Telehealth News: Research & News Recap
Interest in remote patient monitoring (RPM) and its positive impact continues to grow as providers see the benefits of adding telehealth to their workflow. This has led to increased and extensive research on telehealth as well as changes to government policies. Explore recent research on the efficacy of telehealth and understand new rulings from the Center of Medicare and Medicaid Services (CMS) in HRS’ December 2019 Research & News Recap.
Part I. Research Findings - Remote Patient Monitoring and Telehealth
In this section four studies conducted within the last year on various RPM and telehealth topics are analyzed. Real quantitative and qualitative data from telehealth patients was collected, studied, and conclusions were drawn in the studies included below. The results point to the positive impacts of RPM in healthcare and the growth potential of telehealth.
Article 1
Telemedicine Based Remote Home Monitoring After Liver Transplantation
What was studied?
Researchers at the University of Cincinnati conducted a randomized control nonblinded pilot trial aimed at assessing the impacts of telemedicine and RPM on patients who had undergone orthotopic liver transplantation (OLT). The study population consisted of 100 liver transplants recipients randomized into two groups: a control of standard care (SOC) and an intervention of telemedicine-based home management (THMP). The THPM included an electronic tablet and Bluetooth devices that enabled daily text messages, educational videos, and video FaceTime capabilities. Researchers found a decrease in readmission, improved adherence, and improved quality of life (QOL) among the THMP group.
Research Findings
- Vital sign monitoring adherence of 85% among THMP group
- 90 day hospital readmission rate of 28% with THMP, compared to 58% with SOC
- At 90 days, compared to discharge, THMP patients had improved QOL for physical function and general health
- Patients commented that the biggest determinant for QOL was time spent at home, as opposed to in the hospital
- Patients enjoyed the educational content, especially the video educational content on the RPM device
Why do these findings matter?
The traditional postoperative care paradigm is a “one size fits all approach,” often requiring weekly follow up visits to the clinic in the immediate post-op period. Telehealth individualizes care to improve patient outcomes as it incorporates patient preferences, needs, and expectations. This research supports this notion, identifying RPM post liver transplant (LT) as a viable and beneficial option. The magnitude of the THMP’s program on adherence, readmission, and QOL strongly supports the potential of telemedicine for the postoperative LT patient.
While not explicitly studied in this research, telemedicine has also been found to increase medication adherence, self-monitoring, and laboratory testing in LT patients. We believe that there’s huge potential for telehealth and remote patient monitoring technologies post hospital discharge for LT, and other surgery. Keeping patients at home, especially while they’re vulnerable post discharge is the value that telehealth ads. If a postoperative patient can remain at home, receive the same quality of care, AND see improved outcomes, why require weekly follow up visits to the brick and mortar clinic or hospital setting?
Access the full article, here.
Date Published: October 1, 2019
Lee, Tiffany C., et al. “Telemedicine Based Remote Home Monitoring After Liver Transplantation.” Annals of Surgery, vol. 270, no. 3, 1 Oct. 2019, pp. 564–572., doi:10.1097/sla.0000000000003425.
Article 2
Patient Expectations and Experiences of Remote Monitoring for Chronic Diseases: a Systematic Review and Thematic Synthesis of Qualitative Studies
What was studied?
The goal of this study was to gain an understanding of the beliefs, attitudes, expectations and experiences of patients with chronic conditions using remote patient monitoring (RPM). Researchers analyzed over 16 studies with 307 total participants in more than 8 countries. They pinpointed four general themes of RPM to focus their analysis on: including gaining knowledge and triggering action, reassurance and security, concern about additional burden, and jeopardizing interpersonal connections. Results indicated that RPM helped patients with chronic conditions advance their disease specific knowledge, improve care plan self-management, and increase shared decision making between them and their provider. Additionally, RPM prompted earlier clinical assessment and treatment.
Research Findings
- Patients reported that remote monitoring facilitated an increased understanding of their condition
- Patients reported a greater certainty about when to take medical action themselves and felt confident and empowered to self-manage their care plan
- RPM led patients to a sense of reassurance and security in remaining independent at home and “aging in place”
- A reduced level of anxiety and stress in patients was identified due to RPM providing patients a greater peace of mind
- Patients showed a reluctance to learn the new technology in 4 of the studies analyzed
Why do these findings matter?
Chronic disease affects approximately 133 million Americans, more than 40% of the total population. As the prevalence of chronic disease continues to rise across our population, it is essential that providers and patients have tools beyond the four walls of the hospital or clinic. Remote patient monitoring (RPM) is an accepted tool for improving health outcomes and ultimately reducing readmissions. Also at the core of RPM is increasing the patients’ independence, care plan engagement and condition understanding (health literacy).
With the plethora of articles and research being conducted on RPM, it is a challenge to sift through it all and find what the general trends and attitudes toward telehealth are. This study did just that and found that for patients with chronic conditions, RPM has many positive impacts. Equally important to reduced readmission and cost avoidance, is patient perception, ease of use and quality of life. Bottom line, for RPM to be effective, it is vital that patients are comfortable with and believe in it capability. This research discusses how RPM empowered patients to self-manage their care, eliciting a confidence in their care plan and prognosis. We see this time and time again - RPM helps patients understand their condition and gives them the tools to have control over their care plans.
The researchers did mention that patients, especially elderly patients were reluctant to use new technology, and worried about losing the personal face-to-face contact with their provider. These are valid and common concerns. With training and around-the-clock support, the reluctance to new technology can be mitigated. RPM these days is designed with the elderly user in mind. The concern around lack of interpersonal contact brought up by many patients can be alleviated through communication tools such as video, messaging, and calling. In many cases, RPM is used to augment face-to-face visits, i.e. the patient still sees their provider, just not as frequently. RPM can serve as a great check-in and follow up tool between visits.
Access the full article, here.
Date Published: June 5, 2019
Walker, Rachael C., et al. “Patient Expectations and Experiences of Remote Monitoring for Chronic Diseases: Systematic Review and Thematic Synthesis of Qualitative Studies.” International Journal of Medical Informatics, vol. 124, 5 May 2019, pp. 78–85., doi:10.1016/j.ijmedinf.2019.01.013.
Article 3
On Digital Intimacy: Redefining Provider-Patient Relationships in Remote Monitoring
What was studied?
The Centre of Information and Communication Technology conducted this study as part of a clinical trial aimed at assessing the efficacy of RPM for type 1 diabetes. This study analyzed two groups, 15 recruited adult patients with poorly controlled diabetes and 10 pregnant women with previous experience of diabetes self management. Researchers analyzed 396 text message conversations between provider and patient to determine how virtual connection influences the patient-provider relationship. Researchers found that RPM enables patients and their providers to achieve “digital intimacy” redefining the patient-provider relationship.
Research Findings
- 83.5% of the conversations were initiated by the healthcare professionals who were alerted by reading the clinical data.
- There were four recurring themes in content glycaemic control, education, motivation, and context (information regarding the patient's daily lives).
- Both patients and providers believe that the sharing and discussing of clinical data through messages leads to a form of “closeness” not experiences before the user of technology.
- Through the digital platform, clinicians seek explanations of anomalous values, going beyond self management actions and examining the existence of external events
- The remote monitoring technology enables the provider to both “know the patient” and “know about the patient” leading to a more comprehensive care.
Why do these findings matter?
Digital intimacy is defined as “the relationship characterized by a thorough familiarity made possible, sustained, or reinforced through electronic devices by means of both data sharing and personal communication”. Researchers pose that technology-mediated communication between the patient and provider can strengthen their relationship beyond face-to-face encounters. The provider gets insight into the patients routine outside the clinic, while also receiving information about the patients’ disease state - they are able to understand the holistic picture.
This study is very compelling, as it challenges the notion of the loss of personal connection with RPM. These findings show that in actuality, a new type of patient-provider relationship is formed, one that enables thorough communication, and ultimately quality care.
Access the full article, here.
Date Published: January 13, 2019
Piras, Enrico Maria, and Francesco Miele. “On Digital Intimacy: Redefining Provider–Patient Relationships in Remote Monitoring.” Sociology of Health & Illness, vol. 41, no. S1, 2019, pp. 116–131., doi:10.1111/1467-9566.12947.
Article 4
Effect of Remote Monitoring on Patient-Reported Outcomes in European Heart Failure Patients with an Implantable Cardioverter-Defibrillator: Primary Results of the REMOTE-CIED Randomized Trial
What was studied?
This study was conducted to evaluate the effectiveness of RPM among heart failure patients. 595 heart failure patients were implanted with an implantable cardioverter-defibrillator (ICD). The ICDs used in the study were compatible with an RPM system. Post surgery, patients were randomized to either receive RPM plus a yearly in person checkup, or 3-6 month in clinic check ups, and no RPM. At five different points throughout their two year post surgery care, patients in both groups completed questionnaires and surveys to assess their heart failure-specific health status and ICD acceptance. Data regarding each patient's clinical status was collected from patients medical records. Linear regressions were run using this aggregated data in order to compare the scores between the two different test groups. Results showed no significant change between the two groups in terms of the patients health status and ICD acceptance scores.
Research Findings
- Patient-reported heart failure specific health status and ICD acceptance did not differ between RPM and in-clinic monitored patients for the first two years post implantation
- RPM is not different to in-clinic follow up as it related to patient-reported health status
- Between 3 and 6 months after ICD implantation, ICD acceptance improved for In-Clinic patients, while remaining stable in the other groups.
- The ICD acceptance after 12 months for the In-clinic patients became non-significant again.
- During the study, 34/298 allocated in-clinic group switched over to the rpm group, while only 16/302 allocated RPM group needed to switch to the In-Clinic group.
Why do these findings matter?
Heart Rhythm Society stated in 2015 that RPM is preferred over a calendar-based schedule of in-clinic check-ups alone, and recommended that it should be offered to all patients with CIEDs. Before this research was conducted, patient-reported evidence of RPM efficacy for ICC patients was limited and inconclusive.
This clinical trial underscores that RPM is a safe alternative to most in-clinic check ups for ICD patients. There was no difference in the health status and ICD acceptance rates for the first two years after ICD implantation, between those receiving RPM and one yearly clinic check-up vs those receiving multiple clinic checkups a year with no RPM. Results from this research support RPM as an effective replacement or augmentation to the traditional clinical-checkups for ICD patients.
Access the full article, here.
Date Published: October 10, 2019
Versteeg, Henneke, et al. “Effect of Remote Monitoring on Patient-Reported Outcomes in European Heart Failure Patients with an Implantable Cardioverter-Defibrillator: Primary Results of the REMOTE-CIED Randomized Trial.” EP Europace, vol. 21, no. 9, 2019, pp. 1360–1368., doi:10.1093/europace/euz140
Part II. Reimbursement Updates
Over the past year, the Centers for Medicare and Medicaid Services (CMS) have made changes to their policies in order to make telehealth more accessible across the country. A summary of changes released in November 2019 is summarized below.
Article 5
CMS Finalizes New Reimbursement Rules for Remote Patient Monitoring
Overview: This article provides an overview of the new reimbursement rules for RPM that CMS has recently finalized to expand connected health services. CMS recently released its final rule on Chronic Care Remote Physiological Monitoring in which they have finalized two changes:
- RPM services can be delivered “incident to” general supervision (CPT codes 88457 and 99458)
- CPT code 99458, a new add-on code for 20 additional minutes of RPM services in a given month (after code 99457 which is the first 20 minutes of RPM services)
The incident to clause extends RPM reimbursement to more providers, expanding the business application for connected care.
CMS defines an “incident to” service as a service performed under the supervision of a qualified healthcare professional and billed to Medicare in the name of that professional, subject to certain requirements. Importantly, with the new ruling, the physician or other qualified healthcare professional supervising the auxiliary personal does not need to be the same person treating the patient more broadly. CMS also ruled that RPM can be furnished under general supervision rather than direct supervision which the previous rule had stated. This means that both the physician and care team members no longer need to be in the same building at the same time.
The new CPT code, 99458, states patients can receive an additional 20 minutes of mHealth services a month, in addition to the first 20 minutes covered by CPT code 99457.
These new changes greatly expand the potential business models for RPM.
Access the full article, here.
Date Published: November 5, 2019
Wicklund, Eric. “CMS Finalizes New Reimbursement Rules for Remote Patient Monitoring.” MHealthIntelligence, MHealthIntelligence, 5 Nov. 2019, mhealthintelligence.com/news/cms-finalizes-new-reimbursement-rules-for-remote-patient-monitoring.
Article 6
Final Rule (Centers for Medicare & Medicaid Services Article Number 2019-24086)
Overview: This document discusses updates of policies under the Centers for Medicare & Medical Services (CMS), HHS. It addresses changes to the physician fee schedule (PFS) as well as other changes to Medicare Part B Payment Policies. All regulations are to take effect on January 1, 2020. These are the same updates discussed above.
Date Published: November 15, 2019
Access the full article, here.