How one hospital designed its own RPM tools to boost data collection

April 29, 2024 - Remote patient monitoring (RPM) is an important factor in improving clinical outcomes and engaging patients in their care, including in pediatric populations.

These tools have long been a critical part of patient care, with the very first remote monitoring tools arriving in the 1970s and reaching a $5.2 billion market size globally in 2023. Many hospitals turn to vendors to serve up point solutions. However, one pediatric hospital is taking RPM matters into its own hands and seeing positive results.

During the COVID-19 pandemic, Phoenix Children's Hospital saw the value of remote patient monitoring in improving access to care and quality of life for patients and their families. As a result, the hospital developed its own RPM apps to address conditions like cystic fibrosis, leukemia, and headaches. In addition to preventing unnecessary visits, these apps allow for real-time data collection and monitoring. David Higginson, chief innovation officer at Phoenix Children's Hospital, shares more about the hospital's process in developing, testing, and implementing its tools.

Anuja Vaidya:

Hello and welcome to Healthcare Strategies. I'm Anuja Vaidya, senior editor and special events lead at mHealthIntelligence.

Remote patient monitoring has emerged as a critical strategy for improving clinical outcomes and engaging patients in their care across a variety of conditions. A growing body of research backs the use of RPM tools and apps in adult and pediatric populations alike. But challenges remain in technology development, implementation, and patient adoption. Today, we have David Higginson, chief innovation officer at Phoenix Children's Hospital who will discuss the hospital's digital health efforts, the in-house development of home monitoring apps, and the unique challenges of creating and deploying these apps for a pediatric population. David, thank you so much for speaking with Healthcare Strategies today.

David Higginson:

Thank you for having me. I'm looking forward to the conversation.

Anuja Vaidya:

Fantastic. Before we jump into Phoenix Children's RPM strategy, I really wanted to look at the home monitoring landscape as a whole and its impact on pediatric healthcare specifically. So I was wondering, to get us started, could you set the stage and briefly describe the evolution of RPM in the pediatric care space before and during the pandemic?

David Higginson:

Yeah, I think RPM in some form or fashion has been around for a long time and interstage cardiac monitoring has been one of the classic places it's been done. But my observation in the past has been that it was very much point solutions directed at very specific populations that just happened to be in the sweet spot. And what really changed with COVID was just a general acceptance that remote monitoring, even if you classify that as having a conversation with someone, you call someone up on Zoom and you ask them how they're doing, it's a form of remote monitoring. And we really saw people open up to that opportunity and really realizing that could augment what they were doing in person.

And I'll give you a couple of stories about that because I think it really for us at the Children's Hospital brought home what a difference it can make. Many times our physicians weren't really ready to get into that space or didn't want to change their practice, but during COVID we had to, as many people did. And what we heard was some incredible stories from families--families with chronic illnesses with their children who were living two to three hours away from the hospital. That's where their support structure was, where their family was. But two or three times a week, having to drive in that three hours. And moms and dads telling us their whole life was devoted just to driving in. And those were routine checkup visits. They're not initial diagnoses, that's just keeping track of things. And that just went away. And they just had to come now once or twice a month. And I remember a mom telling me just she got a life back. And when you hear about stories like that....

And then another case was where a child had come into the hospital when they were quite young and had multiple surgeries. And they didn't realize it but every time that child came in later on, they were afraid of the hospital because that's where bad things had happened in the past. So being able to sit in their bedroom in their safe zone and have that meeting with a physician, the physician told me, "I actually got a whole lot more information and a lot more practical visit than I ever got before." So I think those very personal stories during COVID made us realize the time is right where we can really get meaningful interactions when people are at home. We don't have to make them come into the physical space. So I think that's what--a kind of really important lesson everybody learned: valuable data can be captured at home in many different diseases. So that was really, I think our core learning from that COVID period.

Anuja Vaidya:

Right, absolutely. And the time, the stress of having to cart a poor sick child back and forth, hours, is just a lot for everybody involved. So absolutely.

And so this kind of segues nicely into my next question here for you, which is: can you describe how Phoenix Children has scaled up its digital health and, particularly, home monitoring efforts over the COVID period and beyond? Even now post-public health emergency, how has scaling this strategy really changed the traditional care pathways at your hospital?

David Higginson:

Yeah, for sure. And I would say that these home monitoring apps are really just a natural progression of a strategy we've been employing for a long time. So we made a bet back in 2012 actually that we weren't going to necessarily pick our EMR based on how pretty the screens were to key into. We were just as focused on our physicians, primarily on the data we were going to get out. And if we were going to ask our physicians and caregivers to spend endless time keying things in and spend a lot of money doing that, then we wanted the value out. We didn't want it for a record-keeping system. We didn't want it for a billing system. We thought, was there really a value we could offer here about getting better data out and then impacting patient's care and making the outcome better with that data, not just, like I said, a record-keeping system? So we've been on this journey since then and our EMR is on the full Microsoft stack. We have instant access to all the data.

It's not a download from the cloud. It's not a little subset of the data we have to wait a day for. It's within three seconds, we get everything in the EMR. So we've really leveraged this data proposition, which is: there are many physicians down at the hospital who will get together at the start of the day of clinic, they will look over the patients coming in a clinical dashboard that's specific to their disease, it will highlight the five patients they need to pay attention to and why they need to pay attention to them, and they will talk about those patients and they'll start the day versus the old school way is someone just shows up on my front door, maybe I saw them three months ago, it's like it's a new day all over again, I'm trying to desperately scramble through the big record to figure out what's important. Whereas our strategy was: let's serve up the key things to doctors and we've developed 60 plus disease-specific dashboards to really guide that work. So we're really trying to make the most out of that visit.

But what we found was with that, we took it to a really great level where the physicians were really using that data and honestly adding more data to their documentation because they wanted to capture more data because they realized it was valuable. That's unusual for a lot of physicians to want to do that, but we were there. But what we really realized--some of these diseases, you need little bits of data all the time. You don't need to wait three months between the visits to find out what's going on. In fact, you can take care of the patient in a much more effective way if you just get little bits of information in between. So home monitoring for us has very much been the focus of how do we get those key data points in between the visits, keep assessing, and if the patient doesn't need to come in, don't make them come in every three months.

And we've hit across this idea of the three-month follow-up is really the lowest common denominator. It doesn't really serve anybody. If you've got an N of one, if you understand what's going on with that patient because once a week, twice a week, once a month, you're getting feedback from the family, you can really adjust that timeframe and get the best outcome for the patient. So at a very big scale, what these apps mean for us is filling in that data gap with meaningful things that are going on with that patient to decide "when do we need to see you again and not making you come all the way from three hours away if we don't need to see you," right? At the same time, if something's out of control and we need to monitor it, maybe come in every week until it gets under control. And so I think that's a far more effective strategy to take care of children than just saying, "come on this routine schedule." So at a high level, that's what those apps do for us. Not every disease really fits that mold, but we found a good number of them do and really there are some sweet spots when you do that.

Anuja Vaidya:

Absolutely. And like you said, this sort of month or three months or six months, whatever the timeline is, a lot can happen in that time. So if you have the ability to really track in between, nothing like it. So definitely a very powerful data and strategy to have for chronic conditions.

So could you describe some of the key home monitoring apps that your hospital is currently using and what are some of the benefits you're seeing from using these, particularly in terms of clinical outcomes as well as patient and even provider experience?

David Higginson:

So we have a number... They're going to seem fairly specialized, but they really hit that sweet spot I was talking about. So one of the first ones we started is a ketogenic diet monitoring app. So we're one of the few places in the country that will put patients on a ketogenic diet and not require them to be inpatient. So you can go home, live your normal life and we'll monitor you remotely and then bring you if you need to. So obviously with that, when we make the switch on the ketogenic diet and start changing the nutrition elements for these very sick kids, it's really, really important for us to know what's going on in the moment. So one of our very first apps was the ketogenic monitoring app. So we have a lot of kids on that and they are filling in on a daily or a twice-a-week basis feedback on how the diet is going, a number of questions.

Now we're not sending them home with 15 different pieces of wearable devices and all that kind of nonsense. These are just normal questions that--the same questions the doctor would ask if you were in person. It's not any different. Maybe they have a scale and they put their weight on there, but other than that, it's not a bunch of high-tech items. So that, what's really important is once that data's being captured, that there's someone on the other end of the hospital who is monitoring it. So many of these devices we've heard about where patients are wearing a wearable, that data gets transmitted to the hospital and the doctor doesn't have any resources to go look at it. And so you send all this data and it's meaningless. So what we've done in all of these is when we build them out is, we very much think about what's the workflow. Not about the technology, not about the wearable, what are we going to do when we get this data back? Because you can imagine how bad would it be to be getting this data and then not acting on it. It's almost the worst-case scenario. So ketogenic diet was one of those.

We have a very robust program with cystic fibrosis, also with leukemia. And you can imagine with leukemia, very much monitoring how patients are doing, how the meds are interacting with them. Interstage heart monitoring is something a classic that's been out there forever. There's a very particular defined set of things that must be done on a certain schedule.

But one of the ones I'm most excited about is a new one we have, which is the headache population. So ones I've described so far are very specialized, maybe only 50 patients on those programs at any one time. But for headaches in children, it's actually something someone told me it's like the fourth most common problem that we treat at the hospital. And it turns out there are a bunch of medications and typically the right combination of those medications, the right dosage, pretty much solves the problem. But it's a bit of a crap shoot. You meet with a patient first time, you try to figure out which is going to be the right medication combination, you send them home, but if you don't see them for three months, they could be suffering that whole time.

So the real opportunity here with headaches is you put them on a medication regimen, you get their feedback in real-time, and then you can make those adjustments and instead of waiting six months to get their regimen correct and the patient suffering, you can fine-tune that in two weeks. And this is for a huge number of patients. So it is really where, to me, that perfect combination here of helping patients not suffer with a fairly simple treatment program, it's not overly complex, and just by increasing the communication. So headache is one we've really just gotten started on, but incredible results so far. And again, I always bring it back to the patient and just lack of suffering. If it was my daughter with these killer headaches and we could fix them in two weeks, not six months, why wouldn't you want to do that? And again, not super complicated, not a bunch of wearables, just really important data coming back. So all these ones have been really impactful and very heartwarming to work on because they really make a difference.

Anuja Vaidya:

Mm-hmm. Absolutely. Absolutely. And yeah, you hit the nail right in the head, why wouldn't you? If you have the capability...

David Higginson:

Yeah.

Anuja Vaidya:

... Really, why wouldn't you? So what I think is super interesting is that these apps were developed in-house. So I'd love to know more about some of the development process. For example, how long does it take the hospital to create apps like these, from the ideas, inception, to the use, and what kind of teams welcome the apps?

David Higginson:

Yeah, happy to add that. So first and foremost, we strive, like every other CIO I know, to--we don't try and chase a solution that we think is very glamorous in IT. We wait till we've got a real clinical problem and then we decide it works. And what I was saying before is there are plenty of diseases where this doesn't make sense. There's no extra value to get that data in between, but there are these ones where it really is a great fit. So that's where we started. So back to our data strategy is once we build these disease management dashboards, when we start to see that we can monitor these patients based on a few key questions, like, "Okay," and there's value in getting that between the visits, this seems like it's a good fit. And once we've done one or two of these, we're very tuned into this now. So we really start with the clinical problem and with the physicians to say, "This would help."

The last thing I want to do is have some glamorous IT halo project where we send a bunch of stuff home with people, they can't get on WiFi, it doesn't get used, and a year later when the grant runs out, it all ends. That doesn't really help anybody, in my opinion. So we're looking for sustainable problems. So once we have them, the great advantage of doing internally, we now have a framework or a central platform where, it doesn't really matter what the disease is, we have this ability to ask questions, get the data back, act on it, monitor it. So once the first one was written, which took about three months to get that going, it's now three to six weeks.

Anuja Vaidya:

Wow.

David Higginson:

And really the only thing we're waiting on is what are the questions we're going to ask--and there's often a bit of fine-tuning there--and what is the workflow? Who's going to look at this when it comes back and make sure we're doing the right thing? The technical piece is minor at this point because we have that framework in place. So yeah, it's a fairly slam dunk from a technical perspective, but most importantly we de-emphasize the fact it's an app or it's IT. The most important is it's a problem that works for this kind of technology.

Anuja Vaidya:

Absolutely. Absolutely. And so how do you go about testing these apps or validating them before you really roll them out fully across the hospital?

David Higginson:

The great thing about this particular case is you are asking patients questions, the same questions you'd ask them in a visit, and if you slightly get the question wrong and we need to fine-tune the question, we just fine-tune it because there's no really harm in asking too many questions, if you like--other than disengagement from the family; we don't want to pepper them with a thousand things all the time. But a lot of it is really done in place. So we'll come up with the initial set of questions. And you can imagine... Sometimes physician documentation templates, we have great aspirational goals of all the things we want to capture and then reality hits and the family only fills out three of the 15 questions and say, "Okay, you know you need to shrink that question base."

So there's a little bit in that first couple of weeks where we're looking at the data coming back, we're looking at the impact we're making and we're like, "You know what? We need to expand or contract the question base." And maybe put it in different languages, not just Spanish, maybe different languages if a certain population that needs it that way. But it's really that real-time changing.

And then early on there's a lot of concern about would the family be able to use the app. So what we are is a text first organization. So we text nearly 5 million texts a year from our platform and we don't expect the family to download and install an app and keep it on the phone. We prompt them with a text message, they click on the text message, it takes them effectively to a webpage that looks like an app and that's how they do their work. So a lot of that learning was in process, it's how do we teach them how to do it, make it as simple as possible, don't make it so you have to have the app on your phone. So there's a lot of trial and error to get that going. But ultimately it's judged by engagement. If we're asking the family for information, they're not doing it, we know we have to change.

So that first month is a lot of iteration, fine-tuning, making sure we're making a difference. And then once it gets locked in, maybe six to eight weeks in, it just carries on and is very sustainable.

Anuja Vaidya:

Mm-hmm. Absolutely. And that speaks to that health equity piece as well, right? Making sure you can do the text messages and you can do phone calls versus everything being video or everything being one particular modality or requiring internet or requiring a different device, yeah.

David Higginson:

This has really morphed over time, but I can't tell you how many conversations I've had with people who want to buy iPads and send them home with families and then we talk to the physicians and say, "A percentage of our family don't have WiFi at home. So you may have WiFi, they don't have it, that's not going to do anything." Nearly everybody has a phone with texting. And so we found from our listening to our family advisory group, so that's really the preferred mechanism. "I don't have to be at home so I can answer those questions while I have a spare moment waiting to pick the kid up at school or whatever the situation is." So yeah, texting is, I think many people have figured out that is the very high penetration rate, lowest common denominator, pretty much everybody has it. There are always going to be a couple of percent people where it doesn't work, but those are the same people that couldn't make it in for an in-person visit, too.

So I think we're always looking to include everybody wherever possible but yeah, we've really gone away from the idea of sending equipment home with people. We never get it back and it's always a challenge. And as an IT department, we can't go and support those people in their homes and they sometimes are intimidated by it. But texting is really I think something everyone understands.

Anuja Vaidya:

Right. And like you mentioned, the last thing you want is to inundate people with devices and different features and capabilities only to have them not use any of it because they're too overwhelmed or they need this technical support that they're not getting at home.

David Higginson:

Right. And we have to keep in mind, while they're called apps, they're really just asking questions, right? They're asking questions that maybe in the old days we'd pick up the phone and asking those questions. Now we're just asking them in a slightly different way. So I think not getting too enamored by technology, not overloading people with complexity, just getting the data points we need, that's all we're looking for.

Anuja Vaidya:

Absolutely. Absolutely. So, could you walk us through the decision to develop these apps in-house versus partnering with a third party company?

David Higginson:

Yeah, absolutely. Phoenix Children's is quite unique in spaces that we are not afraid to do our own internal development, but at the same time, we don't build everything. So I think that many people learned that if you have that kind of tech debt, so if you build everything in house, it's all great for the first six months and then two years later you've got this mountain of products you've got to support and it's really non-sustainable. So we take the approach of, especially in children's hospitals, it's often a hotbed for innovation because many of the big companies aren't interested in building a product that's just for 40 children's hospitals. That's not a big enough market. And I understand that. But children are not little adults. They have their own special set of needs. And so we often have to be innovative. What we tried to do is look for opportunities where the market isn't there yet.

So it's very rare to find anything in the market today which is a common platform for home monitoring where it's not point solutions that we can really leverage that common platform and really focus on this question-answer approach. Rather than just saying, we're not going to go outside, we're going to do everything internally, we're really looking for those opportunities. The market's not quite there yet. We'll develop it if we can do it fairly quickly and then get some experience with it. Maybe it's one to two years. We'll figure out what works, what doesn't. And then if a third party comes along with a better solution, we're ready to change. But it's that testing it out, figuring out what works for us.

I think the other approach is if you don't do that, you can end up just jumping on a third party vendor solution that seems to be a hot topic and you end up compromising and you don't get it very tailored to your organization and you make a lot of shortcuts. And while yes, you've got the support of the company behind you, I think what a lot of people forget is those small software companies may only have one, two people working there and you're just as much risk as you are with someone leaving internally, you just don't see it. We've had this approach now for 10 years. We have lots of internally developed apps, but they all have a fairly short life cycle. So once there's something in the marketplace that will pick it up, we'll switch it out. Once it's matured a little bit. And then there end up being a few things where we really rely on the product but the market isn't there. And that's fine, but we're very, very cautious with that approach. But it's a lot less expensive and it's very tailored to what we want. Again, we're not afraid to do that. We don't use the biggest EMR out there, we use a different EMR so we're used to blazing the trail a little bit. And so it's a culture that's in our organization.

Anuja Vaidya:

That's fantastic. And I would imagine that when it comes to creating apps and tools specifically for pediatric population, you need slightly different things than you would for an adult population. So as our final closing question here, could you just describe some of those differences that you've seen when developing digital tools for a pediatric population versus considerations for an adult population?

David Higginson:

Yeah, I think there were a couple of things. The first thing is even the parents for our children are in their 30s, so we don't really have to deal with that very older demographic group. So some of the things people have to work at in another hospital dealing with a very older group, we don't really have to do that most of the time. So our parents, who are sometimes our customers, very much want a digital experience because that's the rest of their life. So in fact, they push us very hard to say, "I want to book my appointments online. I want to fill out all my forms online. Why do I need to come to the hospital? Why do I have to do everything in a physical way? Why I can't do it virtually?" So that's a really unique push for us. I think that happens a little bit in adult hospitals when the caregiver maybe is the younger the child or whatever taking care of the older adult, but for us it's really front and center.

And then obviously with our patients, many of them are teenagers and they use their phone all the time so that's what they expect. And then the last thing they want to do is call someone up and talk to them, right? That's not what they want do. So that's great. That pushes us forward. That gives us a great audience for these applications. But the other things that come with it is a privacy. So if you are a eight-year-old child and you don't have access to your own phone and you're filling out a form or information that's got some sensitive information you don't want your parents to know about maybe, that's appropriate. How do we protect that privacy if they're having to use a parent's phone? So that's something we think about a lot. And then as you can imagine, some children are just too small to use the apps. So how does that work? As you mentioned before, some people don't have access. So we always have an alternative plan. There's always a backup plan, the phone call and the human is always a quarterback in the situation. But those are really the key things.

I'd say though the great thing is that everybody's up for the digital experience. And in fact, obviously we struggle more keeping up with where our customers are going more than anything. Especially on things like self-scheduling, I think most of our families would prefer not to pick up the phone, but still, that's how we're hardwired. So it's a great environment. And I think more than anything, when you get a chance to talk to the families and the patients and you see in their faces the difference this has made and you hear about the stories, makes it all worthwhile. We can all relate to our own kids. And so it's just such a satisfying place to work in terms of being able to make that difference. And just like the headache example I gave you, what better work than you could do as an IT person to know that you cured some child's headache and you were a factor in that? So I think it's just a great place to work and seeing those families and the impact every day is amazing.

Anuja Vaidya:

Yeah, could not think of a more worthy cause than trying to improve care processes for this very vulnerable population. So fantastic. Thank you so much, David, for coming on the podcast today and sharing your thoughts on this subject. It was a super interesting conversation. And yeah, looking forward to seeing what Phoenix Children's does next.

David Higginson:

Yeah, great. Thank you so much. I really enjoyed it.

Anuja Vaidya:

And for our listeners, feel free to reach out to share your thoughts on this topic. My email address is avaidya@TechTarget.com. That's A, V for victory, A, I, D for door, Y, A at TechTarget.com. You can also use that email address to share any healthcare-related questions or stories that you would like us to consider covering. Also, if you enjoyed today's conversation, please do let us know. You can rate us and write a review on whichever platform you use to listen to the podcast. Thank you so much for listening.