Digital health tools focused on improving patient engagement are starting to have an impact on surgery outcomes. In a recent interview, John Monson, M.D., executive director of colorectal surgery at AdventHealth in Orlando, Fla., described the role of a tool called Twistle in his department’s deployment of Enhanced Recovery After Surgery (ERAS) protocols that begin 30 days prior to surgery and continue 30 days post-discharge.
Although significant innovations have led to advancements in colorectal surgery, the procedures remain high-risk for complications after surgery. As part of a comprehensive approach to improving outcomes, AdventHealth Orlando deployed Twistle in 2018 to improve pre-operative and post-operative patient engagement. The Twistle pathway for colorectal procedures includes education, preparation, appointment reminders, incision checks, side-effect monitoring, and bi-directional texting with patients.
The ERAS protocols have been around for approximately 25 years, Monson said. They include 15 components that are aimed at restoring people's physiology after surgery in a speedier fashion and getting them out of the hospital sooner. “If you consider a patient has an operation on day one, and might be considered to be more or less recovered 14 days later, what enhanced recovery does is bring a patient to the same level in seven days rather than 14 days,” Monson explained.
Before tools like Twistle, the great concern around early discharge from the hospital was that the patients could end up getting into trouble when they went home. How would they communicate about that? Some health systems did virtual rounding, where they would call all the patients to check up on them. It was resource-intensive, and the overwhelming majority of people they were checking on were perfectly fine. “What needed to happen was that the patients needed to have a truly fit-for-purpose method of communicating when things were not right,” Monson said, “and for the hospitals and the doctors to identify patients who were not progressing well.”
This gets to the shortcomings of traditional methods of communicating with patients after surgery or hospitalizations. “We had lived in the model of the previous 30 years, which is patients trying to page a fellow or calling an answering service in the middle of the night, or turning up to the emergency room, because you can’t get in touch with people or being put on hold or somebody's not calling you back,” Monson said. “They are all drivers of frustration and dissatisfaction, or even worse, unnecessary admission to the hospital or a poor outcome because if you don't know about it, you can't undertake some form of minor intervention that may prevent an issue escalating to something serious. So when we were faced with an opportunity to jump on board with what I guess could be called disruptive technology, there were clear reasons to do it, because the previous system really couldn't have been worse.”
“We need to be able to check on the patients that were not doing well. Those were the ones that we should be calling, not the 90 percent of patients who were perfectly well. That was just a waste of time.”
Twistle immediately addressed a number of those issues in a couple of areas, Monson explained. The evidence is that the more of those 15 pieces of enhanced recovery that you implement, the more the benefit. If you can get up to about 80 percent compliance, you get the biggest bang for your buck, he said.
“One of the things that Twistle does is engage with patients in the run-up to surgery, reminding them to stop their drugs, to take a shower with an antiseptic, reminding them to drink fluids only and to take their antibiotics. This happens automatically, and you don't have to have a bunch of staff calling people up and leaving messages. Post-operatively the system sends a message asking ‘Are you okay? Is your pain bad? Or do you have any problems?’ It is a very effective bidirectional messaging system, so that the patient is able to send a message to say, ‘Excuse me, my leg fell off yesterday. Is that normal?’ Normally, they would have to pick up the phone and try and get through to an office. If they think it's a serious issue, they just get in a car and go to an ED. where they'll get admitted, and all sorts of things happen. They'll get 27 scans, and they'll be in hospital for several days, and it may have just required somebody to answer the message saying ‘No, that’s perfectly normal, don't worry about it.’”
“If a patient doesn't like the look of their wound, they can take a picture of the wound and send it through to us,” Monson said, “and my nurse practitioner can look at that wound and say, ‘That looks absolutely fine; don't worry about it,’ and get that answer back to the patient in a matter of minutes. “Or they'll look at it and say. ‘I'm going to order some antibiotics to your pharmacy, or they can say you need to come into the ED.’”
AdventHealth says it has seen a real positive impact with Twistle, including a reduced length of hospital say of 33 percent, a reduced readmission rate of 27.7 percent and reduced ED visit rate of 33 percent.
“These results are pretty remarkable, but entirely understandable if you delve into the drivers of those outcomes,” Monson said. For example, he noted that a lot of work has been done in the last decade on the causes of readmission to hospital. One of the early studies was on heart failure. There were two basic causes of readmission to hospital after discharge with heart failure. The first one was because the medicines had not been reconciled properly. The second one was because the patient's heart wasn't working.
“Clearly, there's not much you can do about the second one. But there's a heck of a lot you can do about the first one because it's your fault,” he said. “It's not the patient's fault.” Similarly, in colorectal surgery, there are serious complications, but also much less serious ones such as patients being dehydrated. If you can communicate about that and intervene, you can avoid trips to the ED and hospitalizations, he said.
Although Twistle is currently only used for colorectal surgery at AdventHealth Orlando, Monson said recently his team has begun to have conversations with other specialties, including a new initiative in bariatrics. But spreading its use across 50-hospital AdventHealth may take more time. For one thing, COVID hit at the same time as the organization decided to transform its entire electronic health record system across the nation to Epic.
“If you talk to any hospital system that is implementing a new electronic medical record system, they have major bandwidth issues,” Monson said. Another issue is that when you talk to an administrator, he said, they may see all apps as the same. It’s quite challenging to get people’s attention to talk about systemwide change in an organization the size of AdventHealth. “It’s the ultimate supertanker,” he said.
