Remote Patient Monitoring and Telehealth

The evidence so far doesn’t show an improvement in the outcomes of people who use wellness and fitness tracker kinds of apps on their smartphones. But there is some evidence of benefit for chronic-disease apps and for home monitoring.

Because of this technology, some observers believe, an increasing number of patients will be discharged from hospitals to home rather than to skilled nursing facilities or rehab facilities.

In addition, many homebound seniors will be able to manage their chronic conditions at home with the help of remote monitoring, patient education, and virtual and in-person visits from care teams, predicted E. Ray Dorsey and Eric J. Topol in a 2016 article. For people with chronic conditions, including the two million elderly people who are homebound, “the patient-centered medical home will increasingly be the patient’s home,” they wrote.(1)

The best evidence on home monitoring comes from studies of patients with congestive heart failure (CHF). Several years ago, Geisinger Health Plan, based in Danville, PA, reported that home monitoring for patients with CHF cut readmissions by 44% compared to a control group.(2)

In another study, more than 3,000 patients with CHF at Partners Healthcare received in-home monitoring of weight, blood pressure, heart rate, and pulse oximetry. These data were uploaded daily, and decision support software identified the patients who needed attention. As a result of this approach, hospital readmissions dropped by 44% as compared with usual care, the study found. The program generated cost savings of more than $10 million in a three-year period.(3)

In a 2018 report, the eHealth Initiative, a nonprofit research and advocacy firm, argued that remote patient monitoring can improve outcomes. “By continuously tracking the routine and biometric measurements of people with chronic conditions, providers are empowered to intervene earlier in disease progression, which helps prevent complications that can result in unnecessary in-person or hospital visits.”(4)

Moreover, the report said, remote patient monitoring (RPM) can help clinicians track patients’ health conditions after hospital discharge.

RPM improves outcomes in post-acute care by helping patients and doctors manage short-term care after in-person treatment with remotely collected data. Programs educate patients on their condition, recovery needs, and pain management while providing regular reminders, early interventions, post-discharge information, or medication adherence tracking. With the information garnered from patient-generated health data, providers are able to evaluate the effectiveness of treatments and customize care plans between patient visits.(4)

Fear of the Bad Event

Waldren expects the use of remote monitoring equipment to result in an increasing number of people being discharged from the hospital to home. But he thinks there will be some resistance among physicians who fear that recently discharged patients could get into trouble at home.

“There’s the fear of the bad event—not that they couldn’t manage the condition at home, but that they don’t catch something and it spirals out of control with remote monitoring.”

Then there’s the question of accuracy. Home monitoring equipment is not manufactured to the same specifications as the monitoring equipment used in hospitals. Joseph Kvedar, MD, vice president of connected health for Partners Healthcare, says RPM’s accuracy will always be limited because more accurate home and mobile monitoring gear would cost too much.

Kvedar, a big proponent of telehealth, has long maintained that a better screening method to “separate the noise from the signal” in monitoring data is needed before most providers will pay attention to home device data. Some progress has been made in this area, he says, but screening remains a challenge for physicians. “We have to be able to analyze these data streams and report insights,” he notes.

Basch agrees. “To monitor patients with certain conditions, I don’t need to see their blood pressure every five seconds. I don’t need to see their weight seven times a day. We don’t need vast streams of monitoring data. We need to start smaller and increase as we need it.”

mHealth Apps Proliferate

Back in 2012, only five years after the advent of the iPhone, there were between 20,000 and 30,000 mobile health apps on the market.(5) By 2015, there were 165,000 mHealth apps available in the iTunes and Android app stores.(6) In 2017, the number of these apps had almost doubled to 318,572, according to IMS Health.(7)

Consumers are interested in very few of these apps. In 2015, just 12% of mHealth apps accounted for 90% of consumer downloads, and 36 apps generated nearly half of downloads.(6)

Of the top 25 apps downloaded, 80% had at least one positive observational study demonstrating clinical efficacy, IMS Health reported.(7) But a randomized controlled trial of multisensor apps found no short-term benefits in health costs or outcomes for patients monitoring their glucose, blood pressure, and heart rhythm with connected devices.(8) Moreover, apps that track a patient’s diet or symptoms don’t necessarily lead to behavior change, and patients tend not to stick with chronic disease apps for more than a few months.(2)

As noted earlier, the overwhelming majority of mHealth apps are designed for healthy people who want to quantify their health and keep fit. Of the apps aimed at people with chronic conditions, the most numerous programs are those that focus on rheumatoid arthritis, Parkinson’s, Alzheimer’s, mental health, walking and gait, epilepsy, and migraine.(7)

Some mHealth apps are part of programs that help patients with a particular disease, such as diabetes. For example, Livongo Health sells a program that gives diabetic patients a blood glucometer, free test strips, and a software application that offers coaching and tracking based on the patient-generated data. Welldoc’s FDA-cleared BlueStar system for diabetes management analyzes patient data, compares the data to past trends, and sends analytics to the patient’s healthcare team. It also features behavioral coaching and educational content for the patient. Both companies claim significant cost savings from the use of their apps.(9),(10)

Meanwhile, the market for mHealth apps is growing. According to a recent consumer survey by Stanford Medicine and Rock Health, an investment research firm, 42% of respondents now track some aspect of their health digitally, up from 18% in 2015. One in three respondents owns a wearable monitoring device, such as a Fitbit or an Apple Watch, and one in four wearable owners uses it to manage a diagnosis.(11)

But there’s a disconnect between this burgeoning consumer interest and the response of healthcare providers to date. A 2014 study by Manhattan Research found that a third of doctors had recommended mHealth apps to patients in the previous year; however, only a small percentage of doctors prescribed particular apps, and most of those were fitness and diet applications.(12) In 2018, a spokesman for IMS Health said those numbers hadn’t changed much.

Eric Topol, who has written extensively about mHealth, said in a 2014 article that many physicians are not adopting the technology because they’re resistant to change, don’t want to be drowned in data, and are concerned about potential liability. Also, he said, there weren’t enough good studies on the accuracy of the apps.

Because of the inherent problems of reimbursement for remote monitoring in a fee-for-service world, it’s likely that the technology will blossom only after U.S. healthcare transitions further to value-based care.

While recognizing that doctors have good reasons to be cautious about prescribing mHealth apps, Topol was optimistic about the future of this technology. So is Waldren. The combination of remote monitoring with video visits, he says, might improve care for chronic diseases, but to really move the needle on chronic care, he notes, “there will have to be better technology to extend the ability to do the physical exam remotely.”

Because of the inherent problems of reimbursement for remote monitoring in a fee-for-service world, it’s likely that the technology will blossom only after U.S. healthcare transitions further to value-based care. Speaking of telehealth in general, Topol and Dorsey noted that closed systems such as Kaiser Permanente, the Department of Defense, and the VA system all encourage the use of telehealth to improve health and reduce costs. The rise of bundled payments and ACOs, they said, offers opportunities for further experimentation with telehealth.

Kvedar, in a paper cowritten with Molly Joel Coye and Wendy Everett, also viewed telehealth as a vehicle to make healthcare more efficient and effective.

This approach facilitates remote diagnosis and treatment, continuous monitoring and adjustment of therapies, support for patient self-care, and the leveraging of providers across large populations of patients. Because these technologies improve the sharing of data and tasks among teams, they allow team members to practice at their highest levels of skill and training. Physicians and nurses can then work more efficiently by allocating their time to the patients who most need attention.

References

1. Dorsey ER, Topol EJ. State of telehealth. N Engl J Med. 2016;375:154-161. DOI: 10.1056/NEJMra1601705. www.nejm.org/doi/full/10.1056/NEJMra1601705 .

2. Terry K. How mobility, apps and BYOD will transform healthcare. InformationWeek. July 2012. https://dsimg.ubm-us.net/envelope/280742/481693/strategy-how-mobility-apps-and-byod-will-transform-healthcare_750049.pdf .

3. Kvedar J, Coye MJ, Everett W. Connected health: a review of technologies and strategies to improve patient care with telemedicine and telehealth. Health Affairs. 2014. www.healthaffairs.org/doi/10.1377/hlthaff.2013.0992 .

4. The return on investment of patient-generated health data and remote patient monitoring. eHealth Initiative issue brief. July 2018. www.ehidc.org/sites/default/files/resources/files/ROIPGHD_7.26.18_final.pdf .

5. Trong K. Preliminary results are in from the massive Apple Heart Study. MedCity News. March 18, 2019. https://medcitynews.com/2019/03/preliminary-results-are-in-from-the-massive-apple-heart-study/ .

6. Terry K. Number of health apps soars, but use does not always follow. Medscape. Sept. 18, 2015. www.medscape.com/viewarticle/851226 .

7. IMS digs deep into mHealth, finds $7B in value. Klick Wire. April 19, 2018. www.klick.com/health/news/blog/mhealth/ims-digs-deep-into-mhealth-finds-7b-in-value .

8. Comstock C. Scripps wired for health study results show no clinical or economic benefit from digital health monitoring. Mobihealthnews. January 19, 2016. www.mobihealthnews.com/content/scripps-wired-health-study-results-show-no-clinical-or-economic-benefit-digital-health .

9. Muoio D. Positive outcomes from WellDoc’s BlueStar translate to cost savings, analysis finds. Mobihealthnews. January 4, 2018. www.mobihealthnews.com/content/positive-outcomes-welldocs-bluestar-translate-cost-savings-analysis-finds .

10. Comstock J. Lilly-funded study shows Livongo diabetes program can save employers $20 to $50 per member per month. Mobihealthnews. May 9, 2019. www.mobihealthnews.com/content/north-america/lilly-funded-study-shows-livongo-diabetes-program-can-save-employers-20-50 .

11. Lovett L. Rock Health, Stanford report: Consumerization of health reshaping doctor-patient relationships, data conversations. Mobihealthnews. Oct. 29, 2019. www.mobihealthnews.com/news/north-america/rock-health-stanford-report-consumerization-health-reshaping-doctor-patient

12. Terry K. Over a third of docs recommend mHealth apps, survey shows. Medscape. June 10, 2014. www.medscape.com/viewarticle/826460 .