How to Set up a Remote Patient Monitoring Program

Assessment, Selection & Deployment.

   90% of USA’s 3.5 trillion healthcare expenditures are for chronic and mental health conditions. One of the ways to fight back against chronic and mental care is through Remote Patient Monitoring. The RPM Market is growing at 14% every year. I write a bi-weekly report on the remote care space, and regularly encounter new companies who are interested in selling the remote care package. But how does RPM implementation look like behind the covers? There aren’t that many posts that provide you a game plan of how to put all the pieces together, from A to Z. There are some gems however, freely made available in the web. Using those, and combining our own expertise in the space, this piece is titled “How to Implement your RPM Program”.  

  Previously, we have covered how to set up a chronic care program. But that was mostly going over the Medicare rules, and did not have much information on your internal operations and your potential interactions with RPM vendors. It was more a guide to abide by the regulations and demonstrating how value can be generated by fulfilling all the requirements set by Medicare. This is post goes beyond that. But as CMS’s rules and regulations are so integral to being reimbursed, at some point, this post will segue into a section discussing that. But for the majority of the piece, it will be much more RPM operations centric, talking about how to think, approach, and implement a RPM solution.  It is divided into Assessment, Selection and Deployment.

ASSESSMENT PHASE 

1. Think of All Internal and External Stakeholders 

First things first, you need to think of everyone in your organizations before setting up your RPM program. Going remote also inexplicably means going digital. This impacts the whole organization and the patients it cares for. So before embarking on this journey, do an organizational assessment of what challenges you are looking to solve with the technology. Prepare SMART goals that can be achieved via RPM. 

The organization (leadership), its staff, and its patients are three separate stakeholders, all of whom can have pain points that can be addressed via RPM. Hence, it is best to solicit feedback from all, from the executives, from the clinicians, and also from the patients. Involving all stakeholders centers the initiative to go remote around a true need, whether that is to solve a problem and/or capitalize on an opportunity. It also ensures purpose and long-term stability for the project. 

How to Agree to Something that Affects All? 

Triangulate your area of concerns by thinking of three stakeholders. Identify and prioritize opportunities/problems faced by 1) patients, 2) frontline clinicians and staff who come into contact with patients, and 3) administrators who manage operations for the hospital. Finding common areas of opportunities/problems faced by all will deliver the greatest value. Be aware of adopting new glitzy technology simply because it is the latest in its field. It may not address the type of need identified in your assessment phase. Go into the process with the intent of finding someone who will be a long-term partner who will understand your needs before implementing the program. Through this exercise of triangulation, you will build consensus on your most immediate need that affects everyone. 

2. Identify the Patients 

Your RPM solution cannot be for everyone from the get-go. There is a process of testing it out on a smaller subsection, evaluating the results, and optimizing settings as necessary to see marked improvements. Only after these things have been done, can you scale your solution to a larger patient population. But of course, when setting up experiments, your sample group must be homogenous, or else it leaves too many extra variables which could all account for the differences in results of the program. Thus, you must identify the patients who will be beneficiaries of your RPM project.  

How do you identify patients? 

  You first have to identify if the care in question is long term or short term, because RPM is excellent for both. Short term care includes post-acute care management, either after a surgery or transitory care management in the patient’s homes where the patient adjusts to normal life after receiving critical care. Long term care includes examples of chronic care, where the condition is likely to remain for the rest of the patient’s lives, but has to managed at a low cost, and hence provided inside the patient’s homes.  

Chronic Care 

For the sake of Medicare reimbursement, identifying those patients in your EMR with more than one chronic disease was an important classifier (and it still is a qualification criteria if you want to build a Chronic Care Program). However, the multiple (more than one) chronic disease criteria is not a prerequisite anymore for chronic care since the introduction of Principal Care Management in 2020. With the codes introduced in the Principal Care Management Program, there is a separate reimbursement track for patients with a single chronic disease. If you want to serve chronic care patients under Chronic Care Management (for the long haul), you will identify those patients with one or more chronic conditions. If you want to manage disease specific care (short term) under Principal Care Management, you will identify those patients with that specific chronic condition. 

More important than the number of chronic conditions the patient has, are the actual diseases themselves. Every condition has their own goals which clinicians are looking to achieve for that patient population. Thus, the best way to identify patients for your RPM program, is to segregate them by diseases, so their respective goals can be achieved. A pro tip is to target patients who are receptive to technology, since the success of the program will no doubt dependent on patient engagement with RPM. With the evolution of healthcare payment models and their shift towards quality, there is a lot of value in managing a healthcare population and not merely getting reimbursed for the services provided to them. Thus when you have a patient population with a single condition, you can monitor their progress via RPM. 

Acute Care 

Acute Care, before or after critical care (including surgeries) is a great application for remote care, and they are all short term in nature. Patient identification could involve identifying all those going into surgery, providing pre-surgery and post-surgery care. It could also involve all those who are being discharged but will need to be rehabbed adequately to avoid readmission.

3. Identify the Goals 

 
Once you have identified your patient population, it’s time to establish goals. After all, if you don’t establish benchmarks to measure the program against, it will be hard to justify scaling up later. It’s important to have proper baseline metrics in place, and an endpoint for evaluating results. Different patient populations will have different goals. Agree on the type of results most appropriate for the type of remote patient monitoring you are looking to implement. Identify checkpoints throughout the program to evaluate your progress towards the goal. 

Based on peer-reviewed studies and case studies made available on the web, we have collected an assortment of information on RPM programs, regarding their inputs and outputs. The results of the output measures were mixed, but it is possible to find an instance of a positive result for every output measure. In other words, the actual result achieved depends on several other variables as well, and should not detract from setting the goal. The result achieved is only a consequence after a goal is set.  

Here are some of the more popular RPM programs going around, their inputs and outputs.

* There is a section reserved for cost and operational outcomes in the end. The output for the following programs refers only to clinical outcomes.

Heart Failure (HF) Programs
 
Input 

Congestive Heart Failure can have many causes, most common of which are ischemic heart diseases, high blood pressure or diabetes. It can also happen due to arrhythmia, cardiomyopathy, congenital heart defects of heart valve diseases. Any condition that weakens the heart over time can cause it to ultimately lead to congestive heart failure, which is chronic in nature. 

After such an episode of care to treat heart failure, record daily symptomatology such as shortness of breath, chest pain, irregular heartbeats, swelling, fatigue and decreased alertness. Collect information remotely on the following: blood pressure, heart rate, symptoms and weight. Vital signs and clinical alerts should be sent daily to central nursing station. Nurses are to conduct telemonitoring reviews to check up on the patient, also called video-based nursing visits. Protocolized actions are taken to manage the course of care for the heart failure patient. Clinical decision support cards can prompt a clinician to adjust medications, refer to a specialist, send a patient for imaging or bloodwork. 

Output 
  • The following should increase: Health related quality of life (HRQOL), functional status, patient satisfaction and lifespan. 
  • Decedents to survivors ratio should decrease. 
  • Healthy lifestyle changes should be implemented to stop the progress of heart failure.  
Chronic Obstructive Pulmonary Disease (COPD) Programs
Input 

 In general, the pulmonary function or spirometry test is conducted to diagnose COPD. The FEV1/FVC ratio from the test should be below 70% for a COPD diagnosis. With COPD, stages are very important. Your goals should be tailored to the stage of care the patient is in, to better manage their care. FEV1/FVC ratio aside, your FEV1% can be compared to the rest of the population of the same sex, age and body type. Depending on the percentage of the patient’s predicted FEV1 value, they may be classified as having mild, moderate, severe and very severe COPD. 

COPD assessment test (CAT) 

GOLD Stage of COPD  Percentage of predicted FEV1 value 
mild  80% 
moderate  50%–79% 
severe  30%–49% 
very severe  Less than 30% 

 Record physiological variables, symptoms, and medication usage daily.  Record major symptoms such as dyspnea, sputum color and volume, and minor symptoms such as coughing and wheezing and vital signs. Take special consideration for patients with a moderate Acute Exacerbation of COPD (AECOPD). Record instances of all such exacerbations.  As COPD is a progressive disease, the goal is to lower the symptoms and manage the disease. It is rare that the actual lung function actually improves, with the exception of smoking cessation. Thus, use the program as well to ensure smoking cessation. 

Output 
  • COPD symptoms should decrease. 
  • The following should increase: Health related quality of life (HRQOL) and exercise capacity. 
  • Smoking cessation should occur for smokers. 
High Blood Pressure (Hypertension) Programs
Input 

Since hypertension often has few or no symptoms, it is commonly undertreated, leading to severe and life-threatening complications such as heart failure as discussed before. A lot of patients experience higher blood pressure in clinical settings. Combined with poor measurement techniques or measurement bias, relying on singular readings only in clinical settings can be misleading. RPM providers a more accurate picture of a patient’s blood pressure by monitoring it more frequently and over longer periods of time. 

Thus, daily access to blood pressures can better predict future cardiovascular events, or assess the effectiveness of current treatment to cue changes if needed to bring high blood pressure under control. Patients receive the blood pressure cuffs or monitor and a tablet or cell phone containing the remote care software. Using the remote care platform, they answer questions daily about symptoms and medication adherence while the tablet receives data on vital signs from the cuffs or monitor, which are transmitted to the call center. From such data, clinicians and pharmacists can then adjust antihypertensive therapy accordingly.  

Output 
  • The following should increase: patient awareness, detection, and monitoring of hypertension. 
  • Uncontrolled hypertension should decrease. Control of systolic BP to less than 140mm Hg, and diastolic BP to less than 90mm Hg, measured in 6 months intervals. For patients with diabetes or chronic kidney disease, the cutoff point for systolic BP is 130mm. 
  • 8.45 mm systolic drop in 6 months can be achieved. 
  • A 3% drop in SBP has been associated with a 8-14% chance of stroke reduction. A 4.5% drop in SBP has been associated with 15% reduction in coronary heart disease. 
  • At a patient population level, the % of population with avg. Blood pressure of 130/80 should increase. 
  • Sustained engagement after 6 months can be achieved.
  • RPM’s positive impact on SBP can increase if the intervention is long-term and if the intervention includes multiple behavior change techniques. 
Diabetes Programs
Input

Active care management with home telemonitoring. Includes transmitting blood glucose, blood pressure, weight to nurse practitioner, and monthly Calls for diabetes education and self-management review . The nurse practitioner adjusted medications for glucose, blood pressure, and lipid control based on established American Diabetes Association targets. The taking of oral hypoglycemic agents and/or insulin must be managed. For pre-diabetes patients, there can be a diabetes prevention program.

A Blood Glucose Meter (BGM), commonly known as a Glucometer,  provides a single reading of glucose. Continuous Glucose Monitoring (CGM) provides multiple readings of glucose over a 24 to 48 hour cycle. A Glucometer works by pricking the skin, while a Continuous Glucometer works by inserting  sensor underneath the skin.

A RPM platform will account for both clinical data from EHR and  patient readings from glucometers, CGMs and insulin pens.

Output 
  • HA1c can be reduced from 8.5% (1.7% SD) to 7.4% (1.3% SD). 
  • Decrease average HA1c by 0.5% in patients with type 2 diabetes. Greater reductions in HA1c  in 3 and 6 months.
  • Decrease % of population below HA1c of 8.  
  • The following can be achieved: 28% of population dropped an entire BMI category. Avg weight loss 4.4 kg.

Operational Metrics  

Disease metrics aside as seen in the programs above, one should also track cost and quality metrics that align with the organization’s overall strategic objectives. These include all readmission data, patient satisfaction and health care cost. The reason for doing so is so that you can appropriately attribute increase in quality and cost-effectiveness to the program. This is important as physicians now have to participate in quality programs, that go beyond just traditional fee for service. Digital health solutions can help the organization participate in programs such as Quality Payment Program (QPP) and the Merit Based Incentive System (MIPS). 

Output 
  • The following should all decrease: ER Visits, hospitalizations, GP visits, ED presentations, hospital admissions (all cause and disease related), measures for 1 month and 6 months.  
  • Total cost should decrease. Includes inpatient, outpatient, and ED), acute care utilization after transition to home. 
  • Mean annual healthcare costs can fall by 4%, despite higher mean annual pharmacy expenditure, attributable to medication compliance effect of better care coordination. 

4. Identify the Location

While it makes sense to target certain conditions, some organizations may want to start by looking at certain locations. This could be certain health centers or certain states, whatever makes sense for them. It’s good to first identify the right patient population, and then narrow down the facility/ facilities where the program is to be implemented, depending on if they have right resources to implement such a program. But as mentioned before, in some cases, the geography may even triumph the actual condition, when it comes to developing a program. No matter the order of segmentation, as long as one filters by condition and geography segmentation; one can zoom in on their target patient population.

5. Figure out your RPM’s relationship with your EHR

Whatever RPM solution you onboard, understanding how it fits into your EHR system is crucial. We emphasize on EHR and not EMR, because an EHR encompasses the whole patient history and information contained in it could be helpful when designing the workflows or clinical pathways to be implemented using the remote patient monitoring program.  

EHR contains many components which make it synonymous with the patient workflow. But in reality, a patient’s workflow could contain many other things as well which might not be part of the EHR. Unless of course, you choose to make it a part of it. Thus, figuring out EHR integration (if necessary) is crucial, when developing your RPM workflow. It can fit into the existing workflow in the EHR, or it could have its own workflow. Almost all organizations choose to integrate the new RPM bases workflows into their EHRs, as EHRs have become so essential to manage a patient’s healthcare in light of their whole patient history.  

SELECTION PHASE

You are now done with your assessment phase. You have identified the area where a digital solution like RPM could have the biggest impact, both in terms of alleviating problems but also increasing care quality and growing the organization. You have also managed to get all key stakeholders on the same page. You have done your due diligence on the patient population on which the pilot will be conducted, regarding the condition and the location. You have identified the goals that need to be achieved, and the metrics that need to be tracked. You have also figured out where the RPM program fits within your existing workflows in your EHR system. After all, patients aside, it will be the clinicians who will be using the product. Internal assessment is now complete, and by the virtue of it, you already have the following questions to ask in the selection phase to potential vendors: 

1) Are you specialized in any specific conditions? 

2) Would you be able to cover the area that we are looking at? Logistics related. 

3) What features does your software offer to manage our workflows? 

  Asking the above three questions will enable you to tremendously narrow down your list of all vendors. Based on what you are looking for, you will see there are a handful of vendors that have experience with the conditions you want to manage, who can cover the logistical aspect of it all, and who have the features that you want to manage your workflows. 

 To pick the solution that is an ideal fit, you should think about the following areas of the RPM program. 

6. Figure out what devices, platforms and apps to include in your RPM Program

Once you have your workflow sorted out for a patient population, that includes what kind of role RPM is supposed to play in it, you are ready to begin evaluating different RPM solutions that could get the job done. RPM solutions consist of hardware (the devices that patients will use to record data and interact with healthcare professionals) and software (the platform which will be used to record, store, transmit the data, plus help clinicians coordinate care). 

You will want to ask the following questions. What is the relationship like between the device manufacturer and the software platform?    If you hire different parties to manage devices and the care software, then it’s a matter of holding each party responsible. But in case of a full-service solution, where one vendor provides you everything you need to conduct your RPM program, you would want to know what type of business associate agreements are in place between the device makers and platform owners.   This is important when a device needs to be replaced for whatever reason. If you purchase your own devices, you will be responsible for replacing them. If you lease them, they may be replaced by the RPM vendor providing them to you.     The device maker has to be FDA compliant. The RPM platform has to be HIPPA compliant. These are non-negotiables, as the USA healthcare regulations must be abided.  

What is the user experience like for patients?  

You will want to know if they will need an email address and password. Usually, when kits are delivered to patients, they do not need any login information. Everything is pre-configured to provide the most optimum user experience, so they can power up the device and be ready to go.    If patients bring their own devices however, they may need an email address and password for them to get on the care platform.In case it’s a Bring Your Own Device (BYOD) program, it is important to have the platform readily available for download from the web as an app. In our case, downloading aTouchAway will be all that the clinicians and patients need to do, as the other device makers used to record patient data are already integrated within our app. So for example, you will not need to download separate apps for each of the devices.  

What are the Device Considerations? 

It’s important to research the accuracy of devices, their battery life, and other miscellaneous features that make them more robust, such as being waterproof. We are device agonistic, meaning whatever devices you choose to record patient data, we’ll be able to integrate with them. We’ll also be able to provide the degree of accuracy of their measurements.    You must make sure that all data recorded from devices is converted into readable data, and can be exported. There must be a documentation of all the variables that are being collected from the RPM program, and the frequency at which they are sent to the vendor cloud. In our case, the data is collected and transferred in real time to the vendor cloud. Frequency of data capture can be set as desired.   You have multiple options available to you to manage device logistics. If you buy the devices to use them for programs for a certain period of time and reuse them, you will need to store them somewhere. You could store them in pharmacy. You could consider mobile device management. Patients could also bring their own devices, which saves you the trouble of having to worry about device logistics. However, it has been observed the patient compliancy to the program increases when they get the devices for free. You will need to account for returns and defective devices. Your mobile device management vendor and finance dept. should be able to help.  What are the Support Considerations? If there’s an issue with the device, the support center will take care of it. Usually with RPM solutions, there will be several lines of support. 1st line comprises of very basic support, helping patients to turn on their tablets for example. The need for such support can actually be mitigated by proper training upfront. Both for your clinicians, and for your patients. Training for clinicians and other staff are usually part of the pricing equation when receiving a quote. Training to patients is usually undertaken by the healthcare organization, and they have to decide if they want to offer their own 1st line of support. The device maker will have an established process for returns or damaged devices. If you lease the devices from the RPM solution, then the RPM vendor will take care of it. It is the case with aTouchAway. 

7. Make The Decision

Once you have considered the operational aspect of all the hardware and software (read: user experience, device, support and integration), it is time to make a decision. You will get a more refined list of prospects in light of all the above considerations. Of course, a second opinion helps when drafting your shortlist. You can talk to organizations like yours, attend healthcare technology conferences like HIMSS (and local HIMSS chapters), TEDMED, Connected Health, Health 2.0 or Rock Health. Check out this resource when I have compiled all the best healthcare tech conferences to attend in 2020. 

At this stage, you should also ask for case studies and referrals, schedule demos to see the solution in action and even test the technology with staff members and patient advocates if possible. After all this scrutiny on top of the internal assessment and selection considerations, you will be left with a few ideal choices. You are now ready to make a decision after lengthy process of due diligence.

How to Fund it? 

Though this stage could just as easily be in the beginning as well, it could be in the selection phase as well if the vendor provides any financing options. We offer a 4-month free pilot program. If you have a budget earmarked for the RPM solution, that is great. If not, consider how you can make room in the budget and what departments might be willing to pitch in. Additionally, consider external funding such such as government grants, accelerator sponsorships or community support. 

The beauty of a RPM program of course, is how it funds itself via reimbursements. So whether you use traditional or alternative methods of funding, you can recoup the cost of the program plus gain all the value addition benefits that is expected. 

If you are using RPM to implement a chronic care program, here is how much you can expect to be reimbursed from Medicare. The amount reimbursed will depend on the monthly minutes and the complexity of cases. 

DEPLOYMENT PHASE

Congratulations! At this stage, you would have chosen the right RPM solution for your business after a thorough internal assessment and external inquiry. Now it’s time to deploy your RPM program. Initial deployment consists of any number of months where logistics and clinical workflows are optimized. In this time, the standard of care is set for the patient population. This is extremely helpful when scaling up later or renewing the contract with your RPM solution. Where do you start? 

8. Anticipate all Staff Obstacles

Make sure to resolve any HR issues if there are any. Abide by licensing when skilling up staff who will be involved in the program. Be careful not to overburden your current staff, or you risk protests from different unions of healthcare professionals. It should not be an issue however, as the product is meant to improve patient outcome, which every healthcare professional wants as well. It is usually more a case of not consulting with the union bodies before introducing new technology. 

9. Train Both Patients and Clinicians 

It is important to understand the level of support you will be getting. It’s best practice to have multiple lines of support. The first line of support takes care with simple on-boarding issues, such as “my device is not turning on”, or “my device is not syncing with my tablet”. It may be worthwhile to outsource this first line of support to an IT support vendor. In that way, you can reserve your RPM vendor as the second line of support to deal with more serious issues where you cannot figure something out or get something to work, or simply have a question about what is possible. Having multiple lines of support will help you separate user issues vs software issues. 

Keep in mind, second line of support will not be needed as much if there is satisfactory training provided to both patients and providers at the beginning of the program. This is why the quantity and quality of training provided to all users at the onset of the program is so crucial. It sets them up for success.

Educate the Patient 

  It is great that your organization saw the value in remote patient monitoring. But will the patients feel the same way? While some level of education is already provided when patients are being trained, education is an ongoing process. This can be education about the program, and also education about their course of care. The former helps to get accustomed to the program, the latter helps in learning more about their diseases. 

  Education can be delivered in both text and video. There could be a welcome video and a well vetted library full of educational resources licensed from Mayo Clinic, AMR or the client’s own materials. To go one step beyond, education could be customized for each patient based on their learning style. 

10. Document the Process 

You had already considered the process in the assessment stage, regarding how the RPM solution will be used by the care team, and how its interaction will look like with all those that come into contact with it. So you have some idea about the process already, but now that you’ve got the solution, it is time to put it into action. Depending on how thorough your assessment stage was, it could simply be a matter of documenting what you had agreed on. If there were any gray areas that you had not figured out just yet, now would be the time to do so.  

It would be wise to engage your IT team to provide input on the workflow design. See if the updated procedures for RPM can be implemented. In no particular order, it can include tasks such as patient identification, patient training, device management, data monitoring, analysis, interventions and even billing to close the loop on an entire patient cycle.  

Define the clinically relevant data points, and develop protocols for them to be collected, identified and communicated to the correct care team members. It’s important here to pair with a RPM solution which lets you customize access privileges. Define everyone’s role in the program. See the following template taken from the American Medical Association Digital Health Implementation Playbook. 

it all begins with the physicians/providers, as they are responsible for referring patients and ordering the RPM program which can be billed by themselves or other qualified healthcare professionals (QHPs). The nurse/care manager has a big role to play in running the program and they can be supervised by the physician/provider or QHPs. The Medical Assistant/Patient Care Tech and Practice Manager also have important roles to play, but they are operational in nature. In many cases, such support can also be provided by a third party. There are pros and cons of outsourcing a telehealth/remote patient monitoring program. 

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