ACC Offers Guidance for Remote Patient Monitoring

Remote patient monitoring (RPM) can be used in the management of a variety of cardiovascular care situations but incorporating it into practice raises questions that new guidance from the American College of Cardiology (ACC) aims to answer.

The workbook was put together by a committee chaired by Tony Das, MD (Baylor Scott and White Health Heart Hospital, Plano, TX), as part of the ACC’s Innovation Program, which is focused on the digital transformation of CV healthcare delivery, and is accessible for download from the website.

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“The general goal was to simplify what appears to be kind of a complicated problem,” Das said. “We wanted to give some guidance for how to start to evaluate devices that you might want to use in remote monitoring, to try to identify what kind of structure you need in your practice or in your hospital to be able to do it, and to give people some ways of taking what's a pretty broad category that has a lot of players in it and [provide] a bit of a road map towards instituting it in their practice and with their patients.”

The workbook covers different categories of current RPM technology, clinical objectives of using them, limitations and considerations when adding RPM to clinical practice, coding tips, and billing guidance.

By definition, RPM is the recording, saving, transmitting, and interpretation of specific health parameters, continuously or intermittently, outside of a clinical setting. While remote monitoring has guideline indications for patients who’ve had a cardiac implantable electronic device (CIED) or implantable cardioverter-defibrillator (ICD)—Class I, level of evidence A—many other RPM devices such as consumer-grade wearables and phone apps are not recommended by guidelines, nor are they cleared or approved by the US Food and Drug Administration.

Surveys have shown clinicians are looking to professional medical societies to provide guidance on the optimal use of direct-to-consumer devices, according to Das and colleagues. Such data also suggest that clinicians would be more likely to use RPM if there was more robust research to ensure accuracy and integration with electronic health records (EHRs). Most RPM programs are not currently set up that way and instead have to be scanned or uploaded into the EHR by staff.

Outsourcing and Best Practices

The workbook offers advice on things to think about before starting an RPM program, such as types of conditions that can be monitored, staffing needs, and reimbursement issues.

To TCTMD, Das said his own experience with RPM was that he started small with wearables that measured BP and weight. Those patients were managed by medical assistants. After about a year, they outsourced this role to a third-party company that now manages the process. His practice is currently using RPM in over 1,000 patients.

“Our general philosophy [regarding] do you need extra staff is that the short answer is no. But, as the volume goes up, and if the density of patient interactions increases, then to maximize the benefit of the program and maximize the profitability of the program, you really do need a well-organized process,” he told TCTMD.

In the section on best practices, Das and colleagues suggest limiting the number of RPM devices with separate platforms or using dashboards to monitor specific disease states.

“For instance, consider following HF patients with a single platform with a BP cuff, weight scale and an O₂ saturation device all connected to a reporting format with an easy-to-read dashboard,” they write. “In addition, consider setting up practice-based escalation rules for abnormal (red) or normal (green) findings on the site, which will allow for easy patient intervention when necessary.”

One improvement that Das said is still to come is “a single agnostic platform” that would transmit physiologic data from several types of devices monitoring different conditions. Being able to do that could potentially allow for preventive intervention prior to adverse outcomes, possibly avoiding emergency department visits and/or hospitalizations.

“The process of integrating them is kind of an ongoing project that's happening with several companies that I believe will ultimately do this, but it's going to take some time,” Das added.

Auditing of any RPM program is another important factor, and the workbook authors suggest doing it monthly “to allow for quality assurance with random patient dashboard reviews.”

In addition to the benefit of obtaining real-time clinical information from patients, another perk of RPM may be the satisfaction that patients and their families gain from being more involved in their care.

“We’ve found that many of our patients are grateful for the contact [with staff] that they get and some of them report feeing a closer relationship with our office because of it,” Das said. Patients also gain a better understanding of why the monitoring is being done, which in the long run may improve compliance with wearables, he added.