Ross Sommers, MD

Definition of Terms

According to the Institute of Medicine, an estimated 26.2 billion dollars are spent on medical care for premature infants annually. (1) As staggering as these figures are, they don’t even include post-NICU medical spending which averages $33,000 for each infant per year, with 72% directed toward inpatient care. (2)

Digital healthcare is defined as the convergence of digital technologies with health, healthcare, living, and society to enhance the efficiency of healthcare delivery. (3) It is a rapidly growing industry with an estimated 4.2 billion dollars invested in companies during the first half of 2019 alone. (4) Many devices and platforms have been developed, enabling adults with chronic conditions to receive quality care at home. Despite the high cost of caring for NICU graduates, there is, at present, no digital healthcare solution for this population.

There are several possible explanations for this finding. As with other novel therapies, whether device or pharmaceutical, the pediatric population is all but insignificant when compared to adults with similar morbidities. Consequently, industry is reluctant to invest in a small market. Another possible concern is that historically, the adoption rate for digital health tools has been relatively low. (3) Moreover, the viability of the use case for newborns is contingent upon the acceptability of such a service to parents.

Several recent trends put many of these concerns to rest.

Numbers

In a retrospective analysis of 4973 NICU Medicaid patients, the one-year readmission rate was 36.8%.(2) Based on the estimated 3,800,000 USA births per year and a 10% NICU admission rate, this comes to an additional 12.5 billion dollars of annual healthcare spending. This value is similar to the estimated annual expenditure of 17.4 billion dollars for the 34% of Medicare patients requiring readmission during the first 90 days post-discharge. (5)

On a positive note, in the era of accountable care where hospitals are fined for Medicare readmissions, the numbers for adults are improving.(6) It is also giving rise to a new generation of digital analytics companies such as Jfvion that provide hospitals with predictive tools to identify patients at higher risk for readmission, Care Centrix that offers post-acute home care services, and remote monitoring management companies such as Vivify Health, that was just acquired by the healthcare insurance United Healthcare. (7)

Medicaid, which is increasingly covering the cost of newborn care, has not yet started to penalize hospitals for NICU readmissions. There is an increasing level of dissatisfaction on the part of the public as well as policymakers with the ever-increasing spending on healthcare. As the cost of post-discharge care for NICU graduates is nearly equal to the cost of caring for the elderly Medicare population, it is only a matter of time before hospitals will be penalized for NICU readmissions. Despite the smaller size of our patient population, the high post-NICU readmission rates are not sustainable in today’s healthcare cost-conscious environment.

User Adoption

In a recent report on home care for babies with BPD, half of the 125 parents of affected infants still in the NICU indicated a preference for earlier discharge with home oxygen therapy. (8) However, three months post-discharge, 78% of 110 parents stated that they would have preferred to have been sent home earlier with oxygen, including
97% who initially preferred home oxygen and 60% who preferred to stay longer in the NICU to wean off oxygen. The authors concluded that “earlier education to increase comfort with home technology may facilitate NICU discharge planning”. These findings provide support for the move toward reduced length of stay made possible through
increasing adoption rates of digital health tools.

A recent survey published by Rock Health and the Stanford Center for Digital Health demonstrated several interesting findings. (4) First, the overall acceptance of digital health tools is increasing over time.

Second, healthcare consumers appear eager to share health data, both analog and digital metrics, with their healthcare providers. Naturally, the willingness is greatest when the provider is the patient’s personal physician. This is particularly relevant to the NICU environment where parents have spent months in the hospital, building trust and
developing a level of comfort with the physicians, nurses, and NNPs who have been caring for their infant.

Third, online health is reshaping the physician-patient relationship with patients increasingly asking physicians to prescribe or discontinue a medication, propose a diagnosis, or propose a treatment based on online information. This is particularly evident in the younger millennial Uber generation, accustomed as they are to placing the control of much of their lives in the realm of digital tools.

It is clear that there is a transition to a progressively more digital consumer healthcare experience, and the post NICU discharge population should be no different.

Current status

NICU transition home programs already currently exist. Women and Infants Hospital of Rhode Island has developed a transition home program consisting of a team of four clinical social workers and seven family resource specialists (FRSs) who previously had an infant in the NICU and were paid employees. FRSs were matched with families based on primary language and common backgrounds. The FRS provided education and supportive intervention services under the guidance of social workers. Post NICU intervention included a call within 24 hours from an NNP home visit within the first week, transmittal of summaries to PCP referral to early intervention, and round the clock on-call by study physicians by telephone up to 90 days post-discharge. Medicaid savings related to decreased readmissions over the 90 days was $4590 per infant or $18,360 per year. (9) Based on the average $33,000 spent per year on NICU graduates a 56% cost savings and based on the 12.5 billion spent per year post NICU care for these infants this would correlate to about 7 billion dollars saved per year if this service were offered to all NICU graduates. Social tools are a critical component of an NICU discharge service in conjunction with a digital health service.

Our Experience

We created Firstday Healthcare for the families of our NICU graduates to assist them with a successful transition home. Our universal platform consists of remote continuous vital sign monitoring, 24/7 telemedicine, and a user smartphone app with a built-in EMR.

Continuous vital sign monitoring

Continuous remote vital sign monitoring signals are acquired using the Isansys Healthcare platform. A single-use, neonatal specific, 7-gram sensor that utilizes reusable standard EKG leads placed on the chest takes the average heart rate, respiratory rate, and cutaneous temperature. In addition, a Nonin WristOX may also be placed on the foot. Data is sent by Bluetooth to a dedicated tablet gateway device where one-minute average values are sent to the cloud. Our platform takes these values from the cloud for display on the monitoring provider’s desktop as well as on the parent’s Firstday Healthcare app. If the value triggers an alarm for predefined values, an alert is sent by SMS text to the parents and a master phone list of providers.

Telemedicine

Our app features built-in HIPPA compliant text, video chat, and file attachment. In this way, we are able to securely communicate with families for concerns they may have that are beneath the threshold for detection by vital sign monitoring. High definition photos and videos are stored in a HIPPA compliant cloud account and associated with the user EMR. If a more detailed exam is required, we utilize a Tyto device that is given to all of our parents. All interactions are shared with the infant’s pediatrician. In the event of a true emergency, our staff assist in contacting EMS services and alert the hospital to the infant’s arrival.

User App

In addition to accessing their infant’s vital signs, the user app was built with an integrated, simple EMR prepopulated with the infant’s NICU medical course prior to discharge. In the app, parents will find a simple explanation of their infant’s ongoing medical diagnoses with the plan of care, current medications, laboratory and imaging results,
vaccinations, as well as the ability to plot their growth parameters using Fenton and WHO curves. The app also includes the contact information of their follow up providers as well as dates and times of appointments with built-in SMS reminders. Parents are encouraged to share with us documents from appointments with all of their ongoing care providers by taking a photo of the document with their phone’s camera. Our team then transcribes the summary and attaches a copy of the original document. In this way, parents are able to find a summary of all ongoing interactions with our providers as well as other specialists all in one location. If necessary, parents are times. In order to promote coordinated care, we grant access for other providers to the infant’s EMR where they are also able to view the latest vital sign data as well as medical information. We believe that in order to prevent ER visits and readmissions, it is important to empower the parents and the infant’s providers with both their infant’s vital sign data and with a concise, up-to-date medical summary. Work on hospital EMR integration using FHIR API codes is in progress.

Our findings

We have been offering our solution pro bono to families of high-risk infants who would not have been on monitoring without our service. Parents had received routine NICU discharge teaching including education on safe sleep practices. Moreover, parents were told that the Firstday home monitoring service is not intended to prevent
death from SIDS but rather, to serve as an early warning of clinical deterioration. The feedback from the early user experience in this feasibility and acceptability pilot has been used to refine our platform further. Despite the relatively small numbers of infants managed to date, several important clinical findings have already been identified. In one case, a low respiratory rate of 5 and heart rate of 61 triggered an alert. The baby was sleeping alone in his stroller bassinet with his face pressed against the side. The mother responded to the alert by removing the baby from the stroller. Thankfully, the baby appeared stable and well. This event represented a detection of a potential life threatening event related to an unsafe sleep practice.

As much as we would like to believe that the NICU infants that we discharge home have resolved all of their medical complications of prematurity, based on post-NICU mortality rates, clearly this is not the case. In a retrospective NICHD study of 4807 infants with an average gestational age of 25 weeks followed to 22 months corrected age,
investigators identified a post-NICU mortality rate of 22.3 per 1000 ELBW infants. (10) This rate is approximately 4-fold higher than the national average of 5.9 per 1000 births. (11) It is worth noting that independent risk factors for post-NICU mortality included a length of hospitalization greater than 120 days but did not include being discharged home on oxygen treatment.

Although parents often tell us that they are willing to wait as long as it takes to take their infant home as long as they are completely well, the point when that milestone is reached is poorly defined. The AAP has issued guidelines for safe discharge from the NICU (12) that are necessarily vague as every hospital establishes its own local protocol for the duration of observation, the “spell watch,” after a change in vital signs is detected. In the absence of remote home monitoring, it is impossible to know how many infants continue to have vital sign changes after discharge. As we expand our cohort of infants monitored at home, we hope to provide further valuable insights into the frequency and time to resolution of changes in our former preterm infants’ vital signs.

References

1. Behrman, Richard E., et al. Societal Costs of Preterm Birth. National academies Press (US), 2007. www.ncbi.nlm.nih.gov, https://www.ncbi.nlm.nih.gov/books/NBK11358/.
2. Kuo, D.Z., Berry, J.G., Hall, M. et al. Health-care spending and utilization for children discharged from a neonatal intensive care unit. J Perinatol 38, 734–741 (2018) doi:10.1038/s41372-018-0055-5
3. I Sim – The New England Journal of Medicine, 2019 – ncbi.nlm.nih.gov 1. N Engl J Med. 2019 Sep 5;381 (10):956-968. doi: 10.1056/NEJMra1806949.Mobile Devices and Health.
4. https://rockhealth.com/reports/2019-midyear-digital-health-market-update-exits-are-heating-up/
5. Jencks, Stephen F., et al. Rehospitalizations among Patients in the Medicare Fee-for-Service Program. New England Journal of Medicine, vol. 360, no. 14, Apr. 2009, pp. 1418–28. DOI.org (Crossref), doi:10.1056/NEJMsa0803563.
6. Shah T, Press V, Huisingh-Scheetz M, White SR. COPD readmissions: addressing COPD in the era of value-based health care. Chest. 2016;150(4):916-926
7. https://www.cnbc.com/2019/10/30/unitedhealthcare-acquires-vivify-health-patient-monitoring-start-up.html
8. Lau, R., Crump, R.T., Brousseau, D.C., Panepinto, J.A., Nicholson, M., Engel, J., & Lagatta, J.M. (2019). Parent Preferences Regarding Home Oxygen Use for Infants with Bronchopulmonary Dysplasia. The Journal of Pediatrics.
9. Liu, Yiyan & McGowan, Elisabeth & Tucker, Richard & Glasgow, LaShawn & Kluckman, Marianne & Vohr, Betty. (2018). Transition Home Plus Program Reduces Medicaid Spending and Health Care Use for High-Risk Infants Admitted to the Neonatal Intensive Care Unit for 5 or More Days. The Journal of Pediatrics. 200. 10.1016/j.jpeds.2018.04.038.
10. De Jesus, Lilia C., et al. Risk Factors for Post-Neonatal Intensive Care Unit Discharge Mortality among Extremely Low Birth Weight Infants. The Journal of Pediatrics, vol. 161, no. 1, July 2012, pp. 70-74.e2. DOI.org (Crossref), doi:10.1016/j.jpeds.2011.12.038.
11. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm
12. Hospital Discharge of the High-Risk Neonate Committee on Fetus and Newborn Pediatrics November 2008, 122 (5) 1119-1126; DOI: https://doi.org/10.1542/peds.2008-2174

Disclosure: Dr. Sommers is a practicing Neonatologist and founder of Firstday Healthcare a digital health solution for high risk NICU graduates.