Planning an RPM Strategy From the Ground Up

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).

This is the second part of a two-part story on that round-table. Part 1 was posted on Thursday, July 14. Quotes have been edited for clarity.

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.