Remote Patient Monitoring (RPM) is not a new concept and the system has refined over the last 3 decades. There is a recognized need to increase the usage of such a service in light of the global pandemic. New technologies e.g. 5G networks have improved the ability to stream large volumes of data. The prediction is that RPM will gain a stronger foothold and be the main care system for patients. While it may seem that everyone is talking about RPM, do you actually know everything there is to know about it? This article acts as a primer to RPM. Following articles in the coming weeks will provide deeper insights into this area.
Let’s start the ball rolling with a few terminologies:
Healthcare is defined as the organized provision of medical care to individuals or a community.
Telehealth is defined as the delivery and facilitation of health and health-related services including medical care, provider and patient education, health information services, and self-care via telecommunications and digital communication technologies.
Telemedicine is the delivery of health care services, by health care professionals using information and communication technologies for the exchange of information for the diagnosis, treatment, and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers.
In the article What Is Telehealth?, the technologies used can range from mHealth (mobile health), video and audio technologies, digital photography, remote patient monitoring (RPM) and store and forward technologies. RPM involves the reporting, collection, transmission, and evaluation of patient health data through electronic devices such as wearables, mobile devices, smartphone apps, and internet-enabled computers. It is a continuous cycle of data collection, data transmission, evaluation of the data, notification of the patient, and intervention.
What are the devices used for remote monitoring?
Devices used for remote monitoring vary depending on the clinical condition of the patient. Fitbit, Garmin, and Apple were consumer-grade devices that provided health-related data. In recent years these consumer devices have moved towards being medical grade. Apple’s ECG app was cleared by the FDA as a Class II device in 2018. Fitbit’s ARIA Wifi Smart Scale is actually also a Class II medical device. A medical-grade health monitor needs to be approved by the relevant healthcare authorities in the countries that they are used in.
Remote patient monitoring devices can include blood pressure monitors, continuous glucose monitors, electrocardiography (ECG) devices, heart rate monitors, medical alert systems (e.g. for falls), maternity care monitoring, pediatric at-home monitoring, pulse oximeter, smart scale, medication monitoring, patient wearables. To ensure the quality of data collected for use in medical diagnosis, treatment, and management it would be highly desirable that the device used is an approved medical device as classified by the relevant regulatory authorities. The medical device approval will in general also cover the digital network where the information is transmitted and accessed for analysis.
How does remote monitoring work?
Remote monitoring has been in existence for decades. The main form of data transmission used to be the telephone. Some of the earlier use cases were in the cardiac and diabetes space. The patient would measure their health parameters using devices e.g. blood pressure monitors, blood glucose monitors. They rang the physician or nurse relaying their results. The physician or nurse will then provide directions for further care. In the case of pacemakers, the information is relayed by connecting the pacemaker to a telephonic device. These methods are still viable options depending on the clinical situation and communication infrastructure.
Remote monitoring based on simple phone calls showed a positive effect on the health outcomes of patients. Even as early as 1997, the use of a remote monitoring system produced a 3-fold reduction in diabetes-related crises (hyper- or hypoglycemia) and HBA1c (a marker of diabetes control) fell significantly in patients actively using the system. The system was a voice-interactive, physician-directed care offered 24 hours a day via touch-tone telephone. Patients called the number each day to self-report their blood glucose levels, symptoms, dietary changes, planned exercise, stress, and other lifestyle events. They received immediate advice with respect to medication dosing changes and other pertinent feedback.
More recent studies showed increased patient satisfaction when using remote monitoring versus traditional on site consultations. One of the studies was on prenatal care and remote monitoring was conducted with the use of fetal Doppler and blood pressure monitoring with the data transmission and communication through the phone or online communication.
Who is part of the remote monitoring team?
The cardiovascular space has been one of the early adopters of remote monitoring and the Heart Rhythm Society outlines the roles and responsibilities of the remote monitoring team members which include the patient:
- Patient – The patient (and caregiver if there is one involved in the care process) needs to be educated about the benefits and limitations of the system, what to expect from the system, his/her responsibilities (which include keeping contact details up to date, travel plans, keep provider information of any other medical conditions and drug changes…etc)
- Physician – The physician’s interpretation and documentation is the final step and they should be familiar with the capabilities and limitations of the systems in use by their healthcare facility or the service provider
- Mid-level provider – in the US these are nurse practitioners or physician assistants who function as independent practitioners and work under the supervision of a licensed physician. It may vary in other countries. They have to be adequately trained in the area of surveillance. Guidelines that outline their scope of practice should be used.
- Allied professionals – trained personnel who provide a timely and complete review of transmitted information.
- Ancillary staff – non-clinical administrative work needed to support the system e.g. to remind patients of appointments, patient support for connectivity or troubleshooting.
- Institution or Clinic – establish the standard operating procedures for the RPM service including management of device manufacturer and other third-party providers.
- Third-party provider – trained, qualified, and certified in the care of service.
- CIED manufacturer – ensure that adequate evidence is gathered to support the safety and effectiveness of the technology and adherence to regulatory requirements.
As illustrated in the above section the deployment of RPM involves multiple stakeholders. A clear implementation plan that includes the roles and responsibilities of all the involved parties should be in place to make the deployment of such a service safe and effective for the patient.
- RPM is only a subset of telehealth and by itself can address some of the issues surrounding the delivery of healthcare across a distance but not all of it.
- Remote monitoring devices should be verified medical devices so that the quality of data collected.
- Delivery of a successful RPM is a team-based approach that includes the patient, healthcare provider, and device manufacturers.