RPM 101: What Is Remote Patient Monitoring, Its Benefits, and Uses?

Remote patient monitoring (RPM) though by no means a new care modality is evolving rapidly, spurred by the constraints of the COVID-19 pandemic and the corresponding regulatory push to expand access to care.

In its simplest form, RPM involves the use of connected electronic tools to record personal health and medical data in one location that is reviewed by a provider at a different location. The data may or may not be viewed as soon as it is transmitted.

Increasingly, health systems are leveraging RPM to care for patients suffering from a myriad of conditions, including diabetes, hypertension, and COVID-19. In addition, regulatory changes enacted by the Centers for Medicare and Medicaid Services have bolstered this trend, indicating that RPM is becoming an important part of care delivery.

The basics of RPM

RPM can be used to treat both chronic and acute conditions, enabling clinicians to keep tabs on patients in-between clinic visits or when in-person care is not possible.

For chronic care, in particular, RPM enables clinicians to observe patients in near real-time, gather necessary data, and make adjustments to improve care outcomes. This type of continuous tracking is helpful for patients with ongoing care needs, such as those with diabetes, heart conditions, asthma, hypertension, mental illness, and, more recently, long COVID, that is, the long-lasting symptoms following COVID-19 infection and recovery.

RPM programs employ the use of various types of devices, like weight scales, pulse oximeters, blood glucose meters, blood pressure monitors, heart monitors, and even specialized monitors for dementia and Parkinson's disease.

Another category of RPM devices that can be used to track patients' health over the long term are wearables. These can range from more consumer-facing devices like smartwatches to continuous blood glucose monitors.

Wearables especially appear to be in demand, with Deloitte predicting that 320 million consumer health and wellness wearable devices will ship worldwide in 2022. That figure could jump to 440 million units shipped by 2024.

But RPM is not just useful for managing long-term diseases — it can be used for more urgent and acute conditions as well.

Increasingly, healthcare organizations are setting up hospital-at-home programs that enable treatment for higher acuity conditions at home. These programs can provide a wide array of services, including diagnostics like echocardiograms and X-rays, treatments such as oxygen therapy and intravenous fluids, as well as pharmacy and skilled nursing services.

Though hospital-at-home programs involve in-person care, they are supported by continual monitoring of biometrics by a care team and telehealth visits.

Further, remote patient monitoring can be used to track patient recovery once they have been discharged to their homes post-surgery. For example, the University of California Los Angeles Health System has a post-surgery RPM program for heart procedure patients. As part of the program, patients provide an array of biometric data like heart rate, blood pressure, and blood oxygen levels to their care team using devices provided in a kit. The team can track this data to ensure the patient is recovering as expected.

Clinical evidence backing RPM use

Research backing the clinical benefits of RPM has been available for well over a decade, with a study published back in 2005 showing that hospital-at-home care resulted in patients having a shorter length of stay — 3.2 days versus 4.9 days — and fewer complications.

Since then, clinical evidence has only grown, especially in the last two years spurred by the COVID-19 pandemic.

Just last year, a study published in JAMA Open Network found that hospital-at-home interventions that include at least one home visit from a nurse or physician may be a promising substitute to in-hospital care, especially for chronic diseases patients.

Further, RPM was used across the country to monitor COVID-19 patients at home as hospitals struggled to keep beds open for those who became critically ill.

Rochester, Minnesota-based Mayo Clinic published a study in npj Digital Medicine in 2021 that showed low rates of emergency department visits and hospitalization for COVID-19 patients enrolled in an RPM program. The ER visit rate was 11.4 percent, the hospitalization rate was 9.4 percent within 30 days of enrollment, and the 30-day mortality rate was 0.4 percent, according to the study.

Similarly, a Kaiser Permanente study revealed that of 13,055 patients enrolled in its COVID-19 Home Monitoring program between April 2020 and February 2021, 95.5 percent recovered and completed the program, 10.6 percent were admitted to the hospital, and 0.2 percent died.

Not only is RPM linked to enhanced or similar outcomes as in-hospital care for high-acuity conditions, but also long-term chronic conditions, like type 2 diabetes.

A study out of the St. Joseph's/Candler (SJ/C) health system in Savannah, Georgia, published last October, shows that people with diabetes who received care via RPM and telehealth during the pandemic saw their A1C levels drop, with 2 percent and 2.2 percent reductions at three and six months, respectively.

Another organization, Huntsman Cancer Institute at the University of Utah, studied its adult oncology hospital-at-home program and found that during the first 30 days of enrollment, patients in the program were 58 percent less likely to be admitted for an unplanned hospital stay, and those who were admitted to the hospital had a shorter length of stay.

Research organizations that provide funding are also pouring millions into studies focused on the use of RPM for neurodegenerative diseases like Alzheimer's.

In addition, there is research backing the use of RPM for post-surgery care and rehabilitation.

One study, published in 2020, touted a fourfold reduction in rehospitalizations among knee and hip replacement patients who used RPM tools at home rather than participate in a rehab program in person.

And just last year, a study published in the British Medical Association trade journal showed that while an RPM program didn't significantly affect the mortality or rehospitalization rate for non-elective surgery patients, it did significantly reduce pain and was linked with a significant increase in detection and correction of medication errors.

The non-clinical benefits of the modality

RPM's benefits are not limited to clinical improvements alone. The care modality can also help break down hurdles related to social determinants of health, that is, social factors that negatively affect health.

One major socioeconomic hurdle that holds people back from seeking care is transportation. In fact, 3.6 million people in the US do not obtain medical care due to transportation barriers, according to the American Hospital Association.

Transportation issues include lack of access to vehicles, broken infrastructure, long distances, and lengthy times to reach services, as well as transportation costs.

"Inherently, we all know that remote patient monitoring can eliminate that [transportation] barrier as we are meeting patients where they are," said Julie Henry, chief operating officer of digital medicine at New Orleans-based Ochsner Health at an mHealthIntelligence webcast last year. "Access to a provider…through technology and digital reach and telephonic intervention or secure texting and chatting can be that touchpoint rather than [patients] having to go into bricks and mortar."

The additional touchpoints enabled via RPM also provide health systems with more information about their patients' lives, allowing clinical teams to make adjustments to treatment plans in accordance with social determinants of health.

Not only is RPM beneficial for patients facing socioeconomic hurdles to care, but it also offers several advantages to healthcare providers.

One key advantage is the potential for cost savings. For example, Deaconess Health in Evansville, Indiana, saw its 30-day readmission rate drop by half after implementing an RPM program, translating into savings of $500,000 in costs associated with readmission, including penalties.

Another is the care modality's hand in freeing up space in hospital facilities for severely ill patients.

South Shore Health in Weymouth, Massachusetts, combined RPM with mobile health strategies to manage patient care outside the hospital.

"We are a health system that frequently functions at high capacity," said Kelly Lannutti, DO, director of clinical transformation and co-medical director of mobile integrated health for South Shore Health, at Xtelligent Healthcare Media's RPM Virtual Summit last year. "Our hospital is frequently at a 100 percent capacity or more. So for us, it really makes sense to move patients to alternate care settings where possible."

Setting up an RPM program

RPM uptake among providers has been rapid, particularly after the COVID-19 pandemic limited in-person care.

As explored above, RPM can be used in many ways, but identifying a specific need is the first step for any organization looking to establish a new program, according to the AMA Digital Health Implementation Playbook.

Next steps include forming a team, defining goals, and designing the workflow, which can be an incredibly challenging process for low-resource facilities whose staff may already be stretched thin, like federally qualified health centers.

To combat the issue, one California-based FQHC, Northeast Valley Health Corporation, created a new role: RPM project coordinator.

"We did decide that an RPM project coordinator would be most beneficial for really closely monitoring these patients on RPM and providing timely follow-up and acting as the liaison between the patient and our clinical care teams," said Alejandra Mata, program manager of chronic disease at NEVHC, in a phone interview with mHealthIntelligence.

Another critical step for most healthcare organizations is developing or implementing a platform to help them stay connected to their patients and enable data flow between the two. 

Health systems like Jefferson Health, Penn State Health, and UCI Health launched home care programs involving RPM in the past few months in partnership with technology vendors or home health companies.

The American Medical Association recommends finding a vendor that will be a long-term partner. To do so, providers should evaluate vendors across six variables: business, information technology, security, usability, customer service, and clinical validation.

Providers are not the only stakeholders interested in RPM

It's not just providers standing up RPM programs — payers are showing interest in the care modality as well.

Last August, UnitedHealthcare launched a new program in Tennessee that will leverage RPM to monitor pregnant individuals. The insurer partnered with the Tennessee Initiative for Perinatal Quality Care to leverage both RPM and connected health programs to train staff in hospitals across the state.

Humana teamed up with home health provider DispatchHealth to launch an RPM program in Denver and Tacoma, Washington, for chronic care management patients.

Other payers, like Independence Blue Cross, have issued grants to support the expansion of RPM and telehealth programs.

State and federal governments are also jumping on the RPM bandwagon, with the Department of Veterans Affairs announcing plans to pour $1 billion into an expansion of its RPM program and the Illinois Department of Aging launching an RPM program in partnership with Advocate Healthcare, OSF HealthCare, and Southern Illinois University School of Medicine.

Another player entering the RPM space is retail companies. Best Buy purchased RPM provider Current Health for $400 million last October and, in its most recent earnings call, laid out its three-pronged healthcare strategy, which includes virtual care.

The billing and regulatory landscape for RPM

The swift rise in RPM's popularity was supported by numerous regulatory changes and flexibilities enacted during the COVID-19 pandemic.

For example, the CMS waived the requirement for an established relationship between the patient and physician for RPM coverage during the public health emergency.

As the pandemic continued, CMS refined its payment policies for RPM. For example, to meet the requirements to bill CPT codes 99453 and 99454 — two RPM payment codes — 16 days of data for every 30 days of remote monitoring must be collected and submitted.

Further, RPM services can be considered medically necessary for patients with acute conditions as well as patients with chronic conditions.

Last year, RPM reimbursement expanded further when CMS included a new category of CPT codes in its 2022 Physician Fee Schedule to address remote therapeutic monitoring (RTM). The final fee schedule includes a family of five codes that provides reimbursement for services related to the collection of non-physiologic data, such as respiratory system status and therapy adherence.  It also permits therapists and other qualified healthcare professionals to bill for the RTM codes.

But experts noted some limitations in this new category. Nathaniel Lacktman and Thomas Ferrante, partners with Foley & Lardner, noted that the RTM device supply codes apply to particular use cases, leaving out programs addressing neurological, vascular, endocrine, and digestive systems.

"Limiting reimbursement to these specific device types ignores Software as a Medical Device and other devices that collect important non-physiologic data on pain, mood, adherence, etc.," Nixon wrote in a blog post published last July.

At the state level, 27 states have some form of reimbursement for RPM in their Medicaid programs, according to the Center for Connected Health Policy. But a majority of them also have restrictions linked to RPM payment, including restricting the clinical conditions for which symptoms can be monitored and limiting the type of monitoring device and information that can be collected.

In addition to expanding reimbursement for RPM, CMS established the Acute Hospital Care at Home program in November 2020, which allows participating hospitals to treat certain acute care patients at home through telehealth and RPM. The program builds off CMS' Hospitals Without Walls program, which was launched in March 2020 to help hospitals cope with the surge of COVID-19 patients flooding their facilities.  

As of Jan. 20, 90 health systems, comprising 197 hospitals in 34 states, are approved to participate in the Acute Hospital Care at Home program.

The push to advance RPM is ongoing

RPM use has seen sharp increases over the past few years. According to a survey by the American Medical Association, 20 percent of physicians said they used RPM in 2020, which is double the number from 2018. Of the physicians using RPM, one-third were specialists, led by cardiologists (63.3 percent) and endocrinologists and diabetes care physicians (41.6 percent).

Another survey, which polled 300 Americans last May, showed that four out of five US adults are in favor of RPM and nearly half are in favor of incorporating it into medical care.

These statistics indicate that RPM is here to stay. As a result, providers are pushing for its expanded use.

A group of prominent health systems, including Geisinger Health System and Johns Hopkins Medicine, has launched a coalition that aims to back strategies supporting the delivery of hospital-level care at home.

Not only that, Mayo Clinic and Kaiser Permanente poured $100 million into Medically Home, a Boston-based company that operates acute care-at-home programs, last May. Then, earlier this year, the systems joined in a $110 million funding round for the company, showing their ongoing commitment to the hospital-at-home model.

In addition to provider investment in RPM, researchers are developing new, more efficient devices for patients to use at home.

One example of this is an RPM finger clip device, developed by engineers from the University of Missouri, which can noninvasively monitor an individual's blood pressure.

As RPM technology and protocols become more sophisticated, it is easy to see a scenario where a significant portion of patient care is provided outside the hospital's four walls. The brave new world of expanded at-home care is upon us, and it appears that healthcare stakeholders are ready to embrace it.