The SARS-CoV-2 pandemic required health care systems around the world to rapidly innovate and adapt to unprecedented operational and clinical strain. Many health care systems leveraged virtual care capabilities as an innovative approach to safely and efficiently manage patients while reducing staff exposure and medical resource constraints (Healthcare [Basel]. 2020 Nov;8[4]:517; JMIR Form Res. 2021 Jan; 5[1]:e23190). With Medicare insurance claims data demonstrating a 30% reduction of in-person health visits, telemedicine has become an essential means to fill the gaps in providing essential medical services (JAMA Intern Med. 2021 Mar;181[3]:388-91). A vast majority of virtual health care visits come via telephonic encounters, which have inherent limitations in the ability to monitor patients with complex or critical medical conditions (Front Public Health. 2020;8:410; N Engl J Med. 2020 Apr;382[18]:1679-81). Remote patient monitoring (RPM) has been established in multiple clinical models as an effective adjunct in telemedicine encounters in order to ensure treatment regimen adherence, make real-time treatment adjustments, and identify patients at risk for early decompensation.
Long-term RPM data has demonstrated cost reduction, reduced burden of in-office visits, expedited management of significant clinical events, and decreased all-cause mortality rates. Previously RPM was limited to the care of patients with chronic conditions, particularly cardiac patients with congestive heart failure and invasive devices, such as pacemakers or implantable cardioverter–defibrillators (JMIR Form Res. 2021 Jan;5[1]:e23190; Front Public Health. 2020; 8:410). In response to the pandemic, the Centers for Medicare and Medicaid Services (CMS) added RPM billing codes in 2019 and then included coverage of acute conditions in 2020 that permitted a more extensive role of RPM in telemedicine. This change in financial reimbursement led to a more aggressive expansion of RPM devices to assess physiologic parameters, such as weight, blood pressure, oxygen saturation, and blood glucose levels for clinicians to review.
Courtesy ACCP
Dr. Andrew N. Salomon
Currently, RPM devices fall within a low-risk FDA category that do not require clinical trials for validation prior to being cleared for CMS billing in a fee-for-service reimbursement model (N Engl J Med. 2021 Apr;384[15]:1384-6). A shortage of evidence-based publications to guide clinicians in this new landscape creates challenges from underuse, misuse, or abuse of RPM tools. In order to maximize the clinical benefits of RPM, standardized processes and device specifications derived from up-to-date research need to be established in professional society guidelines.
Courtesy ACCP
Dr. James B. Muller
Formalized RPM protocols should play a key role in overcoming the hesitancy of health institutions becoming early adopters of RPM technologies. Some significant challenges leading to reluctance of executing an RPM program were recently highlighted at the REPROGRAM international consortium of telemedicine. These concerns involved building a technological infrastructure, training clinical staff, ensuring remote connectivity with broadband Internet, and working with patients of various technologic literacy (Front Public Health. 2020;8:410). We attempted to address these challenges by using a COVID-19 remote patient monitoring (CRPM) strategy within our Military Health System (MHS). By using the well-established responsible, accountable, consulted, and informed (RACI) matrix process mapping tool, we created a standardized enrollment process of high-risk patients across eight military treatment facilities (MTFs). High risk patients included those with COVID-19 pneumonia and persistent hypoxemia, those recovering from acute exacerbations of congestive heart failure, those with cardiopulmonary instability associated with malignancy, and other conditions that required continuous monitoring outside of the hospital setting.
Courtesy ACCP
Dr. Joshua A. Boster
In our CRPM process, the hospital inpatient unit or ED refer high-risk patients to a primary designated provider at each MTF for enrollment prior to discharge. Enrolled patients are equipped with an FDA-approved home monitoring kit that contains an electronic tablet, a network hub that operates independently of and/or in conjunction with Wi-Fi, and an armband containing a coin-sized monitor. The system has the capability to pair with additional smart-enabled accessories, such as a blood pressure cuff, temperature patch, and digital spirometer. With continuous bio-physiologic and symptom-based monitoring, a team of teleworking critical-care nurses monitor patients continuously. In case of a decompensation necessitating a higher level of care, an emergency action plan (EAP) is activated to ensure patients urgently receive emergency medical services. Once released from the CRPM program, discharged patients use prepaid shipping boxes to facilitate contactless repackaging, sanitization, and pickup for redistribution of devices to the MTF.
Courtesy ACCP
Dr. Kevin A. Loudermilk
Given the increased number of hospital admissions noted during the COVID-19 global pandemic, the CRPM program has allowed us to address overutilization of hospital beds. Furthermore, it has allowed us to address issues of screening and resource utilization as we consider patients for safe implementation of home monitoring. While data concerning the outcome of the CRPM program are pending, we are encouraged about the ability to provide high quality care in a remote setting. To that end, we have addressed technologic difficulties, communication between remote providers and patients in the home environment, and communication between health care providers in various settings, such as the ED, inpatient wards, and the outpatient clinic.
Courtesy ACCP
Dr. Kenneth R Kemp
To be sure, there are many challenges in making sure that CRPM adequately addresses the needs of patients, who may have persistent perturbations in cardiopulmonary status, tremendous anxiety about the progress or deterioration in their health status, and lack of understanding about their medical condition. Furthermore, providers face the challenge of making clinical decisions sometimes without the advantage of in-person examinations. Sometimes decisions must be made with incomplete information or when the status of the patient does not follow presupposed algorithms. Nevertheless, like many issues during the COVID-19 pandemic, patients and providers have evolved, pivoted, and made necessary adjustments to address an unprecedented time in recent history.
Ultimately, we believe that a continuous remote patient monitoring program can be designed, implemented, and maintained across a multifacility health care system for safe, effective, and efficient health care delivery. Limitations in implementing such a program might include lack of adequate Internet services, lack of telephonic communication, inadequate home facilities, lack of adequate home support, and, perhaps, lack of available emergency services. However, if the conditions for home monitoring are optimized, CRPM holds the promise of reducing the burden on emergency and inpatient hospital services, particularly when those services are strained in circumstances such as the ongoing global pandemic due to COVID-19. With further study, standardization, and evolution, remote monitoring will likely become a more acceptable and necessary form of health care delivery in the future.
Dr. Salomon is an Internal Medicine Resident (PGY-2); Dr. Muller is an Internal Medicine Resident (PGY-2); Dr. Boster is a Pulmonary and Critical Care Fellow; Dr. Loudermilk is a Pulmonary and Critical Care Fellow; and Dr. Kemp is Pulmonary and Critical Care staff, San Antonio Military Medical Center, Fort Sam Houston, Texas.