Exploring Clinical Care Use Cases, Digital Health Literacy Gaps in RPM

August 12, 2022 - The virtual care revolution has brought exciting new prospects for remote patient monitoring (RPM). With rapid advancements in technology and growth in patient demand, healthcare providers are exploring new and improved ways to implement RPM services to solve some of healthcare's biggest problems.

RPM refers to care delivery enabled by connected electronic tools. These tools record personal health data in one location, which a provider reviews at a different location, either in real-time or later. The use cases of RPM are varied, backed by growing clinical evidence and regulatory flexibilities that have made it easier for providers to offer RPM and patients to access it. But barriers persist, especially among populations that could benefit from RPM the most.  

Speakers at Xtelligent Healthcare Media's 2nd Annual Remote Patient Monitoring Virtual Summit, held in July, covered a broad range of topics related to the evolving use of RPM, including chronic disease prevention and hospital-at-home programs, and a critical barrier to the widespread adoption of the virtual care modality — the lack of digital health literacy.

SUPPORTING CHRONIC DISEASE MANAGEMENT AND PREVENTION

RPM has the potential to advance chronic care management significantly. The devices used to facilitate RPM, like weight scales, pulse oximeters, blood glucose meters, and blood pressure monitors, are designed to track patient health metrics in real-time and over time, providing clinicians with a treasure trove of data to support clinical decision-making.

At Desert Oasis Healthcare, RPM is being used to manage several chronic diseases, including diabetes and hypertension, said Brian Hodgkins, executive vice president of clinical operations, during a virtual summit panel. The organization is currently working with a group to implement chronic heart failure monitoring through a wearable device that looks at rate rhythm, diastolic heart sounds, and respiratory rate, among other factors.

"I would call us a testing site for lots of RPM technology," said Hodgkins. "We probably get five or six calls a week about people interested in looking at RPM solutions for chronic population health… Then there's also the wearable crowd now. We're starting to look [at] and evaluate this more as a predictive model."

As RPM becomes increasingly well-established as a reliable strategy for chronic disease management, some providers are exploring its potential for chronic disease prevention.

The types of data that can be captured by wearables, such as heart rate and step count, can help providers assess the potential for chronic disease development, enabling them to create targeted strategies to prevent chronic disease patients from deteriorating, said Rebecca Canino, executive director of the Office of Telemedicine at Johns Hopkins Health System, at the virtual event.

But, to successfully employ RPM in chronic disease management and prevention, the collected data needs to be presented to clinicians in an actionable manner.

"To get a baseline, they have to look at averages; they have to really be able to look at it and what it means for that patient and be able to subtly shift that treatment plan to keep folks healthy," Canino said. "It sounds easy — it is not. It's getting that data in, making it actionable, making sure that the patient is a partner in this, that they know that they could get billed for something that they didn't get billed for before."

Technology vendors are also key partners in the deployment of successful RPM programs. According to Steve Bock, chief technology officer at connected healthcare solution provider Trapollo, providers must pick a vendor with significant RPM experience.

"A lot of people get infatuated with the latest cool device or the latest cool app, and I think it's really important to look at the holistic solution, not just the technology platform, but also the services that the vendor provides and the experience the vendor provides so that you [find] a partner that you can trust and a partner that can really lead you to success," Bock said at the virtual panel.  

Technology partners must be able to connect their provider clients to outcomes data and other metrics that can help them assess the impact of their RPM efforts, he added.

As RPM use for chronic disease care increases, providers must be mindful of health equity. Often, the populations that could benefit most from RPM-enabled chronic care are the ones that have difficulties accessing it.

"It really is so critically important," said Stephanie Conners, executive vice president and chief operating officer at Jefferson Health, during the virtual panel. "When you look at the uninsured patients or the patients that are in relatively challenged populations, it is so important that we pay attention to their specific needs."

Ensuring health equity in RPM programs involves not only addressing issues like food and housing insecurities but also closing the digital divide and providing technical support when needed, she said.

But launching and growing health equity efforts require financial support. One avenue through which Jefferson gains this funding is philanthropic donations.

For example, the health system sends nurses into patient homes to support RPM services.

"How do we do that? Some may ask, financially, how do you afford that? Well, No. 1, it's our mission, but No. 2, we have a lot of support, and that support just doesn't come from payers; it actually comes from some incredible donors that support Jefferson and the populations that we serve," Conners said.

IMPLEMENTING SUCCESSFUL HOSPITAL-AT-HOME PROGRAMS

Not only are providers implementing RPM for chronic care, but the pandemics resulted in a growing interest in hospital-at-home programs for acute care.

These programs leverage RPM to provide acute, hospital-level care in the patient's home. Clinicians at Kaiser Permanente, which launched its hospital-at-home program in partnership with Medically Home before the pandemic, have observed several benefits.

"[The program] allows us to treat the whole person, the whole patient, not just their diabetes or their hypertension, but really what embodies you as a whole person," said Vivian Reyes, MD, regional medical director of strategic inpatient initiatives, the Permanente Medical Group, and national position lead for Kaiser Permanente Care at Home, the Permanente Federation, during a keynote session at the virtual event. "We also discovered…that hospital-at-home programs can provide higher quality of care than one gets in the hospital, can provide safer care, and it provides a much better care experience to the patient."

Kaiser Permanente's program involves both virtual and in-person care. The virtual part of the program includes physicians, nurses, and service coordinators.

"They are what we call the brains of the operation, in as much that they're driving the care of the patient. They are creating the care plans and driving all of the activities around the patient's care stay," Reyes said.

The virtual team works with a field services team, which includes clinicians who physically go to the patient's home to provide various services, such as blood draws and IV medications.

"The virtual hub is connected to these hands in the field by workflows," she said. "We spent a lot of time developing high-quality workflows, and that's what we call the heartbeat. We have the brain connected to the hands through the heartbeat of the program. Together, we're able to deliver care."

"Again, this is because of remote patient monitoring," she added. "We would not be able to do this without remote patient monitoring."

Hospital-at-home patients are provided with an iPad, which they can use to connect with their care team and see upcoming scheduled services. They are also provided with Bluetooth-enabled devices, like weight scales and pulse oximeters, which remotely transmit their vital signs to their care team.

Patients are admitted to the program through the emergency department. Participation in the program is voluntary, and if a patient chooses to participate, an ambulance takes them back home, where the suite of technology is set up.

But certain social factors could prevent a patient from being able to participate.

"For instance, at this point in time, we are not taking patients who are homeless, although I hope to change that in the future," Reyes said. "Also, patients who do not have running water are not eligible for the program. This is really because we want to make sure that they have an environment that they can heal in."

But internet connectivity, despite being a major social determinant of health, is not a barrier for Kaiser's hospital-at-home patients. The hospital-at-home program leverages cradle technology, which allows the team to connect the RPM devices to the patient's Wi-Fi or enables them to use cell coverage signal to create a Wi-Fi network within the patient's home, Reyes said.

Though hospital-at-home programs are gaining steam in the healthcare industry, several challenges remain, including an uncertain regulatory future.

"[During the pandemic] CMS put out a waiver program where they would allow you to operate these programs under an inpatient admission, so to speak, under an inpatient model," Reyes said. "What has happened is that it is tied to the public health emergency [PHE], so a lot of organizations are concerned that, well, when the PHE ends, does our program then have nowhere to live, and can we no longer operate our program, which obviously causes a lot of problems."

To combat this issue, Kaiser helped launch the Advanced Care at Home Coalition, which advocates for extending hospital-at-home care flexibilities beyond the Covid-19 pandemic.

ADDRESSING DIGITAL HEALTH LITERACY GAPS

One of the most intractable hurdles to widespread RPM adoption and use is the lack of digital health literacy, particularly among vulnerable populations.

"Digital literacy is interesting because that refers to the level of comfort and confidence that people have in using technology and engaging in a digital experience," said Jared Antczak, chief digital officer at Sanford Health, during the virtual event. "It can be challenging for some people to download, register, navigate a digital solution, potentially connect things like remote patient monitoring devices, if they're not technically savvy."

It is up to providers and their community partners to remove this point of friction and enable people to engage in RPM, he added.

One way to combat digital health literacy gaps is to think through RPM processes from the patient's viewpoint. This includes taking stock of patient preferences and understanding the incentives that patients need to remain engaged, according to Antczak.

Digital health literacy issues are especially hard to address when scaling RPM programs across a large network. So, when Providence Health & Services launched a COVID home monitoring program, they not only provided easy-to-use technology, like standard thermometers, but also deployed interpreter services to support patients with low digital health literacy.  

"…it was very challenging to be able to identify across 90 different [home monitoring program] sites at the time, [in] six different states, which interpreter services to use," said Sherene Schlegel, executive director, telehealth clinical operations at Providence Health, at the virtual panel. "We ended up making that a lot easier on ourselves and contracted with one entity. So, it was a consistent interpreter service that we had available ⁠— over 200 languages. And then we also made sure within our EMR, when we went live at various sites, we looked to make sure that we had the predominant speaking languages for that area available."

Mitigating digital health literacy issues in low-resource care settings, like federally qualified health centers, is vital for ensuring RPM access within disadvantaged communities. But given the limited resources, addressing these issues is even more challenging than usual.

According to Roxana Cruz, MD, director of medical and clinical affairs at the Texas Association of Community Health Centers, conducting thorough assessments of patient needs are essential.

"After you assess the patient and assess what their needs are, as well as what they have access to, then [you have to] increase the access, and in our health center…in particular during COVID, we had to become very creative," Cruz said during the virtual panel. "And one example is that we learned to identify where the patient could seek out Wi-Fi without a cost to the patient. So, we would indicate to the patient, 'This is where you can go, and you can do virtual visits at this site.'"

Evan Harmon, system RPM manager at Baptist Health System, echoed the importance of needs assessments, adding that providers must not assume the digital literacy level of their patients.

"I don't think you ever really want to assume that someone, based on their age, or any of their demographic elements, that they will have a digital health literacy issue," he said at the virtual panel. "I think it's through those conversations that we gain a stronger understanding. You could have an elderly retired nurse that knows exactly what to do with RPM technology or is very familiar with placing a blood pressure cuff, or placing a wearable device, and knows how to do those things."

Patients with low digital health literacy may also be hesitant about RPM protocols and devices, but providers can combat this by having those who overcame their concerns tell their stories. Baptist Health is starting a marketing campaign where they record videos of patients talking about their concerns and how they worked through them.

"I think those are really, really important things that we're trying to do to make this go really well for our patients and set them off with good success," Harmon said.

As providers increasingly adopt RPM, they must take note of digital health literacy issues and other discrepancies in the populations they serve and work to close those gaps to enable patients to unlock the full potential of the virtual care modality.