Remote patient monitoring or telemonitoring is an innovative and novel strategy which seeks to not only promote health, but improve patient engagement, management, and care. The fundamental underpinnings of remote patient monitoring are relatively straightforward – disease-related and/or physiological data are digitally transmitted via a stable network from the comfort of the patient’s home, to a healthcare provider. Examples of such networks include a telephone, the Internet or even video-conferencing applications such as Skype or Zoom (1).
Remote patient monitoring is not a recently conceived idea; in fact, the Lancet published an article in 1879 which proposed the idea of using the telephone in order to reduce unnecessary visits to the physician’s office. Subsequently in 1925, the cover of Science and Invention revealed a physician who diagnosed a patient over the radio whilst envisioning a device which would facilitate a video examination across large distances (2).
Since the development of patient-facing technologies such as the smartphone, cloud computing services such as Amazon Web Services and Microsoft Azure, as well as physician-facing platforms which integrate Internet-of-Things (IoT) devices seamlessly, remote patient monitoring has transitioned from an idea into a reality.
Researchers in telemedicine have argued that remote patient monitoring is an inevitability; this is because communication via web and/or mobile is available for almost 75% of the global population, and there are in excess of 1 billion devices with Internet access worldwide (3) with about 97,000 health-related mobile applications available for download(4). The democratisation of technology has been accompanied by a rapid uptake in the use of wireless devices and smart-phone applications; the literature regarding telemonitoring has seen a rise from just 5 studies published between 2000 and 2002 to over 90 studies published between 2015 and 2018 (1). This increased adoption has also resulted in more evidence that supports remote patient monitoring as a highly effective strategy for improving the patient journey.
Remote patient monitoring or telemonitoring is part of a wider over-arching term – telemedicine. Telemedicine itself is a broad umbrella term which comprises teleradiology, telepathology, telepharmacology, telemonitoring and telesurgery amongst others (5). The fundamental components of remote patient monitoring depend significantly on the complexity of the telemonitoring health system and architecture. Simple telemonitoring strategies comprise of telephone support rendered by healthcare providers (e.g. telephone triage in a general practitioner’s clinic conducted by a nurse) (6) where patients report their own symptomology during a scheduled phone call.
A more complex telemonitoring strategy could leverage a patient-portal (e.g. Remecare by Remedus) for patients to upload their own physiological data and symptoms for subsequent review by a healthcare professional. The feedback loop is closed when the physician-facing electronic health record (Remecare) prompts them to review said data to inform their clinical decision making. An even more complex telemonitoring strategy could consist of wearable IoT devices which are integrated into a smart-phone application and harness a wireless cloud for the seamless transmission of data to healthcare providers or dedicated monitoring centers in a real-time or pre-scheduled manner (1).
Apart from facilitating the transmission of frequently reported symptoms and objective physiological or disease-related data, remote patient monitoring has one other important offering – experience and outcome measures. Patient Reported Experience Measures (PREMs) are instruments which capture patient satisfaction scores with any given health service; they serve as a surrogate marker for the overall patient experience of healthcare (7). PREMs are typically utilised in the general population and within non-specific settings such as the outpatient (clinic) setting. They are used to monitor patient feedback and glean insights regarding the general and comprehensive experience of the patient. PREMs have been validated as reliable measures of how well a healthcare institution can provide high-quality service from a patient’s perspective (8).
Patient Reported Outcome Measures (PROMs) on the other hand, are instruments which are used to measure patient reported outcomes, and measure the patient’s health status (e.g. health-related quality of life). PROMs are typically self-reported questionnaires which measure a patient’s functional status, quality of life, symptomology, symptom burden, as well as health/disease-related behaviours such as generalised anxiety or depression (9,10). PROMs can be tailored to suit general health conditions or specific diseases in order to scrutinise patient-reported outcomes better. One example of a broad-based PROM is that of the EuroQOL EQ-5D which evaluates a patient’s mobility, self-care, usual activities, pain and anxiety or depression (11). Disease-specific PROMs such as the Asthma Control Test (ACT) and the New York Heart Association (NYHA) questionnaires assess pathology-specific symptoms such as asthma and congestive cardiac failure respectively (12,13).
Since PREMs and PROMs can be designed into user-friendly questionnaires in several forms (e.g. Likert scale, multiple-choice or free-text), remote patient monitoring allows patient care navigators, physicians, nurse clinicians and customer care experience officers to integrate these instruments into patient-facing material, be it a smartphone application or a patient portal. This enables healthcare institutions to buttress the objective physiological data with subjective experience and outcome related metrics reported by the patient for a more comprehensive and insightful picture. This high-level oversight can be useful for institutional leadership as well as it enables for an evaluation of clinical effectiveness, cost-effectiveness, and service quality.
From the outset, it can be challenging to comprehend how remote patient monitoring could support or even replace the traditional clinic visit. With the advent of the novel coronavirus 2019 (COVID-19) pandemic however, it is clear that remote patient monitoring can not only replace traditional in-office visits, but even edge them out. In a simple remote patient monitoring system, patients log their physiological data into a patient-facing smartphone application – these data could include basic vital signs such as the systolic and diastolic blood pressure, temperature, heart rate, pulse oximetry value and serum glucose level. With more advanced telemonitoring systems, patients may not even need to log these data, as the IoT ambulatory devices are equipped with Bluetooth functionality which enables for an auto-logging of data into the smart-phone application during a monitoring “session”.
In addition to the physiological data, PREMs and PROMs, remote patient monitoring also simulates the in-clinic visit by obtaining vital symptom-related data from the patient in many structured (e.g. multiple-choice, Likert etc.) and unstructured (free-text, voice-recordings, images etc.) formats. The flexibility of designing patient-facing questionnaires allows for telemonitoring to be speciality-agnostic. For example, a psychiatrist may want to check up on their patient’s symptoms of depression using the well-validated PSQ4D questionnaire which evaluates for mood changes, loss of pleasure, a lack of energy and sleeplessness (14).
Conversely, a dermatologist may want to evaluate their patient’s psoriatic rash after commencing them on pharmacotherapeutic treatment by receiving weekly images of the resolving rash. A general practitioner may want to combine both questionnaire and image modalities by reviewing their diabetic patient’s non-healing chronic foot ulcer as well as review their thrice-daily serum glucose measurements and symptoms of diabetes (i.e. thirst, increased urination, and lethargy).
This flexibility in tweaking the individual components of the remote monitoring system architecture allows for healthcare providers to embrace personalised medicine as a service and deliver precision care to their patients at the level of the individual.
Apart from simulating the evolution of the health condition through disease-specific questionnaires and the physical examination through physiological data collected by IoT devices, remote patient monitoring can also allow for monitoring of other aspects of care. For example, the psychiatrist in the earlier example could evaluate the patient for adverse effects caused by newly commenced anti-depressants – this could be in the form of a free-text and broad-based question, or pre-designed questions which are specific to the adverse event profile of the drug. In the event that questionnaires cannot capture salient data that are essential for clinical decision making, remote patient monitoring can incorporate messaging and/or video-conferencing to open up a line of communication between the patient and the healthcare provider.
In order to successfully on-board a healthcare institution on a remote patient monitoring application/platform, a needs analysis should be conducted. The specific patient demographic or disease group should be targeted for a pilot, and the patient journey should be mapped out from beginning to end, together with the patient interfaces at every juncture (registration, consultation, billing, appointment scheduling etc.). At Remecare, we understand that healthcare is an ecosystem, and the healthcare provider and patient are at the centre of a complex inter-connected web of networks which span business development, finance, safety and quality, and medicine.
To that end, Remecare offers prospective healthcare partners a customised consultation to understand your business and care needs. We understand the barriers to implementation of remote patient monitoring services – reimbursement, cultural shifts, and medicolegal issues. We have navigated these barriers with several customers and have convincing use-case stories which inspire confidence in our capabilities to bring your institution to the forefront of digitalised and personalised medicine.
Remecare provides a golden opportunity to healthcare institutions to embrace ground-breaking technology and realising the vision of personalised medicine in a volatile, uncertain, complex, and ambiguous world. We endeavour to identify the pain-points in the patient journey in order to achieve a safer, more effective, highly personalised and satisfying clinical experience for both patients and healthcare providers alike.
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