1. What is RPM?

First, just what is RPM? Google search responds with: “Remote patient monitoring (RPM) is a healthcare practice where medical providers use digital devices, like blood pressure monitors, scales, or pulse oximeters, to continuously monitor a patient’s health data outside of a traditional clinical setting, allowing them to track and manage conditions without requiring frequent in-person visits; essentially, it’s a form of telehealth that uses technology to collect patient data remotely.” Let’s extend that definition to also include behavioral health monitoring for patients using non-medical devices such as mobile phones and iPads.

2. Social Drivers

1. Covid-19’s infectiousness overwhelmed hospitals with severely ill patients, which drove the isolation of milder infections at the patients’ homes. In the pandemics to come, the vectors and the spread rates will dictate if such isolation will be necessary. But should the patient isolations become necessary, RPM may well offer a lifeline to the sick.
2. Population declines result from a decrease in birth rates and greater death rates compared to pre-pandemic levels. Global Total Fertility Rate (GTFR) has halved from 5.3 per female in 1963 to 2.3 in 2021^[1]\. Japan’s depopulation is now at 0.5% per year and declining numbers are seen just about everywhere globally.
3. Caregiver Shortages^[2] being experienced now in the US are projected to get even more dire. ~70% of Americans who reach 65 in age, will need long-term care while the shortages in care workers will reach 151,000 by 2030 and 355,00 by 2040. That imbalance in the demand-and-supply for healthcare will shift the burden of caregiving to unpaid, untrained family members. They will therefore depend heavily on RPM support. Reading the tea leaves from the immigration politics of 2024, a looming loss of healthcare support workers will only exacerbate the need for RPM support.
4. “Hospital at Home”^[3] (aka H@H) project was launched by Johns Hopkins School of Medicine in 1995. Research shows cost savings of 30% in the “patient care at home” model vs. the in-patient care model. These savings accumulate primarily from reduction in the overhead and re-admission rates. CMS has authorized 133 health systems (320 hospitals) in 37 states by April 2024 to offer an H@H program. Patient outcomes, so far, are decidedly better. “More than 60 different conditions, including congestive heart failure, pneumonia and chronic obstructive pulmonary disease, can be treated at home with proper monitoring and treatment protocols with a CMS waiver” according to the AHA study. RPM is at the heart of this H@H success.
5. If you are a skeptic about the extent to which hospital technology can be extended, dependably and economically all the way into patients’ homes, consider what I call the “Half-way Home” approach. A company now offers electronic carts loaded with 12-lead EKGs, CMPs, troponins, ultrasound imaging, etc. to long-term care homes that house many seniors living together. This concentration of seniors, with their diverse needs, in a building enables multiple uses of the cart in that building by an experienced professional. The facility’s investment in the cart is shared among many seniors, thus making it economically feasible to deliver timely care. The results are amazing: 96% decrease in unscheduled transports, elimination of 30-day readmissions, improved staff skills and facility marketing, and increased family involvement and satisfaction.^[5]

3. Technology Drivers

Let’s consider the technology drivers next, that fuel this RPM evolution.

1. Telecom Network is THE critical technology that enabled the successful monitoring of patient by a distance medical practitioner through communicative devices. Wireless networks have expanded their capacity with the 5th Generation (5G, soon going to 6G) technology which is now widely distributed in the US. Broadband network access, on fiber and coax in rural areas, has also increased due to huge government investments recently. To accelerate broader rural adoption of broadband, FCC’s Universal Service Fund (USF) offers up to 65% annual cash funding support to the rural healthcare facilities through its RHC programs.
2. Compactions in the electronics for chips, memory, and communications (aka Moore’s law) for Bluetooth via cell phones has led to a great rise in Wearables. These wearable devices now monitor a person’s heart rate, pulse oximetry, steps, blood glucose, blood pressure, etc. Even the Afib monitoring devices now range around $100 and are available on Amazon! The availability and the wise monitoring of these wearables are yielding better health outcomes. Real-time adjustments of patient-connected devices, remotely by a caregiver, brings immediate great relief to patients. (I will attest to that personally, having my sleep-medicine doctor adjust the air pressure in my CPAP machine from his office with a couple of clicks on his laptop!)
3. The rise of Artificial Intelligence (AI) is particularly promising in the remote monitoring of patient devices. A skepticism is warranted for the state of current evolution of the AI. But an outright dismissal of its value is also not wise. While we are focused on “Remote” Patient Monitoring (RPM) from a caregiver’s perspective, there is also a “Local” Patient Monitoring (LPM) need. This LPM is caring about the untrained family members who must react quickly to the device alerts and make their beloved patients more comfortable. Artificial Intelligence can help make timely sense of the device readings and provide suggestions / guidance while medical practitioners are being alerted.
4. Electronic Health Records companies also have an opportunity to contribute to RPM’s success. While the importance of privacy in patient records is paramount, a restricted Large Language Model (LLM), that has been trained with anonymized patient data, can be quite valuable to caregivers. The generative AI can analyze a specific patient’s monitored data and offer suggestions to the caregiver on timely diagnostic or care suggestions. This type of LLM can save critical time for the caregivers, who haven’t read the entire context of the care history in the patient’s EHR.

4. RPM Case Studies

1. Survey of Articles on RPM Success: It is prudent to wonder what success record RPM has amassed over the years. A 2020 survey of RPM related articles published by Telemedicine and e-Health^[1] concluded: “After screening 947 records, 272 articles were included. The review showed a growing number of publications over the years, with 43.0% being published between 2015 and 2018, providing generally positive results (76.8%). The United States was responsible for 38.2% of articles. Cardiovascular disease was the topic of 47.8% of studies, whereas surgical pathologies and postoperative care represented only 2.6%. Wireless devices or smartphone apps were the most popular strategy (75.7%), with 17.6% of studies employing tele-education and 24.6% employing teleconsultation measures. Most publications were OCEBM Level of Evidence 2 (73.5%).”
2. Distress Codes & Transfers to ICU: Dartmouth-Hitchcock Medical Center’s 2020 study^[2] of RPM use, with Masimo’s SafetyNet system, showed that over 10 years, RPM reduced distress codes & rescue activations by 65% and a 48% decrease in patient transfers to ICUs (=135 ICU Days). There were zero patient deaths reported.
3. Heart Failure Care: A meta-analysis of 41 studies^[3] in Europe encompassing 16,512 patients, RPM in heart failure care showed significantly lower mortality^[4] and re-hospitalization^[5] where blood pressure monitoring was routinely performed. Catholic Home Care’s RPM program^[6] in caring for Congestive Heart Failure patients reported a 50% reduction in re-admission rates.
4. All-Cause 30-Days Readmission Rates: The use of RPM with skilled home health services led to reductions in readmissions as follows:

5. The Economics of RPM

No evolutionary assessment is complete without the economic considerations.

1. The US imports $14.9B of medical equipment annually. The impact of proposed new tariffs on the healthcare industry will be significant. Comprising approximately 10.5% of the average hospital’s budget, the medical supply expenses collectively accounted for $146.9B in 2023, an increase of $6.6B over 2022, according to data from Strata Decision Technology. In some AHA estimates, the tariffs on the Chinese-made semiconductors, solar cells, syringes, and needles will increase to 50% from the 25% they are at now. Tariffs on batteries, face masks, medical gloves, graphite, other critical minerals, permanent magnets, steel and aluminum products will increase to 25%; many of these items currently are at only a 7.5% tariff.
2. RPM Penetration in health services delivery is growing strongly. In the US, for healthcare services, McKinsey estimates $265B can shift from hospitals to home, without a reduction in quality or access. Global market for RPM devices in 2024 was USD $50.4B and is expected to grow at 19% CAGR to USD $203.7B by 2032^[1].
3. Healthcare Fraud in the US runs in billions annually, as evidenced by cases brought by the US Department of Justice. The “improper payments” tracking by CMS^[2] shows it to be at $103.6B across many categories. Many CMS and USDoJ cases revolve around Durable Medical Equipment (DME) and Medical Tests that were never delivered, yet improperly reimbursed.
4. DME Loss estimates vary widely. ChatGPT response to the question, as projected for a Health System with $16B in annual revenues, brought the following result:

5. Similar questions for DME Fraud Loss estimates (for a Health System with $16B annual revenues) brought a ChatGPT response of 0.5-2% of revenues or $80m-$320m. The fraud consists of billing for unnecessary equipment, overcharging for high-end devices when low-end would suffice, upcoding, phantom billing, kickbacks from suppliers, and patient identity fraud. Even after halving that number, in due skepticism for possible AI hallucinations, this represents a $40m-$160m annual problem for the hospital system. Equipment lost by RPM patients, and never recovered by the health system, can be a significant part of those losses.
6. Asset Tracking (chain-of-custody management) becomes a crucially important part of recovering the DME-on-loan to patients. The savings can go a long way in reducing the $10m-$40m in RPM losses of a hospital system of that size. My interest in RPM stems from having built a SaaS Asset Management tool, AssetRight, for such Chain-of-Custody management, with AI tools, for instant access to the assets’ locations, condition and availability status, technical documents, manuals, maintenance details, providers’ contact info, and Total Cost of Ownership (TCO) till its projected end-of-life.

6. Incorporating RPM into Your Practice

1. Understand RPM and Identify Patient Needs: (1) Assess patient population to identify conditions that benefit most from RPM, such as chronic diseases (e.g., diabetes, hypertension, heart failure), post-operative care, or at-risk elderly populations, and (2) Define goals like reducing hospital readmissions, improving patient adherence, or early detection of complications.
2. Choose the Right Technology: (1) Choose devices tailored to patient needs (2) Use platforms that integrate RPM data into your Electronic Health Record (EHR) system for streamlined access, and (3) ensure devices and systems are interoperable and HIPAA-compliant for data security.
3. Develop a workflow: (1) Define roles on your team, (2) Create protocols for data collections and review, alert responses, and patient communication, and (3) automate the automation tools for data collection and analysis as much as possible.
4. Emphasize Education: (1) Educate your staff on your protocols, RPM device operations and its software, (2) Educate patients (and their home-caregivers) with summaries of how to read and understand the RPM results and what actions to take when the device readings warrant.
5. Explore Reimbursement Opportunities: Medicare Codes for RPM services may be useful in financially supporting your RPM initiative.
   • CPT 99453: Device setup and patient education
   • CPT 99454: Device supply and transmission
   • CPT 99457/99458: Remote monitoring and care management

7. Sources of RPM Training for Your Practice

Several organizations are known to assist healthcare practitioners with RPM related training. Here is a sample:

8. Entrepreneurial Opportunities offered by RPM

We ought to consider how entrepreneurial energies may drive RPM even further.

1. The RPM “democratizes” the high-level health care to ALL size levels of medical practices by reducing the initial investments needed… the so-called leveling of the playing field. Assisting smaller medical practices to take advantage of RPM towards better profitability can be an entrepreneurial opportunity.
2. Supplying temporary personnel to help implement RPM and train the local staff of long-term care facilities.
3. Creating short-term care “hotels” that can comfortably host post-operative recoveries.
4. Providing Training on DME of RPM Devices, as part of Local Patient Monitoring training to patient’s home caregivers.
5. Creating temporary loan programs of RPM devices, as part of the Hospital @ Home programs
6. Developing AI Applications, perhaps privatized for health systems, to monitor RPM devices and alert the remote medical caregivers charged with monitoring the patient remotely.
7. Large Language Models (AI) that are focused on creating medical libraries for each specific health condition. Enhancements of the libraries by the AI, with global literature publications for each specific condition, would be of great value to home caregivers. They can thus consume information on latest advances towards active “local” monitoring of the patient they love.
8. Fraud Detection that can be implemented by hospital systems that can assist in avoiding reputation damage as well as penalties levied by the authorities.

Conclusion

Looking a few years down the road, a lay perspective emerges as follows:

1. Net Growth of RPM will continue as underpayments from CMS for Medicare & Medicaid will continue to squeeze the hospital systems’ profitability. All levels of medical practices, not just big hospitals, will enter the RPM movement with a leveling of the playing field.
2. De-population is too far away to ease the current pain of caregiver shortages on societies. Concentration of the aging population into long-term care and senior living environments will ease the burden slightly.
3. Better focus on “Local” Patient monitoring tools and training is a critical success factor for better patient outcomes, cost efficiency, RPM device care and maintenance.
4. RPM will evolve to merge with the H@H idea. Senior & Long-Term Care facilities will take on the Hospital substitute roles quite effectively.
5. AI tools will help educate home caregivers on the most effective actions needed in caring for their patient.

I welcome your comments sent to cthaker@telebright.com.