Remote Patient Monitoring
Remote Patient Monitoring
The delivery of healthcare through electronic communication, or telehealth, has changed greatly since its introduction. Over the years, telehealth has rapidly evolved with the continued advancement in available technology and the innovations by the healthcare community in identifying new uses and applications for technology. The implementation of electronic health records (EHRs) and expanded access to the internet and medical devices have enabled healthcare to move outside of traditional clinical settings and into a patient’s home.
Remote patient monitoring (RPM) is a type of telehealth in which healthcare providers monitor patients outside the traditional care setting using digital medical devices, such as weight scales, blood pressure monitors, pulse oximeters, and blood glucose meters. The data collected from these devices are then electronically transferred to providers for care management. Automated feedback and workflows can be built into data collection, and out-of-range values or concerning readings can be flagged.
Historically, RPM has been used to measure symptoms of chronic conditions, such as cardiac diseases, diabetes, and asthma. Patients may have experienced this through wearable devices, like Holter monitors that can measure heart rhythms, to remotely detect heart conditions and monitor cardiovascular diseases.1 The American Heart Association recommends remote monitoring of vital signs for hypertension patients given the evidence and large number of research studies showing the benefits of RPM. These benefits include patient engagement in their medical care, patient adherence to their treatment plan, and the ability to expand physician reach and easily provide care to patients without the need for patients to travel for in-person visits.2
A 2017 study by the GAO3 (U.S. Government Accountability Office) showed that RPM was commonly reported by provider associations and patient associations as a significant factor that improved or maintained the quality of care, which further encouraged its use and implementation. Additional studies have shown benefits of remote patient monitoring in managing diseases such as chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF), resulting in fewer emergency department visits, hospital readmission avoidance, and reduced hospital length of stay.4,5
Throughout the COVID-19 public health emergency (PHE), the use of telehealth has been considered an effective patient safety mechanism to limit potential patient exposure to infected patients by replacing in-person visits with telehealth visits and using virtual processes when possible. Like other forms of telehealth and telemedicine, RPM implementation has increased and evolved quickly during the course of the PHE. In addition to increasing their use of RPM for chronic conditions, many organizations began monitoring for acute conditions and have developed programs to monitor affected patients for COVID symptoms outside the hospital setting.6,7 These programs were aimed at reducing the burden on hospitals at times of increased hospital utilization and detecting any change in status of patients. One emergency department provided patients with pulse oximeters and thermometers upon discharge, monitored patients daily, and escalated patients for further care in case of worsening symptoms.8
Patient Safety Considerations for RPM Implementation
Patient safety concerns when implementing RPM include the risk of clinical misdiagnosis or failure to identify when patients need attention from providers. In both these cases, developing robust processes and clear guidelines for providers will help mitigate the risk of patient safety issues. When designing the program, organizations must develop clear protocols for identifying appropriate patients to use RPM and have escalation protocols so that patients with abnormal results are appropriately referred for higher levels of care or have their symptoms managed. Understanding each individual patient’s typical disposition and variability is important as well. Ideally, thresholds for flagging abnormal results should be individualized for each patient.9
Program infrastructure is paramount in ensuring patient safety, including team composition, patient selection, and device management and data collection processes. Organizations must understand the volume of data that will be transferred to systems and decide how the data will be integrated into its EHRs. Appropriate staff are needed to train patients and provide technical support, monitor data, or respond to abnormal values. Successful programs stated that having internal or external dedicated staff to monitor patient status and provide direct communication to patients is an important part of the RPM infrastructure.10
Because RPM processes rely on biometric data transferred by the patient, another risk for clinical misdiagnosis is that patients may not use medical devices appropriately or follow data collection protocols. To support the correct use of devices according to guidelines and avoid false values, organizations should create a strong patient education system that includes feedback to patients. Education should include setting clear expectations with patients about how abnormal values will be managed by clinicians and what would be considered an emergency for the patient to respond to independently.7
Although RPM has substantial benefits to both the health system and patients, there are still barriers to implementing and expanding its use to a broader audience. While telehealth has the promise of providing healthcare access in areas where in-person care may be difficult to obtain, its implementation is limited by technological infrastructure barriers, including lack of access to the internet or inadequate cellular data to support video-based care or frequent connectivity. Digital literacy and lack of knowledge, skills, or confidence to use digital tools can also be barriers to use. These barriers are often found among people who already experience health inequities, such as those living in rural areas, people of some racial or ethnic minorities, people with lower socioeconomic status, and people with limited health literacy and English proficiency. 11 Programs by the Federal Communications Commission and at the Office for the Advancement of Telehealth at the Health Resources & Services Administration aim to expand access to telehealth and fund more services. Further action is still needed at the state and federal levels to increase access to broadband internet. At the health system level, several actions can be taken to address access issues, such as providing phone-based care and check-ins when possible and providing devices to patients free of charge. By understanding their patient populations and their needs, and by creating person-centered care that accounts for inequities and linguistic differences, organizations could more rapidly spread RPM.12
An additional challenge in implementing RPM is billing and payment. The lack of coverage of services and lower reimbursement rates disincentivize organizations from expanding and implementing programs due to upfront costs. The cost-effectiveness of providing RPM can vary by types of monitoring, by diseases monitored, and by the setting in which monitoring is occurring (such as an integrated delivery network, accountable care organization, or large health system).13 Prior to the PHE, the Centers for Medicare & Medicaid Services (CMS) implemented new billing codes and expanded coverage of RPM. At the onset of the PHE, CMS further expanded coverage by introducing waivers and flexibilities for providing telehealth services. Some requirements were relaxed by these waivers, including the need for existing physician–patient relationships and minimum requirements for time spent monitoring.14 In a study completed in early 2022, many physicians across different care settings acknowledged the benefits to the workforce and care provided to patients but stated the primary reason for adopting or failing to adopt telehealth services was related to cost. Physicians interviewed shared that cost-reimbursement challenges, like the lack of payment parity with providing in-hospital services or that reimbursements covered only a small fraction of the actual cost of services, hindered overall telehealth implementation.15
Future Directions and Research
Researchers see the potential to expand telehealth and anticipate that remote monitoring will continue to grow as an integral part of healthcare. As care continues to move outside of the hospital setting and into more home and community-based settings, the use of RPM in managing both chronic and acute conditions will continue to grow. One opportunity for further research is understanding what additional diseases could be managed remotely and monitored using remote medical devices.
Another future direction for RPM is the opportunity to further identify other settings in which RPM implementation would be beneficial. Although many hospital-based and health-system-based RPM programs exist, there is an opportunity to implement and expand RPM to less acute settings, such as nursing homes or senior living centers. Testing and studying RPM in settings outside of the home could further provide benefits to patients living with chronic conditions and prevent the need for more acute care.
Research must continue to understand the impact these new technologies may have on healthcare operations and patient safety. Preliminary research on the value of RPM shows that there is cost-effectiveness when using RPM to manage select diseases like congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). Further research on the cost and benefits is needed to incentivize implementation and coverage across payer types.16 While studies show some identified benefits on patient outcomes, there are opportunities to understand the impact that RPM may have on maintaining patient safety, preventing adverse events, and improving patient experience.
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2. Omboni S, McManus RJ, Bosworth HB, et al. Evidence and recommendations on the use of telemedicine for the management of arterial hypertension: an international expert position paper. Hypertension. 2020;76(5):1368-1383. doi:10.1161/HYPERTENSIONAHA.120.15873
4. Taylor ML, Thomas EE, Snoswell CL, Smith AC, Caffery LJ. Does remote patient monitoring reduce acute care use? A systematic review. BMJ Open. 2021;11(3):e040232. doi:10.1136/bmjopen-2020-040232
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9. Chalupsky MR, Craddock KM, Schivo M, Kuhn BT. Remote patient monitoring in the management of chronic obstructive pulmonary disease. J Investig Med. 2022;70(8):1681-1689. doi:10.1136/jim-2022-002430
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12. Wardlow L, Leff B, Biese K, et al. Development of telehealth principles and guidelines for older adults: a modified Delphi approach. J Am Geriatr Soc. 2022. doi:10.1111/jgs.18123
13. De Guzman KR, Snoswell CL, Taylor ML, Gray LC, Caffery LJ. Economic evaluations of remote patient monitoring for chronic disease: a systematic review. Value Health. 2022;25(6):897-913. doi:10.1016/j.jval.2021.12.001
14. Tang M, Mehrotra A, Stern AD. Rapid growth of remote patient monitoring is driven by a small number of primary care providers. Health Aff (Millwood). 2022;41(9):1248-1254. doi:10.1377/hlthaff.2021.02026
15. Goldberg EM, Lin MP, Burke LG, Jiménez FN, Davoodi NM, Merchant RC. Perspectives on telehealth for older adults during the COVID-19 pandemic using the quadruple aim: interviews with 48 physicians. BMC Geriatr. 2022;22(1):188. doi:10.1186/s12877-022-02860-8
16. Devine B. Assessing the value of remote patient monitoring solutions in addressing challenges in patient care. Value Health. 2022;25(6):887-889. doi:10.1016/j.jval.2022.03.020