The following piece by Dr. Joseph Kvedar originally appeared on The cHealth Blog by Partners Healthcare.
There are several reasons for this lag (and for the corresponding growth in virtual visits).
- The unit of service is a visit. For now, doctors still make most of the decisions on how healthcare is delivered. They have a deeply engrained view of care delivery measured in units of visits. For millennia, this is how we’ve been delivering care and capturing/codifying related work – in terms of visits. Remote monitoring opens a world where the service offered isn’t a visit, but rather surveillance of a population with proactive, preventative care and management by exception. Despite our commitments to the Patient-Centered Medical Home and value-based payment models, we have yet to get comfortable with the workflow around surveillance and management by exception.
- Payment is still a concern. There is progress (see my related post) on this with the unbundling of CPT code 99091 by the Centers for Medicare and Medicaid Services (CMS) and new codes expected for 2019. But uptake of 99091 has been slow because it allows for time spent on the collection and interpretation of patient generated health data at a minimum of 30 minutes of a physician’s review time, per 30 days. It is hard to scale that in a busy practice.
- There are three aspects of the technology that need refining: cost, usability and EHR integration. I intend to expand upon these items in this post.
At Partners Connected Health, we’ve been working on each of these issues, using a new ‘bring your own device’ (BYOD) infrastructure and a process that democratizes the deployment of remote patient monitoring devices. But let me back up for a moment.
For several years, we managed remote monitoring programmatically. We had dedicated staff, a preferred solution and managed our own device inventory. We reasoned that the best use case for remote monitoring was in the context of our value-based payer contracts and that the deliberate roll out of this care model would make the most sense. The logic was good, but the costs of maintaining inventory were simply too high.
At one point, we did an analysis and showed that at the current rate of program effectiveness and cost, we’d need to enroll 10 times the number of eligible patients just to break even on our risk contract bonus payments. When presented with stark data such as this, we asked ourselves, “Can we make the program 10X more effective or should we think about lowering costs”? As we grappled with this reality, we saw other use cases for patient-generated device data emerging across our delivery system; ones that we hadn’t anticipated and that our program structure could not support. For these reasons we felt we had to venture into the brave new world of BYOD.
After surveying the marketplace for options, we formed a partnership with Validic and changed our process in some interesting ways. This is my first progress report on our new approach.
The infrastructure we set up with Validic (and also using tools from Intersystems Healthshare platform) is called the Connected Health Integration Pathway (CHIP). It makes it relatively easy for our patients to collaborate with their physicians around their device data. The first step is that the doctor invites the patient to participate through a link in our patient portal. The patient goes through a straightforward set of steps and links their consumer device account with their patient portal account (this is the step that Validic enables). Through the Healthshare integration, the clinician is able to see patient device data in the context of their Epic record. They can communicate about the data via the patient portal or in the context of an office visit.
This approach gets us out of the inventory business, for starters. It also enables clinicians around our system who have novel ideas about using patient-generated device data to easily set up their own programs. Our role is more enabler/support as opposed to program oversight. In this way, this new infrastructure should help us with the cost conundrum referred to above.
We have been doing this for a few months so we’re just beginning our learning. Here are a few early insights.
- The overlap between people who wish to share their data and those we wish to monitor is small. This is really not a surprise, but it points out that we are still some ways away from true BYOD. Most of the clinicians that are using CHIP are finding ways to distribute preferred devices as part of trials/research programs or other efforts that have budget to support device distribution. So, yes, we are out of the inventory business but we’re not really seeing BYOD.
- Despite our efforts to simplify onboarding, the technology is still complex. Roughly 50% of our earliest cohort of patients had trouble connecting or staying connected. While onboarding is straight forward, patients must use third-party device manufacturer apps on their mobile devices as conduits to move data from sensors to the cloud, and these apps are widely variable in their usability. One glaring challenge is that our preferred blood pressure monitor — from an accuracy/clinical perspective — has a very challenging, non-intuitive app. Just our luck. We’re watching carefully to get a sense of whether the resources we had put into inventory management will simply re-emerge as needed tech support resources. This part is particularly frustrating for me…We need to all work together to reach the goal of frictionless data capture or ‘wear and forget’ data uploads.
- There are indeed many more use cases appearing that we had not thought of. For example, some of our providers are showing lots of interest in using activity trackers to follow post-operative progress and as a proxy for general health improvement.
It is early days in our new BYOD world. I know we’ll get there. I can see a path to ubiquitous use of patient-generated device data through continued improvements in technology (especially ease of use), improved EHR integration and new reimbursement pathways. It is an exciting time.
What’s your experience with BYOD?