Hospital • Disease Management • CHF
`
`Case Study
`
`Mercy Health Center’s Telemedicine Congestive Heart Failure
`Disease Management Program Shows Significant Savings
`with Health Buddy® and Health Hero® iCare Desktop™
`
`Executive Summary
`Mercy Health Center in Laredo, Texas, a member of the Sisters of Mercy
`Health System-St. Louis Region, has shown significant reductions in hospital-
`based utilization with its Telemedicine Congestive Heart Failure (CHF)
`Disease Management Program. Mercy’s program was implemented to deter-
`mine the impact of low cost, web-based, patient interface technology as part
`of an overall CHF disease management program. The program features use of
`the Health Hero® iCare Desktop™, a web-based patient management tool,
`and the Health Buddy appliance.
`
`Mercy Health Center, in collaboration with The University of Texas Health
`Science Center at San Antonio (UTHScC-SA), was awarded a $300,000 grant
`from the Telecommunications Infrastructure Fund Board of the State of Texas
`in 1999. The study, partially funded by this grant and sponsored by Mercy
`Health Center of Laredo with support from UTHScC-SA, aims to improve the
`health status of indigent border residents with chronic disease through the use
`of telemedicine technology. Mercy has utilized the grant to develop a telemed-
`icine disease management program to monitor Laredo’s indigent congestive
`heart failure and diabetic patients. This program achieved all of its goals:
`decreased hospital-based resource utilization, improved patient compliance
`with treatment plans, improved level of satisfaction with health care services,
`and improved patients’ perceived quality of life.
`
`Analysis of the financial and clinical impact of Mercy’s Telemedicine CHF
`Disease Management Program after one year showed significant reductions in
`hospital based utilization and charges, as well as improvements in quality of
`life as measured by the mental component of the SF 12 and patient satisfac-
`tion survey data. Patients in the program showed reduced overall charges of
`$13,159 per patient per year (PPPY). This was primarily due to a 41% reduc-
`tion in inpatient admissions.
`
`The significant reductions in hospital-based utilization and improvement in
`perceived quality of life can likely be attributed to the patient’s enhanced ability
`to self-manage their chronic disease state using the Health Hero intervention.
`Without remote monitoring, patient care is based on episodic encounters
`between patients and their care providers. This program bridged the gap
`between office visits by providing a platform for daily monitoring of informa-
`tion from the patient, allowing patients and care providers to identify problems
`and intervene early. Early intervention can ultimately reduce the cost of care to
`the health care provider, payer and patient while increasing the overall well-
`being and quality of life for the patient.
`
`1
`
`1
`
`Bosch Ex. 2026
`Cardiocom v. Bosch IPR2013-00468
`
`

`

`Congestive Heart Failure
`CHF is a disease that affects 4.6 million individuals in the United States with 400,000 to 700,000
`new cases each year (American Heart Association 1997). This translates to an overall incidence rate
`of 1.5% to 2.0%, and an incidence rate of 6% to 10% in the 65-year and older age group. Heart
`failure is the only cardiovascular condition that is increasing in prevalence and incidence. CHF is
`the number one cause for hospital admissions in the United States with over 1.5 million hospital
`admissions per year. In 1998, there were 727,523 discharges for CHF in the Medicare population
`in the U.S. Associated claims to Medicare were $7.2 billion averaging $9,831 per discharge. The esti-
`mated total cost of CHF in the US for health services and loss of productivity is over $22.5 billion
`per year.
`
`CHF is a chronic, progressive disease that creates symptoms of shortness of breath and peripher-
`al edema. These symptoms have a dramatic effect on quality of life and a patient’s ability to carry
`out daily activities. Self-management practices, including a low-sodium diet and medication
`compliance, are vital in the management of CHF. Monitoring CHF patients using case manage-
`ment programs to reduce re-admissions and in-patient costs has become popular in recent years.
`Numerous studies have demonstrated that care management can reduce hospital costs by reducing
`the number of hospitalizations and ER encounters. For example, Landi et al. (1999), Warner and
`Hutchinson (1999), West et al. (1997), Shah et al. (1996) and Rich et al. (1995) have reported
`reductions in the number of hospitalizations, length of stay per hospitalization and costs associat-
`ed with care management.
`
`Traditional disease management programs seek to improve patient care and reduce hospital-based
`utilization through the use of dedicated case management services. Usually a health care profes-
`sional oversees the care of the home based patient through assessment and education – working to
`improve compliance with medical regimens. Case management that encompasses behavioral
`change, knowledge building and symptom monitoring plays a key role in optimizing medical man-
`agement of chronic diseases such as CHF. Nurturing the necessary skills of self-management
`improves the health of patient and reduces overall healthcare utilization. However, the use of a
`health care professional to effect such change with individual patients is usually a lengthy and
`expensive proposition.
`
`Through the use of a remote telemedicine disease management program, the case manager can
`detect early and repeated symptoms and intervene quickly with multiple patients simultaneously.
`The case manager is able to focus on those patients most in need. In this process, the case manag-
`er monitors daily patient symptoms (e.g., changes in weight, blood pressure, and fatigue) using the
`electronically transmitted health values of his/her assigned patient population and intervenes in a
`timely and appropriate fashion. These timely and appropriate interventions may be as simple as
`instructing patients to elevate their feet, educating patients on diet modification, or making physician
`referrals. In contrast to costly crisis management through ER encounters and inpatient hospital-
`izations, timely detection and response to patient symptoms provides the opportunity for early,
`cost-effective, more appropriate intervention. Use of the Health Buddy and Health Hero iCare
`Desktop allows for the case management to be automated, relying less on the nurse’s intervention
`and more on the patient’s ability to “self-manage” their condition.
`
`Mercy Health Center
`Mercy Health Center (MHC) is located in Laredo, Texas along the U.S.-Mexico border. MHC serves
`Webb County, one of the poorest counties in Texas. One in every three families lives at or below
`poverty level. There are 40-60 colonias, unincorporated areas with grossly sub-standard housing,
`in the Laredo area with an estimated 12,000 residents. Many residents speak only Spanish. The
`National Association of Community Health Centers ranked Webb as 7th in the nation as a “dou-
`ble jeopardy” county, that is chronically disadvantaged in both the overall health of its residents
`and in the extreme shortage of primary care physicians.
`
`Laredo is 94% Hispanic. Hispanics are more likely than any other ethnic group in the nation to be
`without health insurance. Approximately 50% of Laredo’s area residents are uninsured. MHC is the
`safety net for Laredo area residents in need of healthcare, providing millions of dollars of charity
`care annually. Given Laredo’s proximity to the border and its poverty rate, MHC is actively explor-
`ing ways to improve quality of life while reducing its risk as the primary provider to indigent resi-
`dents. This telemedicine disease management program has allowed MHC to improve care by
`focusing on maintenance and prevention rather than crisis management and achieve overall
`reduced costs in the process.
`
`The Health Hero Technology Service
`Health Hero provides its customers with access to a browser-based care management tool, the
`Health Hero iCare Desktop, and the patient communication appliance, the Health Buddy. The
`Health Hero technology platform provides healthcare professionals with an integrated, web-based
`solution that improves efficiency and effectiveness in managing the health of their chronically ill
`patients. The Health Hero iCare Desktop provides care managers with an integrated set of patient
`enrollment, scheduling and monitoring tools thus enabling a care manager to quickly communi-
`cate with and stay abreast of their patients’ day-to-day conditions and prevent critical situations by
`providing early intervention. The care manager is able to access this daily patient information on
`a secure website. The Health Buddy assists the patient in monitoring their disease through educa-
`tion, reinforcement and prompts to action if indicated by daily values. The Health Hero technology
`platform is based on the following design elements:
`
`* Flexibility is key in targeting and addressing the needs of sub-populations
`
`* Simplicity is essential to user compliance
`
`* Timeliness in data collection is required for managing disease progress
`
`* Cost is a critical issue in the practical application of disease management systems
`
`The Health Buddy connects to any existing patient phone line, much like an answering machine.
`It has a large easy to read screen and four large blue buttons for responses. Patients answer per-
`sonalized daily questions in English or Spanish that monitor their disease symptoms, medication
`compliance and disease knowledge as well as providing education about their condition(s).
`Patients’ responses are sent via a telephone line to Health Hero’s secure data center. Patients are not
`required to have internet access to use this system. Daily responses sent by patients can be catego-
`rized and prioritized to alert case managers to the most serious outcomes first.
`
`2
`
`3
`
`2
`
`

`

`Methods and Program Implementation
`To qualify for participation in the study, patients must have been indigent or economically disad-
`vantaged adults. All patients had to be competent, have a telephone, be able to read or have some-
`one willing to assist them daily, have a physician/clinic in the service area and reside in the service
`area. The Health Buddy component of the intervention was delivered in both English and Spanish.
`Patients were referred to the program through the hospital, support groups, clinics, and doctors’
`offices. In addition to receiving the Health Buddy, CHF patients in the program received a weight
`scale and blood pressure cuff free of charge.
`
`Patients answer daily questions about their disease on their Health Buddy. The telemedicine case
`managers review patient answers Monday through Friday. If the values are alarming, or chronical-
`ly outside of designated parameters, the patient is contacted. If warranted, the physician or clinic
`is notified. If it is known when the patient’s next appointment is, the collected information is for-
`warded to the physician or clinic prior to the appointment. A focus of this study was to measure
`the effect of the technology on patient behavior. Consequently, no protocols were established to
`adjust medications or treatments, and patients are referred to their doctor’s office when needed.
`
`Mercy incorporated Health Hero’s patient communication service in January of 2000. As of January
`2001, approximately 57 CHF patients were enrolled in the Health Hero program. Patients enrolled
`in the Health Hero program received a Health Buddy appliance to receive and respond to daily ses-
`sions of questions and educational information from their care manager. The disease management
`program provided patients with 12 months of coaching, education, and reinforcement of self-care
`management skills. The critical program components were educational support, in-home daily
`monitoring and timely physician notification. The in-home daily monitoring and much of the rein-
`forcement of self-care management was done through the Health Buddy. The Health Hero iCare
`Desktop enabled tracking of patients by Mercy’s telephonic support staff and nurses and involved
`regular communication with physicians.
`
`Results
`The utilization measures included inpatient, outpatient, post-discharge care (PDC), (ER)
`encounters and charges. The data analysis compared 1999 hospital-based utilization data, dur-
`ing which time patients were receiving standard care (care before enrollment in the disease man-
`agement program), with 2000 utilization data during the time patients were enrolled in the
`telemedicine disease management program powered by Health Hero. Results from the analysis
`showed reduction in utilization associated with inpatient hospitalizations.
`
`A 1999 comparative CHF sample (standard care) was utilized to assess the changes in utilization
`and charge data when compared to the 2000 Health Hero interventional population. The popula-
`tions analyzed included the 57 CHF patients enrolled in the disease management program in the
`period 1/00 through 12/00. There were 36 females and 21 males in this population. The mean age
`for females was 68 and the mean age for males was 61.
`
`Summaries of reductions in utilization and charges are shown in Table 1 and Figures 1 and 2.
`Hospitalizations for CHF-related causes were reduced by 41% for patients enrolled in the telemed-
`icine disease management program (Z = 1.64, p = .10); with the number of CHF-related inpatient
`hospitalizations being reduced from 1.99 PPPY to 1.18. Total charges were reduced with the
`program by $13,159 PPPY compared with standard care. The reduction in overall charges was
`predominantly due to the reduction in inpatient admissions.
`
`Utilization Measure
`
`Inpatient Admissions
`PPPY
`
`Emergency Room Visits
`PPPY
`
`PDC Visits
`PPPY
`
`Outpatient Visits
`PPPY
`
`Total of All Charges
`PPPY
`
`Reporting Period
`(approx.)
`
`Standard
`Care
`
`Health
`Hero
`
`Utilization
`Reduction
`
`[1]
`Z p-value
`
`1.99
`
`0.93
`
`4.52
`
`1.33
`
`1.18
`
`1.05
`
`4.21
`
`1.75
`
`41%
`
`-13%
`
`7%
`
`-32%
`
`$25,013
`
`$11,854
`
`$13,159
`
`01/99-12/99
`
`01/00-12/00
`
`Z=1.64,
`p<.01
`
`Z=0.29
`p>0.11
`
`Z=-0.36
`p>0.1
`
`Z=0.79
`p>0.1
`
`Table 1. Utilization of Healthcare Services for CHF-related causes:
`Health Hero compared to Standard Care N=57
`
`Notes: [1] Z test for Proportions used
`
`4
`
`5
`
`3
`
`

`

`Quality of Life
`Quality of life was assessed using the SF-12. Surveys were completed by patients on entry to the
`program and quarterly during the program. Data from patients with completed surveys in each
`of the first 2 quarters were analyzed according to a repeated measures design. Differences with-
`in subjects over time were assessed to quantify changes for patients in the program. Table 2
`shows summary statistics for the physical and mental sub-scales for the baseline and two subse-
`quent quarters. There was a significant improvement in the mental subscale for patients in both
`quarters. In the second quarter, after 6 months in the program, a highly significant (t = 4.21, p
`< 0.001) improvement in the mental subscale of 12.06 points was evident, with scores of patients
`approaching those of a normal, healthy American adult. The mean score for the general U.S.
`population for the mental and physical measures is 50, and the standard deviation of those
`scores is 10.
`
`Time
`
`Baseline
`
`Quarter 1
`
`Quarter 2
`
`Q1 - Base
`
`Q2 - Base
`
`Physical
`
`Mental
`
`3.502
`
`35.85
`
`35.59
`
`0.83
`
`0.57
`
`38.24
`
`46.90
`
`50.30
`
`8.66
`
`12.06
`
`Table 2. SF-12 Quality of Life Mean Scores at Baseline and two
`subsequent quarters. The Q1 – Base and Q2 – Base mean differences
`are calculated as means of within-subject differences over time.
`
`20000
`
`15000
`
`10000
`
`5000
`
`0
`
`3.0
`
`2.5
`
`2.0
`
`1.5
`
`1.0
`
`0.5
`
`0
`
`Total Charges Per Patient Per Year (PPPY)
`
`$25,013
`
`$11,854
`
`Standard Care
`
`Health Hero
`
`Figure 1. Total charges (annualized) for CHF-related encounters:
`Health Hero compared to Standard Care.
`
`Hospitalizations Per Patient Per Year (PPPY)
`
`1.99
`
`1.18
`
`Standard Care
`
`Health Hero
`
`Figure 2. Inpatient admissions for CHF related causes:
`Health Hero compared to standard care n=57
`
`20000
`
`15000
`
`10000
`
`5000
`
`0
`
`3.0
`
`2.5
`
`2.0
`
`1.5
`
`1.0
`
`0.5
`
`0
`
`Total Charges PPPY ($)
`
`Number of Hospital Encounters PPPY
`
`6
`
`7
`
`4
`
`

`

`Patient Satisfaction with Using Health Buddy
`Results show that patients in Mercy’s Telemedicine Disease Management Program found the
`Health Buddy very easy to use on an ongoing basis and reported high levels of perceived value from
`participating in the program. From surveys conducted it was discovered that:
`
`* More than 95% of patients using Health Buddy reported increased satisfaction regarding the
`communication with their doctors or nurses on an ongoing basis.
`
`* All of the patients reported that the Health Buddy was easy or very easy to use. Ease of use
`increased over time from 75% saying it was “very easy” to use after the first three months to
`88% at the end of the first year.
`
`* 97% of the patients had no difficulty using the Health Buddy to answer daily questions (see
`Figure 3).
`
`3%
`
`97%
`
`had no difficulty
`using Health Buddy®
`to answer daily
`questions
`
`No Difficulty
`Difficulty
`
`* An impressive 93% of the patients reported that they had a better understanding of their medical
`condition since being on the Health Buddy.
`
`* 93% of patients reported they felt better able to manage their disease.
`
`* 99% of the patients reported that they believed the Health Buddy helped them improve their health.
`
`* Over time, the percentage of patients that reported feeling more connected to their doctor, nurses
`and hospital went up from 88% after three months to 95% at one year (see Figure 4).
`
`96%
`
`94%
`
`92%
`
`90%
`
`88%
`
`86%
`
`84%
`
`Figure 3. Most patients had no difficulty using the Health Buddy® to answer daily questions.
`
`3 months
`
`6 months
`
`9 months
`
`12 months
`
`Figure 4. Over time patients feel more connected to their doctors, nurses and the hospital.
`
`8
`
`9
`
`5
`
`

`

`Conclusions
`The encouraging evidence from this study is that Mercy’s Telemedicine Disease Management
`Program powered by Health Hero Network reduces utilization in CHF patients in the in-patient
`setting. Charge reductions in CHF-related care for the disease management program were $13,159
`PPPY compared with standard care. This was primarily due to a significant 41% reduction in inpa-
`tient admissions. In addition to the reduction in utilization, quality of life was improved as evi-
`denced by a highly significant (t = 4.21, p < 0.001) increase in the mental component of the SF-12.
`
`The challenges faced when caring for an indigent, bilingual population with chronic disease can be
`unique. These patients frequently have barriers to care including transportation issues, financial
`hardship that limits their access to care and language barriers that make it difficult for them to
`understand and follow a prescribed regimen.
`
`Without remote monitoring, patient care is based on episodic encounters between patients and
`their care providers. This episodic approach relies on the patient’s ability and willingness to collect,
`record and act upon disease-related events over an extended period. The Mercy Health Center
`Telemedicine Disease Management Program’s use of the Health Hero telemedicine technology
`bridged the gap between office visits by providing a platform for making daily collections of infor-
`mation from the patient, and making it possible for the care provider to identify problems and
`intervene before problems escalate.
`
`It is well documented that active patient monitoring and case management of chronic conditions
`result in beneficial outcomes to patients and providers. Evaluation of Mercy’s Telemedicine CHF
`Disease Management Program suggests impressive reductions in hospital based utilization and
`encouraging improvements in quality of life. What sets this program apart from traditional case
`management programs is the element of technology provided by the Health Hero Networks iCare
`Desktop and the Health Buddy appliance. Not only does this technology connect the patient to a
`healthcare system, it provides the patient with access to information and support for the devel-
`opment of self-management skills. Changing the self-management behavior of patients with
`chronic disease is fundamental to long term success with any disease management program.
`
`References
`Bigelow, J.H., Cretin, S., Soloman, M., Wu, S.Y., Cherry, J., Cobb, H., and O’Connell, M. (2000).
`Patient Compliance With and Attitudes Towards Health Buddy™, RAND Health, Santa Monica,
`California.
`
`Drummond, M.F., O’Brian, B., Stoddart, G.L., & Torrance, G.W. (1999). Methods for the Economic
`Evaluation of Health Care Programs. New York: Oxford University Press Inc.
`
`Landi, F., Gambassi, G., Pola, R., Tabaccanti, S., Cavinato, T., Carbonin, P.U., & Bernabeu, R. (1999).
`Impact of integrated home care services on hospital use. Journal of American Geriatrics Society, 47
`(12), 1430-1434.
`
`O’Connell, M. and Cherry, J. (2000). The Health Hero® Online Service: A new internet-based
`communications platform for disease management, case management and performance measure-
`ment. Disease Management and Health Outcomes 7 (3), 149-161.
`
`Medication Compliance
`One of the key areas of concentration in Mercy’s Telemedicine Disease Management Program was
`medication compliance. Patients were asked on a regular basis about their medications, ensuring
`that patients understood why it was important to take them and that they remembered to take them.
`The results of a patient survey on medication compliance were:
`
`* At the beginning of the study period, only 34% of the patients reported no problems with miss-
`ing medication doses. 65% of patients reported missing medication doses before starting on the
`Health Buddy. After receiving the Health Buddy, 94% of patients reported that they take their
`medications more regularly (see Figure 5).
`
`Medication Compliance
`
`94%
`
`100%
`
`80%
`
`60%
`
`40%
`
`20%
`
`0%
`
`34%
`
`Before Health Buddy
`
`After Health Buddy
`
`Figure 5.
`
`100%
`
`80%
`
`60%
`
`40%
`
`20%
`
`0%
`
`Percentage of patients who take medication regularly
`
`10
`
`11
`
`6
`
`