Checkups by phone

Gisele Sorenson knew where each person with congestive heart failure lived. With a map in hand, she set out driving in northern Arizona -- across tribal land and to the Grand Canyon -- to find out whether the former Flagstaff Medical Center patients had wireless access.
The answer was key to determining whether patients could be remotely monitored via Bluetooth technology to help reduce their chance of being readmitted to the hospital. What Sorenson found is that not everyone would be able to use a cellphone to immediately transmit medical data, but many were close enough to a hot spot to send the information within a few days.
"Just having them come into the hospital isn't the answer anymore for a lot of reasons," said Sorenson, the hospital's telemedicine director.
The hospital that draws patients from across northern Arizona, including the Navajo and Hopi reservations, is in the midst of a yearlong pilot project aimed at a population that often skips regular checkups or lacks the money or transportation needed to get prescription medication.
It also is trying to limit readmissions because of an upcoming federal rule that financially penalizes hospitals if people are readmitted for certain conditions within 30 days.
The project uses wireless technology and health-monitoring devices to keep the hospital advised of the patients' conditions. Fifty people are being sent home with an Android phone and equipment to check their blood pressure, weight, heart activity and oxygen levels. For those who don't have electricity, they also get a solar charger.
The devices send the readings straight to the phone, which sends them directly to Kelly DeGraff, a hospital nurse. She then can look at the data and determine whether a follow-up call or text is needed. One patient she's been in contact with is Joe Alini, who has been dealing with kidney failure and heart problems.
Before Alini signed up for the project a month ago, his go-to people for medical questions were friends who are flight nurses. Aside from weighing in at the dialysis clinic and getting his blood pressure checked, he said he had no real sense of whether he was doing the things needed to fend off another hospital visit.
Those visits that were happening three or more times a month weren't easy to make. He's no longer employed because his condition prevents him from working, which meant he also lost his residence and his vehicle. He relies on his daughter for transportation and grocery shopping, and he sometimes doesn't have money to fill prescriptions.
This past week he saw a startling change in his weight -- a difference of more than 10 pounds overnight -- his blood pressure was up and his oxygen levels down. He was scheduled to go to dialysis but said the monitoring equipment helped detect the change that was due to a fluid buildup earlier in the day.
He called DeGraff, and she advised him to go to the hospital, which he hadn't needed to do for nearly a month.
"My education has become better," said Alini, of Flagstaff. "I'm not panicking now. I'm calling to say 'should I or shouldn't I,' instead of 'I'm going to the emergency department.'"
The project is backed by the National Institutes of Health, Verizon, Qualcomm Incorporated and Zephyr Technology. It isn't specifically aimed at American Indians, but they will benefit. Nearly 30 percent of patients at the Flagstaff Medical Center are American Indian, the majority being Navajo. Seven percent of them have had congestive heart failure, compared with 4 percent of non-Native patients.
While the illness is no more prevalent in American Indians than others, some precursors to heart conditions include diabetes and obesity.
About 12 percent of people with congestive heart failure are readmitted to the Flagstaff hospital within 30 days. They have symptoms ranging from shortness of breath to organ failure and fatigue, which can keep them hospitalized for more than a week and bump up costs to insurance providers. The national readmission rate for all types of heart failure is nearly 25 percent over three years, according to the U.S. Centers for Medicare and Medicaid Services.
Beginning in October, CMS will begin cutting reimbursements to hospitals that have too many patients readmitted for congestive heart failure, pneumonia and heart attacks. CMS has said readmissions can cost billions a year.
Mark Carroll, director of telehealth for the Indian Health Service, said telehealth is most common in Indian Country with diabetic retinal screenings, dermatology, psychiatry and mental health, pathology and radiology.
In Alaska Native villages, IHS has been using landline phones for at-home monitoring. The agency also is looking at how to best remotely track people with high blood pressure or diabetes, Carroll said.
But he said nothing is similar to the pilot project in northern Arizona. He called the project revolutionary for the health care system, in that it uses leading technology from a regional hospital that gets referrals from a diversity of communities and cultural environments.
"So many folks that I've chatted with in different Indian communities are supportive of this at the concept level," Carroll said. "It makes sense to them, but there are questions about 'how does it work, who can see my information, and who am I working with? Am I going to feel cared for in a good way, or am I going to feel this is a big efficiency thing?'"
Some patients approached to participate in the pilot project balked at the idea, Sorenson said, citing intimidation of the technology. She said some prefer the traditional call on their landline phones for checkups.
One of the hurdles for telehealth in Indian Country has been access to a wireless network, with penetration estimated at 10 percent, according to the Federal Communications Commission. The Navajo Nation is deploying 3G mobile and 4G broadband services through fiber-optic cables and microwave towers. The Hopi Tribe also has a broadband initiative.
Sorenson said the hospital hopes to take advantage of the Navajo build-out, though it doesn't track currently with the pilot project. For those who aren't near a wireless hotspot, Sorenson is counting on family members to help with transportation.
After a year, she said the hospital is hoping to have enough information from patients, their primary care providers and their families to know whether to sustain the program.

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