#DigitalHealth: Five Fallacies of Remote Patient Monitoring

As defined in Wikipedia, remote patient monitoring (RPM) is: “a technology to enable monitoring of patients outside of conventional clinical settings (e.g. in the home), which may increase access to care and decrease healthcare delivery costs.”  I was a pioneer adopter of RPM as a BETA site for Medtronic’s Carelink wireless system which monitors implantable cardiac rhythm devices (defibrillators and pacemakers). RPM has gained significant attention because of recently mandated penalties for hospital readmissions for certain diagnoses (myocardial infarction, congestive heart failure, stroke, and chronic obstructive lung disease).  RPM is seen as a way of remaining in physiologic contact with these patients who might be managed at home via care systems. There are conflicting study results regarding the utility of remote monitoring preventing hospital readmissions. Some studies show no decrease in hospitalizations, and others with significant benefit.

1.    All remote monitoring is the same. There is no standard definition for RPM.  Some studies utilizing only telephone interviews have been called RPM. Other RPM technologies use body sensors which deliver data from the person’s body in an automated fashion into a server and/or a smartphone via an app, and/or an EHR.

2.     All remote monitoring is reimbursed.  RPM of implantable cardiac rhythm devices has been directly reimbursed for many years in the USA.  In fact, when it was first approved for reimbursement by CMS, it was approved at a higher level than in-office follow-up.  Many years following USA approval of reimbursement, European countries are still variable with regards to reimbursement models.  Besides RPM of implantable cardiac rhythm devices, – Not directly reimbursed but is an approved adjunct under the Home Health Resource Groups of the Prospective Payment System (HHRG PPS).

3.    Patients and physicians will welcome and embrace remote monitoring.  My first foray into remote patient monitoring introduced me into the psychological aspects of the technology as much as the bells, whistles, and clicks entailed in performing it. The first pushback from patients is that the technology is replacing the physician, and eliminating the patient-physician relationship. If the technology conveys true benefit to patient care (implantable cardiac device monitoring leads to early discovery of arrhythmias and even led to detection of an eventually recalled defibrillator system wire).  What patients should know is that with any type of well-designed and thought out RPM system they will be more connected both literally and figuratively with their provider.  Interestingly according to the 2012 Study of mHealth by Ruder Finn, 33% patients would like their physician to use a mobile platform for RPM to alert them of serious medical problems.  The first reaction from physicians is that they will be deluged with useless generated data, and that the data will remain in cyberspace without them knowing about it. The first reaction is addressed with good design, with actionable (and customizable) alerts and a workflow system employing non-physician providers.  The second concern is addressed below.

4.    Remote monitoring should be totally automated. The most effective RPM systems have some sort of human interaction involved in closing the monitoring loop. This is advisable for a number of reasons. There needs to be individualization of programmed parameters and alerts. This will allow for actionable alerts that are both meaningful from the provider’s standpoint and beneficial to the patient. Data cannot e managed in a vacuum. There will be false positive and negative readings which must be correlated to the clinical condition of the patient in order to result in optimal management.  Caregivers should be involved in the loop as well.

5.    Remote monitoring is only for recently discharged patients. It is no secret that RPM has both garnered and generated extraordinary attention because of Medicare penalties for hospital readmissions.  Regulatory requirements have driven much of digital technology adoption in the past decade. This includes EHRs, tools to determine and improve patient satisfaction, and patient portals. This is sad insomuch as one would hope that providers would invest in improved patient outcomes independent of mandates, following the tech adoption leads of the retail and finance sectors, focused on customer satisfaction and transaction outcomes. That being said, one would hope that the theoretical improvements brought to patients vis a vis decreased rehospitalizations (though 30 days is hardly a measure of long-term success) could extend to all relevant patients (those not hospitalized with chronic illness as well as those beyond the 30 day discharge period).

I have witnessed firsthand the dawn and benefits of RPM over time.  I look forward to the partnerships of RPM, mobile health, health IT, and non-tech patient-centric care. 

About davidleescher

David Lee Scher, MD is Founder and Director at DLS HEALTHCARE CONSULTING, LLC, which specializes in advising digital health technology companies, their partners, investors, and clients. As a cardiac electrophysiologist and pioneer adopter of remote patient monitoring, he understood early on the challenges that the culture and landscape of healthcare present to the development and adoption of digital technologies. He is a well-respected thought leader in mobile and other digital health technologies. Scher lectures worldwide on relevant industry topics including the role of tech in Pharma, patient advocacy, standards for development and adoption, and impact on patients and healthcare systems from clinical, risk management, operational and marketing standpoints. He is a Clinical Associate Professor of Medicine at Penn State College of Medicine.
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5 Responses to #DigitalHealth: Five Fallacies of Remote Patient Monitoring

  1. Great insight David. I particularly agree with #4. In my experience with RPM in Australia the key for success was the ability to bring in the clinician as required in a suitable way. In our pilot we used video conferencing delivered on the RPM device as an intervention. So if the clinician was concerned about a vital sign result, or if the patient answered a question in a way that raised their concern, or even if they just wanted to eyeball the patient for their own peace of mind, they could trigger a video conference with the patient and have a good old fashioned chat with the patient.
    RPM does provide many new opportunities for providing healthcare in new ways, but sometimes we need to go back to the way we did things before, but utilising the available technology to do it more efficiently.

    • Thanks George. RPM, like any health technology, is a tool made for facilitating better patient care (at least that should be the goal). It must incorporate human workflow and interactive factors.

  2. I have had patients who have done remarkably well on RPM and some who have not. Just like any device or drug we need evidence based guidelines about when to apply this expensive technology. Even in-hospital cardiac monitoring has a hard time proving efficacy. Monitoring is not treatment!

    • Thanks for your thoughtful comment, Ralph. I agree that technology can have a positive impact on health if it is put in the context of a well-designed framework of good clinical workflow design and guidelines.

  3. Pingback: #DigitalHealth: Remote Patient Monitoring, Part 2- Operational Models | The Digital Health Corner

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