Augmenting Enhanced Recovery After Cardiac Surgery with Digital Care Journeys: A conversation with Dr. Marc PelletierAugmenting Enhanced Recovery After Cardiac Surgery with Digital Care Journeys: A conversation with Dr. Marc Pelletier
Thought Leadership

Augmenting Enhanced Recovery After Cardiac Surgery with Digital Care Journeys: A conversation with Dr. Marc Pelletier

November 3, 2022
By
Tracy Staniland

When we think about the patient journey, especially in cardiac surgery, patients are often overwhelmed with lots of paper and verbal instructions. They lose the instructions or misplace the paperwork, or they forget, there's no day-to-day reinforcement, and, ultimately, it's hard to follow.

For healthcare providers it's hard to keep track of how patients are doing between visits, especially after discharge and we know if patients can't follow instructions well, and if providers can't keep an eye on them, bad things can happen, avoidable ED visits and readmissions, higher than expected length of stay, ultimately, higher costs for the health system. 

These are not new problems, however, for healthcare systems faced with mounting pressures these issues are rising to the forefront. With backlogs in surgeries stemming from the pandemic, the ongoing shift to value-based care, financial challenges, and staff burnout on the rise health systems are under increasing pressure to deliver better care at a lower cost and to find innovative, scalable ways to better engage and monitor patients outside the four walls of a hospital. 

According to a study by iData Research (2021), the cardiac surgery procedure volume is expected to continue growing at a rate of about 5% per year, with the largest portion of these procedures being coronary artery bypass graft (CABG) procedures.

Enhanced Recovery After Surgery (ERAS), a set of multimodal evidence-based standardized interventions pre-and post-surgery including pre-op carb loading, early mobilization, post-op, and so forth often involves giving patients very large 50-page plus booklets because there's so many important steps in the journey to cover, and patients are often asked to log data around compliance or other patient-reported outcomes. But it can be difficult to get patients to do that, especially on paper, and even more cumbersome and time-consuming for providers to try to turn that into real useful data.

What if we could transform enhanced recovery after surgery protocols and care pathways into automated digital guidance for patients? What impact could that have on patient education, compliance, and outcomes? 

We recently had the opportunity to speak with Dr. Marc Pelletier, Chief of Cardiac Surgery at University Hospitals Health System and Director of the Heart Surgery Center for University Hospitals Harrington Heart & Vascular Institute, about their Enhanced Recovery After Surgery Program and how they are using a digital patient engagement platform to support their program, optimize  patient adherence to ERAS protocols, and improve clinical outcomes.  

Dr. Pelletier joined University Hospitals from Brigham and Women’s Hospital and Harvard Medical School in Boston, where he served since 2016 as surgical director of the transcatheter aortic valve replacement (TAVR) program. Prior to this role, he spent nine years as head of cardiac surgery at the New Brunswick Heart Centre in Canada. Before that, Dr. Pelletier was a surgeon and an assistant professor at Stanford University. He trained at McGill University in cardiac surgery and Stanford University in cardiothoracic transplantation and ventricular assist devices. His areas of specialty include TAVR procedures, minimally invasive valve surgery, aortic valve and aortic root surgery, surgery for heart failure and minimally invasive coronary bypass surgery. Dr. Pelletier has authored more than 100 peer-reviewed publications, with over 110 abstracts accepted at scientific meetings and participated in more than 110 invited talks. In 2022 and 2021, he was named one of Cleveland’s Top Doctors and was also awarded the Distinguished Surgeon designation at University Hospitals.

Dr. Pelletier thank you for joining us today. Can you provide us a brief overview of University Hospitals? 

University Hospitals (UH), which is a comprehensive health system based in Cleveland, Ohio. UH now has over 20 hospitals, many different health facilities and centers that serve the population primarily of Northeast Ohio. There are over 200 physician offices in 16 different counties and about 30,000 employees with an annual revenue across a system of approximately $5.5 billion. So, it's a big enterprise.

On the cardiac surgery side, we perform approximately 1,500 surgeries per year. In addition to TAVR Program, that's approximately 370 TAVRs a year. How we divide that is we have a main center or quaternary center that does about 1,000, and we have five other regional programs that do anywhere between 80 to 100 cases to about 250 cases. We have a total of 10 surgeons in our group, and we just recruited an 11th, Dr. Arora was heavily involved with ERAS, and we have a great vibrant group supported by a strong perfusion and first assistant program team. 

Why did you decide to provide digital care journeys for your patients? What were the challenges that you were trying to overcome by providing patients with access to personalized digital care journeys?

We wanted to embark on this journey of ERAS as it relates to cardiac surgery. We wanted to look at our pathways and how patients were coming across the experience for cardiac surgery, trying to define that as preoperative, intraoperative or intrahospital and then post-operative, especially the part that's at home.

To have a way to automatically collect that data. We wanted to be able to look at that data on a regular basis, on a rolling basis, and if needed, be able to pivot or make some changes in how we were treating some of these patients and we wanted to be able to monitor them outside of the hospital setting. To have some form of remote monitoring that enabled patients to record how they are feeling and how they were doing.

We could probably build something like that. But the reality is that to build something like that with all videos, all the information, everything that you need in there is labor intensive. We just didn't think that it was feasible. So, we felt that partnering with somebody else would be a really good way to track a lot of these outcomes. 

We sat down as a team, and we went through all the ERAS guidelines and felt that having some electronic way of engaging our patients, especially in the hospital, more importantly, once they got home, either through themselves or their caregiver, we felt that that was really a worthy investment. So that's where we chose to direct some of the guidelines in which ones that we applied in terms of cardiac ERAS.  

When you think about implementing digital care journeys as part of your ERAS strategy, what were some of the key metrics or quality targets you were thinking of?

We wanted to enhance the experience for the patient - to make them feel more connected and part of the reason we wanted to do that is that we're in a really competitive environment in the United States. 

We wanted to find a demarcater and in the United States the reality is that patients can really choose where they get their cardiac surgery care. So, we were looking for something of a differentiator or a demarcater, and we felt that this was something that we should focus on because the focus was really on the patient.

We thought that if we did this, maybe we could see a few different things. We were hoping we could maybe shorten the length of stay. But more importantly, that we could look at tackling the three big reasons why people get readmitted. We know that readmissions after Coronary Artery Bypass Graft (CABG) is a nationally monitored metric, and we also know that patients get readmitted primarily for three things:

  1. Arrhythmias
  2. Tachycardia
  3. Heart failure symptoms, which can be shortness of breath, weight gain, and things of that nature, or sternal wound complications.

So, we thought that if we could monitor patients a bit more closely over the first two to three weeks after they went home, we could impact this. We also know that phone calls to our nurses, visits to the ED, they're all very time-consuming. So, if we could stay ahead of the curve, identify issues before they became really big problems, that maybe we could make a bit of a difference with that.

Dr. Pelletier, what was important to you and University Hospitals when selecting a digital patient engagement/digital care journey platform – and why it was important?

I think when we first started looking at ERAS and initiation of that program, we had realized that several other programs across the country, mainly in other specialties, like colorectal we're using the expertise of people like SeamlessMD. So, we thought if we're going to do ERAS, maybe we could partner with somebody in the digital space that would help us with adherence.

We also know that there's a fair amount of data suggesting that going with somebody like SeamlessMD will help you in terms of your clinical evaluations, your studies, and your results, in terms of readmissions. The biggest thing is we had a lot of discussions with our IT team, and it was really the build. To build this out, to have all the videos, the content, that takes a lot of time. When we partnered with SeamlessMD, we really liked a lot of the content that had already been built. There was still an opportunity to tailor some of it, but we weren't starting from scratch, something already was there, it already existed. For us, that was good.

The other thing is if you do a build with your IT, there's a big upfront cost. Whereas with SeamlessMD, that cost is really transmitted on a per-patient cost. We felt that at least from a financial perspective, that was a little bit more viable and a little bit easier to get buy-in from our Heart and Vascular Institute, as opposed to asking for a large amount at the beginning to build something, we just felt that we could incorporate this into the patient journey and into the global patient costs. So, for us, this made a bit more sense.

Can you tell us how using a digital patient engagement solution has helped with delivering ERAS education? 

To go through ERAS, you start to realize how much documentation we're giving patients, and we're asking them to really review that and to know it all. I think a lot of us know, that's really a hard ask for a lot of our patients. So, this was a way to digitize that. It comes to them more piece by piece, which is a little bit easier to digest and it comes with reminders. 

So, if you give somebody a booklet, and you ask them just to do their chlorhexidine shower at a certain time, to take their energy drink at a certain time, sometimes they forget. When these things come across your smartphone, these reminders, they tend to be much more relatable for most of our patients.

One of the aha moments was that a lot more patients have access to this technology, whether it's a tablet, or phone, or a computer, or their kids do, or their nephews do than we realized. The proportion of patients that are not using this is very low. 

The postoperative piece is really, for us, been the most important piece. I was speaking with my nurse today, who works with me with all our patients, we were talking about what messages she gets from the patients, and really, we've been able to address a lot of these. Over the course of the year, there's not always a ton of them. But we get pictures of their wound if they think that their wound's redder than it should be. If there's drainage, we can talk about it, we can get them to take pictures and send it to us every day, if their heart rate is elevated, if their weight's been up or down. These are things that we can often start to tackle. It's a lot easier to tackle when a patient who's had two pounds of weight gain for a couple days and put them on some Lasix than it is to deal with it a week later now, they've gained 15 pounds, and they're in really bad heart failure, and you have no choice to readmit them. So, it's a lot of those little things that for us have been helpful.

Does your care team find it helpful to get alerts at the right time, any specific stories, or examples that you can share?

We've had a couple of issues with wounds so, we would have somebody take a picture of a wound, a little bit of drainage, you look at it and it looks red. You'd like to see that patient, but sometimes those patients are two or three hours away. They fit enough of the criteria that you're concerned there might be a bit of a wound infection developing, you can put them on an antibiotic, and then you can save them from having to come in at a later time with now a really bad wound infection that's developed into more of a sternal or bone infection. So those have been some of the ones that have stood out.

Also, we've had a few patients also present to us and tell us that their heart rate is elevated, we're able to get an EKG on them and all of a sudden we see that they're actually in rate-controlled AFIB, maybe a little 100 so we can adjust their medications as an outpatient -  we've saved ourselves a readmission, which, again, is a standardized metric that we are all dinged for. We know from the CMS Registry, or our readmission rate should be around 12% and we were sitting at some point around 14%, 14.5%, and we've been able to bring that way down below 10%. So, a lot of those little stories over time add up to a lot for us.

The second part has been really the automation of information when it comes back to us. So, let's say it's 2:00 AM, and they are concerned about their wound or their heart rate, that will generate an automatic email that then our nurse navigators will be able to look at when they come in the morning, or they get an email, generated email, they click on the button, it takes them to the SeamlessMD screen, they then can see who the surgeon is, the patient, what procedure they had and that generates a response. So sometimes that response typically is to call the patient, check in on them, find out a little bit more detail about what's going on, and then we can direct them to where it is that they may go.

Now, in addition to that, there's a whole bunch of data that we've been able to tap into to help us with process improvements. So, we all know that opioids, for example, are not ideal. We want to minimize the use of opioids. We know that they're tied into addiction for some of our patients' data that we've published before shows that 5% to 10% of patients who had never been on opioids are still on them 30 days after the operation. We do not want to contribute to this opioid dependency. If we see that somebody's still using significant opioids 7, 8, 9 or 10 days out, it gives us the opportunity to bring them back, maybe get our pain management team involved, look at different modalities of pain other than opioids. One thing that we've noticed is that our opioid usage, especially beyond seven, eight, nine days is really, really low. It's not zero, but it does allow us to pay a bit more attention to those patients and try to treat them a little bit differently.

What has been the impact on actual clinical outcomes? 

This is one of the studies that we looked at pre- and post-intervention. It is not a randomized prospective trial. What it is, it's a pre- and post-intervention trial, whereas the implementation of SeamlessMD was our intervention and we were able to look at those patients, 95 continuous patients, and then we matched them to a cohort from within a year previous to that intervention that were generally matched in terms of age, the type of surgery that they had, their STS risk score.

We saw that length of stay, we were able to impact it a little bit. But where we really made an impact was on some of those metrics that are reportable metrics, especially readmissions. We saw a significant decrease in our readmission, and we saw a significant decrease in visits to the emergency rooms, we saw a lot fewer phone calls to our office. Now, some of those were probably phone calls that we made to them once they had reported an adverse event and we did see fewer discharges to skilled nursing facility.

We then looked at a similar cohort, but we looked at these just CABG patients. And again, these were patients that had been enrolled in an ERAS program with SeamlessMD, and then a cohort of patients, non-ERAS. Again, we tried to match these as best as we can. One of the things that you see is length of stay. Now, this is incorporating their pre and their postoperative length of stay. So, this isn't the entire length of stay from their acute MI, their diagnosis, their CAT, they stay in the hospital, and they have their intervention done. But again, in this cohort, we saw a lot fewer readmissions, fewer visits to the ER, and, again, fewer discharges to skilled nursing facility.

I think we're all convinced that there's something here, there is something that is helping us to decrease some of these adverse events, and we've only seen positive feedback so far from using this technology.

Dr. Pelletier, thank you for sharing those outcomes. How has providing patients with access to digital care journeys enabled University Hospitals to enhance patient engagement and satisfaction?

Getting back to one of the main reasons that we wanted to do this is that we wanted to provide more personalized care, compared to what some of our competitors are able to do. We wanted to be part of the patient journey more than just that 5 to 10 days that they're in the hospital and we thought that this was a good way of doing it.

We've had good enrollment. It's one thing to enroll a patient, but not everybody gets activated. But the ones that are activated and enrolled, over 90% of them feel a bit more confident about what they're going through, 80%+ feel less worried, and almost 90% would recommend SeamlessMD. I think for any product that you're buying now or using, to have an 89% recommendation is pretty good.

If our patients were telling us that they're happy with this, that they are getting something out of it, and we're also measuring an objective improvement in some of the things that are important to us, then it's a win-win. So, it's a win on the patient's part, it's a win on our part. That made us want to continue to commit and work with SeamlessMD, and we've been doing so now for going on our third year.

To close things out, what advice would you have for other healthcare providers who are considering providing their patients with an application that engages, monitors, and keeps patients connected with their healthcare provider outside of the hospital walls?

I think the first one is the multidisciplinary part. As surgeons were really only one part of the equation, in order to get a patient through heart surgery, it really requires a village, and we all know that. So, everything from our nurses, our pre-operative staff, all the health workers that are in the hospital and post-operatively as well, and certainly, for us, our nurse navigators that play such a crucial role in getting to know these patients, and really giving them somebody that they can talk to on a regular basis if there's anything. We wanted to try to make sure that all the stakeholders were engaged. As we started the process, we did sit down and talk with most of them. I'm not sure if you can ever over-communicate this type of thing. I think engaging everybody was really important.

The next thing is once you implement something is having some form of regular engagement with our healthcare workers, but also with SeamlessMD. I think all of us when we work with industry, they are partners. For example, I cannot do an aortic valve replacement without having a good industry partner that provides us with a reliable valve that I can implant into a patient and feel that I've done a reliable job.

To that end, we look at SeamlessMD as that type of partner for us. We have regular phone calls with SeamlessMD, we have regular meetings, we look at what we're doing, we've changed certain things, we've changed a little bit of the documentation and the material that's coming to those patients. So, you need to have a partner that's going to be working with you so that it's mutually beneficial to all parties.

For us to have a good ERAS program, we must be able to look at the data on a regular basis, try to find out what's working and what's not working, and we have to be able to pivot. For example, there is mounting data about sternal plating, and we know that sternal plating seems to decrease postoperative pain, maybe increase recovery. So, through some of the things we were seeing, maybe a little bit more pain than we would have liked to have seen in some patients, we started plating a little bit more, and we'll see if that has a good impact on what we're trying to do. 

SeamlessMD for us has met the standards of what we look for in a good partner and have been a pleasure to work with.

To hear more insights from Dr. Pelletier about their ERAS Program and how they are using technology to reduce high-cost services and ensure patients maintain compliance with ERAS protocols to optimize recovery listen to the on-demand webinar University Hospitals Use Digital Care Journeys to Enhance Recovery After Cardiac Surgery.

Additional Enhanced Recovery After Surgery Resources:

Augmenting Enhanced Recovery After Cardiac Surgery with Digital Care Journeys: A conversation with Dr. Marc Pelletier

Posted by:
Tracy Staniland
on
November 3, 2022

When we think about the patient journey, especially in cardiac surgery, patients are often overwhelmed with lots of paper and verbal instructions. They lose the instructions or misplace the paperwork, or they forget, there's no day-to-day reinforcement, and, ultimately, it's hard to follow.

For healthcare providers it's hard to keep track of how patients are doing between visits, especially after discharge and we know if patients can't follow instructions well, and if providers can't keep an eye on them, bad things can happen, avoidable ED visits and readmissions, higher than expected length of stay, ultimately, higher costs for the health system. 

These are not new problems, however, for healthcare systems faced with mounting pressures these issues are rising to the forefront. With backlogs in surgeries stemming from the pandemic, the ongoing shift to value-based care, financial challenges, and staff burnout on the rise health systems are under increasing pressure to deliver better care at a lower cost and to find innovative, scalable ways to better engage and monitor patients outside the four walls of a hospital. 

According to a study by iData Research (2021), the cardiac surgery procedure volume is expected to continue growing at a rate of about 5% per year, with the largest portion of these procedures being coronary artery bypass graft (CABG) procedures.

Enhanced Recovery After Surgery (ERAS), a set of multimodal evidence-based standardized interventions pre-and post-surgery including pre-op carb loading, early mobilization, post-op, and so forth often involves giving patients very large 50-page plus booklets because there's so many important steps in the journey to cover, and patients are often asked to log data around compliance or other patient-reported outcomes. But it can be difficult to get patients to do that, especially on paper, and even more cumbersome and time-consuming for providers to try to turn that into real useful data.

What if we could transform enhanced recovery after surgery protocols and care pathways into automated digital guidance for patients? What impact could that have on patient education, compliance, and outcomes? 

We recently had the opportunity to speak with Dr. Marc Pelletier, Chief of Cardiac Surgery at University Hospitals Health System and Director of the Heart Surgery Center for University Hospitals Harrington Heart & Vascular Institute, about their Enhanced Recovery After Surgery Program and how they are using a digital patient engagement platform to support their program, optimize  patient adherence to ERAS protocols, and improve clinical outcomes.  

Dr. Pelletier joined University Hospitals from Brigham and Women’s Hospital and Harvard Medical School in Boston, where he served since 2016 as surgical director of the transcatheter aortic valve replacement (TAVR) program. Prior to this role, he spent nine years as head of cardiac surgery at the New Brunswick Heart Centre in Canada. Before that, Dr. Pelletier was a surgeon and an assistant professor at Stanford University. He trained at McGill University in cardiac surgery and Stanford University in cardiothoracic transplantation and ventricular assist devices. His areas of specialty include TAVR procedures, minimally invasive valve surgery, aortic valve and aortic root surgery, surgery for heart failure and minimally invasive coronary bypass surgery. Dr. Pelletier has authored more than 100 peer-reviewed publications, with over 110 abstracts accepted at scientific meetings and participated in more than 110 invited talks. In 2022 and 2021, he was named one of Cleveland’s Top Doctors and was also awarded the Distinguished Surgeon designation at University Hospitals.

Dr. Pelletier thank you for joining us today. Can you provide us a brief overview of University Hospitals? 

University Hospitals (UH), which is a comprehensive health system based in Cleveland, Ohio. UH now has over 20 hospitals, many different health facilities and centers that serve the population primarily of Northeast Ohio. There are over 200 physician offices in 16 different counties and about 30,000 employees with an annual revenue across a system of approximately $5.5 billion. So, it's a big enterprise.

On the cardiac surgery side, we perform approximately 1,500 surgeries per year. In addition to TAVR Program, that's approximately 370 TAVRs a year. How we divide that is we have a main center or quaternary center that does about 1,000, and we have five other regional programs that do anywhere between 80 to 100 cases to about 250 cases. We have a total of 10 surgeons in our group, and we just recruited an 11th, Dr. Arora was heavily involved with ERAS, and we have a great vibrant group supported by a strong perfusion and first assistant program team. 

Why did you decide to provide digital care journeys for your patients? What were the challenges that you were trying to overcome by providing patients with access to personalized digital care journeys?

We wanted to embark on this journey of ERAS as it relates to cardiac surgery. We wanted to look at our pathways and how patients were coming across the experience for cardiac surgery, trying to define that as preoperative, intraoperative or intrahospital and then post-operative, especially the part that's at home.

To have a way to automatically collect that data. We wanted to be able to look at that data on a regular basis, on a rolling basis, and if needed, be able to pivot or make some changes in how we were treating some of these patients and we wanted to be able to monitor them outside of the hospital setting. To have some form of remote monitoring that enabled patients to record how they are feeling and how they were doing.

We could probably build something like that. But the reality is that to build something like that with all videos, all the information, everything that you need in there is labor intensive. We just didn't think that it was feasible. So, we felt that partnering with somebody else would be a really good way to track a lot of these outcomes. 

We sat down as a team, and we went through all the ERAS guidelines and felt that having some electronic way of engaging our patients, especially in the hospital, more importantly, once they got home, either through themselves or their caregiver, we felt that that was really a worthy investment. So that's where we chose to direct some of the guidelines in which ones that we applied in terms of cardiac ERAS.  

When you think about implementing digital care journeys as part of your ERAS strategy, what were some of the key metrics or quality targets you were thinking of?

We wanted to enhance the experience for the patient - to make them feel more connected and part of the reason we wanted to do that is that we're in a really competitive environment in the United States. 

We wanted to find a demarcater and in the United States the reality is that patients can really choose where they get their cardiac surgery care. So, we were looking for something of a differentiator or a demarcater, and we felt that this was something that we should focus on because the focus was really on the patient.

We thought that if we did this, maybe we could see a few different things. We were hoping we could maybe shorten the length of stay. But more importantly, that we could look at tackling the three big reasons why people get readmitted. We know that readmissions after Coronary Artery Bypass Graft (CABG) is a nationally monitored metric, and we also know that patients get readmitted primarily for three things:

  1. Arrhythmias
  2. Tachycardia
  3. Heart failure symptoms, which can be shortness of breath, weight gain, and things of that nature, or sternal wound complications.

So, we thought that if we could monitor patients a bit more closely over the first two to three weeks after they went home, we could impact this. We also know that phone calls to our nurses, visits to the ED, they're all very time-consuming. So, if we could stay ahead of the curve, identify issues before they became really big problems, that maybe we could make a bit of a difference with that.

Dr. Pelletier, what was important to you and University Hospitals when selecting a digital patient engagement/digital care journey platform – and why it was important?

I think when we first started looking at ERAS and initiation of that program, we had realized that several other programs across the country, mainly in other specialties, like colorectal we're using the expertise of people like SeamlessMD. So, we thought if we're going to do ERAS, maybe we could partner with somebody in the digital space that would help us with adherence.

We also know that there's a fair amount of data suggesting that going with somebody like SeamlessMD will help you in terms of your clinical evaluations, your studies, and your results, in terms of readmissions. The biggest thing is we had a lot of discussions with our IT team, and it was really the build. To build this out, to have all the videos, the content, that takes a lot of time. When we partnered with SeamlessMD, we really liked a lot of the content that had already been built. There was still an opportunity to tailor some of it, but we weren't starting from scratch, something already was there, it already existed. For us, that was good.

The other thing is if you do a build with your IT, there's a big upfront cost. Whereas with SeamlessMD, that cost is really transmitted on a per-patient cost. We felt that at least from a financial perspective, that was a little bit more viable and a little bit easier to get buy-in from our Heart and Vascular Institute, as opposed to asking for a large amount at the beginning to build something, we just felt that we could incorporate this into the patient journey and into the global patient costs. So, for us, this made a bit more sense.

Can you tell us how using a digital patient engagement solution has helped with delivering ERAS education? 

To go through ERAS, you start to realize how much documentation we're giving patients, and we're asking them to really review that and to know it all. I think a lot of us know, that's really a hard ask for a lot of our patients. So, this was a way to digitize that. It comes to them more piece by piece, which is a little bit easier to digest and it comes with reminders. 

So, if you give somebody a booklet, and you ask them just to do their chlorhexidine shower at a certain time, to take their energy drink at a certain time, sometimes they forget. When these things come across your smartphone, these reminders, they tend to be much more relatable for most of our patients.

One of the aha moments was that a lot more patients have access to this technology, whether it's a tablet, or phone, or a computer, or their kids do, or their nephews do than we realized. The proportion of patients that are not using this is very low. 

The postoperative piece is really, for us, been the most important piece. I was speaking with my nurse today, who works with me with all our patients, we were talking about what messages she gets from the patients, and really, we've been able to address a lot of these. Over the course of the year, there's not always a ton of them. But we get pictures of their wound if they think that their wound's redder than it should be. If there's drainage, we can talk about it, we can get them to take pictures and send it to us every day, if their heart rate is elevated, if their weight's been up or down. These are things that we can often start to tackle. It's a lot easier to tackle when a patient who's had two pounds of weight gain for a couple days and put them on some Lasix than it is to deal with it a week later now, they've gained 15 pounds, and they're in really bad heart failure, and you have no choice to readmit them. So, it's a lot of those little things that for us have been helpful.

Does your care team find it helpful to get alerts at the right time, any specific stories, or examples that you can share?

We've had a couple of issues with wounds so, we would have somebody take a picture of a wound, a little bit of drainage, you look at it and it looks red. You'd like to see that patient, but sometimes those patients are two or three hours away. They fit enough of the criteria that you're concerned there might be a bit of a wound infection developing, you can put them on an antibiotic, and then you can save them from having to come in at a later time with now a really bad wound infection that's developed into more of a sternal or bone infection. So those have been some of the ones that have stood out.

Also, we've had a few patients also present to us and tell us that their heart rate is elevated, we're able to get an EKG on them and all of a sudden we see that they're actually in rate-controlled AFIB, maybe a little 100 so we can adjust their medications as an outpatient -  we've saved ourselves a readmission, which, again, is a standardized metric that we are all dinged for. We know from the CMS Registry, or our readmission rate should be around 12% and we were sitting at some point around 14%, 14.5%, and we've been able to bring that way down below 10%. So, a lot of those little stories over time add up to a lot for us.

The second part has been really the automation of information when it comes back to us. So, let's say it's 2:00 AM, and they are concerned about their wound or their heart rate, that will generate an automatic email that then our nurse navigators will be able to look at when they come in the morning, or they get an email, generated email, they click on the button, it takes them to the SeamlessMD screen, they then can see who the surgeon is, the patient, what procedure they had and that generates a response. So sometimes that response typically is to call the patient, check in on them, find out a little bit more detail about what's going on, and then we can direct them to where it is that they may go.

Now, in addition to that, there's a whole bunch of data that we've been able to tap into to help us with process improvements. So, we all know that opioids, for example, are not ideal. We want to minimize the use of opioids. We know that they're tied into addiction for some of our patients' data that we've published before shows that 5% to 10% of patients who had never been on opioids are still on them 30 days after the operation. We do not want to contribute to this opioid dependency. If we see that somebody's still using significant opioids 7, 8, 9 or 10 days out, it gives us the opportunity to bring them back, maybe get our pain management team involved, look at different modalities of pain other than opioids. One thing that we've noticed is that our opioid usage, especially beyond seven, eight, nine days is really, really low. It's not zero, but it does allow us to pay a bit more attention to those patients and try to treat them a little bit differently.

What has been the impact on actual clinical outcomes? 

This is one of the studies that we looked at pre- and post-intervention. It is not a randomized prospective trial. What it is, it's a pre- and post-intervention trial, whereas the implementation of SeamlessMD was our intervention and we were able to look at those patients, 95 continuous patients, and then we matched them to a cohort from within a year previous to that intervention that were generally matched in terms of age, the type of surgery that they had, their STS risk score.

We saw that length of stay, we were able to impact it a little bit. But where we really made an impact was on some of those metrics that are reportable metrics, especially readmissions. We saw a significant decrease in our readmission, and we saw a significant decrease in visits to the emergency rooms, we saw a lot fewer phone calls to our office. Now, some of those were probably phone calls that we made to them once they had reported an adverse event and we did see fewer discharges to skilled nursing facility.

We then looked at a similar cohort, but we looked at these just CABG patients. And again, these were patients that had been enrolled in an ERAS program with SeamlessMD, and then a cohort of patients, non-ERAS. Again, we tried to match these as best as we can. One of the things that you see is length of stay. Now, this is incorporating their pre and their postoperative length of stay. So, this isn't the entire length of stay from their acute MI, their diagnosis, their CAT, they stay in the hospital, and they have their intervention done. But again, in this cohort, we saw a lot fewer readmissions, fewer visits to the ER, and, again, fewer discharges to skilled nursing facility.

I think we're all convinced that there's something here, there is something that is helping us to decrease some of these adverse events, and we've only seen positive feedback so far from using this technology.

Dr. Pelletier, thank you for sharing those outcomes. How has providing patients with access to digital care journeys enabled University Hospitals to enhance patient engagement and satisfaction?

Getting back to one of the main reasons that we wanted to do this is that we wanted to provide more personalized care, compared to what some of our competitors are able to do. We wanted to be part of the patient journey more than just that 5 to 10 days that they're in the hospital and we thought that this was a good way of doing it.

We've had good enrollment. It's one thing to enroll a patient, but not everybody gets activated. But the ones that are activated and enrolled, over 90% of them feel a bit more confident about what they're going through, 80%+ feel less worried, and almost 90% would recommend SeamlessMD. I think for any product that you're buying now or using, to have an 89% recommendation is pretty good.

If our patients were telling us that they're happy with this, that they are getting something out of it, and we're also measuring an objective improvement in some of the things that are important to us, then it's a win-win. So, it's a win on the patient's part, it's a win on our part. That made us want to continue to commit and work with SeamlessMD, and we've been doing so now for going on our third year.

To close things out, what advice would you have for other healthcare providers who are considering providing their patients with an application that engages, monitors, and keeps patients connected with their healthcare provider outside of the hospital walls?

I think the first one is the multidisciplinary part. As surgeons were really only one part of the equation, in order to get a patient through heart surgery, it really requires a village, and we all know that. So, everything from our nurses, our pre-operative staff, all the health workers that are in the hospital and post-operatively as well, and certainly, for us, our nurse navigators that play such a crucial role in getting to know these patients, and really giving them somebody that they can talk to on a regular basis if there's anything. We wanted to try to make sure that all the stakeholders were engaged. As we started the process, we did sit down and talk with most of them. I'm not sure if you can ever over-communicate this type of thing. I think engaging everybody was really important.

The next thing is once you implement something is having some form of regular engagement with our healthcare workers, but also with SeamlessMD. I think all of us when we work with industry, they are partners. For example, I cannot do an aortic valve replacement without having a good industry partner that provides us with a reliable valve that I can implant into a patient and feel that I've done a reliable job.

To that end, we look at SeamlessMD as that type of partner for us. We have regular phone calls with SeamlessMD, we have regular meetings, we look at what we're doing, we've changed certain things, we've changed a little bit of the documentation and the material that's coming to those patients. So, you need to have a partner that's going to be working with you so that it's mutually beneficial to all parties.

For us to have a good ERAS program, we must be able to look at the data on a regular basis, try to find out what's working and what's not working, and we have to be able to pivot. For example, there is mounting data about sternal plating, and we know that sternal plating seems to decrease postoperative pain, maybe increase recovery. So, through some of the things we were seeing, maybe a little bit more pain than we would have liked to have seen in some patients, we started plating a little bit more, and we'll see if that has a good impact on what we're trying to do. 

SeamlessMD for us has met the standards of what we look for in a good partner and have been a pleasure to work with.

To hear more insights from Dr. Pelletier about their ERAS Program and how they are using technology to reduce high-cost services and ensure patients maintain compliance with ERAS protocols to optimize recovery listen to the on-demand webinar University Hospitals Use Digital Care Journeys to Enhance Recovery After Cardiac Surgery.

Additional Enhanced Recovery After Surgery Resources:

Recent news from SeamlessMD

UAB Medicine Deploys Digital Care Journeys for Gynecology to Optimize Enhanced Recovery Program Resulting in a Reduction of 30-Day Readmission Rates by 50%
December 7, 2022

UAB Medicine Deploys Digital Care Journeys for Gynecology to Optimize Enhanced Recovery Program Resulting in a Reduction of 30-Day Readmission Rates by 50%

Learn More
5 Big Takeaways from ERAS USA 2022
December 5, 2022

5 Big Takeaways from ERAS USA 2022

Learn More
TDP 83: U of Rochester Medical Center CMIO Dr. Gregg Nicandri: VR Training to Improve Surgical Quality, Eliminating the Mouse + Keyboard to Streamline Clinical Documentation, SDoH for Equitable Access to Care
November 30, 2022

TDP 83: U of Rochester Medical Center CMIO Dr. Gregg Nicandri: VR Training to Improve Surgical Quality, Eliminating the Mouse + Keyboard to Streamline Clinical Documentation, SDoH for Equitable Access to Care

Learn More