Remote Patient Monitoring Drives Care Outside the Hospital

In addition to allowing providers to monitor and analyze a patient’s condition from outside of the hospital or clinic, remote patient monitoring (RPM) “is a critical enabler of home-based care,” explained Hye J. Heo, MD, vice chair of obstetrics and gynecology, clinical informatics, and associate professor, New York University Grossman Long Island School of Medicine, NYU Langone Health.

Heo presented on RPM during an Institute for Value-Based Medicine® event cohosted by The American Journal of Managed Care and Memorial Sloan Kettering Cancer Center (MSK). The event focused on moving care outside of the hospital, with additional presentations on the oncology hospital at home from Kathi Mooney, PhD, RN, FAAN, of the University of Utah Huntsman Cancer Institute in Salt Lake City, and treatment with at-home infusions from Amy Laughlin, MD, MSHP, of Orlando Health Cancer Institute in Florida.

Although she is not an oncologist, Heo explained that the best practices and learnings from the use of RPM have broad applications for multiple disciplines. The RPM program at NYU has been in place since 2017 and more than 5000 patients have participated. The RPM platform is integrated into the Epic electronic health record and allows patients to synchronize a device—for instance, a blood glucose monitor—with the NYU Langone health app, she explained.

“Moving forward, data…will pass from that device to their phone, and then to the app, which then makes [those] data available in our Epic [system],” she said. “Then, essentially, clinicians can then use that information to…make adjustments in medications.”

Since the COVID-19 pandemic, these digital health services are reimbursable, Heo added. Previously, practices were providing that care and service without reimbursement, but there are now codes allowing clinicians to bill for RPM, in addition to telehealth and in-person care.

As a maternal-fetal medicine (MFM) specialist, Heo provided an example of how RPM is being used for her patients. Diabetes can have a significant impact on maternal and neonatal morbidities, and good glycemic control reduces these risks. Pregnant individuals are typically diagnosed with gestational diabetes in the third trimester, allowing a short window to achieve target control and improve pregnancy outcomes. RPM technology has helped facilitate this process.

Prior to the use of RPM, patients with diabetes were logging their finger-stick glucose test on paper and bringing these records to visits. Patients needing more acute care would fax or email the results, and clinicians would call to provide direction.

In February 2020, the RPM platform became available to MFM, with enrollment offered to all patients. Then, a month later, telehealth medicine became available with the onset of the pandemic and the public health emergency.

More than 1500 patients have utilized RPM services to manage diabetes in pregnancy, and 90% of patients with diabetes being cared for at NYU Langone use the platform. In recently published research,¹ Heo and colleagues showed that use of the RPM technology improved maternal glycemic control and decreased neonatal hypoglycemia compared with patients utilizing a traditional paper-based approach. In addition, patients using the platform had decreased rates of preeclampsia.

She noted that these outcomes were achieved with no changes to staff. The same team was taking care of the same patient population without needing additional resources. “Based on that, use of RPM technology can be used to improve clinical outcomes, and I do advocate that this has to be the trend moving forward,” Heo said.

In October 2020, when hospitals in New York City were at capacity and postpartum patients were being taken by ambulance to an ambulatory site miles away, patients were being sent home postpartum day 1 or 2. “Our major concern was hypertensive disorders [that] are associated with increased risk of maternal and neonatal morbidities. And this is one of the greatest risks for readmission,” Heo said. Leveraging the RPM technology and an electronic medical record (EMR) tool, NYU created a gestational hypertension care program that sent patients reminders twice daily to check their blood pressure, alerting them if the readings may mean they have preeclampsia and need to escalate their care.

According to Heo, patients on the program were more likely to send information, allowing for better titration. “For individuals or organizations that are looking to implement RPM, I think what’s very important to always learn is that while the technology is very powerful and can aid you, it’s not something you just turn on,” she said. “It has to align with your operational structures. So, you have to put that in place first.”

In a panel discussion following Heo’s presentation, speakers discussed the need to move cancer care to a hybrid model with both remote or virtual care and in-person care based on the patient’s needs and circumstances.

The panelists were as follows:

• Erin Bange, MD, MSCE, genitourinary oncologist, MSK
• Lauren Cantor, MBA, venture investor, Yosemite
• Kara Egan, MBA, CEO, Teal Health
• Mario Lacouture, MD, director of the Oncodermatology Program, MSK

Lacouture takes a precision-guided management of treatment toxicities in dermatology that uses pharmacogenomics, analytics, and informatics to tailor preventive and reactive strategies to treat each patient’s adverse events. The strategy also considers the type of drug, the patient’s prior history, and any mutations that might predispose them to greater toxicities.

“We come up with a tailored plan for patients based on their medical record and based on their treatment that they will be starting,” he said. “And we also take advantage of other drugs that are commercially available in our space and apply them to diseases that are phenotypically similar to these toxicities.”

Virtual monitoring of symptoms and toxicities from cancer treatment requires coordination, a report of the patient’s symptoms, and laboratory parameters that can be integrated into the EMR; however, many institutions do not have the capability, Lacouture explained. His practice is to gather data on patients every time they communicate, include it in an assessment, and share it immediately with the medical oncologist. This ensures that any steps taken to mitigate symptoms and toxicities do not impact clinical outcomes, he said.

Using a type of precision care delivery can identify markers and patient characteristics that align with the best type of care, whether that is remote or in person, has more frequent or less frequent check-ins, and uses other types of personalized care, Bange said.

“There [are] some patients for whom we can really de-escalate that [care and] give them some of their freedom back to have quality-of-life time with their family [and] decrease the financial and time toxicities of treatment,” she said. “And there [are] other patients for whom we really need to be doing more.”

Bange believes the hybrid model of care “is the only model,” because everything cannot be just at home or only in person. To move this way, there needs to be institutional buy-in and support, and clinicians and patients must be engaged in the model to feel that it is safe.

Cantor’s venture capital fund has invested in Egan’s Teal Health because it provides a way to screen people quickly and efficiently, providing them with more agency. Teal is working to create the first FDA-approved at-home cervical cancer screening kit. According to Egan, the results of Teal’s 215-person study found 87% of participants said the at-home screening was very easy to use, and they would be more likely to be screened if the Teal kit were available to them.

Yosemite is also looking at ways to build remote care into a hospital’s infrastructure and considering how providers can keep patients in the system to receive care. “We also are starting to think about the way that value-based care plays into all of this and how you kind of wrap an alternative payment modality around having to pull a lot of the care outside of the hospital [and] reduce admissions,” Cantor said.

Lacouture and Bange said their patients do not want to come into the clinic. Patients want to be able to stay home as much as possible, and feedback around RPM and similar initiatives has been “extraordinarily positive,” Bange said.

Patients with prostate cancer, for example, are commonly treated with abiraterone, which requires frequent laboratory testing for the first 3 months. “For some patients, the frequency of the monitoring required to safely administer these oral-based medicines can be too much, and they actually don’t engage in the care appropriately and it can lead to toxicities,” she said. However, the new model allows toxicity monitoring at home with reliable measurements, and patients can continue working without using sick days or taking unpaid time off to get their labs done. “The more [patients] get a taste of it, the more they realize they’re able to live their life,” Bange said.

Often, there is a thought that when patients are not adherent to treatment, it is because they are negligent, but the reality is “they’re making trade-offs,” Egan said. “They have decisions in their life, whether that’s to make money and feed their children or pick up their children. It’s not…black and white.” 

Reference

1. Kantorowska A, Cohen K, Oberlander M, et al. Remote patient monitoring for management of diabetes mellitus in pregnancy is associated with improved maternal and neonatal outcomes. Am J Obstet Gynecol. 2023;228(6):726.e1-726.e11. doi:10.1016/j.ajog.2023.02.015