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The medical center teamed with Rimidi, an Atlanta firm, to track postpartum patients and identify those at higher risk for stroke or other complications.
Christina Yarrington says there’s a group of patients that have been a consistent source of concern.
Yarrington, director of labor and delivery at Boston Medical Center, has long worried about patients who have just had a baby and had a pregnancy affected by high blood pressure. Within days of giving birth, they can see alarming blood pressure increases that can put them at risk of stroke or a heart attack.
These blood pressure spikes often occur several days after giving birth, and after the patients have been discharged from the hospital. They are a driving factor in readmissions and raise the risk of maternal morbidity and death. Half of maternal deaths occur in the postpartum period after the discharge from the hospital, Yarrington noted.
“This has been, for a long time, a population that we have struggled to find the most patient-centered way to maintain communication and care, even after they leave the hospital,” she said.
That’s why Yarrington is very encouraged by the results of a remote patient monitoring program that identifies patients at risk. Boston Medical Center tapped Rimidi, an Atlanta-based healthcare technology company offering remote patient monitoring, to track patients who have recently given birth.
Boston Medical Center gave patients cellular-connected blood pressure cuffs to monitor patients and see if some needed intervention. The program proved to be very successful. Virtually all of the patients checked their blood pressure, and they were able to identify some patients that needed treatment before suffering a stroke or heart attack.
Yarrington and Lucienne Ide, Rimidi’s chief executive officer and founder, talked with Chief Healthcare Executive about the program, connecting with a safety net population, and using technology to improve health equity.
“It really is the team that’s behind this and the rapport they have with these patients,” Ide said. (See portions of our conversation in this video. The story continues below the video.)
Yarrington said the remote monitoring program is especially valuable because it helps patients who otherwise wouldn’t know they are in trouble.
“This is the rub with hypertension,” Yarrington said. “They feel fine. They feel fine. They measure their blood pressure and it comes up as 180 over 110 … That’s high enough to give you a stroke. That’s high enough to cause cardiac damage.”
Some of those patients were able to be treated before facing an emergency.
“I think we’ve had a lot of near-misses, quite honestly,” Yarrington said.
Connecting with patients
More health systems and doctors are turning to remote patient monitoring. Almost one-third of doctors are using remote patient monitoring, according to a recent American Medical Association survey. Hal Wolf, the president and CEO of the Health Information and Management Systems Society (HIMSS), told Chief Healthcare Executive remote patient monitoring will gain prevalence, especially as health systems deal with a shortage of clinicians.
Boston Medical Center tracked patients who gave birth between April 2020 and September 2021. The study was published in Circulation, the journal of the American Heart Association.
The blood pressure checks for patients were simple. They put on the cuffs and press a button. They were asked to do it at least once a day.
Even though it wasn’t demanding from a technical standpoint, Yarrington said she wasn’t sure how many people were actually going to do the blood pressure checks. After all, these are women who just had babies.
“When a person goes home with a newborn baby, their lives are absolutely turned upside down,” Yarrington said.
Among the 1,000 patients who participated, 98.7% checked their blood pressure at least once. On average, patients engaged in 17 measurements during the six weeks after giving birth, the study found.
“I knew, as a mom myself, there would be days, weeks, where things were just too crazy,” Yarrington said. “When we saw that over 97% of our patients had checked a blood pressure at some point at home, and the frequency they checked was so high, I was delighted.”
The devices were designed to be simple and offer a way to track patients without requiring the patients to use smartphones. The majority of patients are on Medicaid and have lower incomes.
While most have smartphones, many have limited data plans. Yarrington said that was a lesson Boston Medical Center discovered early in the pandemic.
“We learned some hard lessons with the rapid rollout of telemedicine during the first wave of COVID, when so many of our visits, even pregnancy visits, went to telemedicine,” Yarrington said. “At least in my patient population, which is a safety net population, meaning the vast majority are insured by Medicaid, reflecting their economic status, the drain of a data plan on a video visit was often prohibitive.
“The problem was not that they didn’t have devices,” she said. “Everybody has a smartphone, almost irregardless of income, but the data plan question was actually a really big deal.”
Ide said that Rimidi took that into account in developing its technology.
"It's really not about the technology and the complexity of it," Ide said. "It's about the accessibility of it to the patients. If you can't get the data, you can't do anything with the data."
“We have found those devices that ask the least of the patient both in terms of behavior, but also in terms of equity and access to connectivity, were really important,” Ide added. “If you’re sending data to a patient phone, and that patient may have limitations on their data plan, that’s going to affect your ability to get that data.”
When Boston Medical Center began the remote monitoring program, Yarrington said the organization employed a bit of a skeleton crew. The program had access to a nurse who worked for six to eight hours per week to monitor the patients.
Rimidi set up alert cards that would show which patients were experiencing higher blood pressure, or low blood pressure, and should be called to see how they were doing or encourage them to come into the hospital. Yarrington said those cards were critical in managing patients.
The company’s technology also allows the nurses to send a text message to tell patients that they’re going to be calling, so they need to answer the phone.
“The common theme, the qualitative theme that we heard from patients who were engaged in this program, was that they felt so well cared for, and they felt like someone was paying attention all the time,” Yarrington said.
Now, the remote monitoring program has a full-time nurse. Boston Medical Center has also expanded the program and is monitoring patients during pregnancy who are at higher risk of a stroke.
The program began in the spring, so patients haven’t delivered their babies. But Yarrington said getting a better window into the health of pregnant patients offers promising opportunities for better care.
“We now have this information about people’s blood pressure at home in that first early phase of pregnancy, and we’re seeing these repeated cases of our patients with chronic hypertension whose blood pressure is out of control,” Yarrington said. “That can be detrimental to the embryo, it’s highly associated with miscarriage, it’s highly associated with malformations to the development of the placenta which can lead to poor fetal growth.”
“This opportunity to intervene early in pregnancy … I anticipate is going to improve the obstetric outcomes overall for these patients,” she said. “I’m really excited to see how our next wave of population care is different than a year or two ago.”
The remote monitoring program has helped reduce the average length of stay for patients who needed to be readmitted after giving birth. It’s also reduced the number of readmission days for patients coming back with hypertensions.
However, Yarrington also said her goal isn’t necessarily to reduce readmissions. If anything, she said she’s hoping to find other patients who need treatment.
“I have no interest in reducing the need to be hospitalized. Sometimes you just need to come to the hospital,” Yarrington said. “And if anything, we’re learning about postpartum morbidity and postpartum mortality, and it is a real thing. The numbers I think are up across the nation because finally families know this is a dangerous time and you have to take it seriously.”