Objective

Reduced kidney function is a concern for safe administration of medicines. Reports on using telehealth datasets for kidney diseases management have been very limited. We aim to assess utility of telehealth and its medication management dataset for monitoring progression of CKD.

Methods

Our real-time and real-world health data-driven telehealth service performs tele-monitoring, tele-healthcare and tele-medicine, and connects both providers-reported and users-reported health datasets. These datasets, which contain vital sign entries, telehealth intervention notes (TINs), medication management-related intervention notes (MMINs), and users’ EMRs including prescriptions, were used for monitoring CKD progression. Unstructured data were analyzed with NLP and ML.

Results

A total of 150,057 drug items (including refills) had been prescribed for telehealth users of complex conditions enrolled during 2009-2019 (n=1,490). On average, each user in the group was prescribed 3.4 drug items per month (di/m) which had gone up to 8.8 di/m for CKD (n=164) users, and to 15.8 di/m for kidney dialysis users (n=13). For extensive service users (>8 years), the average had gone down to 11.1 di/m. In addition, vital sign trending, and specific TINs and MMINs citations were observed.

Discussion

Our results indicate that interventional telehealth can offer effective monitoring of CKD progression in patients of complex comorbidity and/or multimorbidity. Its potential in reducing iatrogenic injury caused by over-medication has yet to be explored.

Telehealth and Medication Management VII. Telehealth Intervention and Telemonitoring Data-based Approaches to Medication Management in Senior Care

Hsin-Hung Huang, Chiu-Yeh Wu, Li-Ting Kuo, Siou-Yu Shih, Ying-Chi Hsu, and  Por Lai

Background

Real-time and real-world health data-based telehealth featuring telemonitoring, telemedicine, and telehealth intervention is gaining broader adoption in healthcare, in particular, amid the Covid-19 pandemic. Evaluation of such datasets for long-term care is under investigated though. As part of a series of telehealth-related reports, this study examines use of such datasets in medication management in senior care.

Methods

We conducted a 24/7 hospital-based telehealth service to access and record service users’ real-time and real-world health data including vital sign entries (mainly, blood pressure, heart rate, and blood sugar) and prompt care follow-ups in forms of telehealth intervention notes (TINs) and medication management-related intervention notes (MMINs). These datasets were used in conjunction with users’ EMRs for optimizing care. A group of 24 long-term (9+ years) senior users of 65+ y enrolled during 2007-2019 were selected in this study based on their abundant vital sign data, TINs, and MMINs.

Results

Collectively, 124,617 vital sign entries, 88,159 TINs, and 15,018 MMINs were recorded with these seniors who had each used 30+ chemical name medications.  When each user’s vital sign abnormality rates in the first and last serving year were compared, 38% of users showed a decreased rate. It was also observed that about 50% of the MMINs could be attributed to medication consultations and reminders.

Discussion

Evaluation of our extensive telehealth outcomes indicates that real-time and real-world health data as well as prompt intervention are keys to effective medication management that is critical to achieving precision health and reducing adverse drug events in seniors of complex conditions.

Objective

Adverse drug events and improper therapy medications are major concerns for precision health and suggest serious deficiency in care continuum. This study aims to characterize association patterns among telehealth datasets for improving therapy medication management.

Methods

Our 24/7 hospital-based telehealth service, which collects and utilizes real-time and real-world health data. The telehealth datasets include vital sign entries, telehealth intervention notes (TINs) and medication management-related intervention notes (MMINs). Co-occurrence network analyses were attempted for characterizing association patterns among visited specialties and medications. Medications prescribed under ICD-9 and/or ICD-10 codes were separated and compared. NLP (natural language processing) was used for analyzing TINs and MMINs contexts.

Results

A total of 1,490 telehealth users given 37,513 prescriptions and enrolled between 2009 and 2019 were selected for study. Other related datasets concerning this group had included 5,506 visited specialties, 13,988 chemical name medications, 652,636 TINs, and 98,940 MMINs. We observed strong association between certain prescribed medications and specific specialties as well as other co-occurrences.

Discussion

Co-occurrence network analysis, NLP, and machine learning are useful tools for characterizing association patterns among clinical visits, medications, and other telehealth datasets, as well as analyzing complex and unstructured datasets in TINs and MMINs.

Coordinated care aiming at integrating healthcare delivery across participating providers is key to enhancing overall clinical outcome and population health. Continuity of care achieved by effective care coordination is important and valuable to both healthcare providers and users, and other stakeholders. Advanced informatics and monitoring technologies have made continuity of care more achievable and affordable. However, there are also concerns about potential increase in physician workload resulting from the use of digital tools and digitization. Furthermore, in the post-pandemic era, it appears a necessity to promptly address issues of both care continuity and providers care burdens in order to effectively respond to the transforming demands for more efficient healthcare. In this study, we report the use of an informatics system-supported interventional telehealth in collecting and analyzing real-time and real-world health data, and integrating these data with EMRs for achieving continuity of care. We also discuss about possible roles of telehealth in reducing providers care burdens.

Keywords— Care Continuity, Care Burden, EHRs, Real-time and Real-world Health Data, Telehealth, Intervention

Identification of actionable insights from complex, structured EMR, and unstructured real-world telehealth data is important for achieving precision medicine. However, effective integration and utilization of the two combined sets of health data for optimizing patient care remain a major global challenge.  In a series of reports on the use of integrated health data for enhancing medication management, we previously showed that interventional telehealth capable of improving therapy medication management. In this study, we describe expanded analysis and organization of  data obtained from our telehealth service operation for further exploring potential of using integrated health data for ensuring effective medication management.

A group of 287 service users of our 24/7 hospital-based telehealth service, who subscribed the service between 2007 and 2019, were selected in this study based on their inclusive availability of all four sets of data, i.e., 1) vital sign entries, 2) telehealth intervention notes, 3) medication management-related intervention notes, and 4) user-authorized details of prescribed medication items. The data analyzed had included entries of 804,524 vital sign measurements, 493,193 telehealth intervention notes, 75,891 medication management-related telehealth intervention notes, and 72,462 prescribed medication items. Detailed analyses of these data revealed valuable information on the nature, type and utility of the medication management-related intervention notes.

This study suggests that our telehealth service is an affordable, convenient, and feasible approach to the urgently needed integration and utilization of both structured EMR and unstructured real-world health data for improving medication management.

Keywords: Structured & Unstructured Health Data, Telehealth, Telehealth Intervention, Medication Management

Roles of telehealth in improving care coordination are well documented. Though, investigators have begun describing telehealth use for accomplishing Quadruple Aim in healthcare, medication management-related functionality and utility of telehealth intervention are largely unreported. As part of a series of reports on using integrated health data for achieving effective medication management, we perform further study on how telehealth intervention may improve patient-centered medication management.

Our 24/7 hospital-based telehealth operation includes tele-monitoring services which collect and use entries of vital sign measurements, and tele-healthcare and tele-medicine services that record telehealth intervention notes including medication management-related notes and consultation notes involving users’ attending physicians. The telehealth-related information independently organized in our telehealth system and the institutionally maintained EMRs contain both structured and unstructured data. In this study, a group of 100 service users enrolled between 2008 and 2019 were selected based on the abundances of their collective entries of 599,186 registered vital sign measurements, 350,624 recorded telehealth intervention notes, of which, about 56,000 were medication management-related, and more than 6,500 prescribed medication items. We examined any correlations between the service intensity and quantities of their prescribed medication items.

It was observed that the quantities of the medication items prescribed to the service users had decreased along with lengthier uses of the telehealth service. There appeared an obvious association between intensiveness of telehealth intervention and outcomes of patient-centered medication management. This study can also lead to investigating association between telehealth use and ADE incidence.

Keywords: ADE, EMR, Medication Management, Telehealth, Telehealth Intervention

Objective  To assess the potential roles of telehealth services in augmenting usability and utility of the current electronic medical record system, amid strong demands for integrating health data and improving overall healthcare outcomes in the era of digital health.

Methods  The telehealth services were conducted through a hospital-based 24/7 tele-healthcare operation using a proprietary informatics-enabled telehealth system for acquisition, processing, analysis and application of the users’ vital sign measures in real-time and real-world modes. The integrated health data, which consisted of the telehealth data and the users’ EMRs and/or “My Health Bank” records, were further utilized through performance of tele-healthcare interventions.

Results  The contents of 516,555 intervention notes recorded with a group of 754 service users were analyzed and categorized with respect to arrival time, clinical & ED visits, physician consultation, medication management, and vital sign abnormality. These intervention notes were indicative of uses of integrated health data, real-time and real-world comprehension of the users’ health conditions, and prompt actions taken by the service team.

Conclusion  Telehealth services can ensure care continuity, reduction of ADEs through detection of polypharmacy, reduction of unscheduled revisits and other users-related healthcare outcomes. The healthcare providers can also benefit from telehealth services by using connected health data for facilitating clinical decision-making and reducing workload burdens. Therefore, telehealth services are capable of augmenting usability and utility of the current EMR system.

Keywords：EMR; Real-time & real-world Health Data; Telehealth; Intervention; Usability; Utility

Objective To assess the potential roles of telehealth services in primary care of seniors and population health management.

Methods The telehealth service operation was performed in collaboration with a hospital-based 24/7 tele-healthcare team using our proprietary informatics-enabled telehealth system for collection, processing, analysis and application of the service users’ vital sign measures, mostly consisting of blood pressure and blood sugar. This telehealth operation had included tele-monitoring, tele-healthcare, tele-medicine, as well as prompt tele-healthcare interventions which collectively constructed the real-time and real-world health data sets for service users. These data sets were integrated in this telehealth operation with the users’ EMRs and/or “My Health Bank” (健康存摺) records. Functionality and utility of the telehealth service were analyzed for assessing its roles in healthcare delivery.

Results Our data base showed a collection of 781,638 intervention notes recorded with 7,431 telehealth service users. For illustration purpose, we used the data recorded with a group of 8 users who had an average age of 82 (71-89) and suffered from complex multiple health conditions (on average, 32 conditions involving 12 different specialties/user) to analyzing functionality and utility of the telehealth service. A total of 9,858 abnormal vital sign incidents were detected (1,232/user), 3,131 medication management related intervention notes were recorded (391/user), and 114 consultations with attending physicians were made (14/user), resulting in, on average, 2.9 ED visits and 3.4 clinic visits per user during the service period.

Conclusion The significantly low rates of ED and clinic visits clearly demonstrated the functionality and utility of the telehealth service. Broader adoption of telehealth services in the healthcare delivery system is worthy of further exploring. Impacts of integrating EMRs with real-time and real-word health data on senior care and population health management warrant further studies.

Keywords：Intervention; Population Health Management; Telehealth; Vital Signs

Objective To assess the performance modalities and outcomes of the telehealth services provided to service users in a highly industrialized city by use of an informatics-enabled telehealth operation.

Methods The 24/7 telehealth service, including tele-monitoring, tele-healthcare, tele-medicine, and telehealth interventions, was conducted by a telehealth service operation in collaboration with a hospital-based telehealth service team using a proprietary telehealth informatics system for acquiring and processing blood pressure and blood sugar vital signs in real-time and real-world modes. Tele-monitoring measurements were performed either at home or at community sites through coordination by the Department of Health of the local city government.

Results In this project, 6,188 telehealth service users were enrolled between December 2014 and December 2018. A total of 149,977 vital sign entries were recorded wirelessly with the telehealth informactics system. Processing of these record had resulted in performance of 92,468 interventions by the telehealth care team. Further analysis indicated that 11.3% of the interventions were medication management related. Among the enrolled users, 1,403 (22.7%), 810 (13.1%), and 663 (10.7%) were detected to show conditions of hypertension, diabetes, and both respectively, including 25 with previously undiagnosed hypertension. The average rate of user satisfaction was 92.7%.

Conclusion Broader adoption of telehealth services in the healthcare delivery system can ensure effective population health management and offer significant savings in healthcare expenditure, however, it is limited by the current reimbursement policies. Home site services showed more productive outcomes compared to those performed at community sites. These results also indicate that interventions play a key role in the informatics-enabled telehealth service.

Keywords：Intervention; Population Health Management; Telehealth; Vital Signs

Abstract Adverse drug events are increasing challenges for population health management due to widespread uses of prescription and nonprescription medications, as well as health supplements among rising senior population. Effective medication management can significantly reduce such preventable adverse events provided that real-time and real-world health data are available. Our teleservices, which consist of telemonitoring, telehealth, and telemedicine, have been established to access, evaluate, and utilize both real-time and real-world health data by uses of remote patient monitoring and telehealth intervention. We describe the nature and structure of medication management-related health data obtained with the senior users of our tele-services, and discuss the outcomes of the telehealth intervention.

Objectives: Telemedicine enables health care professionals to monitor older people with chronic conditions at home. It is a promising approach to patient’s management by means of empowerment of patients and family caregivers. The aim of this case study is to explore how to provide a telemedicine-based care that will meet the needs of the elderly.

Methods: This 74 y/o female patient has the history of DM, hypertension, chronic kidney disease, ischemic heart disease and asthma. Previous operations included cervical and lumber spine surgery, cholecystectomy and endoscopic retrograde biliary drainage. She received outpatient services from neuro/hepatobiliary surgeon, cardiology, endocrinology and nephrology clinics. Referral by the tele-health center nurse to geriatric clinic for polypharmacy was made in October 2017. The role of the nurse is to integrate patient’s medical information from specialists and family caregiver into a geriatrician. We attempted to reduce the number of medications step by step as her physiological data can be visualized on an office desktop screen through cloud-based management system. During subsequent follow-up, blood test showed leukocytosis and hyperkalemia accidentally. Although she only complained of persistent generalized pain despite of current oral narcotic analgesic use, we arranged admission for her in May 2018 for further evaluation.

Results: After parenteral antibiotic treatment in the acute care unit of general internal medicine, her infection was under control. Medications including Spironolactone, Diclofenac, and Azilsartan were discontinued owing to acute kidney injury. Low dose Imipramine prescribed by neurologist was kept for neuropathic pain control although it has potential harm according to Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Early intervention had prevented infection from worsening in such an at-risk frail senior. Under close home monitoring of blood pressure and finger sugar, her medications had been reduced from initial 28 drugs down to 13 ones in total. Moreover, her pain intensity and functional status improved gradually after telemedicine-based intervention.

Conclusions: Through serial assessment of the tele-health care nurse, we can make adaptation of care plan over time as care needs evolve. Telemedicine-based care has the potential to assist geriatricians in timely identification of acute changes of medical conditions in senior patients and reduction of drug-related adverse effects.

Key Words: Telemedicine-based care, Integrated geriatric service, Polypharmacy.

Objectives: The needs for improving current electronic medical record (EMR) systems are under heavy discussions due to some important shortcomings of EMR, such as absence of socioeconomic, behavioral and environmental health determinants, and interoperability. The increasing complexity of healthcare issues adds further pressures. Telehealth interventions may provide solutions to improving the EMR system.  

Method: The 24/7/365 telehealth intervention services provided to users of various health conditions were conducted by the Telecare/Telehealth Center located at the Kaohsiung Medical University Hospital. Vital signs information such as blood pressures and glucose levels were collected, validated and analyzed, in remote fashion, using the Crux proprietary telehealth informatics platform, and were further integrated with users’ EMRs and home-visit findings whenever necessary. The information obtained with a group of more than 5,500 users of the telehealth intervention services were also personalized.

Result:  Through telehealth interventions including tele-monitoring, personal contacts and/or home-visits, 28 service users without pre-history of hypertension (HP) and/or diabetes (DB) were identified with possible HP and/or DB conditions which were subsequently confirmed at the recommended clinical visits. By use of tele-monitoring and telehealth interventions, the health conditions of most of the service users could be well controlled. The results demonstrated that telehealth interventions could achieve significant outcomes which could not be obtained through the EMR systems alone.

Conclusion:  Our telehealth intervention outcomes indicate that such intervention can facilitate EMR transformation and ensure productive population health management (PHM).

In a series of studies on the utilities of integrated health data for achieving medication management objectives, we conduct analyses on therapy medication-related records obtained through telehealth care interventions (THCIs). Our hospital-based, 24/7/365, telehealth care services are provided to a group of active senior users between 2014 and 2018. These users often face challenges of multiple chronic conditions and inadequacies of primary care. In these retrospective analyses, we first attempt to establish a complete and accurate list of therapy medication for each user, then identify all cited medication reconciliation and management issues, as well as adverse drug events recorded at the time of performing the telehealth care interventions. Out of a total of more than 300,000 intervening notes screened, about 41,000 notes are related to therapy medications. Further categorization of these notes with respect to the nature of intervening has been attempted. The results show that these issues and events can be attributed to both patient behavioral and institutional origins, and that most of the interventions have involved issues concerning accuracy of medication, drug safety, medication adherence and compliance, and therapeutic effects. Our findings indicate that telehealth care interventions are useful for assisting patients, who show multiple chronic conditions and lack adequate primary care, in improving their therapy medication management and reducing care burdens, and that such interventions may contribute to significant savings in health expenditure.

Challenges of effective medication management often include, among others, accuracy of clinical and medication records, absence of a patient-centered care coordination, lack of continuity of care, and adherence and compliance issues. Solutions to dealing with these challenges can be very beneficial to all stakeholders. In a series of studies on the utilities of integrated health data for achieving medication management objectives, we analyze and evaluate therapy medication-related data obtained from both electronic medical records (EMRs) and telehealth records (THRs) of the users who have used our telehealth care services between July 2014 and July 2018. A total of more than 2,900 prescriptions prescribed for 116 telehealth services users, who have been treated at one same hospital, are reviewed. Further, durations of the telehealth services provided to these users have ranged from less than one year to more than nine years. In particular, the data on prescription medications are analyzed from both providers- and users-perspectives. Since our interventional telehealth care offers 24/7/365 continuity of care with the focus on telemonitoring of vital signs, we have been able to identify therapy medication-related cases of inaccurate data processing, polypharmacy, and doubtful prescribing. Our findings suggest that telehealth care can substantially enhance implementation of medication management, should play a key role in the coordinated care system, and that THR constitutes a significant part of the comprehensive electronic health record (EHR).

Big health data consist of both health care user- and provider-generated data and outcomes, and include electronic health records (EHR), personal health records (PHR), and environmental health determinants and impacts (EHDI). While EHR, in general, contains individual health records maintained by institutional health care providers that deliver care during medical visits or hospitalization, it may also contain telehealth records (THR) of real-time electronic health information reported by health care users and/or providers. EHRs without THRs often are intermittent, segregated, and lacking behavioral health information and interoperability. These problems cause significant burdens of medication management which requires effective engagement with both care users and providers for achieving productive outcomes. Our hospital-based and user-centered telehealth service, established in the mid-2000s, is the first telehealth operation in Taiwan. Users’ THR information collected from this operation were integrated with their corresponding EHRs maintained by the institutional care providers. In a series of studies on the utilities of integrated health data for achieving medication management objectives, we first perform statistical analyses of the THR data on care users and service uses with respect to the demographic characteristics of users, lengths of service use, and certain medication details. The findings are indicative of further investigations into using integrated health data for improving medication management such as minimizing polypharmacy, optimizing data processing, enhancing medication adherence, and ensuring overall outcomes.

The use of self-monitoring of blood glucose and blood pressure has been increasing in many countries for decades, however, incidence and prevalence of diabetes and hypertension together with their associated complications continue to be alarming. We provided telehealth intervention services to individuals conducting self-measurement of blood glucose and/or blood pressure, and transmission either at home or at selected community sites located in Kaohsiung City, Taiwan, to investigate acceptance, operations, outcomes, and possible population health impacts of our hospital-based and user-centered services.

Abstract—Effective population health management has emerged as an important public policy measure for achieving strategic objectives concerning sustaining budget plans and ensuring competitiveness in the era of an aging society and a pandemic environment. ICT solutions can greatly facilitate achievement of these strategic objectives. In this report, we describe promising outcomes obtained from the use of a hospital-based and telehealth informatics-enabled telecare service model. This 24/7/365 service model features (1) effective integration of health data such as electronic health record, electronic medical record and personal health record, (2) establishment and use of personalized vital sign base lines, (3) design and use of insightful new specific rating scales, and (4) use of well-defined operating procedures for conducting performance in a stringent regulatory environment. Our novel service model has demonstrated its capability to achieve important population health management related strategic goals such as (1) reducing time to access proper medical service, (2) reducing rate of emergency visit, (3) reducing rate of readmission, (4) reducing hospital stay, (5) reducing possible medical errors, and (6) reducing harms caused by possible overuse and/or underuse of medical services. Significant outcome examples in relation to management and prevention of hypertension, stroke and medical error are presented. Potentially, this service model can also be used for evaluation and validation of technological solutions for medicine.

Abstract—P4 medicine, which features systems biology, digital advances, and large scale opportunities, has prompted pluralistic biomedical innovations [1].  Among these innovations are a variety of devices and software applications which require essential incorporation of outcome-based and user-centric approaches to exhibiting usability, functionality and achieving strategic objectives. Our outcome-based and user-centric digital health services have yielded significant outcomes and can be used as an effective model for achieving the health Triple Aim [2] and better population health management.