REMOTE PATIENT MONITORING SOLUTIONS Towards Remote Patient Management

Transcription

1 Chapter 30 REMOTE PATIENT MONITORING SOLUTIONS Towards Remote Patient Management David Simons 1, Tadashi Egami 2, and Jeff Perry 2 1 Philips Research, Eindhoven, The Netherlands; 2 Philips Medical Systems, Milpitas, CA, USA Abstract: Keywords: In this chapter, remote patient monitoring is discussed in terms of domain, applications, benefits, barriers, and existing solutions. In addition, remote patient management is introduced as an enabler to further develop new and improved care models. Examples of today s and tomorrow s Philips activities in this domain are included. Telehealthcare, remote monitoring, home telemonitoring, disease management, Motiva 1. INTRODUCTION Over the last decade, healthcare delivery has gradually extended from acute institutional care, to outpatient care and home care. Traditional outpatient care involves patients receiving care through visits to a hospital, clinic, or doctor s office for diagnosis or treatment without spending the night. Traditional home care typically involves periodic home visits by a nurse or other extended healthcare provider, for the purpose of monitoring and expeditiously treating patients with post-operative or chronic conditions. Home care services may require patients to maintain detailed records about their diet and health to support this care. Advances in communication and information technology have enabled the delivery of healthcare services at a distance, anywhere outside of clinical settings. Such telehealthcare services involve both live audiovisual communication and store-and-forward exchange of digital images and medical information between patients and their care providers, at a distance. In our definition, subsets of telehealthcare services include telemedicine, home telecare, and remote patient monitoring. 505 G. Spekowius and T. Wendler (Eds.), Advances in Healthcare Technology, Springer. Printed in the Netherlands.

2 506 Chapter 30 Telemedicine is used to provide consultative and diagnostic medicine to patients at a distance instead of face-to-face, e.g. when patients are very isolated or when specialist services are in very high demand. Home telecare is the term given to offering remote care of elderly and vulnerable people, providing care and reassurance needed to allow them to remain living in their own homes, via the collection of contextual data and audiovisual communication. Remote patient monitoring (RPM), a.k.a. home telemonitoring, involves the passive collection of physiological and contextual data of patients in their own environment, using medical devices, software, and optionally environment sensors. This data is transmitted to the remote care provider, either in real-time or intermittently, for review and intervention. Existing RPM solutions, and future extensions to remote patient management are the topic of this chapter. 2. REMOTE PATIENT MONITORING Deployment of RPM is driven by two principal concerns: to decrease the total cost of caring for patients with conditions that place them at high risk for hospitalization, and to provide efficiency improvements over models that rely on nurses traveling to residences to care for patients. To date, RPM has been principally deployed in the disease management (DM) domain. DM is a systematic process of managing care of patients with specific diseases or conditions (particularly chronic conditions) across the spectrum of outpatient, inpatient, and ancillary services. The benefits of disease management may include: reducing acute episodes, reducing hospitalizations, reducing variations in care, improving health outcomes, and reducing total costs. Disease management may involve continuous quality improvement or other management paradigms. It may involve a cyclical process of following practice protocols, measuring the resulting outcomes, feeding those results back to clinicians, and revising protocols as appropriate. The primary application of DM is in chronic diseases. Table 30-1 lists the top 9 most expensive diseases in the US in It is observed that chronic diseases make up a significant part of the overall cost, and their prevalence is growing. Also, for many of the expensive diseases, obesity is a risk factor.

3 30. Remote Patient Monitoring Solutions 507 Table Top-9 most expensive diseases (US). Ranking Disease Yearly cost (billions of $) #1 Heart Conditions #2 Trauma #3 Cancer #4 Mental illness #5 Respiratory ailments #6 Hypertension #7 Arthritis and joint disorders #8 Diabetes #9 Back problems Overweight is a risk factor (1B adults worldwide are overweight) Nr. of patients (millions) Compounding this problem, chronic diseases disproportionately afflict the elderly. In the coming years, the so-called age wave (Figure 30-1) will magnify the problem, if no solutions to reducing incidence or costs are found. Figure Proportion of population over 65 by region, 2000 and 2050 (projected). While all patients with these high-cost conditions would likely benefit from some additional support in the home, remote patient monitoring solutions today are not applied for management of all these diseases. To be effective, the technology must be tailored to the disease-specific care process and made acceptable to the corresponding patient-user group. It must also be provided at a price point that enables the care giving organization to justify investment in the technology. Today, most DM programs mainly use RPM

4 508 Chapter 30 solutions in the management of their cardiac patients (CHF, CAD), diabetes patients, and pulmonary patients (COPD, asthma), starting with the most critical ones. Of late, RPM is finding new applications in the domain of post-event rehabilitation (e.g. after cardiac surgery), diagnostic monitoring (e.g. of cardiac events), obesity and weight management, and elderly care. The benefits of RPM solutions are broad ranging but can be grouped into economic benefits for the financial risk holders, operational benefits for the providers and quality of life benefits for the patients. A number of studies have already shown dramatic reductions in key cost drivers for the healthcare community through RPM technology leading to positive financial results. In particular, the TEN-HMS 2 study, sponsored by the European Community, demonstrated a 10% cost saving over pure nurse follow-up, with an ROI of 2.1 when comparing incremental cost savings per patient to additional program fees. In this study of heart failure patients, it was the relative 26% reduction in hospital days per patient that drove the economic savings and increases in quality of life (Figure 30-2). Other studies have shown reduction in costly ER admissions or required home visits by nurses 3. Monitoring vital signs through RPM solutions with follow-up provides efficient early warning mechanisms for the healthcare community to support patient behavior change and avoid costly hospitalization. For example, by tracking a patient s weight over time, a clinician will recognize pending episodes of fluid build-up in a heart failure patient and follow-up with the patient to make the necessary adjustment to their care protocol. Remote Patient Monitoring also addresses key operational needs of the healthcare community. A recent publication by the Duke University Medical Center pointed out that there isn t enough time in a day for physicians in the US to satisfy treatment guidelines for all their patients with chronic illnesses 4. RPM supports effective and efficient population management through automated monitoring and education in line with those evidencebased guidelines for patient management to prevent hospitalizations. Not only is the reach of a disease management organization with a given amount of human resources a bigger patient population, but also the quality of care is enhanced through standardization. This is particularly important given a worldwide shortage of qualified nurses who have typically been the main point of contact with a patient for a disease management service. Finally, RPM poses significant benefits for the patient in terms of quality of life. Patients have reported feeling more secure with this type of supervision (88% of telemonitoring patients in the TEN-HMS study reported feeling safer or much safer while in this type of program.) Patients and caregivers alike appreciate the continued support outside of hospital or physician

5 30. Remote Patient Monitoring Solutions 509 walls in avoiding hospitalization and exacerbation of their condition. Effective RPM solutions not only increase patient awareness and motivation for healthy behavior but also increase patient confidence in managing their condition. Figure Deploying home telemonitoring for heart failure patients reduced both days in hospital (improved quality of life) and total cost of care (see Cleland et al. 2 ). However, a number of barriers have prevented broad development and widespread deployment of RPM solutions. These barriers can be segmented into regulatory, financial, cultural and technical categories. On the regulatory front, a wide variety of organizations and standards may govern the deployment of RPM technologies. In the US, these organizations include the Food and Drug Administration (FDA) and the Federal Communications Commission (FCC). Relevant regulations include the Healthcare Insurance Portability and Accountability Act (HIPAA), promulgated by the Department of Health and Human Services. HIPAA governs the patient health information security and privacy requirements for entities that manage such information. In Europe, analogues of these organizations and regulations exist on both a European Community level (e.g. the Medical Device Directive) as well as on regional and national levels (e.g. regulations of wireless frequency spaces, privacy and security regulations). As a result, developing solutions that can be deployed on a world-wide basis can be a complex undertaking, realistically accessible only to a few companies who have the resources and domain knowledge to cost-effectively navigate this web of requirements and regulations.

6 510 Chapter 30 Financial barriers to widespread RPM deployment also exist. First and foremost of these is the absence of well accepted and wide spread reimbursement models to support remote patient care. The traditional health insurance model provides for compensation to health professionals for a wide variety of services provided in hospitals, clinics and doctors offices. However, these schemes provide little financial compensation for care provided in patient homes or via remote or virtual interactions with patients. As a result, RPM often suffers from two financial barriers. First is the direct barrier to reimbursement for services rendered. The second, more insidious, barrier is the financial disincentive toward remote management, as effective RPM decreases the need for and revenue from traditional bricksand-mortar health services. In turn, this financial disincentive compounds the cultural barrier the traditional healthcare system has to providing continuous remote care. Western healthcare systems have become highly effective at providing acute and emergent care. Corresponding institutions and professional organi- zations have developed around enhancing these practice models. These institutions in turn may resist or retard the evolution of competitive or non-allied care models. Finally, some technical barriers exist to cost-effective development and widespread deployment of RPM solutions. In the medical informatics community there is a saying that the wonderful thing about standards is that there are so many of them. Though the healthcare community evidently recognizes the value of interface standardization, the lack any all-powerful standards setting bodies (or comparable de-facto industry standards) has enabled the proliferation of standards, sometimes resulting in several competing standards being developed for the same domain. As a result, creation of plugand-play devices and services is simply not possible in healthcare today. Security issues also impact the development of RPM technologies. Policy makers continue to wrestle with setting appropriate expectations, regulations and penalties for the maintenance of healthcare information. Tremendous advances in this area over the last few years have driven changes that make healthcare information more safe and secure than ever before. However, the rapid pace of change, as well as the continued existence of legacy technologies that may not be upgradeable to the latest technical approaches, has proved challenging and expensive for many healthcare technology vendors and customers. We are convinced that the barriers to RPM can be overcome, and that the benefits will stand out, leading to a wide deployment of RPM.

7 30. Remote Patient Monitoring Solutions REMOTE PATIENT MONITORING SOLUTIONS Many solutions for RPM exist today in the market, which is very fragmented. Many players have their own proprietary solutions and individual competencies along the value chain. Figure Home telemonitoring solution from Philips Telemonitoring Services. A typical RPM telemonitoring solution consists of the following components (Figure 30-3): 1. Medical observation devices, to measure vital signs such as weight, blood pressure, glucose, and ECG rhythm strips. These devices may be stationary, portable, or body-worn, and have wired or low-power wireless connectivity to transmit the measurement to a care station. Today more and more devices appear using Bluetooth radios, though over time this may change to alternative, more suitable radios when they become widely available. 2. One or more care stations, either stationary (e.g. PC, dedicated embedded device) or portable (e.g. mobile phone, PDA) that act as an access point and store-and-forward unit for the vital-signs observations. In some cases, if the care station allows for user input, it is also used for gathering subjective input from the patient, via short surveys. 3. Connectivity from the patient s homes to a data server at the back-end. Typical RPM solutions are phone-based (POTS) and use dial-up modems to connect intermittently to the data server. Alternative solutions using

8 512 Chapter 30 cellular networks (e.g. GPRS) and Internet are also being marketed, nowadays. 4. At the back-end data center the data for all subscribed patients is being collected and made available for review by nurse care managers. One of the distinguishing features of RPM solutions is the level of specialistic data processing and clinical decision support that is offered to increase the efficiency of the nurse care managers. 5. Typically, the nurse care managers are based in a call center, from which they can place a phone call to the patient or corresponding physician, when results fall outside the expected ranges. So, with today s solutions, objective and subjective patient data are transmitted to the care manager, to allow the most at-risk patients to be prioritized for follow-up. The solutions have proven clinical and financial efficacies 2. The patient, however, is taking a more passive role rather than getting the tools and information to help them the positively change their behavior (healthier diet, exercise, medication compliance) and involve them in manage their own health. This is where the extension from remote patient monitoring to remote patient management comes into play. 4. REMOTE PATIENT MANAGEMENT: A NEW PARADIGM IN HEALTH CARE Management of the chronically ill is still very much driven by the traditional bricks and mortar institutions of the medical community. The majority of those in the generations over 65 rely on their physicians and healthcare network for guidance around daily therapy. Typically, the healthcare community has focused on treating acute conditions and serious exacerbations, not on providing daily support and management. As a result, in this traditional model, patients are largely left to fend for themselves, with the avoidable result that their health status occasionally declines to the point where they must be admitted to a hospital for treatment (Figure 30-4). The challenge is for the care community to work more creatively and efficiently to drive out these high-cost exacerbations and complications. RPM solutions provide a means to smooth the traditional, reactive care management roller coaster, efficiently detecting when a patient s health status is slipping and enabling the healthcare system to intervene to prevent a high-cost event. Responsibility and accountability for healthcare costs is increasingly moving toward the consumer. Consumer-driven health and wellness is emerging as an industry, as individuals wish to take more control of all

9 30. Remote Patient Monitoring Solutions 513 aspects of their health and medical care. Compounding these phenomena, the trend of healthcare systems to push more financial responsibility onto patients is creating incentives for patients to be more savvy consumers of health services. The recent emergence of consumer-directed healthcare plans enables patients who effectively manage their care and risk factors to manage and potentially reduce the direct cost of their healthcare. Figure Traditional vs. telemonitoring care models. Technology, in the form of low-cost unobtrusive monitoring devices, pervasive connectivity, and intelligent, personalized applications and services, is poised to play a significant role in this coming transformation. Many of these technology building blocks are crossing over from the consumer and entertainment sectors into healthcare and wellness. For example, Philips Connected Planet products envision and address a world where consumers can connect and access entertainment, information and services, any place, anytime, anywhere. Philips sees the drivers for Personal Healthcare and Connected Planet technologies being the same digital convergence, backed by expanding access to a broadband infrastructure and breakthroughs in wireless technologies. 5. MOTIVA MOVING INTO THE FUTURE With the Motiva platform 5, Philips is making this convergence vision a reality. Motiva represents a scalable, personalized platform to effectively help healthcare systems manage one of their principal challenges reducing the total cost of caring for an increasingly elderly population with escalating incidence of chronic illnesses.

10 514 Chapter 30 The foundation for Motiva is built on half-a-decade of commercial experience supplying telemonitoring solutions, such as the Philips Telemonitoring Services solution (Figure 30-3). Traditional telemonitoring solutions focus on simply collecting patient status information from devices for display and review by care managers. Broad deployment of these solutions has been hindered by both the cost and the complexity of deploying devices into the home. As a result, these monitoring solutions have generally only been deployed for the highest-risk and highest-cost patients, even though studies like TEN-HMS 2 have shown the approach to be cost effective. The Motiva platform addresses these issues, using technologies that integrate well with normal daily routines and that leverage the cost and scale efficiencies that are common to the consumer electronics domain. For the healthcare system, Motiva enables care providers to more effectively help patients self-manage their conditions. Through an engaging, on-demand multi-media patient interface, delivered over the TV, patients are guided towards healthy behavior, without increasing the demand for costly and scarce live nursing support. Figure Philips Motiva: Leveraging consumer electronics and connectivity to provide secure, reliable health & wellness services to patients at a time and place of their convenience. Leveraging Philips understanding of both consumer solutions and the healthcare domain, Motiva combines technologies, form factors and usability models developed for consumer electronics with architectures, security, applications and services designed to meet the needs of healthcare systems. The result is a platform that enables a transformation in how chronic and other complex conditions can be managed from nurse-andphone based approaches, to one centered around providing patients with the

11 30. Remote Patient Monitoring Solutions 515 information, skills and tools they need to effectively manage their conditions themselves (Figure 30-5). An initial application built on the Motiva platform focuses on supporting the remote management of patients with congestive heart failure (CHF). It comprises a media-rich interactive health channel that is accessible from the patient s own television. This interaction medium works well for the CHF target group of which most patients are older than 55. Also, devices for monitoring weight and blood pressure can be included (Figure 30-6). Figure Philips Motiva patient self-management components. At the end of 2004, a usability study of the Motiva system in New Jersey with the Cardiology Associates of the Delaware Valley 5 highlighted strong acceptance by both patients and clinicians. Patients appreciated both the guidance and interactivity that the Motiva solution supports and readily accepted the TV interface.

12 516 Chapter 30 Just as the names suggests, Motiva motivated me to do the right thing Through personal charts and educational videos sent to me on my TV by my nurse, I learned how to better manage my disease. I weighed myself, took my own blood pressure, answered daily health questions, and the Motiva system tracked how well I was doing. With Motiva, it was easy to learn how improving my lifestyle could help me stay healthier. I m feeling more in control now. - Patient in CADV Study At the other end of the care relationship, the clinicians felt that their connection with patients actually improved with the Motiva system, and that they were more aware of the patients health status. By interacting with patients on a day-to-day basis, we can be more proactive; problems can be detected earlier than they might be otherwise. Chronic cardiac conditions are manageable, but our challenge is to provide patients with the tools and knowledge they need to play a more active role. A patient who is more educated will be more likely to comply with medications, with dietary and fitness recommendations, and in general, to be more involved with their care. - Jeffrey H. Kramer, M.D. Fellow of the American College of Cardiology Principal investigator for CADV The Motiva platform is architected to be extended over time to accommodate applications for other diseases, novel measurement devices (such as unobtrusive, wearable vital sign sensors) and alternative interaction devices (such as web browsers, cell phones, and digital media devices). In addition, the platform is designed to scale toward millions of users and devices, anticipating a future when health and wellness management is a mainstream consumer market. REFERENCES 1. Forbes on-line article April 14, 2005, The Most Expensive Diseases, based on data from Agency for Healthcare Research and Quality; /14/ cx_mh_0414healthcosts.html. 2. J.G.F. Cleland, A. Balk, U. Janssens et al., Noninvasive Home Telemonitoring for Patients With Heart Failure at High Risk of Recurrent Admission and Death (TEN-HMS study), JACC 45(109), (2005). 3. L.R. Goldberg, et al, Randomized Trial Of A Daily Electronic Home Monitoring System In Patients With Advanced Heart Failure: The Weight Monitoring in Heart Failure (WHARF) Trial, American Heart Journal 146(4), (2003). 4. J. Stover, Chronic Disease Management Crippling Primary Care System, DukeMed News, May 31, 2005; 5. Philips Medical Systems, Motiva; telemonitoring/ products/motiva/.