Products & Technology

Owning the Loop

Remote patient monitoring is the norm in some corners of HME, and providers have worked to create a 'loop' of data for their referral partners. The question is, will other developments in connected care break that loop wide open?

remote patient monitoringBig data. The Internet of things. Artificial intelligence. Machine learning. These tech terms get thrown around in all corners of our lives these days, and that includes healthcare. With wearable health devices, to smartphones, to connected home products having grown commonplace, it’s no surprise that home medical equipment is becoming part of that landscape.

In fact, it can safely be argued that HME helped chart some of that territory. For years now, we’ve seen PAP devices in the sleep therapy market report back near real-time information to cloud-based remote patient monitoring (RPM) systems. This provides a number of benefits: it improves patients’ care; it helps physicians and other stakeholders show to payers know therapy is happening; and it lets providers differentiate to their referral partners as the expert product resource that can make this happen. Consider it a win for patients, referrals, payers, and HME providers.

But as big a trend as remote patient monitoring is in the HME world, it’s only one component of a much larger evolution occurring across healthcare when it comes to connected health, patient monitoring and healthcare data.

Picture this: A child repeatedly coughs through the night. A device similar to an Amazon Echo hears the coughing and alerts the parents via a baby monitoring-style app. Well, different coughs have different sounds, so an AI app is able to determine if the cough is viral or bacte-rial. The device asks mom and dad if they want to order some flu medicine. The same scenario plays out in households with similar devices in the local area, and other apps forewarn physicians, schools, senior centers, etc.

This concept was described by Jeff Cribbs, a vice president of research for the Gartner Industries Research group, in his keynote at the June VGM Heartland event, and it speaks to a very attainable and foreseeable health future using here-and-now technology.

So, throwing RPM into such a future isn’t hard to imagine at all. For instance, a remote moni-toring system for sleep therapy patients could integrate all sorts of other health metrics and data on daily activities to get a complete picture of how patients are managing their overall health as it relates to sleep apnea.

The question is, what will be the give and take between what’s happening now in the HME industry, and what’s happening in other corners of healthcare? Moreover, how will this impact HME providers businesses and the care they help facilitate in the process?

WHERE WE STAND

Bearing that in mind, let’s briefly review where RPM has come in its quick development. Remote patient monitoring is a capability well known and long enjoyed by providers of sleep therapy solutions. In a remote patient monitoring care continuum, PAP devices can monitor patient performance and feed that data back to care management systems that physicians can use to see unique health events and tweak care. Those devices can also connect with personal apps that patients use to better manage their care.

Moreover, those devices also help demon-strate patients’ therapy compliance and prog-ress, which is critical in terms of reimbursement. Physicians and clinical staff can demonstrate that patients are sticking with their therapy and benefitting from it, so the payer should continue to fund use of the device. The HME provider, the referral partner, and certainly the patient all benefit from that. So much so that the model has become the norm.

Bearing that in mind “I would say is that the ability to monitor and then, more importantly, efficiently manage patients by leveraging remote patient, or technology-based tools, is really becoming the standard of care,” explains Tim Murphy, business leader of the New Business Solutions group at Philips Sleep and Respiratory Care. “And each of the constituents has now, kind of, built their mindset around that standard of care. That connectivity of a therapy device for a sleep patient in a home really now serves the value that each of those constituents is trying to contribute.”

And how deeply has RPM taken root in sleep? “Remote monitoring capabilities continue to expand within sleep therapy since ResMed first built connectivity into all its new PAP devices in 2014,” notes Gregory Dench, Director of Connected Devices for ResMed. “Today more than 10 million patients worldwide have a cloud-connectable ResMed device. HMEs by and large have embraced the adoption – and benefits – of remote monitoring.

“… Additionally, ResMed will exponentially grow its database of 4.5 billion nights of sleep data, to conduct more large-scale clinical studies in just weeks or months to better understand patient populations and what best practices can guide HMEs and others in helping more patients get on and stay on therapy long term,” he adds.

To give you an idea of the pace of growth, in 2015 market research firm Berg Insight reported the global number of remotely monitored patients grew by 51 percent to 4.9 million. Now, in 2019, ResMed is reporting that it alone has 10 million users of its cloud-connected devices. At the outset of 2017, ResMed reported that 1 billion nights of sleep data had been downloaded using its AirView. Now, two years later, it has a database of 4.5 billion nights.

Moreover, that’s just one vendor. Factor in all the CPAP makers, and you can quickly get an impression of the scale involved with only the sleep segment of remote monitoring. RPM has approached ubiquity in sleep therapy; it’s morphing from a value-add to an expectation.

“The industry itself has really taken advantage of the ability of this kind of technological advancement, has matured dramatically to leverage that capability, to manage patients remotely,” Philips’ Murphy says. “Through automated and cloud-based technologies, to deliver a better outcome that each constituent can see and can act on a common set of information and notifications that are based on that individual patient’s experience — that’s really, kind of, a standard of care on the sleep side.”

Integrate that sleep scenario into the bigger picture of connected health, and it’s a pretty thrilling landscape for homecare, ResMed’s Dench says.

“I think it’s all part of a healthy and exciting movement toward getting a holistic picture of patients’ health and making fast and informed decisions based on that information,” he explains. “The more health information a provider is able to access and incorporate, the more informed that provider’s care decisions and the more personalized that patient’s care will be. Additionally, the more a person can engage with their own health and health data, the more conscious, engaged, and accountable to themselves they’ll become. Wearables and tracking apps can remove barriers to consumers engaging with their own health data and sharing that data with their providers.”

OXYGEN: THE NEXT FRONTIER?

On the face of things, remote patient monitoring seems like a “natch” for portable oxygen. RPM would help providers watch their units in the field and the prospect of watching how longterm oxygen therapy patients use portable oxygen concentrators has some appeal from a clinical standpoint.

To that end development of remote monitoring for portable oxygen concentrators has been a work in progress for a few years. The first forays into remote POC monitoring came with devices that were largely founded on the concept of fleet management: providers would remotely monitor POCs to ensure they were being used and that they were functioning properly. Moreover, depending on the situation, providers could remotely diagnose problems.

Initially, the POCs offering fleet management functionality used a variety of technology approaches for the connectivity, but increasingly POCs with RPM are starting to gravitate toward connecting with apps on users’ smartphones via Bluetooth.

But that soon gave way to the notion of monitoring usage, and thusly patients. For example, let’s say a patient has an oxygen concentrator in his home, and is prescribed to use it for X number of hours a day at X setting. Remote monitoring could show that, for some reason, the patient is either getting more oxygen than was prescribed, or perhaps not getting the correct duration of usage.

However, it became obvious that if that data could be collected, then it could be managed in the same way as sleep and diabetes devices do.

Collecting patient POC usage seems like a good idea. In an outcomes-oriented reimbursement environment, remote monitoring becomes indispensable because it allows those referral partners to work with HME providers and patients to optimize outcomes. In turn, the provider becomes a champion to both its referral partners and patients, and benefits from an ever-growing reputation for effectiveness and forward-thinking care. That’s a hard value proposition to ignore.

But let’s reiterate that: RPM for POCs seems like a good idea. Is it? You might have noticed in the previous usage-data scenario that there was a component of the current sleep equation missing — the payers. Compliance data would immediately bring in payers and Victoria Marquard-Schultz, esq., CEO of oxygen manufacturer Applied Home Healthcare, which makes the OxyGo, a Bluetooth-enabled POC.

“When you talk about remote patient monitoring and you compare it to something like sleep — where sleep has that compliance aspect — it’s something that we’ve talked to our providers about,” she says. “Something that we’re very conscious of is that compliance and that ability to have that in [RPM] technology also ties really heavily into reimbursement. It can be an issue.”

It’s safe to say that when it comes to sleep therapy, reimbursement and RPM are joined at the hip. We’ve all seen high-profile stories in consumer media about payers declining to reimburse patients’ CPAPs because they flat-out refuse to use them. This can sometimes even lead to the provider recouping the device so that they don’t lose on the device cost. In the world of long-term oxygen therapy, particularly in a Medicare context, such a scenario is a nonstarter. POCs are expensive and LTOT patients are typically patients for life.

“When you transition that around to the respiratory side, what I really think you need to focus on, and what I think there’s lessons learned, is there are a lot of things that now that you can do —we can build a lot of things,” adds Philips’ Murphy. But where is that really delivering value to the key constituents that are serving patients, and the patient themselves?

“Where you do create value?” He asks. “That value is really in the improvement of the clinical outcome. The improvement to the efficiency, and cost-effectiveness of care … Versus an approach that would say, ‘Well, if we can do it, we should build it and we should offer it.’ And then getting people to run towards it when maybe, it’s not really matching that overall value. I think that’s the key learning curve.”

But the fleet management aspect of RPM probably sits right inside safe territory for POCs. Logging into a system that lets a monitor see all of its POCs in the field; see which ones are throwing up error codes, which ones need to have their sieve beds replaced; which ones aren’t being used — these are all very useful piece of information for a provider to have, Marquard-Schultz says.

Moreover, it’s important to keep in mind that the fleet management application has a patient care benefit, Marquard-Schultz adds:

“So with ours, if a user were to get an error code, then Mrs. Jones says, ‘Oh, gosh. Well, I don’t really know what it did.’ She calls up her provider and says, ‘My machine beeped at me; I don’t know what it’s doing.’ The provider then can look on their portal and see exactly what the problem is. ‘Oh, Mrs. Jones, you just didn’t have the canula all the way in your nose. Can you fix your canula? It’s saying no breath attached.’

“So, there is that piece of it so that they can help them,” she says. “And that saves the provider from having to send someone go get the equipment or Mrs. Jones coming in and swapping it out. So, there are pieces of that that are very helpful.”

THE FUTURE IS DEVICE AGNOSTIC

Okay, if we know oxygen devices might have don’t necessarily represent the next possible frontier of RPM, (at least for now), then where does the future lie?

The next step in the development of remote patient monitoring in homecare is probably being written in the diabetes care corner of the market. Case in point: Glooko, a digital health and workflow platform for diabetes care and patient monitoring.

As a company, Glooko works in 23 countries and its system serves 15 languages. It is in 9,000 clinic locations and has diabetes data for 2.2 million people flowing through its system, according to Russ Johannesson, the CEO of Glooko, who has a long history in digital health, both on the strategy and operations side.

The solution, called Glooko Enterprise synchronizes the data from “nearly all — about 95 percent — of the diabetes devices that are out there, and put them into a single universal interface for clinicians and care teams to manage,” Johannesson says. “It allows us to upload and ingest the data for more than 190 glucose meters, insulin pumps, CGMs, smart insulin pens, fitness devices and trackers, all of that. We get that data into one user interface for the care teams to be able to manage and look at that data in one place.

“Historically, each one of the device manufacturers had a proprietary piece of software that they were trying to get the clinic to download to be able to view the data just off of their device,” he continues. “And as you could imagine, just wrangling that many different pieces of software to get at data in a unique silo isn’t very valuable. It’s not very efficient for the clinic; they would have somebody working full-time have to manage that process.”

So, Glooko began working with the device companies to make it easier for the clinics to get access to the data. Johannesson says Glooko has a device integration agreement and a data license agreement that allows his company to get that data. The device companies still offer their proprietary systems (typically for free), but physicians and clinical staff that want to see all of the data together on a person, regardless of what devices they’re on in one single place, can use Glooko to do so.

“So it really arose out of the necessity and the need created in the clinics to kind of have that platform and then companies deciding, ‘Hey, it makes sense, we’ll get better distribution when we can make it easier for our clinics and care teams to have access to the data that we’re looking at,’” he explains. “So that is the genesis.”

On the patient side, Glooko offers a mobile application to let patients see their data for selfmanagement, and then they can also push that data to the clinic and care team from afar.

“They can upload that data when they’re not in the office, and then they can also use it, again, for true remote patient monitoring where a clinic or a clinician is looking at that data in between visits,” Johannesson notes.

“As a practitioner in a large center where we’ve got 11 different sites, we used to have to manage six different software platforms and over a dozen different cables and connected devices,” says Mark Clements, MD, PhD, CPI, FAAP, the Chief Medical Officer of Glooko. Also, Dr. Clements is also Associate Professor of Pediatrics at the University of Missouri-Kansas City School of Medicine, and is also a pediatric endocrinologist at Children’s Mercy Kansas City, where he serves as Director of Pediatric Endocrine/Diabetes Clinical Research and Medical Director for the Pediatric Clinical Research Unit. “Glooko has really simplified that. As you can imagine, with well over a hundred devices in use in the U.S. market, just in pediatrics where I work, the knowledgebase and maintaining the knowledge base for how to interact with all those devices is certainly a challenge that centers have.”

Clements adds this is a real boon to patients who sometimes have to deal with limited device choices because of the RPM systems their clinicians prefer.

“If you’re a person with diabetes or parents of a child with diabetes and you have two different devices that you think are right for you that you would like to use, it can be really frustrating to not have the ability to have those devices talk to the same system so you can see all your data in one place,” he explains. “That’s the real-world problem that Glooko is solving for.”

Given that many diabetes patients have preferences for particular devices, a unified monitoring system that lets them retain those devices is a real boon, according to Clements.

“There are some people who really do prefer a particular device and being able to get that device onto a common platform with their other devices and with their diabetes center is important,” he says. “… Whatever device they’re using, it reduces friction in the care system if they can easily communicate
information about their self-management and their outcomes to their provider.”

THE UPSHOT

Let’s review: First, we know that sleep therapy has developed a very successful RPM model that helps patients better manage and adhere to their care and that helps physicians show outcomes to their payers. In fact, it’s been so successful that payers are essentially demanding it at this point and HME providers, with their vendors’ help, are there to provide the entire RPM system. They are in the perfect position to make the entire dynamic happen.

Next, we know that in the oxygen care arena, things are playing out a little differently. Providers and vendors alike see the opportunities to remotely monitor devices in order to troubleshoot devices and help patients use them.

That said they are stopping short of collecting usage data and connecting that to actual care because it doesn’t necessarily translate and it might involve reimbursement in ways that could run counter to effective long-term oxygen therapy models both from a care and business standpoint.

And we know that when it comes to diabetes care, both models are probably going to get exploded as users take great ownership over their care and the types of devices they want. Whatever closed loops any provider is trying to establish are probably going to wind up turning into weak links as we see connected care models continue to proliferate across global healthcare.

Think about it: in a world where apps are constantly being developed to collect and share data on literally everything single activity they engage in – sometimes entirely unbeknownst to us – is there really going to be tolerance for proprietary systems over the long haul? Nearly everyone with a smartphone and wearable is collecting all sort of health metrics and probably happy to share them with physicians.

As a medical professional, Glooko’s Clements wants more data; not less. It comes down to the best way to manage care.

“I think the business insights and the actionable evidence that will be created by remote patient monitoring are going to help me as a clinician not just manage one family at a time, but they’re going to help our diabetes center to differentiate our care across an entire population by identifying — I hope in the near future — the remote interventions that are best matched to the needs of individual groups or cohorts within our center so that we can deliver smarter care faster.”

So, we can likely expect increased demand for RPM across more corners of care: the physicians, the patients, and, yes, the payers. Equipment providers can try and manage that demand, but it will come. There’s an insatiable hunger for it at an economic level.

“I do think that the payers, whether it’s government payers or whether it’s private payers, are going to continue to see the improved outcomes when there is more consistent and ongoing treatment through outpatient monitoring and visibility and I think the demand will continue to increase on that side,” Johannesson says. “I think the technology will continue to expand and keep up with it. The amount and volume of data that’s coming is increasing exponentially and I think the ability to use that to drive actionable insights and decision support between visits is going to continue to increase.”

That means the loop will break open. Growing demand for patient use metrics won’t tolerate a closed data environment.

Should a lack of a closed data loop or increased demands for RPM from payers worry any provider? ResMed’s Dench says no. Loop or no, HME providers still sit in the catbird seat.

“As equipment providers, HMEs are still in the best position to provide patients with a comprehensive and seamless therapy experience by helping them receive both equipment and support,” he emphasizes. “HMEs know their prescriptions and other needs, most likely set them up on their equipment, ideally help resupply them when needed, and can leverage remote monitoring to give them peace of mind as they achieve long-term adherence, or jump in to help get them back on track.”

This article originally appeared in the August/September 2019 issue of HME Business.

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