Remote patient monitoring offers the promise of improving patient outcomes. But experts say the technology will not become truly useful until the healthcare industry figures out how to reimburse physicians appropriately, and develops best practices for using remote monitoring to treat patients with chronic conditions.
Nick Mascoli, MD, an internist at Newton Wellesley Internists in Newton, Massachusetts, has been participating for a year and a half in the Blood Pressure Connect program of his practice’s parent organization, Boston-based Partners Healthcare. At any given time, he has three or four hypertensive patients in this remote patient monitoring (RPM) program. These patients are either new to hypertension management or have had trouble controlling their blood pressure. He believes that automated home monitoring has made a real difference with the latter group.
“What it really allowed us to do was track what the blood pressures were and, even more, make adjustments and titration in the medication doses without repeated office visits,” says Mascoli. “A couple of these folks were young, and it was tough for them to keep coming in every couple of weeks.”
Cardiologist Ravi Ramani, MD, director of the integrated heart failure program at the University of Pittsburgh Medical Center (UPMC), says that remote patient monitoring has helped some patients with congestive heart failure (CHF).
Home monitoring equipment given to these patients transmits data on blood pressure, heart rate, and weight to UPMC care managers, who monitor it on a daily basis. The alerts generated by the software have helped Ramani and some of his colleagues intervene with patients who were gaining weight before they had to be hospitalized. As a result, he has seen readmissions among his CHF patients in the program drop to 12%-14%, compared to 20%-22% for a non-RPM cohort of CHF patients, he says.
Larger, more rigorous studies have also shown that RPM can help improve patient outcomes. However, the reimbursement for this activity has not kept pace with advances in the technology, and many physicians remain concerned that remote monitoring will mean more work for little or no pay. In addition, experts say, more research is needed to learn how remote monitoring can best be used to help patients cope with chronic conditions.
While the move to value-based reimbursement is expected to accelerate the use of RPM, some experts believe it may be 10 to 15 years before remote monitoring becomes a routine part of clinical practice. Even before then, however, it’s likely that patients will demand feedback to the data generated by the home and mobile monitoring devices and apps that are coming on the market.
To prepare for this future, doctors need to understand the potential and the limits of what’s available now and what may be coming down the pike soon. Here is a brief summary of developments in this area and how you might be able to take advantage of them.
Both home and mobile monitoring gear is available for patients with chronic conditions, but more research has been done on home devices, which have been around for over 15 years. In addition, notes Joseph Kvedar, MD, president of Partners’ Center for Connected Health, many chronic-disease patients are not adept enough with technology to use a Bluetooth-enabled device with a smartphone.
There are also signs that the technology may be advancing faster than patients and physicians can use it. For example, Duke Medicine in Durham, North Carolina, has begun to test Apple HealthKit-a type of software that aggregates monitoring data from multiple devices--with CHF patients. But since last September, when Duke launched its pilot, only one patient with that condition has been enrolled in the program. Most Duke heart failure patients don’t have iPhones enabled with HealthKit, notes Zubin Eapen, MD, medical director of the Duke heart failure same day access program, who directs the pilot.
Some observers think that mobile monitoring data isn’t sufficiently reliable for clinical use. They point to studies showing that some apps and devices produce incorrect data. Steven Steinhubl, MD, director of digital medicine at Scripps Translational Science Institute in La Jolla, California, agrees there’s a lot of “digital snake oil” out there and that chronic disease apps and add-on devices must be validated. But he thinks the U.S. Food and Drug Administration (FDA) is doing a good job of vetting the home and mobile devices within its purview.
“There is no doubt that the data we acquire in a real life setting is not as clean as the data you get when somebody’s laying in a hospital bed or is in a doctor’s office,” he says. “But as we get more sophisticated and understand the data better, we’re getting better at cleaning the data.”
It took several years for home glucose monitoring to become good enough for physicians to rely on, Kvedar adds. Now, he says, it’s so dependable that when a patient with diabetes is admitted to the hospital, clinicians sometimes use a home glucometer to do a quick check on the patient’s condition.
The majority of patients being monitored remotely are those with high-cost chronic conditions, especially CHF. That makes sense, considering that most health plans still don’t cover the cost of equipment or monitoring. Hospitals and healthcare systems that foot the cost of RPM are doing so mainly to reduce readmissions that can result in Medicare penalties and/or to prepare for value-based payments.
UPMC’s use of remote patient monitoring, for example, is part of its value-based reimbursement strategy, Ramani says. To the extent that RPM helps reduce readmissions, admissions and emergency department visits, it supports that strategy. In the short term, it boosts the bottom line of UPMC’s health plan, from which the RPM patients are drawn, and increases the efficiency of the organization’s home care nurses.
UPMC is expanding the program to conditions other than CHF, including pulmonary disease and diabetes, which are often comorbidities of heart failure, Ramani notes. In addition, it will use RPM in a new advanced illness program for end-stage patients.
In the future, RPM will become part of health coaching for patients with less serious chronic conditions, he says.
Partners Healthcare also has integrated RPM into its population health management strategy. In addition to blood pressure connect, the organization has introduced programs for diabetes and cardiac care. Mascoli looks forward to the day when he’ll be monitoring his diabetic patients and adjusting their meds with data from a home glucometer. But Kvedar notes that RPM is being phased in slowly: only a dozen primary care practices at Partners have it so far.
In big healthcare systems, patients are typically enrolled in an RPM program for two to four months-usually long enough to stabilize or improve their condition. Remote monitoring data is transmitted to a hospital or a physician office, where a nurse care manager reviews it and decides whether to do nothing, contact the patient or alert a physician about an urgent situation.
Some physicians take a more hands-on role in communicating with patients. In Mascoli’s practice, for example, a triage nurse looks at each patient’s blood pressure data once a week. While the program contains no automated alerts, it graphically displays the data so the nurse can see the trends and discuss them with Mascoli.
Mascoli communicates the results to patients and makes changes in their therapy via the practice’s patient portal. The monitored patients visit the portal regularly to get his input. “They’re very invested in this, so they’re getting back to me, and there’s a good line of communication,” he says.
Mascoli doesn’t feel that RPM has increased his workload very much. That’s partly because he uses the patient portal with many of his patients. Also, he’s accustomed to having hypertensive patients bring in their blood pressure numbers when they visit. But now, instead of them scribbling those numbers down on a piece of paper, the data are automatically transmitted from a digital cuff. As a result, it’s always there for him to see before a visit, and it’s much cleaner because “they can’t fiddle with the data.”
Ramani and his colleagues usually receive monitoring reports only when they need to intervene or in advance of a patient visit. The data in one of these reports covers the previous month and is displayed graphically to make the information easier to grasp. It has previously been “curated” by a nurse to eliminate obvious outliers.
Despite this preparation, remote monitoring has increased Ramani’s workload, he says. “There’s work you wouldn’t have done before between visits, unless your patient hit the ER. However, this is better care. My patients are more connected to me. They feel empowered. They have the sense of a safety net’” he says.
The major challenge in remote monitoring is screening the data so that clinicians are notified only when a patient needs help or is not responding well to therapy. Just one patient’s monthly data can run six or seven pages, Ramani notes. Scale that up to several hundred patients in a practice that treats a lot of chronic conditions, and the amount of manual screening work becomes overwhelming.
Some monitoring software-as well as EHRs-alerts clinicians automatically when a patient’s values are out of range. These values may include numbers for blood pressure, weight, heart rate, blood glucose, and/or other vital signs. But out-of-range alerts may be insufficient to detect changes in a patient’s condition and determine which ones are important, experts say.
Two major confounders of monitoring data are context and individual variations. Context includes the changes that normally occur in the course of a person’s daily activities. “There’s a difference between the BP reading that a doctor records for a patient during an office visit and the BP reading you might get after you’ve had a fight with your spouse at home,” points out Joseph Smith, MD, chief medical and science officer for West Health, a San Diego firm that combines health policy work with investments in promising new technologies. “That doesn’t necessarily mean you’re having a crisis; it doesn’t necessarily mean you have hypertension.”
There are also large variations among individuals’ vital signs that make it difficult to define what is normal for each person. UPMC has tweaked its software so that doctors can enter the observed parameters for patients whom they know well, Ramani says. But Eapen regards this as an unscientific approach; what is needed, he says, is research on large cohorts of patients to gain a better understanding of these individual differences.
Kvedar agrees that much more research is needed in this area. In addition, he says, we need to learn how continuous monitoring of patients can best be applied in clinical practice. “What people haven’t figured out yet is what new insights am I going to learn about a person’s hypertension by having people take their BP several times a day?” he says. “It’s that basic research that has to precede writing the rules you’re talking about on when to notify clinicians.”
He cites the example of patients who have hypertension and whose BP does not drop at night, as it does in most other individuals. “Those people have a much higher incidence of heart-related conditions and premature heart attacks. Home BP monitoring could help pick those people up earlier if we were using continuous data feeds. So there are things we’ll learn that we don’t know yet because we have a new way of measuring it,” he says.
Steinhubl is also enthusiastic about the potential of continuous monitoring. “What the continuous real world data allows us to do is ask questions we’ve never been able to ask before,” he says. “It isn’t going to be a simple matter of plugging this in and we’ll know what we’re doing. Nobody knows what a normal blood pressure should be when you’re late picking up your kids at school and you’re angry at the traffic. So there will be a lot of learning.”
Adds Smith, “The real benefit from remote monitoring is that you get a window into how patients are doing in the 95% of the time that they’re not in front of a doctor or in a hospital. That’s where the value really accrues. To take really good care of patients, we have to understand how they’re doing in their natural environment.”
Another area where research is needed is how to interpret data coming from multiple sensors. While doctors and nurses have long done this in hospitals, that controlled situation is very different from the ambulatory environment.
Clinicians never rely on one piece of information to assess a patient’s condition, Smith notes. They make an “integrated assessment” based on numerous factors, including face-to-face exams. “The context for making an assessment has always been multi-dimensional data interpretation. When we’re able to do multi-dimensional sensors and look at that data and trend it over time, we’re going to be much better off,” he says.
For a complex diabetic with an out-of- range blood glucose reading, Smith points out, the doctor will want to know the context of that reading: “What did they eat, how active have they been, when was their last insulin dose? What was their blood glucose two hours ago?” Multiple monitoring devices could provide most of that information.
Similarly, Eapen says, Duke is including step count in its evaluation of CHF patients, along with weight and blood pressure. That will help physicians evaluate the patients’ functional status. But it is not enough to look at the step count of patients who have recently had surgery, he notes, because they’ll be taking fewer steps.
RPM requires a new approach to care delivery that is both patient-centered and team-based, Kvedar notes. “This is really about a new model of care, not about taking your current model of care and throwing a lot of device data on top of it.”
Steinhubl agrees. “For this to work, it requires rethinking how we provide care. It isn’t just making the mobile technology fit into our current system of care. Innovative thinkers will have to develop new systems of care to take advantage of these technologies,” he says.
But Steinhubl doesn’t believe we necessarily have to wait 10 or 15 years for patients to benefit from home or mobile monitoring. Systems could be developed-indeed, some of them are already emerging-that would allow patients to send their monitoring data to a cloud-based platform and receive automated feedback on what it means, based on algorithms.
A U.K. study of hypertension patients with monitoring equipment has shown that they can treat their own condition with the right algorithms, he notes. “There’s a lot of stuff that physicians don’t need to look at,” he points out. The platform could just alert the doctor or another clinician when there’s something they have to deal with.
Of course, that comes back to the question of whether the screening algorithms will ever be good enough for clinicians to rely on them. Smith thinks that’s a false dichotomy. “The question is, can we automate that well enough to lighten their burden, so they’re confronted only with the cases that are likely to be true outliers? The answer is, we can and we must. So undeniably, we’re going to be using artificial intelligence with curated support to make these kind of decisions on patients who are having streams of data coming back to their nurses and doctors.”
Physicians who don’t work for a health system that is testing RPM may wonder how they can get involved. One way to do so is through the new Chronic Care Management (CCM) program of the Centers for Medicare and Medicaid Services (CMS). CMS won’t pay for the monitoring equipment, but it does count the review of remote monitoring data toward the 20 minutes per month that your practice must devote to nonvisit care for eligible Medicare beneficiaries. The average monthly CCM payment is about $42 per patient.
CCM has many requirements, and observers say that it would be much easier to meet them if a practice were certified as a patient-centered medical home. But if your practice is in that category, you’ve already gotten a leg up on remote monitoring. For one thing, you’re likely to have a nurse or other care team member who is specifically assigned to handle care coordination. That person can review the RPM data.