First Posted on his blog on 8/8/2013
Technology in medicine advances at a rapid pace. In the US today most patients have access to mobile phones, smartphones and tablets. Medical device makers continue to innovate and create ways in which these technologies can be used by patients and physicians to monitor complex biologic machinery such as implantable cardiac defibrillators (ICDs) and Pacemakers at home–without the need for routine office visits. These technologies create large masses of DATA. These home-generated data can be instrumental in managing chronic disease but can also create logistical as well as legal issues for physicians and their staff.
For the longest time, physicians have relied on patients to bring in a log of their blood pressures or blood sugars from home (often scribbled on a notepad, and often not accurately recorded) in order to determine when medication adjustments are needed. In patients with congestive heart failure, physicians rely on a log of daily weights in order to make changes in the patients daily diuretic regimen in an effort to prevent hospital admissions for decompensation. Now, device makers have created insulin pumps and glucometers that can be downloaded to a laptop and the information emailed to the physician for analysis. ICD makers such as Biotronik actually have created cell phones that interact with the implanted device and transmits regular data to the physician 24 hours a day.
The big question is: Does home monitoring really make a difference in outcomes and does it impact cost of care?
This week in the Annals of Internal Medicine, an important meta analysis was published evaluating the effectiveness of home monitoring technology on outcomes in patients with high blood pressure. In the study, 52 different comparative trials were analysed. Each of these trials evaluated the effectiveness of home monitoring of blood pressure and compared outcomes to patients who received home monitoring plus additional online or in-person support. The study showed that all patients who had remote home monitoring of blood pressure had lower readings at 6 months but only those with home monitoring plus additional infrastructure and support from their physician’s office had more long term benefits. Moreover, those patients with the added support experienced a more substantial reduction in blood pressure when compared to standard care or to remote monitoring without additional support.
As reported in the Wall Street Journal this week, the economic impact of home monitoring and data management on physicians and physician practices may be significantly negative. Currently, physicians are not reimbursed for much of the home monitoring data management (with the exception of ICDs and Pacemakers which are reimbursed by medicare). Many practices are hiring complete departments of highly skilled nurses and staff to deal with the enormous amount of incoming patient data from remote sources. The additional staffing required to process and react to home monitoring data creates additional overhead–all in a practice setting where reimbursement continues to decline. At some point, something has to give.
Don’t get me wrong, I am a huge proponent of the ePatient and of mHealth. Using technology to help patients manage chronic illnesses at home is the way medicine will be practiced in the future–and this practice will ultimately improve outcomes. However, as technology advances, we must also find a way to advance the way in which physicians and their staff are able to process and utilize data in a cost effective and meaningful way for the patient. If the government intends to successfully overhaul healthcare and institute a fully electronic universal electronic medical record, then some consideration must be given to practice workflow, data management and the costs associated with the challenges that these new frontiers will present.
The Annals of Internal Medicine study is clear–home monitoring and data collection helps patients manage their chronic disease–BUT, the largest benefit is seen when home monitoring is combined with additional support from the patient’s healthcare team.