Isn’t there an app for that? Fifteen years ago, when I first started working with remote patient monitoring (RPM) devices, I thought that they would soon become commonplace tools for managing patients with chronic illnesses and those who have been discharged from the hospital and are at risk of being readmitted. Unfortunately, RPM use today remains limited to those patients treated in certain health systems that have embraced the technology (like the Department of Veterans Affairs), or those who are admitted to home health agencies with RPM programs.
Unfortunately, several barriers have prevented the spread and implementation of these promising technologies: lack of a business model, prohibitive costs for RPM services, and research on the effectiveness of RPM that was equivocal, or in some cases, demonstrated a lack of benefit. Despite these challenges, RPM has a key role to play in reducing readmission risk for patients discharged home after an admission for acute illness.
The Chronic Care Act of 2017 underscores the importance of RPM. The bill, which cleared Senate Health Care Committee unanimously on May 24, would bring telehealth (RPM) services to Medicare beneficiaries. Full passage of the bill will give RPM the opportunity to achieve its potential to help patients heal at home.
Although there are many technologies that can be used to monitor activity levels, the most common approach for Post-Acute Care (PAC) consists of a combination of monitoring devices and daily patient surveys to evaluate changes in vital signs and symptoms. Commonly used monitoring devices include scales, blood pressure cuffs, pulse oximeters to measure oxygen levels in the blood, and blood glucose testing meters. Surveys administered to the patient are designed to ask about symptoms specific to that patient’s diagnosis. Data from the monitoring devices and responses to survey questions are usually transmitted through phone lines or cellular technology into software that analyzes the information and identifies changes in clinical condition. The software is monitored by a nurse or care coordinator, who reviews the data from patients being monitored and if necessary, outreaches to the patient to further assess the situation and work with the patient to get care to prevent further worsening of their condition. For example, patients with Congestive Heart Failure (CHF) are at high risk of hospital admission and readmission, and often gain weight when their heart failure worsens and they retain fluid. The RPM system identifies specific amounts of weight gain according to parameters set by the ordering physician, as well as changes in symptoms suggesting worsening heart failure, like shortness of breath. If symptoms are present, or there is a change in weight that exceeds the pre-set parameters, an alert is triggered by the software and the nurse or care coordinator reach out to the patient so that the patient can get care immediately and avoid an emergency room visit or the need for hospitalization. RPM technology enables a few nurses and care coordinators to simultaneously monitor the clinical status of hundreds of patients in different locations.
Given the potential value of these technology-enabled monitoring services, why is access to them so limited? One reason is that there has not been a business model to support widespread adoption. Although fee for service codes now exist and can be used for billing for these services, most insurance benefit packages do not include payment for these services. Because RPM can lead to cost savings, health plans and value-based programs like Accountable Care Organizations (ACOs) are obvious customers, since they usually retain those cost savings. However, uptake of these technologies has been limited due to a combination of factors, including research limited by a lack of large-scale well-designed studies, and mixed results from several studies with some showing clear improvements in readmissions and costs, and others with little or no benefit. Home health agencies who are reimbursed with a lump sum payment for an episode of care have adopted these programs as a way to save costs by replacing nursing visits. But not all home health agencies use the technologies.
Another important barrier is the cost of the technology and supporting software. When RPM systems were first deployed, tablet computers and smart phones did not exist or were not in widespread use, so devices to gather the data and ask the survey questions had to be rented to gather the data and upload it into the monitoring software. Despite the current low cost and widespread availability of tablets and smartphones, most technology companies still charge $50-$100 per enrolled member per month for tablet rental, the monitoring devices (e.g. scales), and the software. This high cost limits the use of the technology to patients at the highest risk of readmission, such as those with CHF or Chronic Obstructive Pulmonary Disease (COPD), and prevents the common use of these tools by patients with other diagnoses like diabetes, depression, or coronary artery disease, where readmission risk is lower thus reducing the potential return on investment. Although there are many apps for smart phones that gather pulse and activity data, few offer the level of reliable monitoring required for clinical care.
Another important barrier to uptake is the lack of clinical uptake by physician practices. Few physicians have experience with RPM and were not trained in how to prescribe RPM. Many physicians are not clear about how RPM fits into the usual diagnostic and treatment paradigms. Consider CHF – physicians are well-aware of the use of echocardiograms and other tests for diagnosis, and how to use medications for treatment. Where does RPM fit – is it a diagnostic tool or part of a treatment plan? Which patients benefit most – those with mild, moderate, or severe CHF? How long does the patient need to use RPM services? Workflow is also challenging – responding to alerts from the nurses overseeing the monitoring station is not usually part of the schedule for busy primary care physicians and specialists.
Given these barriers to use of RPM, why bother to continue to pursue its use for patients discharged home from acute care? Because being able to monitor hundreds or thousands of patients in their homes should be a part of how we manage the majority of patients returning home. Insurance benefits packages should be updated to pay for these technologies as a routine part of care, and organizations taking financial risks for the costs of post-acute care should be encouraged to use RPM. Yes, more studies are needed to show benefits in outcomes and better define which patients can get optimal benefit. But one easy way to improve the Return on Investment for these technologies would be to cut the costs of the technology so that the costs are well under $20 per enrolled patient per month. At that cost, many more patients could be monitored. A recent CareCentrix analysis found that the majority of readmission costs for Medicare and commercial patients are for patients who do not receive any home health services and do not get facility-based rehabilitation. RPM at a reasonable cost offers a scalable solution to the conundrum of what to do to help medium and low-risk patients avoid readmissions. And making RPM more available will create broader clinical experience with prescribing and using RPM, and provide the volume to make it worthwhile for physicians to learn about RPM and for practices to create workflows that incorporate responding to RPM alerts as part of their schedules.
It is time to remove the barriers to RPM and deploy these important tools to reduce readmissions. By focusing on reducing technology-related costs, creating viable business models and financial incentives, and demonstrating return on investment, RPM can take its rightful place in readmission reduction programs.