Remote Health MonitoringPast, Present and FutureLTC Jennifer Stowe, OD, MBA, MHA, FAAO, FACHEMAJ Daniel Yourk, MSN, MHA, FACHEJeanette LittleHolly PavliscsacContributors: Dr. Jana Wardian, Mrs. Kim Wasmuth, Mrs. Sarah Montano,& Mr. Delvon McDanielUNCLASSIFIED

Disclosures and DisclaimerThe views expressed are those of the presenter(s) and do not reflect the officialviews or policy of the Department of Defense or its Components.Presenter’s have no relevant financial or non-financial interests to disclose.Disclosure will be made when a product is discussed for n unapproved use.This continuing education activity is managed and accredited by AffinityCE incollaboration with AMSUS. AffinityCE and AMSUS staff as well as Planners andReviewers, have no relevant financial or non-financial interests to disclose.Commercial Support was not received for this activity

AcknowledgmentsU.S. Army Medical Research and Materiel Command (USAMRMC)Telemedicine & Advanced Technology Research Center (TATRC)The U.S. Army Aeromedical Research Laboratory (USAARL)Brooke Army Medical Center (BAMC)Virtual Medical CenterA special thanks to COL (Ret) Fran McVeigh OD, LTC (Dr.)Sean Hipp, Dr. Jana Wardian,Capt. Beilman, Dr. Derrick Beckman, Patrick Arida, Gina Domis, Kelly Coughlin, AnnaMoore and other collaborators!

Learning ObjectivesUpon completion the participants will:1. Relate to the complexities of starting a Remote Health Monitoringproject. The project management of remote health monitoringproject are complex with IT integration issues to provider integration2. Review how our team overcame barrier to innovation. A fishbonediagram will go over all the hurdles we overcame along with aexplanation of how.3. Describe remote health monitoring and the process. They shouldalso be able to understand the benefits as improvement inoutcomes, adherence and cost reductions.4. Summarize project DREAM is and restate what our team was able toaccomplish.5. Sketch your own remote health monitoring project.

Purpose and OutlinePurpose: To provide an overview of Remote HealthMonitoring (RHM). Review the past, present, and potentialfuture uses of RHM for the Defense Health Agency (DHA).Outline:1. Overview of Remote Health Monitoring2. Common Uses for RHM3. CMS Reimbursement for RHM4. DoD Past Efforts/Early Beginnings5. Project DREAM6. Potential for the Future

Overview Remote Health Monitoring (RHM) is the process ofmonitoring a patient with a system for detecting,monitoring, and reporting physiological informationusing sensory devices. RHM pilots have demonstrated improvements inoutcomes, adherence, and cost reductions.

Common Uses of RHM Treat Patients with Diabetes Using Coaching/Intervention Reduce the Risk of Heart Failure Remotely monitoring Blood Pressure Treat patients who suffer Infertility Some studies show RHM as effective as one round of IVF Prevent Harm from Dementia and Falls Locate, track, and alert dementia patients

Reimbursement for RHM Prior to 2019, the CMS Coding instruction for thebilling of RHM did not incur much profit for RHMprograms. RHM mostly existed in health care modelssuch as Capitated Care Plans. In 2019, CSM implemented new RHM codes thatcreated a profit margin for RHM. This event created asort of “boom” in the private sector for RHM. Note: Coding for RHM is COMPLEX!

DoD Past Efforts in RHMoSmall handful of RHM projects looking into the remotehealth monitoring of Diabetes and project(s) monitoringheat casualties.oAll of these were funded using the Army SurgeonGeneral annual 5M special appropriation to enabletechnology demonstrations. Telemedicine and Advanced Technology Research Center(TATRC) at the U.S. Army Medical Research and MaterielCommand (USAMRMC) AMEDD Advanced Medical Technology Initiative(AAMTI)

Why? DoD mandate for Telehealth: NDAA 2017 Increase Telehealth Services Pilot an RHM project that monitors outcomes for a ChronicCondition(s). One pilot with two sites. San Antonio and theNational Capital Region. Aims of the Pilot: Target a Chronic Disease Reduce Costs Increase Access to Care

The Birth of DREAMThe Virtual Medical Center (V-MEDCEN) andDCOE, a specialty clinic for San Antonio MilitaryHealth System beneficiaries, united to determine thefeasibility of implementing a market-level RHMprogram to monitor chronic health conditions.

DREAM Purpose Initiate RHM for patients with diabetes referred by their PrimaryCare Provider (PCP), Clinical Pharmacists, or identified throughthe Diabetes Center of Excellence (DCOE). Determine if implementing RHM could improve the quality ofcare delivered to patients with diabetes. As well as determine the feasibility of RHM as an enterprisecapability.

DREAM PersonnelAdministration Deputy Director of Operation:Maj. Daniel Yourk, MS Project Manager: Ms. AnnaMoore Medical Director: Maj DarrickBeckman, MD Research Director: Dr. JanaWardian, PhD Business Analysis: Ms. KellyCaughlin, MSDREAM Team 2 Nurses, One HealthEducatoro Kim Wasmuth, RNo Sarah Montano, RNo Mr. Delvon McDaniel,Health Educator

DREAM Strategic Partnerships1. DHA & V-MEDCEN: Funding and support2. DCOE: Diabetes expertise and clinical support3. Telemedicine & Advanced TechnologyResearch Center (TATRC): mCare applicationdevelopment & technology support4. Primary Care Providers (PCPs), ClinicalPharmacists, and Disease Managers: Identifyingand referring eligible patients

What is DREAM?1. Guidance in titration of basal insulin usingAmerican Diabetes Association (ADA) titrationalgorithm.2. Patients receive Bluetooth Enabled (BTE)equipment connected to the DoD-approved mCareplatform.3. Healthy lifestyle coaching and education areprovided.

DREAM Equipment

DREAM Program OverviewWho We ServePatients with Type 2 Diabetes whoalsoo Prescribed Basal Insulino HbA1c 8%o Personal Smartphone

DREAM ChallengesDeveloped from scratch Processes (Referrals/ Feedback) Forms Standard Operating Procedures Patient Education Resources Collaboration with TATRC to enable RHMplatform to meet DREAM needs Non-Research Determinant (NRD)It just takes time!

Other DREAM Challenges Staffing Not all nurses are well-suited for RHM High turn over in RHM nurses Technology Platform instability Unreliable Wi-Fi in Government buildings Equipment Storage BTE glucose meters problems Formulary Strips Coding for Telemedicine

What icebergs weigh down yourDREAM’sBTE Equipment2 Nurses1 Pt TechKnowledgeAHLTAProcessesPt eCoding

by the NumbersNumber Enrolled: 13Average Steps per Day: 7,72753%100%PatientSatisfaction47%Time to Target GlucoseRange :53 yrsAge Range: 37 to 69 yrs oldAverage Age:4.5 weeksAverage A1C Change at3 month Recheck:- 1.3%

DREAM Average FastingGlucose

DREAM Future Developing partnerships at Wilford HallAmbulatory Surgical Center (WHASC) and BrookeArmy Medical Center (BAMC) Group Orientation Expansion throughout the San Antonio MilitaryHealth System, the National Capital Region, andthen throughout the MHS

DREAM ProgramBlood Pressure Monitoring BranchThe DREAM Blood Pressure Monitoring (BPM)Branch was developed to support PCPs with bloodpressure medication titration and post-dischargemonitoring.

DREAM Program JBSABlood Pressure Monitoring BranchInclusion Criteria: 18 years Diagnosed with hypertension Must have a smart phone with no connectivity restrictions On or starting blood pressure medicationsExclusion Criteria: Pregnancy Dementia Any diagnosis requiring real-time blood pressuremonitoring

DREAM Program JBSAHealthy Lifestyle Branch This expansion is intended:o To help ensure the health of service members byproviding a readiness component for military membersand their dependents.o As a tool to assist units and service members who mayneed physical fitness remediation, dietary parameters,and activity-oversight in order to preserve the fightingstrength.o As a tool to support military dependents in maintainingand/or attaining a healthy lifestyle.

DREAM Program JBSAHealthy Lifestyle BranchInclusion Criteria: 18 years Smart phone with no connectivity restrictions Tricare BeneficiaryExclusion Criteria: Pregnancy Dementia Any diagnosis requiring real-time monitoring

Future RHM Projects Acquisition of Disease Agnostic RHM Platform RHM of Glaucoma with TROOP Integration of BATDOK Integrating Sensors (TBI, Core Temp., BlastInjuries, SensoRING)


Back-Up Slides

DREAM Program PresentationWhere We Began Fall 2017: 1st meeting with V-MEDCEN Summer 2018: DCOE agreed to be an RHM site AUG 2018: NRD approval OCT 2018: 5 pallets of BTE equipment arrives NOV 2018: Facilities ready DEC 2018: Development of DREAM begins 14 FEB: 1st Patient 11 MAR 2018: Fully staffed

DREAM Program ProductsSince January 2019Finished Products Physician Referral Form Process Map Screening Script Technology Set Up: mCare & FitBit apps Orientation Patient Orientation Patient Enrollment Form Education Brochures Insulin Titration GuideSharps DisposalBlood Pressure SOPExerciseNutrition Patient Agreement Patient Consent Group PowerPoint Orientation Metrics in Excel FBGA1CWeight Change ORG box mCare Issues Log Patient Satisfaction Survey & Questionnaire Physician Satisfaction Survey Patient & Provider Letters for: DREAM Non-AdherenceDREAM GraduationIn Progress SOP/COOP DREAM Logo and PowerPoint Template Health Educator Coding/Templates DREAM Program Guide Scheduling Power Point Presentation for FamilyPractice/Internal Medicine/Disease Management Billing Codes for RNs AHLTA Note Templates Patient EncountersMonthly Summary for PCMs AHLTA Encounter Templates Healthy Lifestyle Education Materials Program Stage Descriptions

United States Army Aeromedical Research LaboratoryFort Rucker, AlabamaRemote HealthMonitoring: Past,Present and FutureLTC Jennifer Stowe, OD, MBA, MHA, FAAO, FACHEMAJ Daniel Yourk, MSN, MHA, FACHEJeanette LittleHolly PavliscsakContributors: Dr. Jana Wardian, Mrs. Kim Wasmuth, Mrs. SarahMontano, & Mr. Delvon McDanielUNCLASSIFIED

Remote Health Monitoring Past, Present and Future LTC Jennifer Stowe, OD, MBA, MHA, FAAO, FACHE . Increase Access to Care. The Birth of DREAM The Virtual Medical Center (V-MEDCEN) and . AHLTA SOP COOP Pt Ed Materials Wifi Program Guide Pt T