the hospital or their nearest medical center. Care teams can ask patients to submit incision photos the first week after surgery from the comfort of their home and providers can assess the incisions to determine if any further action is required or maybe the patient does not need to come back in if they’re doing fine. This is extremely helpful to providers as it saves time, reduces costs, and ensures that the patient feels connected to their care team.

With a digital care journey app available on a patient's smartphone, they can scroll through education materials provided by their healthcare provider, and self-report outcomes and symptoms. As Misty Eller, Atrium Health puts it “patients can mindlessly look through their phone, and the digital care journey is just one more app that they can access as many times as they like. It’s like ok I checked my Twitter, checked my Facebook, now I’m going to check my SeamlessMD app. Then they can go on with their day. It’s helpful for patients to be able to reiterate those education components. We have 90% engagement of people downloading the app.”

Lowering Costs and Curbing Opioid Use

Digital care journeys provide patients with the comfort of knowing their care team is in the palm of their hand or as close as their desktop computer, but they also provide hospitals, health systems and providers with real tangible clinical outcomes and benefits such as cost savings. Health systems can also leverage digital care journeys as a tool to adhere to enhanced recovery components which has been proven to increase success with ERAS.

As Dr. Joshua Liu, CEO and Co-founder, SeamlessMD explains “One of the things I've learned is the digital technology piece is a tool and what we found in the clinical world is that the clinical components, the workflows that your team has put onto the platform so we have the right elements being pushed to patients that we're trying to get compliance with, when you have the right components in place and you get engagement with that, then you get better outcomes. But that clinical piece, having the right protocols in place is so critical for the technology to be useful.”

Adherence to enhanced recovery components leads to increased success with enhanced recovery. Digital patient engagement technologies like SeamlessMD can help with improving adherence. In the diagram below, you can then see cost benefits UAB has realized as they increased the number of components adhered to. This is just using five components that are best practices in enhanced recovery. If a patient uses none of the components, then the cost of that episode of care is actually very high in terms of the variable cost. Dr. Chu explains, “We know if you follow 100% of components, you can have a great outcome and as a result you're also going to see this benefit from a cost standpoint.”

In April 2022, UAB published a cost-benefit analysis of a patient engagement technology (PET) in cardiac, thoracic, and colorectal surgery with The American Journal of Surgery highlighting patients undergoing colorectal surgery with access to digital patient engagement technology (PET) variable costs of surgical encounter were $102 lower than non-PET, and $1495 lower than pre-PET (p = 0.03). Similar for patients undergoing thoracic surgery with access to digital patient engagement technology total costs of surgical encounter were $9224 lower than non-PET, $2187 lower than pre-PET (p = 0.03).

Virtual care management solutions or digital care technologies can also help curb opioid use by remotely monitoring medication consumption. Historically, some providers may have sent home patients with far more medications than needed, essentially over-narcotizing patients, resulting in patients becoming addicted to specific opioids or patients being anxious about consuming 30-days’ worth of medication without access to their care team and only using five days’ worth.

“Curbing our opioid use, having patients do the risk calculator and being able to identify which patients are at risk and which patients are not utilizing their opioids and don't need them at home. Those are huge things that we've been able to do the last couple years,” stated Misty Eller, during our recent webinar titled How Atrium Health and UAB Medicine Are Using Digital Care Journeys to Improve Quality and Patient Safety.

Digital care journeys have also been proven effective for rural health, providing easy access to patients who live two or three hours from their care team or who live alone and especially the elderly. With the ability to self-report symptoms daily through the digital care journey app on their phone, tablet or desktop computer patients feel less anxious, less alone and feel like they have a lifeline back to their care team.

“It starts with educating patients up front and then making sure that you give them a lifeline on the back end. Like, we always say, we're not sending them out into the wild because people don't survive well in the wild after these surgeries. So, for us, sending them into the wild but also giving them a little bit of a leash where they know they have direct contact to us,” shares Misty Eller.

Digital care journeys not only provide patients with confidence that they have access to their care teams if they need it, but digital technologies provide care teams and healthcare providers with the confidence to safely get patients home sooner.

Shortening Length of Stay with Digital Care Technologies

With many hospitals running at capacity or over capacity during the pandemic, it resulted in many surgical teams evaluating if high-volume routine surgeries could be done the same day and how could surgical backlogs be reduced to optimize different service lines and recoveries.

For UAB, they began performing same day colectomies or same day colorectal surgery. By providing patients with access to a virtual assistant or digital care journey for colorectal surgery, they were able to remotely monitor patients.

“There are patients who can have outpatient colectomies, but you need a good monitoring system. Technologies like SeamlessMD act like a safety net. They are something that essentially helps bird-dog the patient - it is the virtual assistant who can basically see and ask, "How are you doing?" And on the provider side, we can look on our screen literally like a radar screen of these patients to see how they're doing,” explained Dr. Chu.

It's been proven that virtual assistants, or digital health technologies, are more reliable than humans. Digital care journeys don’t take holidays, don’t take vacation, they don’t sleep, hence they are available 24/7/365 days of the year. They are always available and accessible to guide patients step by step through their episode of care. Automating touchpoints with patients pre, during and post hospitalization, enabling patients to self-report symptoms, submit incision photos, and access evidence-based education whenever in the palm of their hand enables patients to self-manage their care, feel like they are part of their care journey, reduce anxiety and the fear of being alone.  Relying on one person or a small group of people is not sustainable, not scalable and it’s not dependable.

For example, UAB and Atrium are engaging patients with their surgical care plan and their enhanced recovery care plan, by pushing digital reminders to patients just in time so they can be on track with that step and if they want patients following a certain protocol, like get up and walk, day one, day two post-op, they can track if the patient is doing it or not. Beyond educating patients and collecting data, imagine if health providers can tell a patient, "Hey, you met your goals for walking, or you know what, you didn't meet your goals and here's reasons why you should get up and walk today and be motivated to recover." Research indicates that giving patients just-in-time feedback about their progress motivates them to recover and do more.

Improving Health Literacy

Health literacy is the ability to obtain, read, understand, and use healthcare information to make appropriate health decisions and follow instructions for treatment. The U.S. Department of Health and Human Services (HHS) defines health literacy as “the degree to which individuals have the capacity to obtain, process, and understand basic health information needed to make appropriate health decisions.

Providing patients with access to digital care journeys that combine the best of the fields of health literacy, adult education, and online accessibility enabled UAB to battle low health literacy and address all patient populations. Keeping information at a Grade 6 reading level, using large font, simple step-by-step illustrations, screen reader tested, color blind tested and adhering to WCAG 2.0 Level AA ensures that patients can access, read, understand, and process the information.

“Addressing health literacy is super important. It undercuts everything that we do in healthcare. Programs like SeamlessMD really provide the tool to help engage and to help better educate patients in ways that are health literate. I think that's another huge opportunity for these digital journeys,” shared Dr. Chu.

Health literacy matters in a lot of non-surgical conditions like diabetes and chronic diseases, and it absolutely matters in surgery. UAB has been able to show that patients with limited health literacy, low health literacy, are at risk for having more complications, longer length of stays. All the bad things that can happen in surgery can still happen despite being even under enhanced recovery programs.

The diagram below was presented by Dr. Connie Xiao at the International ERAS Congress in early June 2022 in Madrid and won best abstract for this concept. The point is health literacy matters. Any tools that health systems have to better address health literacy, can have all these downstream effects, and just improve the experience of all patients.

Enhancing the Patient Experience with Interactive Digital Care Journeys

As challenges such as healthcare consumerism, staffing, rising number of patients, revenue retention, and value-based care impact the healthcare industry, leading health systems are deploying technologies like EHR-integrated digital care journeys across multiple clinical areas to address all patient populations from chronic care, surgery, oncology, maternity care, mental health, and more to optimize the patient experience.

Early adopters like UAB and Atrium Health through clinical studies have proven that providing patients with access to digital care journeys before, during and after hospitalization can reduce readmissions and ED visits, shorten length of stay, increase patient engagement, and improve the patient experience through enhanced recovery after surgery.

“One of the greatest strengths of these technologies and this idea of engagement with patients is to improve the experience. We've had a great experience with this program for our patients at UAB,” shared Dr. Chu.

Watch the on-demand webinar How Atrium and UAB use Digital Care Journeys to improve Quality and Patient Safety to hear more from Dr. Chu and Misty Eller as they share clinical examples of how digital patient engagement technology can support enhanced recovery after surgery initiatives, curb opioid use, reduce readmissions, shorten length of stay, and lower costs.

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