VPExam Virtual Care for Heart Failure Optimizing Transitions of Care Quality Improvement Project (VPExam QI)

Key Findings•A total of 84% of VPExam QI patients required moderate-significance modification of clinical care based on VPExam data, including volume status assessment with jugular venous pressure (JVP)/edema (47.6%), cardiopulmonary auscultation (33.3%), electrocardiogram detection of arrhythmias (14.2%), and structured data transmission of vitals, medication reconciliation, and labs (95.2%).•Nursing satisfaction (4.8/5) and compliance with follow-up (100%) was high. No significant technical errors were detected with deployment on over 550 devices.•VPExam QI intervention was associated with a 30-day hospital readmission rate of 9.52% from a baseline readmission rate of 15.9%, with a relative risk reduction 40.16%. Readmission rates fell precipitously, to 0%, for the last 4 consecutive months of VPExam QI. Thirty-day mortality rate was 4.76%.•VPExam QI provides supporting quality and feasibility data for increasing adoption of virtual care platforms with minimal barriers. Actionable physical exam and structured data optimize quality of transitional care, allowing for significant reductions in readmissions and mortality. Heart failure (HF) is a leading cause of morbidity and mortality in nearly 5.7 million Americans. With improved survival and an aging patient population, the cost associated with HF management is expected to reach close to $70 billion by 2030.1Ponikowski P. Voors A.A. Anker S.D. et al.ESC Scientific Document Group2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC.Eur Heart J. 2016; 37 ([Erratum in: Eur Heart J 2016;PMID: 27206819]): 2129-2200Crossref PubMed Scopus (8578) Google Scholar Skilled nursing facilities (SNFs) are progressively used to care for older patients with significant comorbidities, including HF.2Orr N.M. Forman D.E. De Matteis G. Gambassi G. Heart failure among older adults in skilled nursing facilities: more of a dilemma than many now realize.Curr Geriatr Rep. 2015; 4: 318-326Crossref PubMed Scopus (15) Google Scholar However, morbidity and mortality rates are high for hospitalized HF patients discharged to SNFs, with 30-day readmission rates between 27% and 43%, owing to errors in transitions, inadequate discharge planning, and lack of appropriate follow-up with health care providers.3Jurgens C.Y. Goodlin S. Dolansky M. et al.American Heart Association Council on Quality of Care and Outcomes Research and the Heart Failure Society of America. Heart failure management in skilled nursing facilities: a scientific statement from the American Heart Association and the Heart Failure Society of America.Circ Heart Fail. 2015; 8: 655-687Crossref PubMed Scopus (34) Google Scholar Optimizing HF management in SNF populations who are underserved yet at high risk for hospitalization is a critical area of focus for value-based care. The COVID-19 pandemic has increased utilization of telemedicine for HF management. Telehealth is a growing field of importance owing to value-based care and population management incentives, as well as increased acceptance in the general and medical population since the COVID crisis. Numerous meta-analyses have demonstrated that compared to conventional care, the addition of telemedicine in HF management leads to reduced hospitalization and mortality.4Zhu Y. Gu X. Xu C. Effectiveness of telemedicine systems for adults with heart failure: a meta-analysis of randomized controlled trials.Heart Fail Rev. 2020; 25: 231-243Crossref PubMed Scopus (55) Google Scholar,5Gingele A.J. Ramaekers B. Brunner-La Rocca H.P. et al.Effects of tailored telemonitoring on functional status and health-related quality of life in patients with heart failure.Neth Heart J. 2019; 27: 565-574Crossref PubMed Scopus (10) Google Scholar However, there is a paucity of data regarding the use of virtual care in SNF and home care patients with HF. Telemedicine platforms have traditionally presented numerous obstacles, including affordability of equipment, difficult-to-use technology requiring extensive training, lack of standardization, and patient privacy issues. These barriers are especially challenging to SNF and home care populations, who often have significant comorbidities, functional impairments, and barriers to transportation and access.6Woo K. Dowding D. Factors affecting the acceptance of telehealth services by heart failure patients: an integrative review.Telemed J E Health. 2018; 24: 292-300Crossref PubMed Scopus (23) Google Scholar Telemedicine can offer these populations improved access, but this is typically at the expense of clinical data such as a comprehensive physical examination and other structured data including vitals, medication reconciliation, and laboratory results. Many of the most common and expensive cardiopulmonary diseases rely on physical examination for detection of decompensation or exacerbation (Figure 1). VPExam is a Health Insurance Portability and Accountability Act (HIPAA)–compliant medical device data system that assists in overcoming barriers to traditional telemedicine using a combination of augmented reality–based guidance leading a minimally trained nurse or medical assistant (MA) through appropriate camera positioning for video capture based on anatomical landmarks. VPExam augmented reality–guided overlays, combined with sample videos as well as text and audio instructions, teach users how to obtain optimal video recordings of clinical findings such as evaluation of jugular venous distention and degree of lower-extremity edema in a reproducible manner. VPExam is integrated with Bluetooth-enabled stethoscopes, including the Eko Duo with single-lead electrocardiogram (ECG), to capture a full heart and lung exam with active user instruction (Figure 2). Virtual physical examination components are customizable by providers to optimize an efficient clinical workflow. The type of physical exam can be customized by medical specialty. Default physical exam components for VPExam QI included evaluation with (1) head-to-toe pan, (2) oral mucosa, (3) jugular venous assessment, (4) lower-extremity edema evaluation, (5) cardiac auscultation with single-lead ECG at the right upper sternal border and right lower sternal border, and (6) pulmonary auscultation at 2 sites. VPExam app data acquisition creates a partnership between minimally trained users (nurses or MAs) and physicians to efficiently gather and transmit relevant medical data to the Physician Portal. On average, nurses/MAs required a single 20-minute training session before becoming clinically proficient to use the platform in clinical practice. VPExam nurse assessment was completed in under 5 minutes on average. VPExam data were reviewed by the managing physician using the Physician Portal in under 2 minutes on average prior to proceeding to real-time video encounter with the patient and saved in the electronic medical record (EMR). Time-efficient review of asynchronous, clinically relevant patient management data has proven critical for ongoing physician engagement when using virtual care telemedicine. In addition to physical exam data, VPExam allows nurses to transmit structured data including manual transmission of vitals, voice recognition–based virtual history and review of systems, medication reconciliation with photographs of pill bottles, and a document scanner to transmit laboratory results, orders, logs, ECGs, etc (Figure 3). Providers reviewed VPExam Physician Portal asynchronous data prior to initiating a real-time HIPAA-compliant video conference with the patient. The Eko stethoscope with ECG can also be used by the provider during real-time synchronous video conferencing in coordination with the nurse/MA user with the patient (Figure 3). VPExam routinely transmits digital physical exam data for comprehensive assessment of volume status, cardiopulmonary auscultation, ECG detection of arrhythmias, and structured data including vitals, medication reconciliation, and labs. VPExam Partner Portal allows physicians to collaborate with partners at SNFs and home care to schedule VPExam follow-up post discharge. VPExam Partner Portal sends automated e-mail notifications to administrators or directors of nursing at partner facilities. SNFs and home care have HIPAA-compliant access to coordination-of-care data as well as prepopulated electronic home care or SNF orders sent by physician users (Figure 3). VPExam also offers additional remote patient monitoring (RPM) using Apple Health and Google Fit Health Kit data transmission to the VPExam Provider Portal, including blood glucose, body mass index, cardio fitness, blood pressure, ECG, heart rate, oxygen saturation, walking heart rate, and weight (Figure 4). VPExam RPM allows for transmitting alerts such as tachycardia with arrhythmia from a smartwatch, revealing a patient going into atrial fibrillation, or greater than 3-pound weight gain from a Bluetooth scale, revealing a patient suffering from decompensation of HF. Abnormal RPM data can trigger deployment of personnel to perform VPExam in a patient’s home or facility for earlier intervention by a physician. For VPExam QI, supplemental health kit–based RPM hardware was not routinely deployed as part of the workflow. The focus was placed on the core VPExam technology of a tablet paired with Bluetooth stethoscope to transmit physical exam data as the primary intervention in order to avoid additional confounders. VPExam QI was designed as a single-arm prospective comparative community case study recruiting patients admitted for HF at University Hospitals Regional Medical Centers with anticipated discharge to SNFs or home care as well as those requiring urgent cardiology consultation with VPExam intervention. Primary outcomes included the degree to which unique VPExam digital physical exam data to assess volume status, cardiopulmonary auscultation, ECG detection of arrhythmias, and structured data of vitals, medication reconciliation, and labs would impact individual transition-of-care management as well as VPExam impact 30-day all-cause rehospitalization rates. The design also sought to assess feasibility of transition-of-care workflows within SNFs and home care, compliance with follow-up, technical stability of the platform, nursing staff satisfaction with the platform, and financial analysis of virtual care networks. The study design attempted to overcome common barriers to traditional telemedicine. Training barriers were reduced using user-friendly VPExam augmented reality–guided overlays to guide new nurse and MA users through how to obtain optimal video recordings of clinical findings such as jugular venous distention and degree of lower-extremity edema. The VPExam platform was cost-effective, requiring only a tablet and Bluetooth stethoscope at each sending site, allowing for rapid scaling within the health system. VPExam was approved by a thorough institutional Information Technology (IT) Architecture review process by University Hospitals of Cleveland IT Department to ensure HIPAA and HITECH compliance. The goal of VPExam QI was to explore potential clinical benefits to active physician-directed disease management using the VPExam technology and workflows for patients undergoing transitions of care. VPExam QI focused on gathering data on patients being discharged to SNFs or home care from a community-based hospital. VPExam QI evaluated whether a comprehensive virtual care platform can enhance the quality of transitions of care. Three SNF and 1 home care partners were selected with the highest numbers of HF patients being discharged to their care from the 2 medical centers before initiation of the pilot to increase data acquisition. University Hospitals of Cleveland’s IT department successfully deployed VPExam on over 550 hospital-owned devices and University Hospitals home care. Prior to deployment of VPExam QI, baseline hospital HF outcome data were collected. From June 2020 to June 2021, patients discharged from University Hospitals of Cleveland Regional Medical Centers received guideline-directed HF therapy in accordance with the American College of Cardiology expert consensus for HF management and The and providers the population from June 2020 to June 2021, as well as the study population from to 2021, with VPExam as the primary intervention. The prospective single-arm community case study of VPExam QI used to patients admitted with HF who from University Hospitals of Cleveland Regional Medical patients with patient received virtual care intervention using VPExam technology and VPExam QI focused on patients who were being discharged to partner SNFs or follow-up from University Hospitals home care. VPExam QI patients for the from through patients to patients were in the VPExam QI, were completed as follow-up within of discharge. were also to urgent as part of VPExam QI in coordination with the to for urgent cardiology The intervention of VPExam was compared to community The data were from community patient data from the hospital system in the months and prior to VPExam intervention. The received guideline-directed HF therapy follow-up at their SNF or home care with telemedicine with physical exam data from the cardiology as the intervention potential a automated was from the of patients admitted to the 2 for as the with Heart from HF patients were based on of greater than or of than The of patients who to the hospital within the last or as well as being active on cardiology consultation The patients being discharged to 1 of SNF partners or for University Health with VPExam included the (1) those not the of HF patients used in VPExam (2) the patient’s (3) patients who are or to with telemedicine VPExam primary was to the degree of of physician-directed disease management based on unique VPExam data including volume status assessment, cardiopulmonary auscultation, ECG arrhythmia and structured data as well as the impact on 30-day all-cause rehospitalization rates. included the (1) the degree of of care or based on VPExam virtual care data (2) 30-day all-cause hospitalization (3) compliance with follow-up post (4) nursing staff satisfaction with using the VPExam platform using a being to 5 being (5) evaluation for technical errors of using a technical and 5 to telemedicine encounter owing to technical and (6) and all-cause mortality for modification of clinical of clinical or in medical patients with VPExam data to in medical data in and medication or errors in medication in medical used to whether to a patient to the in a new With each data were including body mass index, since relevant data with degree of disease and pulmonary and laboratory data including and rate and clinical of patient intervention based on based on on discharge from based on of modification to clinical care, reconciliation data to modification of care, status evaluation and ECG data medical of guideline-directed satisfaction atrial body mass ECG jugular venous based on in a new atrial body mass ECG jugular venous and functional were using were as or as The intervention was as a virtual care to the quality of care. were and using a data in a on a received the of the to before and were to from the study at was from the or from of for the of or data included in this The community case study patient with for patients discharged to SNFs or home care from 2 community University Hospitals of Cleveland Regional patients were on average of the population was and only were active The average body mass of the study population was on was on average The average rate on discharge for patients was The was those HF with reduced and HF with were to be in or The was a with significant and an satisfaction of using this platform was for of nursing staff that were also regarding technical with the use of the platform on a scale, with technical and 5 to use the platform owing to technical For nursing staff in the the was No technical errors were detected partners at SNFs and deployment on over 550 home medical VPExam QI patients received clinical follow-up for and data for months VPExam were patients who and there were patients and at partner SNFs and home care nurses were with VPExam by VPExam Partner Portal. total of of study with home care services and of at the of hospitalized HF patients at University Hospitals of Cleveland Regional Hospitals were into VPExam QI. Cardiology management was based on guideline-directed of patients were on total of of patients were on and of patients were on on follow-up during the The most common for or was acute by including by of patient required only or significant clinical modification of care, 84% of patient required moderate-significance in clinical modification based VPExam follow-up The most common moderate-significance of and medication of moderate-significance clinical included of medication reconciliation errors in of and of in of modification were by volume status assessment (47.6%), cardiopulmonary auscultation (33.3%), ECG detection of (14.2%), and structured data transmission of vitals, medication reconciliation, and satisfaction with the platform was high. Prior to deployment of VPExam QI, baseline hospital HF outcome data were collected. From June 2020 to June 2021, patients discharged from University Hospitals of Cleveland Regional Medical Centers received guideline-directed HF therapy in accordance with the American College of Cardiology expert consensus management and The and providers the population from June 2020 to June 2021, as well as the intervention population from to 2021, with VPExam as the primary intervention. The population of HF patients discharged from University Hospitals of Cleveland Regional Medical Centers from June 2020 to June an average all-cause readmission rate of with total intervention with VPExam QI 30-day hospital rates to for the HF population, with total the of VPExam QI, the all-cause 30-day hospital rate was VPExam was associated with a relative risk reduction for 30-day readmission compared to community than of VPExam QI patients were in months 1 and 2 of the pilot when the readmission rate for the hospital system to However, by months of the pilot more than of VPExam patients were and readmission rates fell to for 4 months (Figure HF patients with HF mortality rate hospitalization is at at 1 and at 5 et the American Heart Association and Heart disease and a from the American Heart PubMed Scopus Google Scholar Thirty-day mortality in VPExam QI was lower at at with a relative risk reduction of compared to mortality of the study population was at a patient population that was high risk significant comorbidities, as by an average of The VPExam QI used the ongoing for a providers to the patients and quality for transitions of care. also hospital systems overcome to new technology barriers in review of quality the (1) the of HF can be and to (2) guideline-directed are owing to on their and (3) SNF providers can be managing HF owing to and at (4) there is and lack of between SNF and their (5) there are in of and access to for care of and (6) there are and N.M. Forman D.E. De Matteis G. Gambassi G. Heart failure among older adults in skilled nursing facilities: more of a dilemma than many now realize.Curr Geriatr Rep. 2015; 4: 318-326Crossref PubMed Scopus (15) Google K. Dowding D. Factors affecting the acceptance of telehealth services by heart failure patients: an integrative review.Telemed J E Health. 2018; 24: 292-300Crossref PubMed Scopus (23) Google M. C. department from skilled nursing facilities through an physician telemedicine J 2020; PubMed Google et failure management in nursing a J 2018; PubMed Scopus (10) Google Scholar VPExam QI that unique VPExam overcome many of these barriers a virtual care between hospital systems and partner SNFs and home care. VPExam deployment to SNFs and home care is and VPExam virtual care high compliance with follow-up, with high satisfaction from nursing for patient management structured data transmission of the platform to modification in clinical management over of data transmission of improved detection of and often in traditional telemedicine. data transmission of medication reconciliation often transition-of-care data transmission of labs including and blood stability improved the quality of medical VPExam is also to clinical with unique physical exam status including jugular venous distention and lower-extremity edema modification management in of and asynchronous stethoscope auscultation of the heart to and as well as auscultation of the to and modification management in over of and asynchronous single-lead ECG transmission for arrhythmia detection including atrial modification management in over of The that virtual care in transitions of care to SNFs and home care offer a to quality of care and risk of errors for cardiopulmonary VPExam was associated with improved in medication based on physical exam data, errors in medication reconciliation, and of medication compliance. a the reduction in 30-day hospitalization and mortality the that unique VPExam virtual care data care providers to optimize transitional quality of care traditional guideline-directed quality adoption of virtual care, there are also financial for of SNF to is to increased morbidity and as well as significant M. C. department from skilled nursing facilities through an physician telemedicine J 2020; PubMed Google Scholar The average cost of readmission is VPExam clinical modification is associated with a significant reduction in 30-day there are over readmissions for readmissions for cardiac arrhythmias, and readmissions with from VPExam cardiopulmonary and volume status evaluation chronic pulmonary disease with with and failure with readmissions of with and by for Research and Scholar VPExam the cost of patients to and including cost and nursing Virtual care also the risk of diseases such as COVID the health care as well as the to the including potential for In addition to the financial to using virtual care to the cost of the platform can also increase individual provider VPExam data were to a of encounter on average, increasing to with an average increase in of and relative VPExam services are for RPM using and with VPExam QI received RPM from including and the VPExam QI is a quality and feasibility study during an COVID crisis. that of virtual care in other hospital systems at a as a quality be to outcomes the of care. Virtual care offers earlier detection of clinical decompensation to underserved and by in reduced risk of hospital and mortality on discharge. In improved transitional care assists health care systems in care and more efficient utilization of and care significant of the VPExam QI is the of a owing to the to and for data in a a case study with the most appropriate for The were deployed from community-based in that not be to more or health care be by access to especially for health for VPExam technology deployment was with SNFs and a home care the has to SNFs in of patients home with home care discharged to SNFs and home care on average have greater and barriers to care than patients discharged to home such the intervention of VPExam QI was focused on the HF The included 2 2 2 cardiology nurse and 1 with training were during VPExam QI to of data analysis and guideline-directed VPExam QI were completed as follow-up or urgent of the for a lack of modification of clinical management in the VPExam QI was that the of the study to access to cardiology care for urgent an VPExam was not with partner SNFs and home care. The of VPExam technology in these of can be in the by the platform with a clinical supporting these of and offers greater potential virtual care to transitions of care in the underserved SNF and home care patient populations a to high readmission rates in HF VPExam offers to efficiently transmit virtual physical exam cardiopulmonary and volume status with supplemental structured data, including vitals, medication reconciliation, and labs critical to HF management. platforms offer to optimize quality of care, readmission and mortality rates. Virtual care in HF management is a intervention with quality for SNF and home care who traditionally have access to care. not only focus on how virtual care can be integrated to quality of care, but also the of health care the growing of health care and hospital for digital allows physicians the to the be used in workflows to optimize and quality of care. The the and University Hospitals of Cleveland Heart and for financial and institutional for digital physician and clinical The VPExam QI study was by University Hospitals of Cleveland Heart and The is the of the and not the of University Hospitals of