As healthcare reform forces a reimbursement shift from the traditional fee-for-service model to the new pay-for-performance model, keeping people healthy will force healthcare providers to do things such as prevent hospital readmissions, or keep people from needing a hospital stay at all. And that will happen only if providers have some insight into what patients are doing at home.
The concept is that better chronic care management will keep costs down. If patients can manage their health better outside of the hospital, costly major medical episodes are less likely to occur. After all, Medicare will levy $227 million in penalties against hospitals in every state but one for the second round of the government’s campaign to reduce the number of patients readmitted within 30 days.
If you’ll remember, I blogged last month about how readmissions—while a cause for concern—are not as big a problem as many might think. While I genuinely believe that to be true, how to prevent readmissions is still a question that many hospitals still grapple with.
One answer might be in the form of remote patient monitoring (RPM)—a technology to enable monitoring of patients outside of conventional clinical settings—comes in. RPM is a critical piece in increasing access to care and decreasing healthcare delivery costs, and recently, many efforts have been made by healthcare systems to turn to this burgeoning technology.
For one, a new 24/7 remote monitoring system from the Mayo Clinic will improve care and shorten hospital stays for critically ill patients, according to Mayo officials. The Enhanced Critical Care program will offer monitoring of the sickest patients at six Mayo Clinic Health System hospitals in Austin, Albert Lea, Fairmont and Mankato, Minn.; and Eau Claire and La Crosse, Wis.
"It's like having an extra set of eyes on every patient," Dany Abou Abdallah, M.D., a pulmonologist and director of the critical care unit in Eau Claire, said. "With this program, operations center nurses and physicians continuously review patients' vital signs and other data. The minute they notice a potential problem, they can alert the local care team.”
The Center for Connected Health (CCH) in Boston and the Oakland, Calif.-based Center for Technology and Aging (CTA) have also collaborated on the development of a tool for analyzing the return on investment (ROI) for RPM technologies, enabling healthcare providers to evaluate the financial benefit of these technologies for patients with chronic heart disease.
The ROI Tool was developed and tested with a number of healthcare organizations participating in the CTA Diffusion Grants Program. HealthCare Partners (HCP), a large physician group practice based in southern California, used the ROI tool to quantify the value of its remote patient monitoring program for chronic obstructive pulmonary disease (COPD). Using the ROI tool, HCP’s interactive voice response program had a positive ROI of 1.3 to 1 after one year, and is projected to increase dramatically to 18.9 to 1 by year five.
Another example is when the use of a home telemonitoring system helped reduce 30-day hospital readmission rates by 44 percent among patients with congestive heart failure, according to the Danville, Pa.-based Geisinger Health Plan's evaluation of its patient monitoring program. Geisinger's home telemonitoring system allows patients to receive scheduled calls through an interactive voice response system developed by telehealth company AMC Health. The calls ask patients about their symptoms and then store the responses online and in patients' electronic health records. The responses then are analyzed to determine whether the patient requires a follow-up visit with a nurse or case manager.
There are many more examples of RPM technologies being used, and mounting evidence points to a growing market. According to a research report from the New York City-based Kalorama Information, sales of advanced remote patient monitoring devices have risen 20 percent from the year before. The market for the devices has constantly ticked up, going from $4 billion in 2007 to $10.6 billion in 2012.
And over the next five years, remote patient monitoring will result in cost savings of up to $36 billion worldwide, according to an announcement on the mHealth market from Juniper Research. Additionally, research published in January by analyst firm Berg Insight estimated that 2.8 million patients worldwide were using a home monitoring service based on equipment with integrated connectivity at the end of 2012, and Berg predicted those number of connections would climb to 9.4 million worldwide by 2017.
Needless to say, the numbers are spiking, and there’s no indication that it will be stopping anytime soon. Despite these figures, though, as well as the efforts made by healthcare organizations, some evidence has called home telemonitoring into question. A study published in the Journal of Medical Internet Research looked at systematic reviews and meta-analyses of home telemonitoring of patients with chronic conditions between 1966 and 2012. They focused on 24 reviews, nine of which were meta-analyses. Most such studies over the years deal with remote monitoring for patients with chronic heart failure, but in recent years, monitoring has grown more prevalent for other conditions, as well, such as diabetes, hypertension and asthma.
"Based on our assessment, we found that with the recent increase in reviews of [home telemonitoring] interventions, an important number of these articles appear to lack optimal scientific rigor due to intrinsic methodological issues," the researchers wrote. "Furthermore, their overall quality does not appear to have improved over time."
What’s more, British researchers whose work was published earlier this year in BMJ, followed more than 1,500 patients suffering from chronic obstructive pulmonary disease, diabetes, or heart failure over the course of a year who used telehealth, as implemented by the Whole System Demonstrator Evaluation. They found that, when compared to patients who received regular care without telehealth equipment, there were no significant improvements in reported quality of life or anxiety or depression symptoms. The authors said that evidence was lacking and telehealth offered "no net benefit" to patients, and thus, should not be considered as a tool to improve health.
And despite the fact that the majority of accountable care organizations (ACOs) that responded to a survey from Spyglass Consulting Group said they are using remote patient monitoring technology as an early symptom management tool to remotely monitor and manage high-risk chronically ill patients, more than 50 percent of organizations interviewed questioned the clinical effectiveness of RPM technology and their ability to generate a positive ROI.
Without a doubt, remote patient monitoring faces some big obstacles. A recent article in Information Week pointed out a few: Older patients might be unfamiliar with the technology, and people of all ages still have to be persuaded to use it. There is little standardization among the devices because of the number of companies in the market, so IT faces an integration headache getting them to work with existing electronic health records (EHRs).
Another obstacle is that regulators view some monitoring apps the same as medical devices, and so they need Food and Drug Administration approval for use in clinical settings. Providers also need to figure out how to use all the data collected. For instance, how to automate the analysis to alert a nurse or doctor at the right time to follow up, but not so often that clinicians are overrun with warnings?
I don’t doubt that challenges exist when it comes to home telemonitoring. But the efforts that have been, and continue to be, made are certainly encouraging, and they give me hope that RPM can be a key to better care. When it comes down to it, it's in the best interest of hospitals to prevent readmissions, and in the best interest of patients to improve their care without going back to the hospital. RPM can help with both, and that seems like a no-brainer to me.