Delivery of hospital-level care in patients’ homes has become increasingly common since the Centers for Medicare & Medicaid Services established the Acute Hospital Care at Home waiver during the COVID-19 pandemic. While home hospital programs have become increasingly adopted by health systems across the country for managing medical conditions such as pneumonia or congestive heart failure, home hospital for surgical and postoperative patients represents a new frontier of clinical innovation.
In npj Digital Medicine, Boston area experts provide a framework of the key considerations on the safe and effective adoption digital technologies they’re using in a pilot of a surgical home hospital in bariatric surgery at Brigham and Women’s Hospital.
The authors are Kavya Pathak, MD, a clinical fellow in the Department of Surgery at the Brigham, Jayson S. Marwaha, MD, MSc, a fellow in the Department of Biomedical Informatics at Harvard Medical School, and Thomas C. Tsai, MD, MPH, a minimally invasive gastrointestinal and bariatric surgeon at the Brigham and co-director of the Healthcare Quality and Outcomes Lab at Harvard T.H. Chan School of Public Health.
Remote Patient Monitoring
Postoperative surgical complications may be uncommon but can potentially develop into serious conditions such as sepsis. The ability to detect early warning signs of physiologic stress is critical for a surgical home hospital to ensure comparable quality of care for surgical patients in the immediate postoperative period.
The Brigham uses the Biovitals platform (Biofourmis, Boston, MA), which integrates data from wearable devices (blood pressure cuff, pulse oximeter, and a patch that measures temperature, heart rate, and respiratory rate). Artificial intelligence predicts health deterioration or improvement. All bariatric surgery patients enrolled in the home hospital randomized controlled trial have complied with wearable device use.
A key innovation of surgical home hospital is ensuring that the remote patient monitoring data is easily accessible to clinicians to streamline clinical decision-making. Device data are displayed on a secure portal on the Biofourmis website or a smartphone app accessible to clinicians. Abnormalities prompt virtual or in-person visits, depending on severity. The platform also features a patient-facing interface with daily reminders.
The interest in home hospital programs has spurred continued innovation in remote patient monitoring and wearable devices. More important than the technology or platform is creating workflows that integrate diagnostic data, documentation, and clinical tasks to optimize workflows for bedside clinicians. Because care is often virtual and or in-person but asynchronous, remote monitoring data must be accessible to all care team members, particularly during rounds and other team-based care events.
Clinical Risk Prediction
Clinical risk prediction models use retrospective observational data and statistical methods—sometimes machine learning–based methods—to predict an individual patient’s likelihood of a designated clinical outcome. These tools are potentially useful components of home hospital care but are not yet widely used in these settings.
At the Brigham, risk prediction models are used to identify candidates for post–bariatric surgery home hospital by assessing the risk of pneumonia, sepsis, and death by analyzing demographic factors and comorbidities.
Workflows for surgical home hospital programs have to provide an appropriate mix of virtual and in-person visits based on illness acuity and procedural complexity. The Brigham combines virtual surgeon visits with in-person visits from registered nurses and paramedics. Other care models may combine in-person visits from surgical advanced practice providers, surgicalists, or medical hospitalists with virtual surgeon visits.
Emerging technologies, such as connected auscultation or smartphone-monitored abdominal palpation, will allow patients to examine themselves and report the findings.
The Path Forward
Digital technologies are expected to play an increasingly important role in extending the clinical vigilance and assessment of the inpatient ward into patient’s homes in the acute postoperative period or for management of nonoperative surgical conditions. Key areas of future focus will be to ensure data interoperability (the ability of devices to communicate with each other and electronic health record systems), data security, and equitable access for all patients. The goal of digital technologies in hospital programs is not to substitute for a surgeon or physician’s clinical expertise but to provide dynamic, real-time clinical data to streamline clinical decision-making that assures high-quality and safe recovery of patients from the comfort of their own bed.