Experts say that obesity rates have doubled over the past two decades, with roughly 42% of the American adult population now fitting that description, and they anticipate that half of the world's population will be obese by 2030. Obese Americans run a much high risk of developing chronic conditions like diabetes and heart disease, and they account for roughly $480 billion in annual direct healthcare costs.
Yet the healthcare industry has long struggled to define obesity.
"Obesity has not been traditionally seen as a disease," says Maria Daniela Hurtado Andrade, MD, PhD, a specialist in endocrinology with the Mayo Clinic and part of the research team. "That limits treatment options" as well as how payers view treatments. "Our goal is to collect all this data to understand how it can lead to a very good understanding of predictors to weight loss and weight loss interventions."
The biobank registry collects biological and clinical data from patients, including DNA, metabolomics, hormones and observational information such as behavioral assessments. The data will help researchers gain a better picture of obesity, and has already been instrumental in mapping out four specific obesity phenotypes.
The Mayo Clinic's Rochester campus is contributing patient outcomes from 2,000 patients undergoing treatment for obesity to the biobank, and it will be participating in the nationwide study aimed at monitoring the phenotypes of patients undergoing a variety of treatments in health systems across the country.
Hurtado sees biobank registries as the next step in the ever-growing precision medicine movement, which aims to not only perfect the gathering of individual data but design treatments that address specific patients or groups of patients.
From that point, researchers focus on phenotypes, or the combination of genes and environmental and behavioral factors that cause certain conditions. Hurtado calls this activity of studying and mapping the function of genes "the Snapchat of the state of health."
"We don’t have that understanding of obesity yet," she says, because the healthcare industry has been slow to characterize it as a disease. "Too many [providers] have a view of obesity as 'You caused it.' They don't see it like they see cancer" or other chronic conditions like diabetes, asthma, and COPD.
According to Phenomix and the Mayo Clinic, there's a movement within healthcare to take obesity more seriously and classify it as a chronic condition, caused by not one specific disease but "a constellation of diseases." While its roots may lie in the DNA, they feel that outside factors including age, race, gender, education, and socioeconomic status also have an impact.
Hurtado says the partnership between Phenomix and the Mayo Clinic is important because it legitimizes the biobank at a time when other research institutes may be developing their own resources, which in turn leads to data silos that hinder research. Officials hope the Mayo Clinic's participation will spur other health systems to join.
“This is an exciting time in the evolution of obesity medicine,” Mark Bagnall, CEO of Phenomix Sciences, said in a May press release announcing the Mayo Clinic partnership. “Our biobanking agreement with Mayo Clinic is an important opportunity to make vast strides in how we understand the complexities of obesity treatment. We believe the biobanking registry investment will better support obesity centers by providing concrete evidence and insights into how DNA and other factors need to be considered in treatment. The upside is significant for patients and payers. Patients get the right treatment the first time and payers avoid paying for a costly trial-and-error approach.”
Hurtado says both the registry and study will be "life-changing."
"In the past, treating obesity has been like shooting in the dark," she says. "Now we're beginning to take it seriously. This will lead to positive outcomes in treatment, which will make payers take interest ... and become more open to coverage."
Vanderbilt University Medical Center has designed an innovative care management program that has helped Metro Nashville Public Schools save thousands of dollars and improve outcomes for its pregnant teachers.
A bundled payment program developed by Vanderbilt Health for the Metro Nashville Public Schools (MNPS) health plan saved more than $400,000 in its first year, while dramatically improving clinical outcomes for expectant teachers and their babies.
The success of the MyMaternityHealth program, says CJ Stimson, MD, JD, chief medical officer at Vanderbilt University Medical Center and Vanderbilt University Employee Health Plans, is based on the idea that patients and their care providers are a team.
"People don't feel like their health systems are going with them on their journey," says Stimson, who's also senior vice president of value transformation in VUMC's Office of Population Health. "So we told them we'll take all the risk."
Bundled payment programs were once considered the future of healthcare and the foundation for value-based care, but there have been just as many failures as successes. In their most basic form, they assign a certain payment that a care provider will receive from a payer for a care path, such as surgery or acute care treatment. The care provider creates a treatment plan based on the knowledge that they will be paid that one amount, accepting the risk that treatment won't become complicated and cost more than what was paid.
The program compels providers to focus on improving outcomes and ensure that each treatment offers value. And it creates an incentive for trying new strategies that reduce costs and boost outcomes.
Stimson, who spent several years as an advisor to the Center for Medicare & Medicaid Innovation, which defined Medicare's bundled payment strategy, says the program gives care providers the freedom to map out how they want a treatment plan to work.
"Our providers were the ones who really designed that clinical experience," he says. "It really kind of liberated them."
CJ Stimson, MD, JD, chief medical officer at Vanderbilt University Medical Center and Vanderbilt University Employee Health Plans and senior vice president of value transformation in VUMC's Office of Population Health. Photo courtesy VUMC.
In this program, providers are given the freedom to follow their care plan without, as Stimson puts it, "asking for permission all the time."
"How you pay for care matters," he says. "This changes how you deliver care. You throw out all the old payment rules and start with a clean slate, and you design the best patient experience that you can."
The program recently earned a KLAS Research Points of Light Award for Vanderbilt Health and Cedar Gate Technologies, which provided the technology infrastructure that allows Vanderbilt to gather and track data and manage their patient population. According to KLAS, the award "celebrates success stories—or points of light—from payers, providers, and healthcare technology companies that work collaboratively to align care delivery with health plan sponsor initiatives to reduce inefficiencies and improve the patient experience."
Stimson says he'd initially proposed musculoskeletal care as an ideal service for a bundled payment plan, but the MNPS health plan suggested maternity care. The health plan was seeing high rates of C-sections and neonatal intensive care unit (NICU) services, two expensive services that are sometimes linked to a lack of preventive care or gaps in maternity care.
The key to an effective bundled program, he says, lies in the data. Care providers need that information to map out a care management plan that anticipates needs before they occur and reacts to trends before they develop into concerns.
"Predictability is important," he says. With that data in hand, providers have a better chance of identifying gaps in care and correcting them, or recognizing that a certain patient may be trending toward a complicated birth and putting resources in place to ease those complications.
Vanderbilt and the MNPS health plan have seen some measurable results since launching the bundled payment program. The c-section rate dropped from 40% to 29%, a 25% reduction over the historical marketplace experience, while NICU spending decreased about 16% in the first year. That amounted to about $400,00 in savings during that first year, alongside an increase in healthy births and a Net Promoter Score in the 90th percentile.
In addition, the program removed out-of-pocket costs for patients, saving each mom-to-be as much as $2,500.
"That's a significant savings," Stimson says. And it's a key metric for this population. Eliminating those out-of-pocket costs reduces stress on new or soon-to-be mothers and their families, taking away a factor that can lead to complex or complicated births and healthcare challenges.
Stimson says the program works because it eliminates one of the biggest hassles in care—who pays for what and when—and gives patients and their care providers the freedom to focus on care. And with data in hand from their technology platform, care teams are more confident in knowing how each patient is doing and can spot trends before they become concerns. Patients, meanwhile, get help when they need it, and are encouraged to follow doctor's orders and maintain healthy habits.
Vanderbilt now has several bundled payment programs up and running: Total joint, spine, bariatric, and cochlear implant services were launched in 2021, and medical weight loss, osteoarthritis, and shoulder pain were added this year. Across these bundles, the health system is seeing roughly 250 enrollments per month so far in 2022.
"We want to keep expanding our portfolio to other service lines," Stimson says.
He'd also like to introduce more telehealth and digital health services, even remote patient monitoring, to create what he calls a "care package" around patients. There might also be room for care navigators to help patients identify and access healthcare services and additional resources.
And he'd like to show off the program to other health systems and explain how it works.
"We don’t have it all licked," he says. "These programs only work if everyone is on board … but this proves that [bundled payment programs] can make a difference."
Amazon has announced plans to buy concierge care company One Medical for almost $4 billion, positioning the retail giant right in the middle of an ever-growing battleground for primary care.
Amazon is getting into the primary care business.
The retail giant has announced that it is acquiring One Medical, the concierge-styled primary care company with a telehealth platform and more than 125 brick-and-mortar locations scattered across the country. The deal, valued at roughly $3.9 billion, would be Amazon's third-largest acquisition, giving the company a physical footprint alongside Amazon Pharmacy and Amazon Care, a virtual care platform for businesses.
“We think healthcare is high on the list of experiences that need reinvention,” Neil Lindsay, Amazon's senior vice president of Amazon Health Services, said in a press release. “Booking an appointment, waiting weeks or even months to be seen, taking time off work, driving to a clinic, finding a parking spot, waiting in the waiting room then the exam room for what is too often a rushed few minutes with a doctor, then making another trip to a pharmacy – we see lots of opportunity to both improve the quality of the experience and give people back valuable time in their days.”
“There is an immense opportunity to make the health care experience more accessible, affordable, and even enjoyable for patients, providers, and payers," added One Medical CEO Amir Dan Rubin, who will continue as CEO.
The announcement fits with the idea that primary care is becoming a hotly contested battleground, featuring competition from traditional healthcare organizations as well as telehealth companies and payers with their own provider networks and retail behemoths like Amazon, Google, Walmart and Walgreens.
All are trying to lay the groundwork for on-demand primary care services, either in person or through virtual care channels. Amazon's strategy is to make that encounter as ubiquitous as buying something on its website.
Nathan Ray, a partner in the healthcare segment of national management and technology consultant West Monroe, said the deal makes Amazon a major player in the ever-shifting healthcare market.
"Amazon continues to make forward progress towards being a broad and dynamic healthcare entity with the acquisition of One Medical, their activity here and in recent past within many of the most actively evolving areas of healthcare has shown they have an evolving strategy towards developing their role in the healthcare marketplace and now entering primary care (and risk contracting) the true center of focus and change after incrementally building relevance in DME, pharmacy, virtual care and employer health," he said in an e-mail to HealthLeaders.
"Amazon and One Medical will have some great opportunities to continue to improve on today’s technology and in particular evolving digital intelligence and engagement technologies that drive intervention, clinician effectiveness, and action based on both historic and real-time data and analytics that underpin the ability to develop and scale successful care models," he added.
Ray noted further that the deal does have some concerns.
"This move tells us both that Amazon is aware of what they lack, but also that they really may not have a grand strategy as of yet but are continuing to find value buying (particularly on the downbeat of the market here) and developing both solutions and services within the healthcare space that give them options," he said.
"The biggest questions I have are when will we begin to see more of Amazon’s signature of technology enablement, easy access, low cost and service quality begin to reveal itself within healthcare through this acquisition, and how might Amazon’s skill with those design elements yield market advantage," he added. "Primary care is a highly dynamic space with payers, providers, and healthcare services and technology organizations all focused on many of the same population health and risk attribution tools and concerns and a slow war of care models, utilization, and financial performance playing out as significant capital has entered from both private and public markets over the last 3-5 years particularly motivated by growth coming from managed care, particularly Medicare Advantage."
The characteristics are part of a Special Fraud Alert issued by the Health and Human Services Department's Office of the Inspector General, and give healthcare organizations an idea of what to look out for in dealing with telehealth companies.
Federal officials have issued a Special Fraud Alert targeting contracts with telehealth companies and offered seven characteristics of an arrangement that could be illegal.
The notice, issued by the Health and Human Services Department's Office of the Inspector General, follows several recent investigations into companies claiming to offer what they define as telehealth services, but which often constitute illegal marketing schemes.
"While the facts and circumstances of each case differed, often they involved at least one practitioner ordering or prescribing items or services for purported patients they never examined or meaningfully assessed to determine the medical necessity of items or services ordered or prescribed," the OIG notice reads. "In addition, telemedicine companies commonly paid practitioners a fee that correlated with the volume of federally reimbursable items or services ordered or prescribed by the practitioners, which was intended to and did incentivize a practitioner to order medically unnecessary items or services. These types of volume-based fees not only implicate and potentially violate the federal anti-kickback statute, but they also may corrupt medical decision-making, drive inappropriate utilization, and result in patient harm."
Telehealth advocates like the American Telemedicine Association have long argued that many of these cases don’t involve telehealth, and they've worried that the industry will be tarnished by a few bad actors. In a blog post analyzing the OIG notice, Nathanial Lacktman, a partner with the Foley & Lardner law firm, chair of its telemedicine and digital health industry team and a national expert on digital health law, also noted that difference.
"[The] OIG was careful to state that not all telemedicine companies are suspect, and this alert is not intended to discourage legitimate telemedicine arrangements," he wrote. "Indeed, in 2021, [the] OIG previously noted, '[f]or most, telehealth expansion is viewed positively, offering opportunities to increase access to services, decrease burdens for both patients and providers, and enable better care, including enhanced mental healthcare.' [The] OIG is aware that many practitioners have appropriately used telehealth services during the current Public Health Emergency (PHE) to provide medically necessary care to their patients."
To help healthcare organizations identify potential problems in their telehealth arrangements, the OIG highlighted these characteristics:
The purported patients for whom the practitioner (clinician) orders or prescribes items or services were identified or recruited by the telemedicine company, telemarketing company, sales agent, recruiter, call center, health fair, and/or through internet, television, or social media advertising for free or low out-of-pocket cost items or services.
The practitioner does not have sufficient contact with or information from the purported patient to meaningfully assess the medical necessity of the items or services ordered or prescribed.
The telemedicine company compensates the practitioner based on the volume of items or services ordered or prescribed, which may be characterized to the practitioner as compensation based on the number of purported medical records that the practitioner reviewed.
The telemedicine company only furnishes items and services to federal healthcare program beneficiaries and does not accept insurance from any other payer. (Lacktman pointed out that [the] OIG noted instances in which a telemedicine company requires the practitioner to use audio-only technology to facilitate engagement with purported patients, regardless of their preference, and does not provide the practitioner with other telehealth modalities. Additionally, a telemedicine company may provide a practitioner with purported 'medical records' that reflect only cursory patient demographic information or a medical history that appears to be a template but does not provide sufficient clinical information to inform the practitioner’s medical decision-making.)
The telemedicine company claims to only furnish items and services to individuals who are not federal healthcare program beneficiaries but may in fact bill federal healthcare programs. (As noted by Lacktman, an attempt to carve out federal healthcare program beneficiaries from arrangements with telemedicine companies may still result in criminal, civil, or administrative liability for a practitioner’s role in any resulting fraudulent activity that involves federal healthcare program beneficiaries.)
The telemedicine company only furnishes one product or a single class of products (e.g., durable medical equipment, genetic testing, diabetic supplies, or various prescription creams), potentially restricting a practitioner’s treating options to a predetermined course of treatment.
The telemedicine company does not expect practitioners (or another practitioner) to follow up with purported patients nor does it provide practitioners with the information required to follow up with purported patients (e.g., the telemedicine company does not require practitioners to discuss genetic testing results with each purported patient).
The alert comes as healthcare organizations are trying to navigate the murky waters of the Public Health Emergency brought on by the pandemic, which prompted federal and state regulators to issue waivers allowing for expanded use and coverage of telehealth services. It also led to an increase in criminal activity, and to confusion around what could and couldn't be done with virtual care.
That confusion will likely escalate when the PHE ends.
"As the pandemic’s intensity diminishes, many telemedicine companies that were previously cash-only retail medicine are now billing health insurance and the federal healthcare programs (including Medicare, Medicaid, and TriCare) in order to diversify their sources of revenue and addressable market," Lacktman pointed out. "This is a good thing for patient access to care and continued growth of digital health services. At the same time, this diversification in patient-payer mix, the expiration of PHE waivers, and the abatement of the pandemic will encourage {Department of Justice] and HHS-OIG to increase investigations of telemedicine companies and target arrangements and practices the government agencies believe are illegal."
"The alert emphasizes the risk of illegal kickbacks posed by suspect arrangements between telemedicine companies and practitioners," Lacktman continued. "If one purpose of the payment arrangement is to induce referrals of Medicare patients, that arrangement – particularly if notorious and not protected by a statutory/regulatory Safe Harbor – can place all participants at real risk of civil and criminal enforcement. Even subtle suspect arrangements can cause an employee or other knowledgeable person to file a qui tam / False Claims Act action under seal in court. If that occurs, DOJ is required to investigate the allegations in order to decide whether or not to intervene and take over the prosecution. Even non-criminal civil actions are a serious enforcement tool DOJ regularly relies upon to stop health care companies from entering into such arrangements."
The American College of Emergency Physicians is partnering with PA Consulting on a new platform aimed at helping emergency care providers access data and resources to improve services and outcomes and reduce administrative burdens.
ACEP will partner with PA Consulting on the platform, which will form the foundation for ACEP's newly launched Emergency Medicine Data Institute (EMDI).
“The ACEP Emergency Medicine Data Institute will transform information that physicians and others can rely on to support clinical innovation and patient management,” ACEP President Gillian Schmitz, MD, FACEP, said in a press release. “We are very excited to launch a resource with the potential to transform care delivery and empower clinicians at the bedside with analytics from emergency departments around the country.”
"This is a fantastic opportunity for us to build a multi-year engagement around data and analytics in healthcare," added Nilesh Chandra, a healthcare expert with PA Consulting and the ACEP project lead "We know that large scale datasets are critically important to solving the most pressing challenges in healthcare. This was true in the 1840s when John Snow used incidence and address information to trace a cholera outbreak to a water well in London, and data’s importance has been made abundantly clear in the last few years with the Covid-19 pandemic. Emergency department data has the potential to fundamentally transform the care of patients and improve lives."
The new data platform is expected to integrate with more than 1,000 hospitals, collecting clinical and billing data on emergency care. The information will be used in EMDI's Clinical Emergency Data Registry (CEDR), offering healthcare providers a resource to identify best practices, new treatment and therapies, and other services aimed at reducing the reporting burden and boosting outcomes.
David Danhauer, MD, is retiring after 37 years in healthcare, the last decade spent as chief medical information officer at Kentucky-based Owensboro Health. He talks to HealthLeaders about the challenges and successes and his role as an enabler for innovation.
Danhauer has served as chief medical information officer and senior vice president at Kentucky-based Owensboro Health for more than a decade. While with the health system, he oversaw the implementation of an electronic health record platform, supported the growth of an ambulatory care group that now comprises 180 providers in 30 locations, and helped design a $500 million, 450-bed regional hospital.
Prior to that, he was a pediatrician, first running a solo practice for 11 years, then as part of Owensboro Pediatrics.
Danhauer recently spoke about his experiences in an e-mail Q&A with HealthLeaders.
Q: How has the role of Chief Medical Information Officer changed over the years?
Danhauer: CMIO roles have been evolving from an EHR enabler to a strategic clinical IT leader/expert. This transition has required the development of skill sets in leadership/management, project management, and contracting, as well as the ability to network at regional and national levels. The need to stay current with evolving technologies and trends is critical to the success of any CMIO.
David Danhauer, MD, chief medical information officer and senior vice president of Owensboro Health. Photo courtesy Owensboro Health.
Q: How does the CMIO fit into a health system's leadership structure, and what are the CMIO's responsibilities?
Danhauer: The CMIO is the lead clinician in all things IT. It is the true blending of clinical expertise with IT expertise. The CMIO must be a master of language translation between clinical and IT roles.
Q: How has innovation played a part in your role?
Danhauer: Having the passion for always improving how we provide care has helped me stay focused on innovation. Keeping my clinicians' point of view in the forefront allows me to challenge IT be innovative and patient safety-minded.
Q: What are the biggest challenges you now see in healthcare that innovation can address?
Danhauer: Our regulatory burden on clinicians is a constant challenge. IT is looked at to minimize the impact on clinicians, but finding new ways to mitigate this has been challenging. Cyber security vs the need for access keeps me awake at night.
Q: Could you list the 3 or 5 most impactful innovations in healthcare that you've seen, and why they've made such an impact?
Danhauer:
EMR adoption: This has been the most disruptive change in medicine ever.
Interoperability: Providers now have immediate access to the clinical info they need at the time of care.
IT Mobility: Providers can now access data when and where they need it.
AI and Data Modeling: Collections of massive amounts of clinical data with intuitive research allow for trending at levels never before possible.
Q: What are you most excited to see in healthcare going forward?
Danhauer: For my providers, I look forward to the advanced computerization that allows them to treat patients rather than deal with computers. This ambient environment allows for seamless documentation without the interference of a computer. AI will allow for improved diagnosis and therapy for all our patients.
Q: What has surprised you the most about what you've seen happen in healthcare?
Danhauer: My dream of simplified workflows for providers has been upended by the regulatory burdens now placed on providers. Certainly the advancement of data availability has helped, but many are overwhelmed by too much data.
Q: What worries you the most about the future of healthcare?
Danhauer: I hope the future will allow for better ergonomics, improved AI for data presentation and simplified workflows.
Q: What are you biggest accomplishments?
Danhauer:
EMR adoption and usability.
Development of a provider support team specifically related to the IT needs of providers with top notch ratings.
IT governance structure.
Regional CMIO group meetings.
IT patient safety engagement.
State and national HIE interoperability.
HIMSS National Physician Committee Chairmanship.
HIMSS Fellow.
Many regional and national presentations on top IT issues.
Q: Any regrets, or things you wish had been done differently?
Danhauer: I feel the CMIO should have a larger seat at the leadership level as it comes to organizational strategy.
Q: What are your plans for retirement?
Danhauer:
More family time!
Travel.
Scuba diving around the world.
Explore new hobbies.
Dedicate more time to my church and local charities.
In a move expected to anger virtual care advocates, the Centers for Medicare & Medicaid Services has proposed dropping Medicare coverage for audio-only telehealth services, including telephone calls, in its 2023 Physician Fee Schedule. The proposed action would take place 151 days after the end of the public health emergency.
The Centers for Medicare & Medicaid Services has proposed dropping Medicare coverage for audio-only telehealth services once the Covid-19 public health emergency is over.
The proposal imperils a service that had become popular during the pandemic, when health systems shifted in-person care to virtual channels to cut down on hospital traffic and reduce the spread of the virus. Thanks to federal and state waivers tied to the pandemic, healthcare providers were allowed to connect with patients on a telephone or other non-video platform for some healthcare services and be reimbursed for those services.
In its proposed 2023 Physician Fee Schedule (PFS), however, CMS aims to eliminate separate Medicare coverage for those services, except for some behavioral health services. That coverage, found in CPT codes 99441-99443, would end 151 days after the end of the PHE, which is expected to take place next year.
The decision won’t sit well with healthcare providers and consumers who see the telephone as a vital channel for healthcare services, especially in rural areas where access to audio-visual telemedicine is limited or even non-existent. Telehealth advocates have been lobbying Congress – and several bills have been introduced – to make audio-only telehealth coverage permanent.
The proposal was highlighted in a blog penned by Foley & Lardner attorneys Nathaniel Lacktman, who chairs the Telemedicine & Digital Health Industry Team and serves on the American Telemedicine Association's Board of Directors; Thomas Ferrante and Rachel Goodman.
"With the exception of certain telemental health services, CMS stated two-way interactive audio-video telecommunications technology will continue to be the Medicare requirement for telehealth services following the PHE," the three attorneys wrote as part of an analysis of all telehealth coverage changes in the proposed 2023 PFS. "This is because Section 1834(m)(2)(A) of the Social Security Act requires telehealth services be analogous to in-person care by being capable of serving as a substitute for the face-to-face encounter."
"In CMS' own language, 'We believe that the statute requires that telehealth services be so analogous to in-person care such that the telehealth service is essentially a substitute for a face-to-face encounter,'" the post continued. "As audio-only telephone is inherently non-face-to-face, CMS determined, that modality fails to meet the statutory standard."
Some states and payers have changed their telehealth guidelines to enable coverage for audio-only telehealth, while others have rolled back those freedoms. Opponents say the telephone isn't a good channel for establishing a doctor-patient relationship or conducting healthcare.
The American Medical Association, meanwhile, has come out in support of permanent coverage.
"Payment for audio-only visits has been a lifeline for patients during the COVID-19 PHE," AMA President James Madara, MD, said in a January 28 letter to Acting CMS Administrator Elizabeth Richter. "The need for these services to be available will not diminish when the PHE ends, and the AMA strongly urges CMS to continue separate payment for the CPT codes in the future."
"While not a high percentage of visits, even during this PHE, access to audio-only services is critical for patients who do not have access to audio-video telehealth services," the letter continued. "Discontinuing payment for these services would exacerbate inequities in healthcare, particularly for those who lack access to audiovideo capable devices such as seniors in minority communities that have been devastated by COVID-19."
As the changes are part of a proposed rule, telehealth advocates point out there is still time to submit comments to CMS. The agency will accept those comments up until 5 p.m. ET on September 6.
Healthcare organizations are turning to remote patient monitoring to improve care management and give patients an on-demand connection to their care teams, but they need to plan carefully to make sure the program is sustainable and scalable.
Healthcare organizations are looking to enhance care management by connecting and collaborating with patients outside the hospital, clinic or doctor's office, and they're often doing this with remote patient monitoring (RPM) platforms. Using digital health technology, they're developing programs that allow a care team to monitor a patient at home, gathering vital signs and other data, communicating with the patient when necessary, and creating treatment plans that can be modified in real-time.
HealthLeaders recently conducted a round-table with three health system executives to talk about their RPM programs and strategies. This panel featured Carrie Stover, MSN, NP-C, national senior director of virtual care for Ascension; Sarah Pletcher, MD, MHCDS, system vice president and executive medical director for strategic innovation at Houston Methodist; and Kathryn King, MD, MHS, associate executive medical director at the Center for Telehealth at the Medical University of South Carolina (MUSC).
Q: Do you have dedicated staff for your RPM program? Do you centralize the platform and allow staff to manage patients from other locations like home? Or is this something that you integrate within the provider population?
Carrie Stover: We have a centralized team of nurses and enrollment specialists. Before COVID, they all sat in a bunker setting and monitored patients. We learned with COVID that they don't need to be in a centralized location. They absolutely can be remote. So all of our staff since COVID have been remote and will stay remote.
One difference between 1.0 and 2.0 is that our nurses are now documenting directly in the EMR. We have multiple EMRs, and we do not have standards or consistency in our technology, which is a huge challenge. But we have our nurses document directly in those EMRs so that they’re functioning as an extension of the practice and building the relationship between the practices and the monitoring nurses.
Carrie Stover, MSN, NP-C, national senior director of virtual care at Ascension. Photo courtesy Ascension.
We have recognized that physicians had no idea who was doing this monitoring. We hadn't built those relationships or a high degree of confidence in those physicians that these are highly skilled, highly qualified nurses doing great assessments on their patients and only escalating when necessary. We now have a centralized team, and we encourage them to develop those relationships.
We also are developing leads, or champions by diagnosis, and so that we don't have all of our nurses monitoring and managing every patient population. We're trying to create pods of primary and secondary areas of specialties, so that they can develop those relationships and expertise with that patient population, and then that relationship with the physician practice.
Sarah Pletcher: That's a must. It's on that dedicated team to implement aspects of the [program], like training ER staff to send patients home with a device or supporting outpatient clinics. All the complexities and nuances really speak to the importance of having a centralized team where you can consolidate that expertise and distribute parts of the care continuum thoughtfully, as opposed to trying to have everybody think they can do it, doing it differently, running into billing, tech, and integration inconsistencies, having redundant staffing models or accesses where every department now thinks they need to hire monitoring tech. I'm a fan of centralizing everything you can, and then providing service not only to the patients but to the providers and other clinical stakeholder groups who are part of the care landscape.
Kathryn King: These programs are really meant to be scaled. Likely the ROI will not be realized unless you are able to scale to populations. The best way to do that is with a centralized team of monitoring nurses. Our first remote patient monitoring programs were monitoring patients for providers at free clinics and [federally qualified health centers], who would never be able to scale and support financially a centralized pool of monitoring nurses. We could monitor all their patients and communicate with the providers. We knew that those populations of patients needed to be as effectively managed as possible.
We [will have] patients with multiple disease states or metrics to be monitored. You could be in a hypertension monitoring program and a diabetic remote patient monitoring program, and having those siloed is not helpful to the patient. That really speaks to centralization so that we can are monitoring patients, not metrics or diseases.
Q: Do you recruit nurses for this program? Do you train them specifically for RPM?
Kathryn King: We have nurses who are specially trained to interact with the technology and the patients. Through that, we've gained a lot of efficiencies in nurses who are really good at monitoring several different metrics at the same time.
Sarah Pletcher: Not every nurse is well-suited for monitoring, just like not every physician is well-suited to be a telemedicine physician. And it goes the other way as well. The nurses monitoring patients in our VICU program have loads of bedside and specialized ICU experience, but they've been picked because of their fit for following a broader patient population and algorithm-based care. Being a good fit to interact with lots of different bedside teams is a special skillset.
Sarah Pletcher, MD, MHCDS, system vice president and executive medical director for strategic innovation at Houston Methodist. Photo courtesy Houston Methodist.
We do carefully select those folks. Not only is this helpful to bedside nursing staff and other care team members, it's another career opportunity for them, whether they're looking to diversify their portfolio, extend a career, or save a career for perhaps a nurse who isn't able to handle the physical demands of floor nursing any more. It can be a great way to keep people in the profession.
Carrie Stover: It definitely has been an evolution. Back in the day, our nurses tended to be more toward the case management side of remote monitoring, especially as we were monitoring chronic conditions and patients who had been discharged from the hospital or identified by their physicians. We were training people who had some experience, oftentimes case managers, on the technology.
As we think about higher acuity use cases, and as we added postpartum hypertension, and as we continue to think about hospital at home and more continuous or near continuous monitoring, we have to think about how and who we're recruiting, their expertise and capabilities. It's going to require a different kind of training on virtual assessment. Not everyone is suited to provide telemedicine, and not every nurse is suited to provide remote monitoring, do that virtual assessment, and interact with people day to day who are at home or wherever they are. What we're doing now is training nurses for specific areas and types of remote monitoring and disease trajectories.
Q: How do you choose the technology for an RPM program, or the vendor that you want to use? What do you look for in tools, in vendors, that would make for a good fit?
Sarah Pletcher: Good common sense carries the day most of the time. When you try out some of these sensors, devices, scales, blood pressure cuffs [and] stickers, it's a lot easier than you think to pick one that is not going to be disruptive to the patient and easy for the care team to use.
With a vendor partnership, that's a whole art to itself. You're not only evaluating their goods, but looking at their leadership team, their mission, and the health and sustainability of their company. What's on their company's roadmap? Where are they in their development cycle? What are some of the integration constraints that you might face? Implementation and account management success?
Some vendors put all their assets into sales, and once you've signed the contract, there's not a lot waiting for you in terms of implementation partnership. I spend a lot of time with the leadership of a company because that relationship really has to work and carry you through the challenges that you know you're going to face throughout the sales and implementation and account management life cycle.
Q: Do you look first at in-house programs, running them yourselves, or is there an interest in outsourcing some of these services?
Sarah Pletcher: It depends on what you're trying to do. It's often going to end up being a blend of build and partner. Particularly when it comes to scale, niche expertise and supply chain constraints, partnership is essential. Where it can be an argument to build it yourself is when it comes to the clinical team that you're putting on the other end of some of the technologies. It depends on where you're at in your journey, [your] investment in innovation, to what degree you're going to take on the tech, maintenance support, etc.
Carrie Stover: We just finished an RFI and RFP at Ascension, and it was incredibly painful because of all of the things that we've talked about.
Add to that the turmoil in the industry. Because of COVID, remote monitoring has really increased in popularity. Several of the vendors that we were working with, that had some good elements and capabilities, were acquired by another company while we were evaluating them.
It becomes complicated, but at the end of the day, identifying those requirements and capabilities that are most important to your organization and your programs is critical. The days of having specific tools that are attached to tablets and kits are gone. We are really interested in an agnostic platform that will allow us to decide what tools we use and how often we use them.
There have been some challenges in the past with pathways, for example, that were FDA-cleared, and so we couldn't make changes. We're now interested in evaluating and developing our own programs.
One of the things that's important from a technology perspective but that we don't often think of is reporting and data analytics. We have so much information that's feeding into these platforms, [and we want to use] that information to drive change and identify patients who are or are not benefiting from the program. There are questions that don't have value, or things that we should have been asking and didn't. Do we really need to check people's blood pressure twice a day, is once a day good enough?
Kathryn King: Traditionally, choosing a telehealth vendor came down to video capability, endpoints and integrations. Remote patient monitoring software is really data gathering, storage, analysis, and display software, more than telehealth 'software.' It's all about how can you, in the easiest way possible, gather only actionable data in huge quantities, store that data, analyze that data such that I can learn from it, and display it in a way that is helpful to certain groups of providers, as well as the patient? What I'm looking for, really, is are you going to easily get the data and make it usable?
Kathryn King, MD, MHS, associate executive medical director at the Center for Telehealth at the Medical University of South Carolina (MUSC). Photo courtesy MUSC.
Q: Do you look to technology with an eye toward the future, where you might use it for another RPM program or more services?
Kathryn King: I am uninterested in niche and condition-specific solutions. The algorithms, or clinical content associated with those, take a lot of work. A lot of companies are developing [products based on] their area of expertise, but we're looking [for solutions] that have potential in different, really usable, actionable ways. We're likely to see these companies start merging and buying each other up anyway.
Q: How do you measure the value of an RPM program? What benchmarks are you looking for to prove that this program is working and that it can continue and that you can build on it to keep it going?
Sarah Pletcher: Ideally, you're going into a program knowing what you want it to achieve, and you've identified some metrics and benchmarks for how you're going to evaluate it. That seems obvious, but is surprisingly rare. If you've done that, then you have a way to evaluate whether it's working. Do your patients like it? Do your providers like it? Do your nurses like it? Are you achieving your clinical outcomes? Are you getting use? Maybe it's an amazing kit that you send home, but it turns out patients don't like to stick their arm in a blood pressure cuff twice a day for a month. If you've done your work on the front end, then you should know what you're trying to achieve and have some metrics in mind for how you're going to pursue it.
I'm not interested in niche options. I'm also not looking for a modular 'here's the 10 things it comes with' toolkit solution because that doesn't allow me the speed to run with whatever the market's bringing me. That being said, I'm excited about what I call ‘hero’ products: multi-parameter sensors that can be helpful for loads of conditions and use cases, and with which I can build in other specialty sensors. I am particularly excited about a sticker that collects several pieces of data continuously. I think that's a great space to get right, because its so easy for the patient and then you can add modular pieces to that, tag other specialty conditions, or parameters, that you need to measure.
Q: Is there a certain data point or benchmark that surprised you at how valuable it was for you, something that you weren't expecting to collect, or you weren't really giving a lot of thought to, but it turned out to be important to the program?
Sarah Pletcher: We’ve done loads of inpatient monitoring and are transitioning to the outpatient space. What I'm looking ahead to is not so much what I'm surprised is valuable, but the opposite- something I assumed was critical to measure but turns out to be overrated. I have a feeling that respiratory rate is going to be a lot more valuable when it's collected correctly and continuously, and I suspect that blood pressure might not be as valuable a vital sign as we've thought. I think we're going to be equally surprised by things that aren't as valuable as we thought as we are about ones that are.
Carrie Stover: We've spent a lot of time optimizing and standardizing our programs and focusing on outcomes and measures because historically, although everyone will tell you that every heart failure program that they've initiated has had tremendous value and great results in terms of preventing readmissions, when you look at it, no one was using the same numerator or denominator, and nobody was defining anything the same way. We are really specific about how we're defining success and what are the outcomes that we're measuring.
We have the Ascension Data Science Institute. I'm not claiming that we did all of this ourselves, but we had some really smart people to help us build those dashboards to ingest all of that information and evaluate it.
In terms of metrics that are surprising, with our postpartum hypertension program, one of the things that impacted us tremendously is postpartum visit adherence. Did this new mom go to her postpartum visit? We've seen an increase, overall, from 56% to 95%. Really impactful, and maybe not something that we would've measured if it wasn't tied to one of our national quality goals.
We also have a clinical quality escalation meeting every week with some of our nurse leaders and physician leaders to look at red alerts, what happened from those red alerts, and what was the escalation path, so that we can identify if there are things that we're doing that don't have value, or are there educational opportunities, both on the nursing side and on the physician side, about how to manage these patients.
Kathryn King: How do you demonstrate the value of the program? That is such a key question. Value is in the eye of the beholder. If you're going to take into account every bit of increased quality, or everything you got out of healthcare, over every cost to your system, it really has to do with who are you providing the value to and what did they get for what they gave.
There are lots of different value cases for remote patient monitoring. Maybe the value case is that monitoring blood glucose works really well for the current fee-for-service model, so we are actually going to have a good defined ROI on that program.
Maybe it's that Medicaid came to us and said, 'We need moms to go to their postpartum well visit.' We're going to ask mom some questions, we're going to text message them and help them get to that visit and their newborn follow up visits. That provides extraordinary value to a large payer in our state, and so on and so forth. It's about defining why are you doing this in the first place. Then, what is the value of that program? How do you add value to why you're doing this? That's where you define your metrics.
As far as what's surprising to me, in our COVID post-discharge program we had a lot of physiologic metrics and a lot of validated questionnaires from other pulmonary diseases. Yet the most helpful thing to ask someone ended up being, 'Are you better today than you were yesterday?'
Q: Do you design RPM programs to have limited lengths? Do they have an endpoint, or are you designing programs that can, as in chronic care management, continue for years?
Carrie Stover: Historically, we would've said that this is our anticipated timeframe and patients may come off before or after. Now we're thinking about this as a new care model, where we're using technology to support the interactions and the engagement. What we'd like to do is move people up and down the spectrum depending on their needs: lower acuity, higher acuity, monitoring, and then patient-reported outcomes. One question a day or one question a week and maybe some of these nudge interactions.
We are recommending an anticipated length of stay on the program just to give people some idea of what we're anticipating. It's easier with higher acuity use cases like hospital at home, or a postsurgical use case, but when you get into chronic disease that becomes more complicated. Where we would like to be is that we're not just like cutting you off; we're moving you up and down this spectrum of connected care based on what you need and where you are in your disease trajectory.
Sarah Pletcher: It's like prescribing a medication or physical therapy. You're always assessing, evaluating, moving forward, reevaluating, reassessing. Can you graduate? Can you change the frequency? Obviously the length of time a patient can tolerate being in one of those [programs] is going to align with how complex and disruptive and burdensome it is.
With regard to benefits and ROI and thinking a little bit outside the box, the ‘placebo effect’ and the ‘Hawthorne effect’ are still effects, therefore effective. Even if all that a remote monitoring program achieves is that the patient feels a little bit more engaged in managing their own chronic condition or their health, that has huge benefit- even if the data doesn't change what the care team does or there's no great predictive algorithm or alert. If all it achieves is that the patient feels like it's helping them or that it engages them more, that’s not to be dismissed. We'd be delighted if many of our medications could achieve that much.
That's an important thing to not overlook. When you're thinking about your metrics at the beginning- consider ways to measure patient perception. It doesn't all have to be around what hard data from the technology are we gathering.
Maybe a patient thinks ‘Hey I'm doing something the will help me with my high blood pressure, I'm going to take my medication, I'm going to pass on the can of Pringles. ‘ The data didn't do that. The tech didn't do that. It was just the patient being more engaged.
Kathryn King: We tend to say OK, I think it's going to last this long because we're building siloed things. But this is just part of caring for patients, and patient care doesn't have a beginning and end. It's a continuum of care. There will be [some] sliding back and forth for all of our patients. At some points it might look like just engagement, and at some points it might look like physiologic monitoring.
But this is all for a therapeutic effect. The length of therapy is determined by that therapeutic effect, just like any other therapy that we would prescribe. That is how we take care of patients, rather than 'Today you are on a remote monitoring program and it will be over in three months.'
Sarah Pletcher: We need more evolved reimbursement codes. For example, if a patient goes home from the hospital after a surgery or illness and we slap a sticker on them and a week of close monitoring later they look great, they should take it off- they're done, they're good. But if the reimbursement code says no, it has to be for 16 or 30 days, now we're locking people into arbitrary lengths of time that aren't aligned with what the patient needs.
Q: How do you emphasize patient engagement, or patient activation, and how do you help the patient take charge of his or her own health?
Sarah Pletcher: You have to think about how you're going to survey patients. Again, it seems obvious, but is often overlooked. Everyone just wants to default to the standard survey that gets sent out to patients [but which] really doesn't reflect these new programs. You have to find a way to engage the patient. Do you like this? Does it help? Do you feel better? Would you recommend this to somebody else? Do you feel cared for? I mean this is basic, basic, basic.
Kathryn King: Remote patient monitoring is very tightly wound to what we call a patient engagement cycle or a cycle of engagement with our patients, whether it's just a brief outreach or hands-on physiologic monitoring. The point of the technology is to collect and display data in an actionable way and, as someone said, 'a way that is helpful to the patient.' That is so important. Can I display back the data to a patient in a way that is engaging to them?
For instance, I'm a general pediatrician. At every well child check, I turn the screen around and show a mom her child's growth chart. That's why she came, just to see the growth chart. She knows her child grew, but it's such a fulfilling thing to look at your child's growth chart. And that is true of most of the data about our health. We like to see it.
For a long time, people were all about developing healthcare apps. With weight loss apps, it is not actually the amount of calories that correlates to weight loss, but that you logged into the app at all. That you interacted at all is more connected to weight loss than what you actually ate. So when you engage with healthcare, you are more likely to be healthier. All we're trying to do is help you engage in a really easy way with healthcare.
Carrie Stover: The idea that I'm supposed to check my blood pressure, so I ought to take my blood pressure medication before I do that, has some intrinsic value. We've [done] a study with our postpartum hypertension pilot, and we learned not just about what our physicians or our monitoring nurses are thinking, but what our patients are thinking and why and how they're participating. We learned that just because they're participating, just because they are checking their blood pressure once or twice a day, doesn't necessarily mean that they are happy with or engaged in the program. Sometimes it's a source of frustration.
We have to do a better job of connecting with our patients, because oftentimes they will do exactly what their physician asks them to do, but it doesn't necessarily mean they understand the value. If we could turn that around, show them how much better their blood pressure is controlled or whatever it is that we're measuring and engage them in not just the measuring but also in the evaluating of the results, we could have a lot more benefit.
About the importance of respiratory rate when it's collected accurately, that made me laugh a little bit because one of the many questions that we were asking our COVID population when we first started monitoring them was to [track] their respiratory rate. Anything over, I think, 24 or 28 would set off an alert to our nurses. I would be willing to say that 99.9% of the time, patients were counting it inaccurately. That taught us that we have to be thoughtful of what we're asking people to do, and just because it seems easy for us as clinicians or as people who work in hospitals and health systems, it doesn't necessarily apply to the general population.
We have struggled, as I think everyone has, with all of these disease-specific applications. It's easy to monitor someone or create an app that helps somebody monitor one thing, but so many patient populations don't just have diabetes or hypertension. Having all of these one-off applications that do just a couple of things is not helpful. We have to get to the point where we're making these things not only tech-friendly for patients, but making sense clinically and helping people manage their overall health.
Kathryn King: One other benefit that we were surprised about was in interviewing patients. They said it made me feel like I wasn't alone. There is a huge benefit in that, and it's difficult to quantify that benefit. In our program for postpartum discharge we'll be working with both moms and babies. While there are a lot of metrics, the bottom line is it's a period of time when a lot of people feel very alone, and if we can help people not feel so alone, I think there's great benefit in that.
Sarah Pletcher: That 'I'm not alone' comes from the patients, but if done right it also comes from the bedside team. If you're doing inpatient monitoring, someone else is watching, there's another safety net. The physician [feels that] I'm not alone in managing my patient's chronic conditions. I have some of these partnerships. Reduced isolation is a big thing.
The other reality, particularly when you're talking about longer term monitoring, is that behavior change is hard. It's hard to get long-term utilization and traction. One of the things that excites me about the consolidation and disruptors coming onto the market is that some of those partnerships will yield more people who study how to get people to engage sliding into health. Maybe the same science that knows what YouTube video I just have to watch at midnight is hopefully also going to help me craft some of the sticky solutions to keep patients engaged in optimizing their care.
Q: How do you see our RPM evolving? And is there one government policy or action or something that would really help RPM to evolve?
Kathryn King: The ultimate goal, for most of us, is that it becomes just a normal way of how we take care of patients. One day telemedicine will just be medicine. I think there's a lot of fear about overuse when it comes to reimbursement of remote patient monitoring. Hopefully this might be a little Polyanna of me, but we're to a point where we realize that, overall, everyone wants to take better care of their patients. From a policy standpoint, whenever we can look at supporting the healthcare system and taking better care of patients, we will be closer to that goal.
Sarah Pletcher: I think the technology solutions are going to get smaller, faster, smarter, cheaper, better, easier, stickier, and more integrated. I hope that we'll continue to see more utilization, more engagement, more AI, and therefore more predictive insight so that we can be a lot more tailored and personalized with the healthcare that we deliver. We need the regulatory and payment models to try to keep up or give health systems and providers latitude to figure out how to leverage these models in their care.
Carrie Stover: As we continue to create these solutions that are extensible across the whole care continuum, these don't have to be program-specific or platform-specific uses that have a beginning and an end. They become part of the tools that we use to help patients get better. Just like we use the laboratory and imaging and all of those things to help us evaluate how a patient is doing related to their disease and how we can help them be better, these will just be tools, not very specific programmatic platforms that have this beginning and an end and are only applicable in certain circumstances.
Health system executives at a recent HealthLeaders round-table explained how to create an effective remote patient monitoring strategy, from selecting the right patient population and technology to securing staff buy-in.
Healthcare organizations are looking to enhance care management by connecting and collaborating with patients outside the hospital, clinic or doctor's office, and they're often doing this with remote patient monitoring (RPM) platforms. Using digital health technology, they're developing programs that allow a care team to monitor a patient at home, gathering vital signs and other data, communicating with the patient when necessary, and creating treatment plans that can be modified in real-time.
HealthLeaders recently conducted a round-table with three health system executives to talk about their RPM programs and strategies. This panel featured Carrie Stover, MSN, NP-C, national senior director of virtual care for Ascension; Sarah Pletcher, MD, MHCDS, system vice president and executive medical director for strategic innovation at Houston Methodist; and Kathryn King, MD, MHS, associate executive medical director at the Center for Telehealth at the Medical University of South Carolina (MUSC).
Q. Could you please define remote patient monitoring and how you've used it in your health system?
Carrie Stover: We've had remote monitoring in place for chronic disease since 2014, but those programs were developed market-by-market and physician practice-by-physician practice - or organically, as I like to say. Historically we defined remote monitoring the same way that [the Centers for Medicare & Medicaid Services] does: Using a connected device and being monitored by a team of nurses.
Over the last few years, and particularly with COVID, we've seen that we don't always need to have a connected device. We've started to think about this in terms of a connected care spectrum, from patient nudges, wearables and patient-reported outcomes through traditional remote patient monitoring, and then onto higher acuity monitoring in terms of hospital at home and even some in-facility monitoring.
Sarah Pletcher: It can be any solution where you have a remote care team looking after a patient, informed by some data about the patient. There’s a wide variety - we’ve seen an evolution in how continuous that monitoring might be, or how synchronous, and how robust, and how automated, the depth and scope of data, degree of artificial intelligence, the timeline to intervene [and] what that care team is and can do. And are you using AI and algorithms? There needs to be a continuum, but at the highest level remote patient monitoring can be anytime we are using data to look after a patient, the care following the patient closer to where they are.
At Houston Methodist, we are using virtual care and monitoring technologies to care for patients in hospitals across the health system, as with our VICU program and telesitting service and to offer access to care to the patients wherever they are, as with our Virtual Urgent care, and we use virtual platforms to allow our primary care and specialty care providers to see and monitor patients at home.
Kathryn King: It's difficult to not have payers define remote patient monitoring for us. Certainly, I think it is helpful in that it gives us a common language. But at the end of the day, this is really about how can we take better care of our patients.
It comes down to, if you could wipe the slate clean from what we were taught in medical school, which is you treat chronic disease in 15 minutes every three months, and instead say, "What's the one question I could ask my patient every day that would help me better manage their health?" What is the one piece of information we need every day to make a better decision about this patient's care.
Q: What are the biggest benefits of an RPM program?
Kathryn King: It is about more efficient, effective care for our patients. Whenever you're talking about a digital transformation or a change in healthcare, that's what it should come down to: That patients feel like they are getting better access to better care and providers feel like they are delivering higher quality care. Remote patient monitoring is a great example of exactly how to do that.
Sarah Pletcher: It can be much more efficient, allowing us to better use hospital, nurse and doctor resources, and there's more freedom, convenience, independence, and wellness for the patient, and the technology can allow us to be more proactive. We're identifying things earlier so that we can impact better outcomes for the patient. Better care delivered more efficiently? that's the ideal. You're looking to serve the patient and move the needle forward on the value continuum, so ideally you tick all the boxes.
Sarah Pletcher, MD, MHCDS, system vice president and executive medical director for strategic innovation at Houston Methodist. Photo courtesy Houston Methodist.
We're trying to take increments of time and effort and distribute those for maximum gain. If technology helps me know who I need to spend time [with] in a moment or a day or a five-minute increment, I'd far rather do that than spend it on the people who don't need me and miss the one that does. If I am the patient, I don’t want to be bothered if everything is OK. I think we're all trying to get the most bang for our buck.
RPM is the most powerful tool we have available to us, to use data to elevate where we should be leaning in to use more resources, and then being able to pull away and not waste resources that are often disruptive to the patient. If we don't have to wake that patient up three times a night to check their vitals; but can instead watch them from a wearable patch while they sleep … not only am I not wasting hospital resource time, but I'm also creating a more healing-friendly environment for the patient and catching problems earlier.
Carrie Stover: With traditional benefits, which is why everyone started thinking about remote monitoring years ago, [we're] reducing readmission rates and improving stickiness to your system. It [also] helps to fill in gaps, what we call the white spaces between physician visits, to help us better understand our patients. There are so many challenges that patients face that we don't know anything about because they happen in that white space in between visits.
Understanding what's happening to them clinically, but also socially, is so important. I think we've seen some unintended consequences related to improvements in visit adherence by having that relationship with that monitoring team, and decreasing calls to the practice. [We're] making sure that when we're escalating something to a physician, that it really requires a physician and that it couldn't have been handled by somebody else.
Q: What are the biggest challenges to launching an RPM program and how do you address them?
Sarah Pletcher: The challenges are different depending on your RPM journey. At the beginning, it's ‘What should I do?’, ‘Where's the ROI?’, and ‘How do I get started?’ Then, [it's] making sense of a complex and rapidly moving technology market - software, hardware, and considering form factors as well as the potential service partner landscape, and then it's trying to make sense of the operations.
It often isn't the fun, sexy things the launch innovative technology but the boring, essential workflows, algorithms, protocols, and change management meetings. The challenges are different depending on where you are on the journey and [they're] absolutely surmountable, but pack your tool belt before you set out.
Q: Are there challenges that you didn't expect to have that cropped up?
Sarah Pletcher: Trying to make sense and keep up with the vendor market. I knew that it was complex. I don't think I fully appreciated all the different niche areas, not of the devices and sensors and gadgets and cameras per se, but all that middle stuff. Data aggregation and data storage and data visualization. And the management software for people using data and how quickly you can build algorithms within the data and when and where EMR integration is essential and where you should avoid it like the plague.
There were a lot more nuances in what I'll call middleware than I appreciated. It's been fun to navigate that and come up with a strategy for a very diverse and complex market. But in particular, that middle area required a little more lean-in than I mentally budgeted for.
Kathryn King: Whenever we talk about something disruptive in healthcare, and certainly most telehealth is meant to be such, we talk about culture change. It is a cultural shift, thinking about how you manage patients, particularly large populations. There are a lot of things that go along with that, from provider acceptance to digital literacy. Payment is probably the largest barrier to widespread implementation.
We have seen during the pandemic that when payment and reimbursement restrictions were lifted, a lot of barriers fell away with other modalities. We're starting to see the same thing with remote patient monitoring.
Kathryn King, MD, MHS, associate executive medical director at the Center for Telehealth at the Medical University of South Carolina (MUSC). Photo courtesy MUSC.
If we're only willing to do it within the strict guidelines of what is reimbursed through a fee-for-service architecture, we're going to limit ourselves and, in some ways, make things less efficient and broaden disparity gaps. For instance, when I ask a physician, "What is one piece of information you need to make a clinical decision?" That might not be a physiologic metric uploaded directly from a device for 16 days during the month, but I have teams that want to make it that because that's what we will be reimbursed for. That is pushing us in the wrong direction.
Q: Is there one challenge or one barrier or something that came up that really surprised you?
Kathryn King: When I think about this, I think about building programs to increase efficiencies. And I realize that we also need to think about the direct ROI, which looks like dollar signs, but sometimes value can be calculated downstream and in a different way than straight reimbursement.
Getting people on board for that was something I did not anticipate. When we were so excited about these known fee-for-service billing codes, in fact it would threaten to widen disparities by really self-selecting patients, and that would potentially lead us in the wrong direction from an efficiency standpoint. I am happy that we have these codes to put to the test, but I think that what we are learning is that other payment models are needed and we need to keep pushing on that.
Sarah Pletcher: The reimbursement models we have for remote patient monitoring. The billing codes select patients and care teams who can comply with a rigidly defined frequency and cadence of data collection. That's what worries me, that 'magical thinking' that seems to keep cropping up in the RPM space.
People get excited about the technology, and a payment model that can support meeting the needs of the patient, and they think it's reasonable that a super busy primary care doc whose in-basket is bursting, who's booked seven months out for just a follow-up visit, somehow they're going to be able to handle all these incoming alerts, escalations, and alarms and review all this data.
Similarly, for a patient who's struggling to manage their own care, because they're elderly or they've got comorbidities or dual diagnoses, suddenly we think they're going to be up for climbing on a scale and attaching their blood pressure cuff and doing several actions every day to deliver enough data.
Then there are the care teams. We forget about the existing burden on our nursing staff and hospital providers and think, ‘Oh, well, it should be no problem for them to do, A, B, C, D, E.'
I find that I'm constantly [playing] whack-a-mole on [that] magical thinking that crops up in the design of these programs. I agree that limited billing codes is one piece of it, and I hope that with more optimized payment examples it'll be easier to overcome some of these other challenges.
Carrie Stover: One challenge that I was unprepared for was that we have lots of programs that meet every one of the stringent CMS criteria, and it should be so easy to bill for that. It's 16 days, it's a connected device, all of those things, but we've discovered that we are leaving lots of money on the table because it's very hard to bill for something in a practice that, number one, is time-based, and number two, is not tied to an encounter.
We have these massive workflow documents and diagrams that detail what we need the remote monitoring team to do and provide to the practice, and then what somebody at the practice has to do in order to turn that into a bill. It's really complicated. Developing that value, even when you can bill in a fee-for-service world, most of the time we are not because it is so incredibly complicated and complex. It has created so many tasks.
Carrie Stover, MSN, NP-C, national senior director of virtual care at Ascension. Photo courtesy Ascension.
With the program, the challenge is related to logistics and support. As we think about all of these devices and who needs what, I call it the virtual care Clue game. Who's where with what device being looked at by whom?
With logistics, the best way to enroll someone and get engagement is when they need it. It's coming from their physician or their discharge nurse in the hospital, and that sounds simple. We're going to give this patient a kit and they're going to go home and turn it on. But it's not simple. Managing lots of locations with lots of variations of those kits is challenging, and sending those kits to the patient's house, you've now created this 24-, 48-, 72-hour gap between when everybody agreed that they need this thing and when they actually get this thing. Are we going to enroll them face to face? Via video? All of those things need to be solved. It's further evidence that sometimes we, with all of the best intentions, end up with a lot of technology in the closet collecting dust, because we haven't really thought through the workflow.
With support, you have people who are trying to utilize these Bluetooth connected devices, {but] they may not have the expertise. The vendors all say that everything will work right out of the box, and that may be true for the first two weeks or four weeks or 70 times, but at some point that device is going to come disconnected. How that gets reconnected and who helps them can be an issue. Are they calling the nurses or are they calling the enrollment specialists? If you haven't really thought it through in the beginning, you have a good chance of having an awesome program fail for all the wrong reasons.
Q: How do you identify patients or the population that you want to monitor at home? And how do you prepare patients for this program? What do you look for in the home setting that will make them good candidates for an RPM program?
Carrie Stover: That's been part of our journey from 1.0 RPM to 2.0 RPM. 1.0 was a little bit of a free for all. We'd take anybody who wants to participate. In 2.0, we're more thoughtful and specific about inclusion and exclusion criteria. How do we identify patients that are appropriate clinically? How do we identify people who are at the right trajectory in their disease progression to participate? Then, understanding who's going to benefit the most from these programs from a clinical perspective, because we can't monitor everybody all the time.
When we think about assessing a patient from their ability or interest in participating, that engagement is so much better when that discussion is initiated by their physician. There's no substitute for that conversation.
We also think about the home environment. Even though these devices are cellularly connected, we have regions where patients have zero cell coverage. That's part of our assessment. We have a team of enrollment specialists to determine whether a patient should be kitted or unkitted, whether they can use an app or an unconnected device vs. a connected device or a tablet. They assess their interest in the program, their willingness to participate, and help walk through that enrollment process.
It creates a scenario where we're [eliminating] the patients who may need our help the most and may have the worst access to other forms of care. We've been really specific about creating equity solutions, but it doesn't solve the problem by any stretch of the imagination.
Kathryn King: From a population-based approach, at one end we're talking about high-touch, technologically based remote physiologic monitoring, which poses a lot of barriers. At the other end, where folks are starting to explore, is the lower-touch, not-as-specific, technology-based monitoring of patient-reported outcomes – asynchronous engagement and therapeutic monitoring. That's what we're tending towards from a standpoint of equity: What is the lowest tech solution to reach our clinical goals.
At that point you're looking at what population can I engage in this way. We're piloting a lot of programs. One that has been particularly successful is in perinatal behavioral health, [targeting] anxiety, depression, and substance use during pregnancy, because we know those are tied to the highest causes of maternal mortality in our country. That tends to be a time when people are very engaged in their healthcare. We're trying a lot of programs, both for mothers and newborn babies, that look like a low-tech, text message-based monitoring programs.
If we're debating the right population for this, we need to ask ourselves if this is a population that we need to engage in a different way. They're not a great population for X, Y, or Z. Well, then maybe we need to do A, B, or C to better monitor and engage this population.
Sarah Pletcher: It’s trying to fit the program to the population that you're trying to reach, and then choosing the most minimalistic and successful tools to achieve the goals that you're aiming for. For sending a patient home with a kit, for example, you need the ‘just plug-it-in’ level of simplicity, whether that's a cell or a WiFi, or even just using their own device. And in terms of sensors, it can be as simple as a sticker that they wear home from the hospital or a whole suite or a toolkit when truly needed.
One thing that is underconsidered is it doesn't always have to be the patient managing these tools themselves in their home. It can also be leveraging a partnership. Are they getting visiting nursing? Is there a family member who can assist? For patients who may not have cell or WiFi connectivity, are there places that they can go, [such as a] church, grocery store, community or senior center, soup kitchen, that can be data hubs, that can be a partner if the patient's going there anyway? Can those be our distribution centers rather than always trying to make it work in the patient's home environment?
Selection and enrollment are critical, but if there's a population that we're struggling to reach, we've got to think outside the box to bring that program to them, even if it means redefining where that is.
Q: How do you develop support among your staff for these programs? What are their most common concerns about RPM, and how do you address them?
Kathryn King: When you start the conversation, wipe the slate clean. Why do we think we need to manage things in 15-minute increments every three months? Most providers are really on board [and] know what they would ask their patient every day. Where we run into some hiccups is in the algorithmic management of patients by a centralized team of nurses. We hear from providers who say, 'Well, I really manage my patients individually, and there are certain things that I need to consider on an individual basis for each one of my patients.'
We direct the conversation toward gold standard treatment guidelines, and we want to work with them to develop an algorithm that will help them adhere to the highest quality guidelines for the majority of the population that really fits into that algorithm. Once we have an algorithm that they feel comfortable with, we will use it to take care of a large percentage of the population in a way that they would want them taken care of. There will be some patients who do not fall into those guidelines, and it will be very clear through remote patient monitoring that those patients need to be escalated to the provider for individualized treatment that only they can provide.
Basically, you frame it as 'How about I take all of the patients that are really easy for you to manage and make sure the patients that you really need to see get to you.' Usually they say, 'Oh yeah, that does make sense. That would make my life easier.' Again, we're not taking patients away from their provider; we are helping to [identify] the patients that they have to spend a larger amount of time with.
Sarah Pletcher: We have a buy-in matrix for providers with three core pillars. They are time, money, and tech. It can't be a huge waste of the provider's time or an intrusion into their off-time. It can't cost the provider or have them lose out on reimbursement to participate. It doesn't have to be a huge windfall or save them loads of time, but can't be a big loser on either of those dimensions. In terms of the tech, it has to be basically decent. It doesn't need to be earth-shattering. It just needs to be reliable and do what it's meant to do with modest support.
If you get those things, then providers can be motivated for lots of different reasons- maybe to look after a chronic condition by value metrics, or because it's cool or because they get to be the first person in their practice to try something or to create convenience and peace of mind for their surgical patients. There are all sorts of ways you can amplify buy-in, but I haven't seen a program succeed if it doesn't have solid foundation in those first three pillars.
Carrie Stover: With providers, that has been a challenge. It reminds me of the early days of the EMR when people thought there was no way that we could ever come up with consistent order sets by disease process because every physician treated their patients differently and individually. We have spent a lot of time and energy undoing some of the organic growth of remote monitoring.
With RPM, historically there have been centralized monitoring nurses whose job was to take that alert and pass it on to the physician. We've spent some time thinking about the job of that remote monitoring nurse. Just as a patient in the hospital is evaluated by a nurse before anyone calls a physician, we do the same thing. And as we start to monitor higher acuity patients, we have a team of very highly skilled nurses who have lots of clinical experience. We've developed very clear assessment protocols and escalation paths.
We’re finding that 60% to 70% of the time, nurses can resolve that alert. The rest of the time they may be initiating a patient case and sending a note to the physician. Very rarely, about 1.5% of the time, they are actually escalating to a physician. And then that's resulting either in a medication change, a virtual visit, or perhaps a trip to the emergency room.
The message that we're creating for physicians to get buy-in is that we're not looking to inundate you with additional data points and information. We're trying to create a valuable set of information for you to better interact with and treat your patient population.
Independence Blue Cross is backing three programs developed in Penn Medicine's Center for Health Care Innovation with $200,000 grants aimed at helping the programs address gaps in care for underserved populations.
The Clinical Care Innovation Grants aim to help the three programs, which address barriers to healthcare access for underserved populations, scale up their services. Philadelphia-based Independence Blue Cross is among the nation's most forward-thinking health plans in identifying and supporting new technologies and strategies that target gaps in care.
The grants will support:
Healing at Home, a program led by Kirstin Leitner, MD, an assistant professor of Clinical Obstetrics and Gynecology; Lori Christ, MD, an assistant professor of Pediatrics; Laura Scalise, MSN, RN, a nurse manager; and Emily Seltzer, a senior innovation manager at the Center for Digital Health that uses an AI-guided chatbot to provide on-demand assistance and resources, including mental health services, to new mothers during the vulnerable "fourth trimester;"
The Pregnancy Early Access Center (PEACE), a program led by Courtney Schreiber, MD, professor of Obstetrics and Gynecology and chief of Family Planning, which provides resources for pregnant women, including and especially services both before and after birth for women who experience miscarriages; and
A program led by Jeanmarie Perrone, MD, a professor of Emergency Medicine and director of the Penn Medicine Center for Addiction Medicine and Policy, that improves access to buprenorphine and other substance abuse treatment services, including telehealth outreach and navigation services, for people of color.
“The funded projects this year also address areas in which some of our most vulnerable patients may see the greatest benefits,” Elissa Klinger, director of health equity for Penn Medicine’s Center for Digital Health, said in a press release. “For example, black women in Philadelphia experience higher rates of severe pregnancy related health problems, particularly in the postpartum period, so programs like Healing at Home can enhance critical postpartum support that may ultimately help drive down rates of maternal morbidity. PEACE provides urgent and timely pregnancy care while promoting health equity. And increasing access to buprenorphine and other substance use treatment services targets the burdens of substance use and overdose striking in communities of color in Philadelphia.”
"Independence Blue Cross looks for novel interventions with strong early evidence and high potential to improve value-based care, so winning three awards is meaningful validation of Penn innovation programs,” added Roy Rosin, chief innovation officer of the University of Pennsylvania Health System and interim executive director of the Center for Health Care Innovation. “Our teams have shown they can make a difference in areas of care and patient populations that could benefit most from change, and with Independence’s partnership, we can advance and scale this work.”
Three Penn Medicine programs were also chosen last year for grants from Independence Blue Cross. Each of those programs has either expanded to serve more patients or launched a new study.
