David Putrino

Remote patient monitoring in the era of COVID-19

April 20, 2020
by Lauren Dubinsky, Senior Reporter
With New York on the frontlines of the COVID-19 pandemic, hospitals have been overwhelmed by an influx of patients. With limited resources, and little time to prepare, physicians and other hospital personnel were forced to come up with creative ways to provide care.

As of mid-April, there have been over 240,000 positive cases of COVID-19 in the state with New York City accounting for over 130,000 of those cases. The Mount Sinai Health System, the city’s largest academic medical system, addressed this by repurposing a remote patient monitoring platform for stroke patients to care for patients with confirmed or suspected COVID-19 whose symptoms are not severe enough to require hospitalization. It was launched in late March and has since enrolled hundreds of patients.

“When the crisis hit, there were a lot of companies offering various telemedicine solutions, but we couldn’t customize them to our needs and the needs we were seeing in a rapidly changing circumstance,” said David Putrino, co-director of Mount Sinai’s Precision Recovery platform.

In addition, any new technology must pass information security reviews and go through new vendor processes. The health system did not have time for that, so it made sense to turn to a platform that was already vetted and approved by the hospital.

The stroke program, which is still up and running, monitors patients’ blood pressure and neurological signs through an app that asks them questions on a daily basis. To make it suitable for COVID-19 patients, Putrino and his colleague, Dr. Christopher Kellner, changed the questions to focus on ease of breathing and severity of cough.

Putrino noted that they are being “very conservative” with how they are managing these patients because “with remote patient monitoring, it is very easy to become complacent when you are just looking at numbers.”

The patients are asked a series of questions once per day through a mobile application called MyCap. If they answer two or more questions differently than they did the day before, that’s an indication that their symptoms are worsening.

Those patients immediately receive a Zoom video conferencing call from one of the Precision Recovery providers. Among those providers are nurse practitioners, physical therapists and occupational therapists who are trained to identify signs and symptoms of respiratory decline.

If the providers determine that the patient only got a little worse that day but is fine overall, they will closely monitor them and ask them to report their symptoms twice per day in some cases. However, if the symptoms have more severely worsened, then the provider will quickly hand the situation over to a triage physician.

“These triage doctors are waiting to take calls with patients who are deteriorating quickly,” said Putrino. “If they Zoom [call] and really don’t like what they see then we quickly arrange for emergency care.”

In one case, a patient reported feeling a little breathless and a small amount of pain while breathing, which wasn’t a major cause for concern. However, the next day she was so breathless that she couldn’t complete a sentence so she was immediately admitted to the emergency department.

In some cases, patients with worsened symptoms can be treated with prescription medications or other interventions that don’t require hospitalization.

The Mount Sinai Precision Recovery team spans five hospitals within the health system and is staffed with 22 coordinators, 12 providers and 10 physicians. As of early April, the team has escalated a handful of patients to the emergency room.

Given the nature of this virus and the accompanied symptoms, Putrino explained that telemedicine approaches that only involve a single urgent care visit are inadequate. This virus requires an approach that checks in with patients on a daily basis to track any changes in symptoms, and follows a clear set of guidelines for when a patient needs to be admitted.

It took Mount Sinai between a year and a year and a half to build the Precision Recovery platform. They spent that time vetting different approaches and determining what works best with a clinical workflow and how to make it work on a practical level.

They decided to run the platform on a secure web application called REDCap, which is used by nearly every large research institute in the country. According to REDCap’s website, this application is already in use at other institutions in response to COVID-19.

The University of Washington’s Institute of Translational Health Services is using REDCap to surveil the community and monitor the virus in pregnant women. Vanderbilt University Medical Center’s Occupational Health group in Nashville, Tennessee is using REDCap surveys to monitor any employees who may have been exposed to the virus.

Mount Sinai launched a website — precisionrecovery.net — to help other hospitals that want to deploy a remote monitoring platform like their own. It provides manuals with basic step-by-step instructions to create this platform and integrate it into their own electronic health record.

“This is all about making these tools available to everybody so we can save as many lives as possible,” said Putrino. “We really hope that other hospitals use these resources, and that it can help them in their own fight against COVID.”