By Jonathan Shankman

A tsunami of elderly people – and their chronic conditions – is flooding America’s health care system. According to the U.S. Census Bureau, the population of seniors (65 and over) in the U.S. has passed 50 million for the first time in history and is projected to reach over 70 million in the next 25 years.

This, coupled with the high price of medical care, exceeding $3 trillion a year, and a demographic shift where a smaller proportion of younger people are caring for elders, has put an enormous burden on the health care system. In addition, care fragmentation remains a potentially lethal issue because a patient may be treated by a number of doctors, across disparate venues, while no one clinician is sufficiently familiar with the complete narrative to serve as the declared care coordinator.



Even in those rare instances where the patient has the benefit of competent care coordination, virtually everything done in chronic disease management is reactive. The current system is preoccupied with addressing costly, raging clinical fires, when timelier, proactive vigilance would deliver a far better outcome at a far cheaper price point.

However, thanks to both commercial payer pressures and the Affordable Care Act, a seismic paradigm shift is well underway. First, rather than being reimbursed for process and volume, providers such as doctors and hospitals are now financially on the hook for the outcomes of their care. Second, rather than an emphasis on moving the patient to care expertise, care is being moved to the patient. Both shifts entail a major adaptation to “the wild”. The wild is the home, school, the workplace or any place that is not a brick-and-mortar medical care facility. The intent is to reorient health care delivery so that it is centered on people, their individual conditions, where they live, and the family that supports them. Equally important, in the wild is where the preponderance of chronic disease expression is played out, and where costly health issues first surface in their earliest – and most treatable - manifestations.

Technology, such as Remote Patient Monitoring (RPM), can assist in making the wild a third, legitimate and effective locus of care in complement to that delivered in brick-and-mortar facilities, and help bridge the gap between the overtaxed medical resources and the growing demand for them. It does so by enabling at-risk patients and their providers to be virtually connected long after they’ve left the brick-and-mortar clinical setting. This empowers patients to manage their health at home and comply with protocols that will ensure better control of their chronic conditions. More importantly, the information collected from these devices can greatly support more effective clinical decision-making. If a critical intervention is needed, based on near-real-time data coming from the wild, caregivers can accelerate intervention to avoid acute health problems that are likely to send patients back to the hospital or worse.


Example of RPM work
RPM works by allowing health care professionals to receive biometric, symptom, environmental compliance, and other important data from patients who are being monitored from the comfort of their own homes through a variety of technologies. This data is transmitted in near-real-time, securely, through the cloud, where it becomes actionable information once analyzed and triaged by automated processes governed by best practices. These same technologies also serve to impart automated, focused health education at the best moments, within the context of a patient’s unique disease expression. None of this is meant to supplant face-to-face care, but to inform the care team of how the patient is faring and complying with the plan of care in between in-person encounters, and to greatly expand the number of touches.

New York City Health and Hospitals Corporation (NYC HHC), the nation’s largest municipal, integrated delivery system (with 11 acute care hospitals, five nursing facilities, six large diagnostic and treatment centers and more than 70 community-based clinics), was an early adapter of RPM and enjoyed phenomenal outcomes as a result.

NYC-HHC was looking to improve the care of patients with poorly controlled diabetes, which continues to be an acute problem among the city’s Medicaid population. Working with AMC Health, NYC-HHC developed a unique HouseCalls Telehealth Program that uses RPM in patients’ homes to track blood glucose, weight, blood pressure, as well as self-reported information on symptoms, care asset availability and behavior around diet, exercise, and medication adherence. Data was sent to AMC Health’s secure web portal, with clinical decision support tools that provide customized alerts for each patient, trending analytics and population-wide benchmarking.

Of over 700 patients monitored, 81% had significant and sustained improvement in glycemic control with HbA1c reduced by an average of 1.8 percentage points, with program graduates averaging an astounding 3.3 percentage point reduction, representing over a halving of risk for microvascular complications and peripheral vascular disease. For those who also had baseline hypertension, diastolic BP reduced by 5 mm Hg, representing a 21% reduced risk of cardiac events.

NYC-HHC is just one example. RPM is currently helping at-risk organizations around the country reduce the number of ED visits, hospitalizations (especially readmissions), and lengths of stay in hospitals, all of which help improve quality of life and dramatically contain costs for a wide range of diagnoses and morbidity profiles. We can expect RPM to continue to evolve during the next 5 years, as we will see greater incorporation of RPM into practice management, while the monitoring technologies themselves continue to get more accurate, user friendly, less costly and more informative as the data science evolves.

Jonathan Shankman is senior vice president of Clinical Innovation for AMC Health