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A high touch, high tech approach to COPD monitoring

Living with a chronic, progressive condition is difficult for anyone to cope with. It can greatly impact quality of life and deter individuals from participating in everyday activities. 

For those with chronic obstructive pulmonary disease (COPD), simply walking up a few steps, leaving the house or sleeping soundly often feels impossible due to the persistent cough and breathlessness associated with the disease. 

Without the right means to treat and manage their symptoms, this common condition can be deadly for patients. In the later stages, it can mean frequent trips to the emergency room and long hospital stays.

The impact of COPD is often felt far beyond the patient — affecting their family and everyone who cares for them.

Helping to improve this experience, however, is a new program at Markham Stouffville Hospital (MSH), aptly titled Breathe Better at Home. The first leg of this pilot, which began in 2017, introduced a technology-enabled approach to chronic disease management in MSH’s Centre for Respiratory Health.

“We aim to empower patients to take ownership of their health by giving them the tools and knowledge to better understand their condition,” says Katrina Engel, respiratory therapist and clinical project lead at MSH. 

One of those tools is Cloud DX’s Connected Health Kit ― which allows patients or their caregivers to routinely measure key vital signs from the comfort of their home. 

A custom measure added to the kit was the COPD Assessment Test ― or CAT test ― which has been extremely effective in helping to identify exacerbations. “It’s a standardized test that reduces a patient's symptoms to a number,” explains Engel. “A notification is then set based on that number. It's clinically validated in moderate to severe patients with COPD.”

These results and vitals are monitored by the patient’s care team through a clinician portal. Early warning signs help patients and clinicians intervene promptly with an action plan to address or even prevent acute exacerbations. 

In partnership with Women’s College Hospital and Closing the Gap Healthcare, MSH’s goal was to validate the use of remote monitoring technology for COPD patients. And they succeeded. 

A recent MSH analysis of the program ― which started with 122 kits ― demonstrated that inpatient admissions and emergency department visits related to COPD decreased in the six months following enrollment in the program. There were also potential cost savings, as patients with COPD who were admitted were likely to have shorter lengths of stay.

“This technology-enabled approach is a clinician guided journey of self-discovery whereby the patient becomes more familiar with their physiology and is therefore better able to manage and advocate for their health,” shared Engel. 

For Engel and the team, one of the greatest benefits has been the improved patient experience. Up to 83 per cent of patients who were enrolled said they would continue with the program ― citing they feel more empowered, more trusting of their care team and have better access to care when they need it.

“This interaction with technology results in more touchpoints with health care teams who, as a result, are better able to support patients through education and navigation,” says Engel.

Due to the program’s relative success, MSH has invested additional funds for 2019-2020 to expand the program with an additional 125 kits, and a more holistic approach to care.

“We are using the key findings from the pilot to refine our delivery model and narrow our target population to the patients we think would benefit the most ― high health care users with chronic conditions and multiple co-morbidities.”

When asked what’s important for facilities looking to adopt a similar model, Engel shared the following:

  • Many COPD patients have more than one chronic condition, and remote monitoring programs should prioritize treating the patient as a whole.
  • The success of the program relies on patients’ judgment. It’s unrealistic to think they can do it on their own. Simply sending them home with equipment and an action plan isn’t enough. They need easy to follow action plans, more personalized treatment and plenty of interaction with the care team.
  • The success of the program relies not on the vital signs reading themselves, but what the clinician and patient choose to do with the information. It is important to build a program with the infrastructure needed to support and treat irregularities in vitals rather than telling the patient to go the emergency department.
  • Clinicians are a key stakeholder. They need a seat at the decision-making table and an active role in program design. Some clinicians said it increased their workload, others felt it did not. Overall, many went above and beyond the call of duty as they recognized the value of the program and that their patients were receiving better care.
  • Tools alone don’t solve access issues for patients. There is still a need to rectify gaps in care when specialists are required, particularly when patients have an urgent issue.

Across Canada, 44 per cent of adults over the age of 20 have at least 1 of 10 common chronic conditions. If patients had access to more programs like Breathe Better at Home ― which gave them the tools, education and support required to safely manage these conditions from home ― imagine the possibilities.


This material is for informational purposes only. It is not intended to be a substitute for professional medical advice and should not be relied on as health or personal advice. The opinions stated by the authors are made in a personal capacity and do not necessarily reflect those of the Canadian Medical Association and its subsidiaries including Joule.  Feel passionate about physician-led innovation? Please connect with us at