Digital Health: What we know about remote-patient monitoring

Evidence for clinical effectiveness, cost, and patient experience

Covid-19 caused the acceleration of awareness of digital health technologies, telemedicine, and other virtual care models. Out of all of these, perhaps the most impactful will be remote-patient monitoring (RPM).

RPM models involve collecting real-time patient data while patients are not located between the four walls of the healthcare facility. Typically, this happens from a connected medical device like a wearable, blood pressure cuff, or blood glucose meter. But, it can also involve subjective data like mood, symptoms, and medication adherence in some circumstances. The idea is to proactively adjust care plans for patients based on real-time feedback, but also to empower patients with their own ability to track their health progress on a daily basis rather than every three months.

But, beyond the marketing hype, what do we know about these technologies and new models of chronic disease care?

What we know about RPM

There are three groups of outcomes that are important when evaluating RPM programs for success. These items fall under the same areas of health-system improvement outlined by the Institute for Healthcare Improvement (IHI) under the Triple Aim[1].

First, it is important to understand the clinical benefits of the program itself compared to the standard of care. Did the RPM program for hypertension patients reduce their blood pressure? Did the weight-loss program reduce BMI or waist circumference? Did the program focused on diabetes management provide better blood glucose control? In summary, does the development of an RPM clinical model help patients achieve better health?

Second, the program should have benefits when it comes to controlling healthcare utilization and overall costs for a patient population. With better healthcare services like RPM, we should see improvements in terms of hospitalizations, emergency department visits, and other costly services that result from the poor management of chronic illness. The programs themselves should also be cost-effective so as to not shift medical cost savings to program operations.

Third, it is necessary to understand the patient perspective of RPM programs. When done correctly, RPM programs provide a new experience with healthcare services, and with them come new challenges for patient engagement. It is essential to understand patient satisfaction compared to standard clinical models. Do patients use the program long-term? Do they express value? Are these models received better than current face-to-face services?

To evaluate the current state of the evidence for RPM, I performed a keyword search in PubMed to see the trends in publication over time. Using the terms “remote,” “patient,” and “monitoring,” I pulled the raw data and produced the figure below. In 1997, there were less than 50 studies published, whereas, in 2019, there were close to 800 studies published covering the topic. After iPhones and smartphone ownership rates took off after 2007, the growth in RPM studies on PubMed accelerated.

Many people new to RPM models assume that this is a frontier area of healthcare services. While adoption has been slow in the market, the body of clinical evidence for these models is actually fairly robust, but somewhat lacking in definitional clarity.

Thus, I performed a literature review looking for systematic reviews and randomized clinical studies covering RPM models as well as studies that evaluate both the cost-effectiveness and patient perceptions of these clinical models.

Do RPM-based Virtual Care Programs Work?

In 2016, a systematic review[2] reported findings on RPM programs across a wide range of chronic conditions and care settings. Sixty-two published studies were included in the review. Most of the studies looked at programs that incorporated a wide variety of interventions with multiple components, while a good portion of others looked at programs that primarily used a smartphone-based interface and some included wearables. This review is fairly comprehensive and provides good conclusions about the effectiveness of these clinical models.

By and large, the authors conclude that the majority of studies report positive findings with respect to health outcomes. According to this review, RPM-based virtual care programs work well with respect to health outcomes.

The Agency for Healthcare Research and Quality (AHRQ) conducted a similar review of technology-enabled care delivery services. They mapped, see below, the evidence for multiple modalities under telehealth including RPM. their conclusion was that RPM is one of the most studied and most beneficial models.

Economic Outcomes

One of the primary barriers to the widespread-adoption of high-touch chronic care models, more effective chronic disease management programs, and RPM-based virtual care programs is cost. High-touch and personalized models of care are costly when organizations operate on razor-thin margins.

A systematic review[3] of economic evaluations performed by Peretz and colleagues looked at RPM program economics for older adults with chronic conditions. I specifically include this review because if these programs can be cost-effective for a higher-cost, higher-need population, then they will likely scale well into younger, less complex populations as well.

Thirteen studies were included in the review. The authors developed a new metric to compare across the studies called the combined intervention cost that included equipment purchases, servicing, and monitoring. They found that costs for the programs range from $275 — $7963 USD annually.

The three primary findings from the study are as follows:

· Since 2004, RPM program costs have decreased due to lower-cost technologies

· Monitoring a single vital sign is likely to be less costly than multiple vital signs

· Programs focused on hypertension or CHF are less expensive than respiratory or multiple conditions

Given these results, the value and return-on-investment (ROI) from RPM programs is then derived from reducing patient utilization of healthcare services and products. If this reduction is larger than the cost of operating the RPM-based virtual care program, then the program produces a positive ROI. The primary points of savings for RPM will likely be reductions in emergency department visits and hospitalizations from which avoided costs can far exceed the range reported from this study. Indeed, the following review of the evidence suggests these outcomes are possible from programs, but further research is needed to understand the direct ROI attributed to RPM programs.

Patient Experience Outcomes

One of the primary benefits of virtual care programs is improvements to patient experience and satisfaction. More convenient and patient-centered program design frequently accompanies virtual care models, where healthcare services have traditionally lacked patient-centered design. Thus, it is important to understand the patient perspective of RPM-based models of care prior to and during implementation.

One systematic review[4] looked at 16 studies facilitated in eight different countries focused on understanding patient beliefs, attitudes, expectations, and experiences with RPM programs. The study included patients living with common chronic conditions such as chronic obstructive pulmonary disease, heart failure, diabetes, hypertension, and end-stage kidney disease.

Four important outcome-themes are important to understand from this review. Patients reported the following:

· Gained knowledge and improved positive health behaviors (i.e., cognitive and behavioral elements of patient engagement)

· Improved peace-of-mind and security from supportive monitoring (i.e., emotional elements of patient’s engagement)

· Concerns about additional burden and work from monitoring

· Fear about the loss of interpersonal connections and being confused by data (i.e., illustrating the importance of human involvement)

This review suggests that patients report gaining disease-specific knowledge, proactive identification of deterioration, improved ability to self-manage their disease, and greater ability to participate in shared decision making. These are outcomes of significant importance to chronic disease management.

Patients in the study did express concerns that RPM would take away the personal connection to their physicians and the additional burden. It is important to note that this is an important reason why effective RPM programs have a strong level of clinician interaction rather than reliance on data collection alone. Patients still require and request a strong relationship with care providers despite the digitization of some care processes.

References

[1] ​Berwick DM, Nolan TW, Whittington J. The Triple Aim: Care, health, and cost. Health Affairs. 2008 May/June;27(3):759–769

[2] Vegesna A, Tran M, Angelaccio M, Arcona S. Remote Patient Monitoring via Non-Invasive Digital Technologies: A Systematic Review. Telemed J E Health. 2017;23(1):3–17. doi:10.1089/tmj.2016.0051

[3] Peretz D, Arnaert A, Ponzoni NN. Determining the cost of implementing and operating a remote patient monitoring programme for the elderly with chronic conditions: A systematic review of economic evaluations. J Telemed Telecare. 2018;24(1):13–21. doi:10.1177/1357633X16669239

[4] Walker RC, Tong A, Howard K, Palmer SC. Patient expectations and experiences of remote monitoring for chronic diseases: Systematic review and thematic synthesis of qualitative studies. Int J Med Inform. 2019;124:78–85. doi:10.1016/j.ijmedinf.2019.01.013

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Robert L. Longyear III

Robert L. Longyear III

Co-Founder @ Avenue Health | VP Digital Health and Innovation @ Wanderly | Author of “Innovating for Wellness” | Healthcare Management and Policy @ GeorgetownU