By Cook, Thompson, Dearani & Prinsen

Throughout the world, companies are embracing mobile devices to set customer expectations, enlist them in satisfying their own needs, and get workers to adhere to best practices. An effort under way at the Mayo Clinic shows how such technology can be used to improve outcomes and lower costs in health care.

Defining the care a patient can expect to receive and what the road to recovery will look like is crucial. When care expectations are not well defined or communicated, the process of care may drift, leading to unwarranted variation, reduced predictability, longer hospital stays, higher costs, poorer outcomes, and patient and provider dissatisfaction.

With all this in mind, a group at the Mayo Clinic led by the four of us developed and implemented a standardized practice model over a three-year period (2010-2012) that significantly reduced variation and improved predictability of care in adult cardiac surgery.

One of the developments that germinated in that effort was the interactive Mayo myCare program, which uses an iPad to provide patients with detailed descriptions of their treatment plans and clinical milestones, educational materials, and a daily “To Do” list, and to report their progress and identify problems to their providers.

The Challenge

For cardiac surgery (as in many other practices) the cost of care is likely to exceed Medicare reimbursement.  That was true in our Rochester, Minnesota, program, prompting us to examine our cost of care delivery. We examined the cost determinants in the operating rooms, intensive care units, and on the patient floor and found that unwarranted variation in the care process negatively affected the value of care (outcomes divided by cost).

The Solution

We then designed and spelled out all the steps of the optimal care model for routine cardiac surgery, which included identifying both best practices and ways that patients could become more effective partners in their own recovery.

The new care model was demonstrated to be sufficiently robust by rapidly improving results and increasingly predictable outcomes for large segments of patients. With predictability, we were then in a position to share that information with patients and set expectations for participation. (We also theorized that telling patients what they should expect, would also drive provider adherence to the care model.)

We realized that empowering patients and setting their expectations required effectively providing the following to them:

• A “Plan of Stay” that included a “Plan of Day” that outlined expected daily clinical milestones and provided a daily patient “To Do” list that was linked to their clinical status and the recovery events. The plan was configured uniquely for each patient based on his or her surgery, medical conditions, and pre-hospital functional status. (A screenshot of Day 2 of a typical Plan of Day is shown below.)
• Modular Educational Materials about their surgery, their medical conditions, and expected care events each day events in the hospital. This education needed to be “just in time” and relevant to the needs and experience of the day.
• Gaining Strength modules that set daily expectations for physical activities such as walking and breathing exercises and provided patients with tools to self-assess and report things like pain and mobility.  This allowed us to tell patients how much they should walk each day, ask them how much they walked, and, using wireless accelerometry, measure how much they walked .
• Recovery Planning information on how patients should care for themselves after discharge. For example, it included information on wound care, exercise and diet, activity restrictions, follow-up appointments, and potential complications and how to recognize them.

We speculated that an iPad was an ideal means to convey this information to patients and have them report their progress and problems to providers.

In addition to software development, we converted hundreds of pages of patient instructions and educational materials into videos, voice-over slideshows, and text modules that the software could deliver.  An example is falls prevention in the hospital.

Implementation

When the Mayo myCare program went live in February 2012, we limited the participants to patients who were going to have elective cardiac surgery, had a predicted hospital stay of five to seven days, were older than 50 years, lived at home, and could walk. Participants had to speak and read English (because the program was only in English), could not have impaired vision, or suffer from dementia.

Prior to surgery patients were provided with an iPad and trained for 30 minutes in using the program by a registered nurse who then followed up with patients daily during their hospital stay to answer any questions they might have and make sure they understood how to use the program.

After the first 30 days of patient use, we evaluated patterns of program and content utilization by day, content type, and content format. We then modified the program to better meet patients’ needs. Our ability to track daily patient use, essentially in real time,  allowed us to determine that we needed to reduce the total amount of content early after surgery and change the form of that content to make it more usable (video only) when patients were feeling poorly. We delayed providing more challenging content to later in the stay. And recognizing that a large number of patients had hearing impairment, we provided headphones with the iPad to all patients after the first 30 days of testing.

Before and after surgery, patients used the iPad to learn about the plan of day, work through their “To Do” list, and complete their daily education, self-assessments, and recovery-planning modules. The data was aggregated on a server in the cloud and configured into dashboards that the nurses and physicians caring for the patients could view.

Below is a screenshot of the patient dashboard, which includes a predictor for the need for discharge support, compliance with the care plan, daily self-assessment of pain and mobility, and completion of education and recovery-planning modules. “ESDP” means Early Screen for Discharge Planning, a tool that predicts a patient’s need for support after he or she is discharged.

A population and individual patient dashboard showed all patients on the care plan and provided alerts when patients were deviating from their plans. The providers could also click on an individual patient’s name to view a dashboard for him or her.

The program triggered provider interventions when: 1) a patient’s self-assessment tool predicted patients might require home health care or skilled-nursing services at  discharge, 2) patients were not completing their daily education or recovery-planning modules, and 3) a patient’s self-reported mobility was too low or pain scores were too high.

Following discharge, patients were surveyed about their satisfaction with their hospitalization and surgical experience as well as their comfort in using the myCare program.

Results and Benefits

The average user of the program in its first seven months (from April to November 2012) was 68 years old. Of the first 134 patients that participated, 86% used the program to the end of hospitalization. The primary reasons the remaining 14% of patients dropped out were postoperative medical or surgical complications that prevented them from staying on the standardized care program or continuing program use (readmission to the ICU, patient confusion, or cardiac arrhythmias were most common causes).

The typical patient was provided with 67 care modules to work through over five to seven days, and patients completed more than 85% of them before they left the hospital. Patients did particularly well with the self-assessment tools, completing more than 97% of them.

About 70% of patients returned a post-discharge survey. More than 90% expressed overall satisfaction with their care, and more than 90% felt they were well informed about their care while in the hospital. More than 80% said they were very comfortable using the myCare program within a day or two of use, and 98% felt the program provided information that prepared them to better manage their own care after they left the hospital.

Preliminary data also suggest that patient education and participation through the myCare program can help shorten length of stay, reduce cost of care, and improve patient independence after leaving the hospital.

It’s difficult to estimate the costs to reproduce this elsewhere. While the custom software might be built for about $200,000, and iPads purchased for about 10%  of that amount, Mayo’s greater investment lay in the clinical pathway the program supported, Mayo’s body of educational materials, the clinical algorithms behind the program, and the clinical experience and commitment of the providers who contributed to its design and testing. Those contributors included the four of us as well as “floor” nurses, education specialists, discharge planners, physician assistants, social workers, occupational and physical therapists and a patient focus group.

Remaining Challenges

The program was built specifically as a single-practice solution and was not integrated with our electronic health record (EHR), these limited its scalability and usability – fundamental requirements for new electronic health solutions.

Recognizing those limitations, the success of the program, and the fundamental role of patient participation in evolving care models, Mayo is rebuilding the software platform so it can be used to create and deliver care plans in multiple types of surgical practices.

The rebuild will populate the patient’s EHR with the data the program acquires and it will used at Mayo’s multiple sites.

David J. Cook, MD is an anesthesiologist an division head at the Mayo Clinic.

Jeffrey E. Thompson is director of operations management at United Surgical Partner in Addison Texas.

Joseph A. Dearani, MD is a cardiovascular surgeon, professor of surgery, and chair of the Division of Cardiovascular Surgery at the Mayo Clinic.

Sharon K. Prinsen, RN is a cardiac surgery/transplant nurse administrator in the Mayo Clinic’s Department of Nursing.

This post originally appeared in the HBR Blog Network.