Covid Flow – Telemedicine for COVID-19 Patients

Jan 13, 2021 - 13 min. read time

Telehealth and telemedicine describe health care services rendered without face-to-face contact between a provider and patient, and the terms have been around for decades. However, the number of telehealth applications with demonstrable impact have been few and far between, despite the omnipresence of secure telecommunication technologies in most parts of the world.

Benjamin Vandendriessche
CMO at Byteflies & Adjunct prof at WRCU

Covid Flow – Telemedicine for COVID-19 Patients

Jan 13, 2021 - 13 min.

Telehealth and telemedicine describe health care services rendered without face-to-face contact between a provider and patient, and the terms have been around for decades. However, the number of telehealth applications with demonstrable impact have been few and far between, despite the omnipresence of secure telecommunication technologies in most parts of the world.

Reach out to our experts

This story was originally published on Jan 13, 2021 and discussed data on the first three months of Covid Flow (FKA CovidCare@home).

We updated the story on Aug 8, 2021 to include all data collected from Oct 2020 through Jul 2021.

Table of Contents

  • Introduction: a brief history of telemedicine
  • Covid Flow
  • The need for reimbursement
  • Summary

An exceedingly brief and opinionated history of telemedicine

Telehealth and telemedicine describe health care services rendered without face-to-face contact between a provider and patient, and the terms have been around for decades. However, the number of telehealth applications with demonstrable impact have been few and far between, despite the omnipresence of secure telecommunication technologies in most parts of the world. One technological innovation was missing though: the ability to reliably measure clinical parameters at home. More recently, new biometric monitoring technologies (BioMeTs) have entered the market. Think wearable devices that track your health continuously in the background. It is the advent of specialized and user-friendly BioMeTs that promises to transform telemedicine from a niche application into routine clinical care.

Although BioMeTs nowadays are typically internet-connected, devices with similar intended uses already have a long history. The best-known example is the Holter ECG monitor which is a staple of any cardiologist looking to diagnose certain cardiac problems while people are going about their usual activities. A typical Holter monitor (see image below, middle) is worn for 1–2 days.

From left-to-right: (1) Model 445 Mini-Holter Recorder circa 1976 (adapted from the National Museum of American History), (2) example of a contemporary multi-lead Holter Monitor, and (3) an example of the new generation of wearable ECG monitors that can monitor heart rate, respiratory rate, and activity (Byteflies Sensor Dot ECG patch, image is used with permission from copyright owners Stad Antwerpen and Frederik Beyens).

It is the advent of specialized and user-friendly wearable devices that promises to transform telemedicine from a niche application into routine clinical care.

For a long time, the usability of these early ambulatory devices was lacking. The miniaturization of electronics and the rise of the Internet of Things (IoT) made it possible to fit a medical device into the size of a consumer electronics gadget and include functionality that users are now expecting such as cloud-connectivity and interaction via mobile apps. In the healthcare sector, a second and more fundamental factor is at play: patients expect guidance from their healthcare provider on the use of digital health applications. However, in many cases, trust in these novel devices and technologies is lacking with healthcare professionals. It should come as no surprise that someone who does not trust a device or technology will not be able to provide proper guidance on its usage.

And then came along COVID-19 …

During global health crises, such as the SARS-CoV-2 pandemic, healthcare systems are put under enormous pressure, even leading to patients requiring life-saving care to be turned away as resources are stretched too thin. Healthcare professionals embraced various digital health and telehealth applications at breakneck speed to help deal with the overload. At Byteflies, we also decided to do our part and launched Covid Flow.

Google Trends data for the terms “telehealth” (orange) and “telemedicine” (blue) expressed as relative search interest (100 = peak popularity) over the last 3 years. The peak coincides with the rapid spread of the novel coronavirus.

Covid Flow

Covid Flow (CC@H) is a Belgian consortium of technology and healthcare providers who joined forces after the first COVID-19 wave in the spring of 2020 to provide a fast and pragmatic home monitoring solution for COVID-19 patients, thereby freeing up valuable hospital beds (press).

The solution consists of a couple of BioMeTs, a patient app, a healthcare provider dashboard, and a telemonitoring team. You can find some more details on the project website. On the provider side, a dashboard lists all active and past patients, their vital sign measurements and survey answers, and associated trends ranked according to the National Early Warning Score (NEWS2). The dashboard can integrate with the electronic medical records (EMR) of the hospital partners, and when someone’s vital signs deteriorate, the hospital or family doctor can contact them.

CC@H dashboard for healthcare professionals. A NEWS2 score is calculated from a patient’s vital signs. Users can visualize all historical measurements and associated trends for each patient in their hospital. Family doctors can also access the data for their patients.

Just like patients can move through various hospital departments depending on the level of care they need, telemonitoring applications require a clear definition of “paths” (or “patient journeys”, if you will). The primary group of patients that CC@H was used for are on the so-called posthospitalization path (black arrow in the diagram below), i.e. they are discharged from the hospital and sent home with CC@H to complete their recovery under close surveillance. They are in the comfort of their own home but in case their health deteriorates, a swift intervention is possible. A second path is prehospitalization (orange arrows in the diagram): people with a suspected or confirmed coronavirus infection may show up at the emergency department. Before CC@H, the choice was binary: admit that person or send them home. With CC@H, a third option is available when an admission is not yet warranted. Home monitoring can be used until a hospital admission does become necessary. Similar to the second path, assisted living facilities can use a form of prehospitalization monitoring (green arrow in the diagram). Considering these facilities have a high concentration of high-risk individuals, CC@H can be used to monitor a large group of people continuously, to facilitate a quick intervention when social distancing measures are in effect.

CC@H is compatible with various patient care paths. The primary one is posthospitalization monitoring (black arrow). Prehospitalization monitoring can be initiated for people in the emergency department but for whom an admission is not yet warranted (orange arrows) or assisted living facilities (green arrow). The data collected by the CC@H includes vital signs and questionnaire data, which is shared with the telemedicine team and the family doctor (blue dashed arrows).

What did we achieve so far?

CC@H kicked off late September 2020 in the Flanders region (6.6M inhabitants) of Belgium and enrolled around ten hospitals per month until the end of the year. Between October 2020 and July 2021, more than 850 COVID-19 patients were monitored at home, accounting for almost 20,000 vital sign measurements. Instrumental for this fast roll-out was the fact that CC@H is provided for free to the participating hospitals. Byteflies is bearing the bulk of the costs with grant support from VLAIO and the City of Antwerp.

Green dots are CC@H hospitals, red dots are Flemish hospitals not yet enrolled, and light blue dots were regionally out of scope for the first phase.

In just 3 months, CC@H was rolled-out to 28 Flemish hospitals and by February 2021, more than 500 COVID-19 patients had been discharged early to continue their recovery at home.

Enrollment of hospital partners happened while the second wave was ramping up in Belgium. The blue plot in the chart below displays the cumulative number of COVID-19 patients that were sent home with CC@H between October 2020 and July 2021 (left y-axis). For reference, the orange plot displays the new hospitalizations in Flanders per 100,000 inhabitants over that same period (right y-axis). Relatively speaking, CC@H enrollment was growing month over month as more hospitals started integrating it into their clinical workflows. The acceleration from February to March can be explained by the availability of a medical reimbursement path (see further).

Error correction: In the first version of this story published on January 13, 2021, the source of epidemiological data for Flanders was not correctly used leading to an overestimation of the actual number of COVID-19 cases, and thus an underestimation of the impact of CC@H and an overestimation of the potential cost savings. In the current version, that error was corrected.

Total CC@H recruitment in Flanders between October 2020 & July 2021 (blue plot, left y-axis) and total hospitalizations in Flanders per 100,000 inhabitants in the same period (orange plot, right y-axis). The COVID-19 statistics are taken from Sciensano’s dashboard.

Factors to consider when interpreting the CC@H enrollment numbers:

  • By January 2021, approximately 40% of Flemish hospitals were enrolled and that number remained stable until July 2021.
  • Not all patients admitted for COVID-19 are eligible for pre- or posthospitalization home monitoring. It is not straightforward to estimate the real eligibility rate as no standardized protocol was in place across all participating hospitals. Based on our data, 10–25% of hospitalized patients were eligible for the CC@H pre- or posthospitalization paths.

To put the absolute CC@H recruitment and new hospitalization numbers in perspective, the chart below shows the “Relative Reach”. This is defined as the total number of CC@H patients over the total (new) hospitalizations in Flanders that could be eligible for CC@H. The eligibility rates were estimated at 10% or 25% as explained above. At 10% eligibility, the maximum relative reach in a single month was 57% (blue plot). For the higher eligibility rate of 25%, the maximum in a single month was 23% (orange plot). Over the entire monitoring period, between 14–35% of all potentially eligible CC@H patients in Flanders were home monitored, and a larger number of patients was reached during wave peaks.

Reach is the relative number of hospitalized patients that were enrolled in CC@H through the participating hospitals, compared to the total number of hospitalizations in Flanders that are expected to be eligible for CC@H. The relative reach for a 10% eligibility rate is shown in the blue plot and a 25% rate in the orange plot. The COVID-19 statistics are taken from Sciensano’s dashboard.

Considering:

  1. The extremely short onboarding period for a large group of geographically dispersed hospitals …
  2. Of a new and unproven technology …
  3. Based on in-kind contributions from technology and healthcare providers (i.e. without structural reimbursement support) for the first four months …
  4. During a raging pandemic …

Byteflies and all our CC@H partners are immensely proud of this achievement. Of course, with what we have learned and built, the objective is to ensure that in similar future scenarios, 100% of patients eligible for telemonitoring can be reached virtually instantaneously.

The objective of our remote patient monitoring efforts is to ensure enough capacity to monitor all eligible patients in Belgium.

What is the potential economic impact?

A final key factor is the potential cost savings. CC@H was made available for free because we wanted to do our part in supporting our healthcare providers, but a telemonitoring application obviously costs money to build and maintain. And it is not only the technology platform, the “chain of accountability” needs to be ensured as well. In case of deteriorating vital signs or concerns from the patient, a rapid and appropriate follow-up by qualified healthcare professionals needs to be triggered. Luckily, the Belgian authorities responsible for medical reimbursement acted swiftly and by December 2020, temporary reimbursement codes for COVID-19 related telemonitoring were available. By February 2021, all CC@H provider partner could start using these codes which had a further net positive effect on CC@H recruitment during the third wave.

Which begs the question: can a solution like CC@H in fact lead to a reduction in health care costs? From the collected data and feedback from healthcare providers, we estimate that patients are discharged from the hospital at least 1–2 day earlier with CC@H (posthospitalization) or never require an admission (prehospitalization). A hospital day for a COVID-19 patient in Belgium costs around €800 (non-intensive care and excluding any procedures). A telemonitoring week with CC@H is roughly four times less. In addition, the amount of time a patient is under close observation is extended by a full week! In other words, CC@H is not only reducing health care spending, it may also improve the quality of care.

Assuming two hospitalization days were avoided on average across the pool of CC@H patients, we estimate the achieved healthcare cost savings in Flanders for each month CC@H was active in the graph below. During wave peaks, this reached up to €250,000 per month, for a total cost saving of €1.2M over 10 months.

Assuming two hospitalization days were avoided on average for all CC@H patients, the plot displays the achieved healthcare cost saving in Flanders for each month CC@H was active. This considers the average cost of two hospitalization days and the cost for a full week of telemonitoring with CC@H.

CC@H may have directly prevented €1.2M in healthcare costs in Flanders in just 10 months' time while extending the observation period.

If we assume that CC@H was deployed across all Flemish hospitals during this same period, we can also estimate the total potential cost savings in Flanders using the same eligibility rates of 10 and 25% as explained earlier. During a wave peak, CC@H could have reduced health care spending by €0.8–2.0 million per month (blue and orange plot below). For the CC@H active period, this amounts to a total potential cost saving of €3.8–9.4 million in just 10 months with a longer observation period of the patient. Like before, this estimation assumes two hospitalization days are avoided (either via the pre- or posthospitalization path), and only takes those estimated direct costs into account. Whether or not the prolonged monitoring period has additional cost benefits remains to be determined, for instance because we can intervene early for people who are getting worse, potentially preventing a critical care admission.

For the same eligibility rates as discussed previously (10%, blue plot and 25%, orange plot), the cost saving can be estimated when replacing two hospital days with one week of home monitoring. Potential cost savings are calculated for each week with data available. The COVID-19 statistics are taken from Sciensano’s dashboard.

One week of telemonitoring with CC@H is eight times cheaper than two hospitalization days.

What did we learn?

The main objective of the first phase was to rapidly develop an application that would assist our healthcare providers in these unprecedented times, while demonstrating the feasibility of CC@H and the willingness of Belgian hospitals to adopt telemedicine applications. We believe the feasibility is clear, and the willingness and drive of our hospital partners to implement CC@H into their clinical workflows has far exceeded our expectations.

The willingness and drive of our hospital partners to implement CC@H into their clinical workflows has far exceeded our expectations.

We have received feedback from CC@H users, both healthcare professionals and patients. Although some are anecdotal in nature, the takeaways were clear:

  • On average, 1–2 hospitalization days can be replaced by one week of CC@H monitoring in the posthospitalization path. In the prehospitalization path, the potentially avoided number of hospitalization days could be higher, but we currently do not have enough information to estimate that.
  • CC@H patients have been recalled to the hospital based on their telemonitoring data; we are working with our hospital partners to get a clearer picture on the impact of these recalls.
  • The main demographic open to using CC@H is born after 1960.
  • The average monitoring duration was 6–7 days per patient and adherence was well over 95%.
  • Patient users overwhelmingly communicated that CC@H gave them peace of mind, especially the combination of vital sign monitoring and the communication channel to their healthcare provider. Example (Dutch).
  • In the first 3 months of CC@H, Byteflies built more than 30 new features based on feedback from the hospital partners, demonstrating that agile co-development and safe medical devices can go hand-in-hand.

The need for reimbursement

For most digital medicine application, regulatory clearance and reimbursement by a payer are critical to drive adoption by healthcare providers. Encouraging steps have been made by regulators over the last few years. High profile examples are the Digital Healthcare Act (DVG) in Germany and the FDA Digital Health Center of Excellence in the US. In Belgium, the mHealth pyramid system is being developed.

Specifically to battle COVID-19, the FDA provided emergency use authorizations for certain medical devices. Although similar broad emergency uses never materialized in the EU, many countries did pass temporary COVID-19 specific reimbursement policies. Likewise, Belgium’s single payer system introduced a lot of support measures to deal with the pandemic. In December 2020, the National Institute for Health and Disability Insurance (RIZIV/INAMI) launched a pilot study to monitor COVID-19 patients at home which was drafted in collaboration with Byteflies and other stakeholders*. This pilot study defines reimbursement codes for telemonitoring of pre- and posthospitalization COVID-19 patients, and its availability led to a marked acceleration in CC@H enrollment as we showed above.

*The link is the official press release in Dutch and French, a non-official English summary is available here.

The RIZIV pilot study is a textbook example of diverse stakeholders coming together to solve a unique problem.

The pilot reimbursement allowed CC@H to continue to provide a pragmatic telemonitoring solution for our physicians and nurses in the frontlines of the pandemic at a larger and more coordinated scale, while also collecting the evidence that supports a more permanent roll-out for this type of telemonitoring reimbursement codes.

We commented on the potential cost savings of CC@H. However, the real take home message is that for many chronic conditions, such as heart failure, chronic obstructive pulmonary disease, epilepsy, multiple sclerosis, and Alzheimer’s disease, to name just a few, the potential health care cost savings are orders of magnitude larger if we succeed in decentralizing a significant portion of care to the home environment. If done right, this will also improve the standard of care.

Summary

In the three first months of CC@H and with limited financial means, we focused on an incredibly quick onboarding of hospital partners. Conservative estimates indicate that we reached up to 57% of the COVID-19 patients eligible for home monitoring in months with a high number of cases. This was only possible because our hospital partners recognized the potential of CC@H.

Despite encouraging vaccine news, COVID-19 is unfortunately not yet a thing of the past. Our primary objective in the short-term is to keep supporting the Belgian healthcare system. Of course, we have longer-term goals as well. Although no one wants to think about future pandemics, they will happen, and we will be better prepared, hopefully with permanent reimbursement codes in place. But more importantly, the promise of digital health applications for chronic conditions is finally ready to materialize.

Covid Flow was rolled out at an unprecedented speed because our hospital partners saw the need and recognized its potential.

Despite all the hardship COVID-19 has and is causing for a lot of people, we hope that some silver lining will emerge, including the understanding that patient-centered digital health applications are here to stay and are quickly becoming an essential part of routine clinical care. Now is the time to ensure that these roots take hold permanently. Not for the sake of technology adoption, but for the sake of a holistic, value-based and compassionate healthcare system that puts the needs and well-being of the patient first.

The information contained in this article represents the views and opinions of the writer(s) and does not necessarily represent the views or opinions of other parties referenced or mentioned therein.

The article is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare professional with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you read in this article.

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This story was originally published on Jan 13, 2021 and discussed data on the first three months of Covid Flow (FKA CovidCare@home).

We updated the story on Aug 8, 2021 to include all data collected from Oct 2020 through Jul 2021.

Table of Contents

  • Introduction: a brief history of telemedicine
  • Covid Flow
  • The need for reimbursement
  • Summary

An exceedingly brief and opinionated history of telemedicine

Telehealth and telemedicine describe health care services rendered without face-to-face contact between a provider and patient, and the terms have been around for decades. However, the number of telehealth applications with demonstrable impact have been few and far between, despite the omnipresence of secure telecommunication technologies in most parts of the world. One technological innovation was missing though: the ability to reliably measure clinical parameters at home. More recently, new biometric monitoring technologies (BioMeTs) have entered the market. Think wearable devices that track your health continuously in the background. It is the advent of specialized and user-friendly BioMeTs that promises to transform telemedicine from a niche application into routine clinical care.

Although BioMeTs nowadays are typically internet-connected, devices with similar intended uses already have a long history. The best-known example is the Holter ECG monitor which is a staple of any cardiologist looking to diagnose certain cardiac problems while people are going about their usual activities. A typical Holter monitor (see image below, middle) is worn for 1–2 days.

From left-to-right: (1) Model 445 Mini-Holter Recorder circa 1976 (adapted from the National Museum of American History), (2) example of a contemporary multi-lead Holter Monitor, and (3) an example of the new generation of wearable ECG monitors that can monitor heart rate, respiratory rate, and activity (Byteflies Sensor Dot ECG patch, image is used with permission from copyright owners Stad Antwerpen and Frederik Beyens).

It is the advent of specialized and user-friendly wearable devices that promises to transform telemedicine from a niche application into routine clinical care.

For a long time, the usability of these early ambulatory devices was lacking. The miniaturization of electronics and the rise of the Internet of Things (IoT) made it possible to fit a medical device into the size of a consumer electronics gadget and include functionality that users are now expecting such as cloud-connectivity and interaction via mobile apps. In the healthcare sector, a second and more fundamental factor is at play: patients expect guidance from their healthcare provider on the use of digital health applications. However, in many cases, trust in these novel devices and technologies is lacking with healthcare professionals. It should come as no surprise that someone who does not trust a device or technology will not be able to provide proper guidance on its usage.

And then came along COVID-19 …

During global health crises, such as the SARS-CoV-2 pandemic, healthcare systems are put under enormous pressure, even leading to patients requiring life-saving care to be turned away as resources are stretched too thin. Healthcare professionals embraced various digital health and telehealth applications at breakneck speed to help deal with the overload. At Byteflies, we also decided to do our part and launched Covid Flow.

Google Trends data for the terms “telehealth” (orange) and “telemedicine” (blue) expressed as relative search interest (100 = peak popularity) over the last 3 years. The peak coincides with the rapid spread of the novel coronavirus.

Covid Flow

Covid Flow (CC@H) is a Belgian consortium of technology and healthcare providers who joined forces after the first COVID-19 wave in the spring of 2020 to provide a fast and pragmatic home monitoring solution for COVID-19 patients, thereby freeing up valuable hospital beds (press).

The solution consists of a couple of BioMeTs, a patient app, a healthcare provider dashboard, and a telemonitoring team. You can find some more details on the project website. On the provider side, a dashboard lists all active and past patients, their vital sign measurements and survey answers, and associated trends ranked according to the National Early Warning Score (NEWS2). The dashboard can integrate with the electronic medical records (EMR) of the hospital partners, and when someone’s vital signs deteriorate, the hospital or family doctor can contact them.

CC@H dashboard for healthcare professionals. A NEWS2 score is calculated from a patient’s vital signs. Users can visualize all historical measurements and associated trends for each patient in their hospital. Family doctors can also access the data for their patients.

Just like patients can move through various hospital departments depending on the level of care they need, telemonitoring applications require a clear definition of “paths” (or “patient journeys”, if you will). The primary group of patients that CC@H was used for are on the so-called posthospitalization path (black arrow in the diagram below), i.e. they are discharged from the hospital and sent home with CC@H to complete their recovery under close surveillance. They are in the comfort of their own home but in case their health deteriorates, a swift intervention is possible. A second path is prehospitalization (orange arrows in the diagram): people with a suspected or confirmed coronavirus infection may show up at the emergency department. Before CC@H, the choice was binary: admit that person or send them home. With CC@H, a third option is available when an admission is not yet warranted. Home monitoring can be used until a hospital admission does become necessary. Similar to the second path, assisted living facilities can use a form of prehospitalization monitoring (green arrow in the diagram). Considering these facilities have a high concentration of high-risk individuals, CC@H can be used to monitor a large group of people continuously, to facilitate a quick intervention when social distancing measures are in effect.

CC@H is compatible with various patient care paths. The primary one is posthospitalization monitoring (black arrow). Prehospitalization monitoring can be initiated for people in the emergency department but for whom an admission is not yet warranted (orange arrows) or assisted living facilities (green arrow). The data collected by the CC@H includes vital signs and questionnaire data, which is shared with the telemedicine team and the family doctor (blue dashed arrows).

What did we achieve so far?

CC@H kicked off late September 2020 in the Flanders region (6.6M inhabitants) of Belgium and enrolled around ten hospitals per month until the end of the year. Between October 2020 and July 2021, more than 850 COVID-19 patients were monitored at home, accounting for almost 20,000 vital sign measurements. Instrumental for this fast roll-out was the fact that CC@H is provided for free to the participating hospitals. Byteflies is bearing the bulk of the costs with grant support from VLAIO and the City of Antwerp.

Green dots are CC@H hospitals, red dots are Flemish hospitals not yet enrolled, and light blue dots were regionally out of scope for the first phase.

In just 3 months, CC@H was rolled-out to 28 Flemish hospitals and by February 2021, more than 500 COVID-19 patients had been discharged early to continue their recovery at home.

Enrollment of hospital partners happened while the second wave was ramping up in Belgium. The blue plot in the chart below displays the cumulative number of COVID-19 patients that were sent home with CC@H between October 2020 and July 2021 (left y-axis). For reference, the orange plot displays the new hospitalizations in Flanders per 100,000 inhabitants over that same period (right y-axis). Relatively speaking, CC@H enrollment was growing month over month as more hospitals started integrating it into their clinical workflows. The acceleration from February to March can be explained by the availability of a medical reimbursement path (see further).

Error correction: In the first version of this story published on January 13, 2021, the source of epidemiological data for Flanders was not correctly used leading to an overestimation of the actual number of COVID-19 cases, and thus an underestimation of the impact of CC@H and an overestimation of the potential cost savings. In the current version, that error was corrected.

Total CC@H recruitment in Flanders between October 2020 & July 2021 (blue plot, left y-axis) and total hospitalizations in Flanders per 100,000 inhabitants in the same period (orange plot, right y-axis). The COVID-19 statistics are taken from Sciensano’s dashboard.

Factors to consider when interpreting the CC@H enrollment numbers:

  • By January 2021, approximately 40% of Flemish hospitals were enrolled and that number remained stable until July 2021.
  • Not all patients admitted for COVID-19 are eligible for pre- or posthospitalization home monitoring. It is not straightforward to estimate the real eligibility rate as no standardized protocol was in place across all participating hospitals. Based on our data, 10–25% of hospitalized patients were eligible for the CC@H pre- or posthospitalization paths.

To put the absolute CC@H recruitment and new hospitalization numbers in perspective, the chart below shows the “Relative Reach”. This is defined as the total number of CC@H patients over the total (new) hospitalizations in Flanders that could be eligible for CC@H. The eligibility rates were estimated at 10% or 25% as explained above. At 10% eligibility, the maximum relative reach in a single month was 57% (blue plot). For the higher eligibility rate of 25%, the maximum in a single month was 23% (orange plot). Over the entire monitoring period, between 14–35% of all potentially eligible CC@H patients in Flanders were home monitored, and a larger number of patients was reached during wave peaks.

Reach is the relative number of hospitalized patients that were enrolled in CC@H through the participating hospitals, compared to the total number of hospitalizations in Flanders that are expected to be eligible for CC@H. The relative reach for a 10% eligibility rate is shown in the blue plot and a 25% rate in the orange plot. The COVID-19 statistics are taken from Sciensano’s dashboard.

Considering:

  1. The extremely short onboarding period for a large group of geographically dispersed hospitals …
  2. Of a new and unproven technology …
  3. Based on in-kind contributions from technology and healthcare providers (i.e. without structural reimbursement support) for the first four months …
  4. During a raging pandemic …

Byteflies and all our CC@H partners are immensely proud of this achievement. Of course, with what we have learned and built, the objective is to ensure that in similar future scenarios, 100% of patients eligible for telemonitoring can be reached virtually instantaneously.

The objective of our remote patient monitoring efforts is to ensure enough capacity to monitor all eligible patients in Belgium.

What is the potential economic impact?

A final key factor is the potential cost savings. CC@H was made available for free because we wanted to do our part in supporting our healthcare providers, but a telemonitoring application obviously costs money to build and maintain. And it is not only the technology platform, the “chain of accountability” needs to be ensured as well. In case of deteriorating vital signs or concerns from the patient, a rapid and appropriate follow-up by qualified healthcare professionals needs to be triggered. Luckily, the Belgian authorities responsible for medical reimbursement acted swiftly and by December 2020, temporary reimbursement codes for COVID-19 related telemonitoring were available. By February 2021, all CC@H provider partner could start using these codes which had a further net positive effect on CC@H recruitment during the third wave.

Which begs the question: can a solution like CC@H in fact lead to a reduction in health care costs? From the collected data and feedback from healthcare providers, we estimate that patients are discharged from the hospital at least 1–2 day earlier with CC@H (posthospitalization) or never require an admission (prehospitalization). A hospital day for a COVID-19 patient in Belgium costs around €800 (non-intensive care and excluding any procedures). A telemonitoring week with CC@H is roughly four times less. In addition, the amount of time a patient is under close observation is extended by a full week! In other words, CC@H is not only reducing health care spending, it may also improve the quality of care.

Assuming two hospitalization days were avoided on average across the pool of CC@H patients, we estimate the achieved healthcare cost savings in Flanders for each month CC@H was active in the graph below. During wave peaks, this reached up to €250,000 per month, for a total cost saving of €1.2M over 10 months.

Assuming two hospitalization days were avoided on average for all CC@H patients, the plot displays the achieved healthcare cost saving in Flanders for each month CC@H was active. This considers the average cost of two hospitalization days and the cost for a full week of telemonitoring with CC@H.

CC@H may have directly prevented €1.2M in healthcare costs in Flanders in just 10 months' time while extending the observation period.

If we assume that CC@H was deployed across all Flemish hospitals during this same period, we can also estimate the total potential cost savings in Flanders using the same eligibility rates of 10 and 25% as explained earlier. During a wave peak, CC@H could have reduced health care spending by €0.8–2.0 million per month (blue and orange plot below). For the CC@H active period, this amounts to a total potential cost saving of €3.8–9.4 million in just 10 months with a longer observation period of the patient. Like before, this estimation assumes two hospitalization days are avoided (either via the pre- or posthospitalization path), and only takes those estimated direct costs into account. Whether or not the prolonged monitoring period has additional cost benefits remains to be determined, for instance because we can intervene early for people who are getting worse, potentially preventing a critical care admission.

For the same eligibility rates as discussed previously (10%, blue plot and 25%, orange plot), the cost saving can be estimated when replacing two hospital days with one week of home monitoring. Potential cost savings are calculated for each week with data available. The COVID-19 statistics are taken from Sciensano’s dashboard.

One week of telemonitoring with CC@H is eight times cheaper than two hospitalization days.

What did we learn?

The main objective of the first phase was to rapidly develop an application that would assist our healthcare providers in these unprecedented times, while demonstrating the feasibility of CC@H and the willingness of Belgian hospitals to adopt telemedicine applications. We believe the feasibility is clear, and the willingness and drive of our hospital partners to implement CC@H into their clinical workflows has far exceeded our expectations.

The willingness and drive of our hospital partners to implement CC@H into their clinical workflows has far exceeded our expectations.

We have received feedback from CC@H users, both healthcare professionals and patients. Although some are anecdotal in nature, the takeaways were clear:

  • On average, 1–2 hospitalization days can be replaced by one week of CC@H monitoring in the posthospitalization path. In the prehospitalization path, the potentially avoided number of hospitalization days could be higher, but we currently do not have enough information to estimate that.
  • CC@H patients have been recalled to the hospital based on their telemonitoring data; we are working with our hospital partners to get a clearer picture on the impact of these recalls.
  • The main demographic open to using CC@H is born after 1960.
  • The average monitoring duration was 6–7 days per patient and adherence was well over 95%.
  • Patient users overwhelmingly communicated that CC@H gave them peace of mind, especially the combination of vital sign monitoring and the communication channel to their healthcare provider. Example (Dutch).
  • In the first 3 months of CC@H, Byteflies built more than 30 new features based on feedback from the hospital partners, demonstrating that agile co-development and safe medical devices can go hand-in-hand.

The need for reimbursement

For most digital medicine application, regulatory clearance and reimbursement by a payer are critical to drive adoption by healthcare providers. Encouraging steps have been made by regulators over the last few years. High profile examples are the Digital Healthcare Act (DVG) in Germany and the FDA Digital Health Center of Excellence in the US. In Belgium, the mHealth pyramid system is being developed.

Specifically to battle COVID-19, the FDA provided emergency use authorizations for certain medical devices. Although similar broad emergency uses never materialized in the EU, many countries did pass temporary COVID-19 specific reimbursement policies. Likewise, Belgium’s single payer system introduced a lot of support measures to deal with the pandemic. In December 2020, the National Institute for Health and Disability Insurance (RIZIV/INAMI) launched a pilot study to monitor COVID-19 patients at home which was drafted in collaboration with Byteflies and other stakeholders*. This pilot study defines reimbursement codes for telemonitoring of pre- and posthospitalization COVID-19 patients, and its availability led to a marked acceleration in CC@H enrollment as we showed above.

*The link is the official press release in Dutch and French, a non-official English summary is available here.

The RIZIV pilot study is a textbook example of diverse stakeholders coming together to solve a unique problem.

The pilot reimbursement allowed CC@H to continue to provide a pragmatic telemonitoring solution for our physicians and nurses in the frontlines of the pandemic at a larger and more coordinated scale, while also collecting the evidence that supports a more permanent roll-out for this type of telemonitoring reimbursement codes.

We commented on the potential cost savings of CC@H. However, the real take home message is that for many chronic conditions, such as heart failure, chronic obstructive pulmonary disease, epilepsy, multiple sclerosis, and Alzheimer’s disease, to name just a few, the potential health care cost savings are orders of magnitude larger if we succeed in decentralizing a significant portion of care to the home environment. If done right, this will also improve the standard of care.

Summary

In the three first months of CC@H and with limited financial means, we focused on an incredibly quick onboarding of hospital partners. Conservative estimates indicate that we reached up to 57% of the COVID-19 patients eligible for home monitoring in months with a high number of cases. This was only possible because our hospital partners recognized the potential of CC@H.

Despite encouraging vaccine news, COVID-19 is unfortunately not yet a thing of the past. Our primary objective in the short-term is to keep supporting the Belgian healthcare system. Of course, we have longer-term goals as well. Although no one wants to think about future pandemics, they will happen, and we will be better prepared, hopefully with permanent reimbursement codes in place. But more importantly, the promise of digital health applications for chronic conditions is finally ready to materialize.

Covid Flow was rolled out at an unprecedented speed because our hospital partners saw the need and recognized its potential.

Despite all the hardship COVID-19 has and is causing for a lot of people, we hope that some silver lining will emerge, including the understanding that patient-centered digital health applications are here to stay and are quickly becoming an essential part of routine clinical care. Now is the time to ensure that these roots take hold permanently. Not for the sake of technology adoption, but for the sake of a holistic, value-based and compassionate healthcare system that puts the needs and well-being of the patient first.

The information contained in this article represents the views and opinions of the writer(s) and does not necessarily represent the views or opinions of other parties referenced or mentioned therein.

The article is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare professional with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you read in this article.

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