Remote Patient Monitoring and Self-Responsibility

At HIMSS next week, I'll be doing 5 presentations about the future of healthcare IT, focusing on patient directed data exchange, internet of things, and telemedicine.     Remote patient monitoring,  which combines all three, will be increasingly important.

Remote patient monitoring can take numerous forms,  and the evidence supporting these tools is mixed. Here’s another excerpt from our new book—The Transformative Power of Mobile Medicine—co-authored by Paul Cerrato that dives into the issues.  For those interested in reading the entire book, the publisher is offering a deep discount until March 31, 2019; coupon code: HIMSS2019.

Many thought leaders are convinced that remote patient monitoring improves patient care, but surveys suggest that health-care professionals are still not convinced. An analysis from the New England Journal of Medicine Catalyst Insights Council asked respondents to rate various patient engagement initiatives. “Remotely monitoring using wireless devices/wearable” was listed as the least effective way to engage patients while having physicians, nurses, or other clinicians spend more time with patients was listed as the most effective tactic. [1] There is also uncertainty about the benefits of remote patient monitoring in the scientific literature. Of course, remote patient monitoring can take so many different forms that it’s impossible to make a blanket statement about its effectiveness. But a randomized controlled trial (RCT) that included more than 1400 patients (median age 73 years) who had been hospitalized for heart failure generated less than encouraging results. Michael Ong, MD, from the University of California, Los Angeles, and his colleagues divided the group into an intervention arm, which received health coaching phone calls along with the collection of vital signs that included blood pressure, heart rates, symptoms, and weight with the help of electronic devices, and a control arm that received the usual care [2]. Ong et al. couldn’t find any significant difference in hospital readmission rates 180 days after discharge for any cause: 50.8% were readmitted despite having all the extra attention and access to all the high-tech monitoring devices versus 49.2% in the usual care arm. Similarly, the investigators detected no difference in 30-day readmission or 180-day mortality. The experimental group did, however, report better quality of life at 180 days.

 On the other hand, Essentia Health, a Minnesota-based system that includes 16 hospitals and 68 clinics, has been using home telemonitoring with a body weight scale to keep track of CHF patients. Patients weigh themselves every morning and answer a few basic questions about their symptoms. Their responses are transmitted via telephone line to the computers that triage the incoming data and alert clinicians to those in need of additional attention. Essentia has been able to reduce 30-day readmission rates to less than 2% with the program. The average readmission rate for CHF patients
is 25%. [3-4]

Detecting statistically and clinical significant benefits for remote patient monitoring is complicated. Unfortunately, Americans are used to being passive recipients of health care. When they see their physician, they expect to receive a pill or have a procedure performed. The only demand on their time and attention is taking the pill or undergoing the operation. Asking patients to take on a more active role in their care, including weighing themselves daily, taking blood pressure readings, and so on, requires a stronger sense of self-responsibility and better cognitive skills. It also requires a deep, long-term commitment from the health-care care organization launching the program. Providers cannot expect to “patch” a remote patient monitoring system into the mix without a great deal of planning and commitment from physician leaders and clinicians in the trenches. Tracy Walsh, a senior consultant with the Advisory Board, sums up the issue succinctly: providers need to “track program metrics that closely map to the organization’s broader strategic objectives.” [5]. Walsh provides a detailed graphic to help providers choose wisely. It addresses three basic questions regarding remote patient monitoring:

·     Is it technically feasible?

·     Is it clinically relevant?

·     Is it cost-effective?

References

1.     Volpp KG, Mohta NS. Patient engagement survey: improved engagement leads to better outcomes, but better tools are needed. NEJM Catal May 12, 2016;. Available from: https://catalyst. nejm.org/patient-engagement-report-improved-engagement-leads-better-outcomes-better-toolsneeded/.

2.     Ong MK, Romano PS, Edgington S, et al. Effectiveness of remote patient monitoring after discharge of hospitalized patients with heart failure: the Better Effectiveness After Transition_Heart Failure (BEAT-HF) randomized clinical trial. JAMA Intern Med. 2016;176:310-18.

3.     Siwicki B. Essentia Health slashes readmissions with population health initiative, telehealth. Healthcare IT News. March 15, 2016.

4.     Agency for Healthcare Research and Quality. Heart failure disease management improves outcomes and reduces costs. ,https://innovations.ahrq.gov/profiles/heart-failure-disease-management-improvesoutcomes-and-reduces-costs?id5275.

5.     Walsh T. Studies are conflicted about remote patient monitoring—here's what we think. Advisory Board March 31, 2016;. Available from: https://www.advisory.com/research/market-innovationcenter/
the-growth-channel/2016/03/remote-patient-monitoring-roi.