Breaking down barriers to remote care, with Mount Sinai's Dr. Arshad Rahim
In a new episode of Cadence Conversations, Arshad Rahim, Chief Medical Officer of Population Health at Mount Sinai, spoke with Head of Legal and Chief Compliance Officer at Cadence Meryl Holt, about how to break down barriers to ensure remote patient monitoring gets expanded across the country for the benefit of patients, providers, and health systems.
In his role at Mount Sinai, Rahim is a champion of value-based care and responsible for a wide-ranging portfolio which includes provider engagement across the health system. He currently works with about 100 different primary care practices to drive access, accurate risk adjustment, and reducing acute utilization. "We've tried to make value-based care just care, just essentially believing that it's just the right way to deliver care," Rahim shared.
He has also been a proponent of leveraging new technologies to improve the ways in which Mount Sinai delivers care, including remote patient monitoring (RPM) technology. "I'm definitely a big believer in the value of remote patient monitoring. We have to prove and figure it out, disease state by disease state," Rahim said.
One of the ways that technology like RPM can help improve patients' experience with a health system, according to Rahim, is by allowing them to avoid unnecessary hospital or emergency room visits. "The ability to keep people out of the acute setting when not necessary, provide a better patient experience, I think that's what technology has allowed us to do further," he said.
Rahim has worked to ensure thousands of patients get enrolled in remote monitoring to help manage their chronic conditions. "We're trying to bring care upstream and be proactive, and that's very different than the kind of the sickness-based model that we've been working in for the last 35, 40 years," Rahim shared.
Thus far, RPM has led to positive clinical outcomes in patients, such as reducing systolic blood pressure for hypertension patients. "That's huge," Rahim said. "These are small things. It's a silent killer. But it's well-proven that if we make those changes and really support patients to achieve those goals, it can prevent strokes, prevent heart attacks, and prevent even cardiovascular related death."
Rahim said that approximately 2,300 patients have been enrolled in RPM to manage their hypertension, and he believes this has become a major differentiator and reason why patients are drawn to Mount Sinai. "Oftentimes, these don't necessarily get talked about, some technologies [that have] an ability to drive market share. But I truly believe, and I've actually seen some examples of certain employer groups or labor unions that I think took a maybe even deeper look because of some of the work we've done in remote patient monitoring and even specifically in hypertension," he said.
The challenge with implementing RPM across Mount Sinai thus far has been establishing a playbook since it is still such a new technology. "There's no playbook here at a very basic level," Rahim said. "Which disease states do you choose? How do you select your patients? Which particular actual technology vendor? There's a lot. It's just a newer area. But there's been a lot of enthusiasm, but there's a lot of figuring it out, and there's figuring it out together going on."
These are universal challenges across health systems that are also considering implementing an RPM program of their own. In that spirit, Rahim offered up several lessons learned based on Mount Sinai's experience to help educate others and set up their own playbook for success.
1. Establish a care standard for how to manage chronic conditions
According to Rahim, the first priority for Mount Sinai, even before implementing an RPM program, was to establish its own care guidelines for how to manage patients with chronic conditions. "I just colloquially term it "the Mount Sinai way" of managing certain chronic diseases," Rahim shared. For Mount Sinai, that meant developing its own ambulatory care guidelines across six chronic disease states. "That helped at least establish a foundation," he said.
With that foundation in place, the next step was to answer the question of "who can actually help ensure that that care standard is followed and do that in the most efficient way." "For us," said Rahim, "it really ended up being under the CDTM protocol, the Collaborative Drug Therapy Management in New York state, to be able to use clinical pharmacists with supervising physicians."
2. Set up the technology to enable clinicians to easily adhere to the standard
With the care standard in place, the next step for Mount Sinai was to build a technology layer that enables clinicians to easily follow that standard. "We've built registries and dashboards in Epic to really be able to track our adherence to the standard," Rahim shared.
Setting up the technology to be able to seamlessly support clinicians, while scaling up to serve a large patient population, is absolutely critical. "Ultimately, this is really about goal-directed medical therapy, and that could be medications, but very well not as well, and how do we implement that and really care for our population," Rahim said.
3. Build infrastructure to be able to track and measure outcomes
A third lesson is the importance of creating a comprehensive way to evaluate and measure program success. "If you're going to really try to transform care," Rahim said, "you need to have that competency and program evaluation and program measurement. And I think you need that to be able to do these programs because you'll also need the system financial support over a period of time. In general, their love language is numbers, so you need to show them some numbers."
Rahim said data is also one of the most important tools to be able to show the efficacy of RPM to policymakers and ensure the technology continues to get expanded for the benefit of patients and clinicians. Rahim said his conversations with policymakers typically revolve around seeing relevant clinical data that shows RPM's efficacy. He said that policymakers are often asking questions like: "What should we be covering? At what level? What should we continue to cover?" "I really think it comes down to the data now," Rahim shared.
For Mount Sinai, that means looking specifically at how RPM can improve specific patient outcomes across several key areas. "We're looking in two major areas, really acute utilization reduction and then really blood pressure control. Or blood pressure control and even blood pressure reduction. I would say specifically in that area, blood pressure reduction, then you can tie it to, and we're not measuring it yet, but you could predict some reduction as maintained in major adverse cardiac events, or MACE as a lot of people refer to."
Listen to the entire podcast above and to hear future episodes, subscribe to Cadence Conversations wherever you get your podcasts. Previous episodes of the podcast include Ardent Health Services CEO Marty Bonick discussing the health system's partnership with Cadence, CEO of Community Health Systems Tim Hingtgen discussing how CHS approaches digital innovation, and Dr. David Shulkin, 9th Secretary, U.S. Department of Veteran Affairs, discussing the future of remote patient monitoring.
If you're a clinical or health system leader and you are interested in whether Cadence's remote monitoring program could be a good fit for your health system, please get in touch and you can learn more about our program here.
Read the full transcript of the conversation below:
Introduction: Welcome to Cadence Conversations, where we're talking with prominent physicians, healthcare leaders and tech entrepreneurs about their experiences driving innovation and progress. This week, Meryl Holt, Head of Legal and Chief Compliance Officer at Cadence, got to chat with Arshad Rahim, Chief Medical Officer of Population Health at Mount Sinai. They had a chance to talk about the potential of telehealth, along with the obstacles in expanding remote care and key factors in program evaluation. So let's get to this week's Cadence Conversation.
Meryl Holt (MH): To begin, you recently became the Chief Medical Officer and SVP of Population Health for Mount Sinai Health System. We'd love to hear a bit about your background at Mount Sinai and how you got to your current role.
Dr. Arshad Rahim (AR): I've been passionate probably my entire career about the value-based care equation and driving value in healthcare. And I think, essentially through a variety of roles, initially a lot more in quality and provider engagement, got really interested in working on the denominator of the value equation and had an opportunity with an organization that was very passionate about doing that as well at Mount Sinai Health System.
So I joined about six and a half years ago and am responsible for the provider engagement, working with about a hundred different primary care practices to drive essentially the major areas of success in value-based care, which would summarize as access, quality, accurate risk adjustment, and reducing acute utilization. Eventually, I guess just got interested in having a broader and broader portfolio to make a bigger and bigger impact, amongst about 450,000 lives that we manage in value-based contracts.
Value-Based Care and Ensuring Quality Outcomes for Patients
MH: How do you think about making sure that you're hitting all of the marks in terms of efficient and effective care delivery as you're serving hundreds of thousands of patients at once?
AR: It's a very large footprint to try to manage. We do have to really risk stratify and focus across that population. In general, we've tried to make value-based care just care, just essentially believing that it's just the right way to deliver care. We should have always been doing this. It's nice to have some of the more financial incentives around doing it, whether it's in the contractual structure, in shared savings, or whether it's in some of the fee-for-service reimbursement.
I think one core aspect of it is just: How do we approach a patient in the ambulatory setting? And that doesn't necessarily always mean even in our clinics. It means patients as they exist 24/7, 365. And I think over the last six years, we've been able to establish much more of that culture, and I think it helps to define very specific metrics too, because optimal care can mean a variety of things. But we've defined those metrics, we incentivize to those metrics, and we regularly report and provide transparency. And I think that's as powerful as anything.
How Technology Can Drive Quality Care in Healthcare
MH: Mount Sinai also has a strong reputation for innovation both through homegrown initiatives as well as through its partnerships. What health technologies do you view as having the most potential and really have the opportunity to scale effectively through your system's footprint?
AR: There definitely is a tremendous amount of innovation going on in the industry, across healthcare delivery. Obviously, probably part of how we connected was in the belief around remote patient monitoring and the value that it can provide the patients, especially in regard to excellence in chronic disease management. So I'm definitely a big believer in the value of remote patient monitoring. We have to prove and figure it out, disease state by disease state. I think for example, we've made a lot more progress in areas such as hypertension and maybe a little less in heart failure right now, with noninvasive monitoring.
I would say another area that we have is our community paramedicine program and essentially an alternative to 911 to be able to get a patient's care in the home and hopefully keep them at home. And this is largely for acute unscheduled care. I'm a believer, I was an initial supporter just when I saw the idea and helped use some district money to fund it about six years back. And now we've grown it. We have about 1,200 encounters that we did last year with roughly keeping two thirds of those people at home safely. And the ability to keep people out of the acute setting when not necessary, provide a better patient experience, I think that's what technology has allowed us to do further.
How to Scale Remote Patient Monitoring to Providers and Patients
MH: It does seem as though some of the advancement we're seeing in digital health really is about team-based care, both at the system level, but then more broadly as you noted, Cadence and Mount Sinai recently collaborated in the public health space around issues affecting remote patient monitoring specifically, and I am wondering because this area is somewhat new, what have been some of the challenges you've encountered as you try to expand this to as many patients as possible?
AR: One is probably there's no playbook here at a very basic level. Which disease states do you choose? How do you select your patients? Which particular actual technology vendor? There's a lot. It's just a newer area. But there's been a lot of enthusiasm, but there's a lot of figuring it out, and there's figuring it out together going on, which also can be complicated. I think the ability to do multiple disease states well, I think is still something that we're working through. I think we've had more success in certain disease areas versus others, and it may come down to a variety of things in terms of really and truly the physician commitment or the referral commitment to that particular modality, may come down to accurate patient identification. There may even be just technical challenges in terms of getting patients up on devices and getting them used to that.
What I have found interesting, at least for us, we have heavily relied on a pretty well-trained clinical workforce of clinical pharmacists. They're definitely quite capable of once they get the data, using it in a productive manner to drive, I would say, at least initial better patient outcomes. We still need to gather more and the measurement of it is complex and sometimes not the best core competency that you have in a major health system or any healthcare delivery network, that ability for program evaluation too. So that's part of what we're working on.
One of the more successful areas for us has been hypertension management. And we've had upwards of 2,300 patients enrolled. And, frankly, I think it's a differentiator just in the market. Oftentimes these don't necessarily get talked about, some technologies as the ability to drive market share. But I truly believe, and I've actually seen some examples of certain employer groups or labor unions that I think took a maybe even deeper look because of some of the work we've done in remote patient monitoring and even specifically in hypertension.
How Mount Sinai Approaches Chronic Disease Management
MH: You raised a really key point about the variation in remote care delivery. Are you able to speak to the benefits that patients are seeing when you utilize a higher level of clinical licensure, like a clinical pharmacist, as part of the remote care model?
AR: One thing for us foundationally is that we didn't approach it just for remote patient monitoring. We approached it on the overall idea of care standardization. And honestly, probably like every other health system, as you grow and you have X number of hospitals or delivery entities, you probably have X plus one number of opinions on how things should be done. We established, in some ways I just colloquially term it "the Mount Sinai way" of managing certain chronic diseases, and developed our own ambulatory kind of care guideline. And we did that in six chronic disease states. And so that helped at least establish a foundation. Then we have to have the level of, essentially, based on that, who can actually help ensure that that care standard is followed and do that in the most efficient way. And for us, it really ended up being under the CDTM protocol, the Collaborative Drug Therapy Management, in New York state, to be able to use clinical pharmacists with supervising physicians.
And we've built registries and dashboards in Epic to really be able to track our adherence to the standard. So we've looked at RPM as a tool in that. It's not the only tool we have. But ultimately this is really about goal-directed medical therapy, and that could be medications, but very well not as well. And how do we implement that and really care for our population. And some are in value-based care contracts, but honestly we measure all patients that have a certain disease state that are engaged with our system and want to see their compliance with those evidence-based metrics.
How to Approach Policymakers with Remote Patient Monitoring Data
Meryl Holt: Policymakers at the state and federal level are very focused on the data as they assess the future of programs like remote monitoring and other interventions. What data are you collecting at Mount Sinai on your remote care program that you've found helpful in framing up those discussions?
AR: I interacted with some folks from CMMI a couple times in the past few months. I feel like they're really looking for what's the data. There's so much innovation going out there, what should we be covering? At what level? What should we continue to cover? And I really think it comes down to the data now. So I think just building that infrastructure and repeatedly collecting it, because you also have to go off some gestalt, that if you think that this can add a lot of value, you kind of need to start there with that philosophical commitment and somewhat figure it out because a lot could go right or go wrong in your operations and it has less to do with the modality in some ways.
So for us specifically, right now, looking at case match groups, we're looking in two major areas, really acute utilization reduction and then really blood pressure control. And we have enough N in that group, or blood pressure control and even blood pressure reduction. I would say specifically in that area, blood pressure reduction, then you can tie it to, and we're not measuring it yet, but you could predict some reduction as maintained in major adverse cardiac events, or MACE as a lot of people refer to. So those are our major areas.
Now when you come to, and we're looking at case matched groups, I will say I hadn't thought of this, but I'm not sure what a core competency program evaluation is for a lot of healthcare delivery entities. I know some people that don't work in the big health systems kind of make fun of health systems sometimes and say, "We just try a bunch of things, but we don't really measure it as it works and then we move on to the next thing."
And there might be some truth to that, frankly, but I think that this is, if you're going to really try to transform care, you need to have that competency and program evaluation and program measurement. And I was told that we may have great competencies on the medical school side and the research side, but not on the healthcare delivery side. And I think you need that to be able to do these programs because you'll also need the system financial support over a period of time. And in general, their love language is numbers, so you need to show them some numbers.
RPM Outcomes Data at Mount Sinai
MH: Are there any particular numbers that you're excited about with respect to your current remote care program that you want to share?
AR: Yeah, I mean, I think we do see a signal. I'm still working on the magnitude of the signal of reduction in acute utilization and so trying to get specific, but I do see a signal there. We have seen a reduction, I don't remember the exact number, but at least five to 10, and it was maybe even closer to 10 millimeters of mercury in average systolic blood pressure. And so that's huge. These are small things. It's a silent killer. But it's well-proven that if we make those changes and really support patients to achieve those goals, it can prevent strokes, prevent heart attacks, and prevent even cardiovascular related death. So these small changes, consistency, and the consistent impact of those, can have a major impact in people's lives over an extended period of time.
The Future of Innovation in Healthcare
MH: Any additional innovations you're going to keep a close eye on over the next five years?
AR: One that comes that's frankly, little disappointed it's as controversial as it, but frankly just even telehealth in and of itself and where that reimbursement is going to go. There's opportunities for optimization just in basic telehealth, how do you get the blood drawn, even the registration process, and how do we make it easy for patients to use technologies? I was having this discussion recently about heart failure and there's a variety of devices. I think you could go disease state by disease state and what is your early warning signal? You could really look at all of that. In a lot of ways, we're trying to bring care upstream and be proactive, and that's very different than kind of the sickness-based model that we've been working in for the last 35, 40 years.
Some other really interesting things are just I think some of the direct to consumer options that folks have to engage in, I guess, in care delivery. Like we see it with maternal health, we see it with men's health. I think those are very interesting. And what will be is the whole idea is to get the needed care, get it in the most efficient manner possible, and ensure as many people get it as possible too, that really need that care. And I've been a believer, I think that we should, an engaged consumer of healthcare usually has better outcomes. So I think anything in that space too I'm kind of watching because I still think we have a lot of opportunity, but there's increasing demand in that area as opposed to everything will be dictated very prescriptively by my healthcare provider.
MH: Absolutely. Arshad, thank you so much for the lively and interesting discussion. I really appreciate the time.
Conclusion: Thanks again to Dr. Rahim for taking time to chat with Meryl this week. If you're interested in learning more information about Cadence and how to get involved, visit cadence.care and please get in touch with our team. To make sure you get updates on our future conversations, please subscribe to Cadence Conversations wherever you listen to podcasts. At Cadence, we believe that everyone deserves to receive the best care possible and we won't stop working until that vision becomes reality.