The Role of Remote Patient Monitoring

For those interested in the role of remote patient monitoring (RPM), David Lee Scher, MD is an interesting blogger to follow. He has extensive interest and experience in the field of mobile health. He was a pioneer adopter of RPM as a beta site for Medtronic's Carelink wireless system. This monitored implantable cardiac rhythm devices such as defibrillators and pacemakers.

This has gained attention because of mandated penalties for hospital readmissions for certain diagnoses such as myocardial infarction, congestive heart failure, stroke, and chronic lung disease. RPM is a way of staying in physiologic contact with these patients regardless of their location – at home, during travel, and in care homes. While studies are reflecting radically mixed results, there is promise.

Dr. Scher list five issues he has faced and these are interesting. Please read his blog here and then peruse his blog page here. I will only summarize his writing.

#1. All remote monitoring is the same. There are many definitions for (RPM) from using the telephone for talking to the patients to today's use of implants to cell phones and then to electronic health records.

#2. All remote monitoring is reimbursed. This was a surprise to me. RPM monitoring is reimbursed in the USA and has been for many years. The real surprise is that the rate of reimbursement by the Centers for Medicare and Medicaid Services (CMS) is at a higher level than in-office follow-up.

#3. Patients and physicians will welcome and embrace remote monitoring. Not all physicians are on-board with this and saying that the data is unusable. Many just do not want the expense of having someone to monitor the data being received. Many are utilizing gathering centers and they in turn will notify the individual doctors of alert conditions. With the penalties that are being handed out by CMS, doctors will soon realize they need to use RPM.

#4. Remote monitoring should be totally automated. No, don't take the human factor out. They are needed to individualize the programmed parameters and alerts because each patient will be potentially different. Data can't manage itself, although some physicians wish this were possible. False positives and negative must be correlated to the clinical condition of the patients. Only this will optimize management. Caregivers must be involved and understand what is happening as well.

#5. Remote monitoring is only for recently discharged patients. It is unfortunate that it has taken regulatory requirements to drive digital technology to be adopted. This has caused much poor technology for healthcare and even poorer patient care. It is the failure of health technology that has not adopted the model of the retail and finance sectors that focus on customer satisfaction and transaction outcomes.

The remainder is my thoughts only and not of Dr. Scher. Because of regulations (laws) mandated by Congress, the opportunistic technology business saw huge profit potential and did not care whether their products served the proper purpose. They could always make changes for more profits and therefore the medical and hospitals of our country were sold a faulty product.

Because of Congressional urging and pressure by CMS, some health information technology companies are attempting to address the issue and correct problems now. Others that feel they are too above this are continuing to look for more ways to milk the regulatory cow. As a patient, I can only hope the milk sours for them and forces them out of business. Both physicians and patients need more productive innovation to make our healthcare system both more efficient and profitable for all concerned.

ACA Will Help Spark Boom in RPM

RPM means remote patient monitoring and will be here to stay under the Affordable Care Act (ACA). Initially this started with heart patients, but it will expand. And yes, diabetes is on the list of types of patients that will be remotely followed. Now why would they do this, considering that few type 2 diabetes patients receive education on managing their diabetes? Not only that, but without the personnel available to educate people with diabetes, how can they expect patients with type 2 diabetes to feel anything but contempt for remote patient monitoring.

I expect to see something appear in the American Diabetes Association (ADA) website as early as this summer hinting at the possible monitoring to be done and when it will start. Then, I am guessing that the ADA 2014 guidelines will have much more to say about this. If not this summer, then announcements will happen by the summer of 2014 and will be part of the ADA 2015 guidelines. It is coming and of this, I have no doubt.

This press release says a lot about RPM for five major chronic illnesses that will grow by 6-fold by 2017. This is because the ACA will be pushing hospitals and physicians to stop the revolving door treatments by hospitals. In 2012, clinicians reviewed remote patient monitoring data for about 227,000 patients with congestive heart failure (CHF), chronic obstructive pulmonary disease, diabetes, hypertension, and mental illness. The figures include a number of other patients with asthma, coronary artery disease, and hemophilia.

CHF patients were almost half of PRM in 2012. In 2017, diabetes will overtake CHF and the monitoring will grow by 67.5 percent from 2012 to 2017. The next fastest group of RPM will be patients with mental illness. Demand for this monitoring comes from patients and private insurers, which seek to reduce costly hospitalizations. All of these trends build on an even larger one, an aging population beset with chronic conditions.

The ACA will bring financial incentive into play to promote RPM and this will mean rewards for physicians and hospitals that comply. In addition to sharing payment for an episode of care, they will earn a bonus, or take a pay cut, depending whether they come under or exceed a cost target. With the financial incentives and penalties that the ACA can and will enforce, hospitals and physicians will have money reasons to physically monitor patients. Then there are those providers that want to remotely patient monitor at home for improved care whether there are monetary rewards or not.

The one factor not included in this article if the role of the Food and Drug Administration and how fast they will be approving these remote monitoring devices. This could be the flaw in the current thinking, but this should not delay progress for long as CMS and most insurance payers are on board and looking to the benefits this will provide.

Currently, the task of reviewing RPM data falls to nurses at third party triage and call centers services. They then alert the relevant physician to flagged changes. Currently, under the existing fee-for-service reimbursement, there is no incentive to take remote medical data that will not result in a billable office visit. Under the ACA, there will be many financial incentives for physicians to change their way of doing business including penalties.

Presently, remote-monitoring systems are relegated to call centers, but this will change as pressure is put in place for the electronic health records (EHR) to be capable of tracking this data. Yes, the manufacturers of EHR systems are balking; however, congressional pressure is being applied quite liberally to force them to make their systems more responsive to receiving RPM data and working together (interoperability) to correspond with competing EHR systems. This can only be positive as the Health and Human Services and Centers for Medicare and Medicaid are applying pressure saying their systems will not meet useful standards, as they exist. The pressure is to make all systems “telehealth-ready.”