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Evidence for Remote Patient Monitoring (RPM): The Glass is More than Half Full
Over the years, there have been a number of meta-analyses examining hundreds of studies relating to effectiveness of RPM. The latest one of these is Systematic Review of Home Telemonitoring for Chronic Diseases: The Evidence Base, published in the May/June 2007 issue of the Journal of the American Medical Informatics Association (JAMIA).
My colleague Tim Gee, respected fellow blogger and world renowned connectologist, summarizes this latest study under the headline “Impact of Remote Monitoring Still Inconclusive”.
Tim, I’m concerned that folks might draw the wrong impression from your use of the word “inconclusive”. While I’d have to concede that the word “inconclusive” is technically correct, I don’t think your headline conveys an accurate picture of the state of RPM development.
The word “inconclusive” accurately applies to the quality of the evidence in the studies, but doesn’t accurately describe the robust state of developments occurring in RPM. The quality of the evidence refers to the methodologies of the studies: lack of a control group, lack of randomization, small sample sizes, heterogeneity of studies, etc.
Here’s a related example. The x-ray was invented in the year 1895. An article in the year 1900 might have noted that the “evidence” to support the value of medical imaging was “inconclusive”. Should we have backed off the future development of this technology?
Researchers tend to be a cautious bunch by nature and training. So while a researcher might accurately use the word “inconclusive” to describe the scientific evidence supporting RPM, an executive, manager, clinician or strategist shouldn’t necessarily draw that same conclusion.
Let’s probe a little deeper into the very article that you characterize as “inconclusive”. There are two sections of a scientific paper where researchers sometimes let their hair down — the “Discussion” and “Conclusions” sections. Take a look at the conclusions the authors draw in the JAMIA article:
Based on the results of this review, home telemonitoring of chronic diseases seems to be a promising patient management approach that produces accurate and reliable data, empowers patients, influences their attitudes and behaviors, and potentially improves their medical conditions. Nevertheless, more studies are still required in this area to build an in-depth body of knowledge related to its clinical effects, cost effectiveness, impact on the utilization of health services, and acceptance by health care providers.[p.274]
…and here are a few more meta-analyses of RPM and related technologies where the authors 1) agree that the quality of the scientific evidence is “inconclusive” and 2) let their hair down a bit in the discussion and/or conclusion sections:
Telemedicine for the Medicare Population—Update, Agency for Healthcare Research and Quality (AHRQ), February 2006
Several limited studies showed the benefits of home-based telemedicine interventions in chronic diseases. These interventions appear to enhance communication with health care providers and provide closer monitoring of general health, but the studies of these techniques were conducted in settings that required additional resources and dedicated staff. [Structured Abstract]
Interactive Health Communication Applications (IHCAs) for people with chronic disease, The Cochrane Collaboration, August 2005
The reviewers found that IHCAs improved users’ knowledge, social support, health behaviours and clinical outcomes. It is also more likely than not that IHCAs improve users’ self-efficacy (a person’s belief in their capacity to carry out a specific action). It was not possible to determine whether IHCAs had any effect on emotional and economic outcomes. The included studies involved different IHCAs, with different characteristics, for a wide range of chronic diseases. There was variability in several of the outcomes, and the results should therefore be treated with some caution. There is a need for more large, high quality studies to confirm these preliminary findings, to determine the best type and best way to deliver IHCAs, and to establish how IHCAs have their effects for different groups of people with chronic illness. [Plain language summary]
Socio-Economic Impact of Telehealth: Evidence Now for Health Care in the Future, Volume 2, Policy Report, Health Telematics Unit, University Calgary, January 2003
Conclusions. Overall, valuable data and levels of evidence exist that support telehealth, and that can now be used by policy makers, decision makers, and researchers when making decisions specific to telehealth. These have been summarised in this report. However, evidence of high scientific quality for telehealth applications is still lacking. What has been clearly demonstrated is the feasibility of using telehealth in many clinical areas and for many health, clinical, educational, research, and administrative activities.[p. 11]
Finally, I’ll let my own hair down (something very difficult to do as it’s less than an inch thick). There is NO question in my mind — zero, zilch, zip, nada — that RPM is beginning to transform care and care management. I’m not sitting on the sidelines.
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Vince, this is a very nice synapsis of this particular paper and other existing review papers on remote telemonitoring.
I am a firm believer in the RTM concept for certain segments of the population that require frequent monitoring. There is no doubt in my mind that the current DM nursing model does not work with these individuals. Consider that CHF patients who gain weight overnight due to edema are very likely to end up in the ER, hospital or both. Under the standard DM nursing model, such a patient would receive a call once a month (or as infrequent as once evry 3 months). How could this admission be prevented under such model?
On the other hand, RTM provides daily updates on physiological and symptom-based measures most likely to identify an acute exascerbation. This triggers a call from a nurse that can help prevent the ER visit or hospitalization.
Does everyone need daily monitoring? Of course not, however, it is currently underused in the population that most needs it. I foresee the future population health management model relying on this technology to a much greater degree.
Remote Patient Monitoring – Some of Us Are Already Quaffing From the Brimming RPM Glass While Others Examine Whether There’s Anything In There Worth Drinking…
From the vantage point of a DM company that considers RPM a key enabling technology in a rapidly growing business (50% CAGR over 4 yrs) with unsurpassed outcomes:
• Asking “Does RPM deployment for DM really work?†is about as meaningful as asking, “Do antibiotics for community acquired infections really work?â€
– The appropriate antibiotic for a given bacterial infection is very effective, whereas antibiotics given for viral infections are not only ineffective, but harmful
– Likewise, appropriate RPM, deployed for the right patients with certain chronic conditions collecting suitable biometric and other data in consumer-friendly ways can augment the effectiveness and efficiency of DM programs
• RPM is not RPM is not RPM
– Not all RPM is equal – there are many diverse technologies available
– More parameters can be monitored than are cost-effective
– The technology of RPM is becoming more commoditized with time
– The art of RPM – what data to collect and how often, how to keep the process/devices simple and convenient for consumers, how to sustain optimal compliance over time – is embedded in the service components of RPM and is a significant differentiator among current offerings
• RPM technology already efficient and effective in appropriate DM contexts
– Unit cost will continue to drop over time, but it’s already cheaper (per given unit of outcome) to use RPM vs. not in many situations
– Alere’s experience is that cost of providing program for given performance is less expensive substituting RPM for manpower
– Though not yet at “no pain, immediate gain†threshold necessary for widespread adoption across payors, providers, or even DM community, today’s RPM is currently an effective and efficient component of leading population health mgt programs
– What to monitor, how to integrate biometric, symptom, other data into meaningful information and workflows to optimize intervention types, timing, customization is the key to effective RPM
Thanks to Vince for bring this up and to all of the other RPM advocates. I can only add one point and that is to say that academics make their living by doing research and most research papers end up by noting the ‘need for more research’. Its their way of up-selling to their marketplace. This is not to suggest any nefarious intent but simply a reminder that we all like to justify our existence.
Our organization has turned a corner in its thinking re:the use of this technology for the right select groups of patients. we’ve seen over and over that quality of care improves while admissions and ER visits decrease.
These postings beg the question: What is the role of science in diffusing promising medical technologies like RPMs and Rx drugs today (or even VK’s example of x-rays in the 19th century)? The answer? It depends.
With Rx drugs, the FDA mandates scientific research on safety and effectiveness first–when “proven” OK, the drug can then be marketed.
With x-rays (at least when they were introduced), surgical techniques, dietary supplements, RPM and most other medical (and non-medical) innovations in the economy … the product/service is marketed and rises or falls based on business principles. But what is the role of scientific research in this business-based scenario? It depends.
On the one hand, if the market demands rigorous research on effectiveness, the “RPM advocates” (JK) will see that it is done, and done objectively (at some point). When multiple high quality studies are done, the phrase “inconclusive evidence” should fall asunder.
On the other hand, if there is no market imperative for such research, evidence of RPM effectiveness will remain “inconclusive,” and those who really care will choose to spend their money elsewhere.
I, for one, believe the market will demand a science-based accountability of RPM – if for no other reason than to enable a purchaser to more easily make a rational decision on buying RPMs vs, a new x-ray machine vs. a newly minted (and expensive) prescription drug to be placed on the formulary. One business/economic principle we can never forget: Resources are limited (this still is true in the US health care system, isn’t it?)