Creating your Remote Monitoring Workflow
“I appreciate and love that question, “chest pain?”. [The nurse practitioner] recommended I go to Emerg and I found out I had blood clots in my lungs. I’m sure this saved my life as I would have kept making excuses that it was a pulled muscle from the surgery or how I moved during the recovery. <3 the close connection.”
- SeamlessMD Patient
SeamlessMD is designed to be a stand-alone patient self-monitoring tool however it can also be leveraged by clinical teams to actively monitor patients outside of the hospital, in order to catch problems sooner and reduce unnecessary ED visits and readmissions.
Monitoring of the program can be done via the program's alerts functionality or via the patient roster. Turning on alerts is optional and is typically discussed during the care plan implementation.
During implementation, the team will need to decide:
- If the team is going to monitor patient responses (or instead keep SeamlessMD as a patient self-education tool only)
- If the team is going to turn on alerts or monitor via the patient roster only
- Who will receive alerts and/or monitor patient responses on SeamlessMD
- How the team wants to receive alerts (email, dashboard only)
- What patient issues to be notified about
Please Note: Patients will see messages throughout the program indicating that the program is not monitored so that they understand the responsibility is on them to follow through with the recommendations they receive. This message about the program not being monitored may be phrased differently for various programs.
Typical Monitoring Workflow
Patients complete a health check (or any survey) and receive a particular recommendation from the program to advise them on next steps to follow. The clinical team will receive notifications when a patient reports selected concerns.
How do alerts work?
Alerts are notifications that clinical team members receive when patients report selected concerns upon completion of a survey, typically their health check.
How are alerts received and viewed?
Team members can receive alerts via email or through the SeamlessMD Alerts dashboard. If your site has an Epic In Basket integration, team members can also receive alerts via In Basket.
Who can receive alerts/monitor patients?
Typically, clinical team members involved in the patient’s care are best suited to receive alerts (i.e. physician/physician assistant, nurse practitioner, or registered nurse, or an individual in a clerical role for triaging), OR it may be a dedicated remote monitoring lead responsible for monitoring all patients on SeamlessMD.
Here are some common examples:
- Physician and/or Physician Assistant
- Registered Nurse or Nurse Practitioner
- Clerical role (to triage/schedule follow up call)
- Dedicated remote monitoring nurse or nurse practitioner
Different team members can also receive alerts for different concerns (e.g., a dietician receives diet-related alerts, and a triage nurse receives wound concern / infection-related alerts).
What issues can trigger alerts?
Team members can receive alerts for any question/symptom included in any survey. Alerts are most common for the main health check.
We recommend selecting 5 - 10 issues unless you have a dedicated monitoring resource. Most clinical teams select issues where a nurse intervention may help prevent ED visits or readmissions (e.g., patient uploading a wound photo, reported signs of infection).
How many alerts will get triggered?
How many alerts you receive will depend on how many issues you’ve selected. Alerts can be added/removed as needed in order to optimize your workflow.
Based on our hospital partners, we typically see the following distribution of health check recommendations across all health checks submitted:
Typically, only a subset of the "call your healthcare team" issues will trigger an alert.
Example: 500 patients enrolled per year (42 patients/month); 75% complete a health check
- 312 health checks completed per month
- 47 health checks trigger a recommendation to call their healthcare team per month (15%)
- 25 health checks trigger an alert per month (8% - depending on # of alerts turned on)
Do alerts need to be turned on?
Alerts are optional!
SeamlessMD is designed to be a stand-alone patient self-education tool. After submitting a health check, the patient ALWAYS receives a recommendation what to do (e.g. call their healthcare team, follow these self-care tips).
If set up as a self-education tool, patients will see various messaging in the program indicating that the program is not monitored:
Sample Workflows for Patient Monitoring
Workflow 1: Unmonitored |
Workflow 2: Decentralized |
Workflow 3: Centralized |
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| Activities | ||||
| How providers receive alerts and monitor patients | N/A - Providers do not receive alerts SeamlessMD is used as a patient self-management program only. Patients receive education to monitor their care. |
Individual clinical team members receive alerts directly for their patients and/or related to specific concerns (e.g. Nurse A receives alerts for Physician A, or ostomy nurse receives alerts about ostomy issues) |
All alerts are sent to a central role /shared inbox. The monitoring role receives and responds to all alerts for all patients. This role can triage/escalate to another clinician as needed |
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| Benefits | ||||
| Pros | Minimal time commitment from clinical team | Ability to intervene and address patient issues sooner Higher impact on clinical outcomes (e.g. ED visits, readmissions, etc.) |
Ability to intervene and address patient issues sooner Higher impact on clinical outcomes (e.g. ED visits, readmissions, etc.) |
|
Cons |
Lower impact on clinical outcomes (e.g. ED visits, readmissions, etc.) | Higher time commitment from clinical team | Higher time commitment from clinical team |
Example Workflow in Action
- 2.5 dedicated NPs + medical clerk monitoring patient dashboard (during business hours)
- Receive alerts and monitor dashboards to identify when a patient’s health status changes, enabling the care team to intervene sooner;
- Patients are also provided with the team’s phone number in-app to call for concerns and get help sooner
- Key Results: Reduction in length of stay and 30-day ED visits; 90% patient activation; and 97% of patients felt more confident at home after surgery