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Bring Your Own (Health Monitoring) Device: Progress and Challenges

March 12, 2018

As we see virtual visits go mainstream (witness the recent prime time TV ad from UnitedHealth Group during the Winter Olympics), adoption of remote patient monitoring is lumbering along, still in the land of early adopters.

There are several reasons for this lag (and for the corresponding growth in virtual visits).

  1. 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.
  2. 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.
  3. 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?

8 Comments leave one →
  1. March 13, 2018 10:23 am

    As usual some very good thoughts. The visit mindset locks us into synchronous services, and we will never optimize care without stepping into the realm of asynchrony, where data collection and synthesis are not simultaneous events conducted by a lone provider. At least our remote care devices have allowed us to project our decision making across geography.

    I do think you are being overly kind in your comment about 99091. At 30 min per patient, this is a complete non-starter. Conservatively, if I see only 50 polychronic patients per week, and want to provide them with 99091 services, it will increase my work week by 25 hours! Any guess where this is going?

    Team CMS needs exchange their anachronistic model, based on 30 minutes of provider collection, review, and interpretation, for a model that focuses on the interpretation of the data (think decision) itself. Informed decision making is what makes providers special! We interpret data, and we do it fast. Who spends 30 minutes making a decision? In the ED, for every 30 min I spend collecting data I spend no more than 5 seconds processing it (to a decision). If I can’t identify a rash in the first 5 seconds, another 18,895 seconds isn’t going to help me.

    Technology and software innovations are focused on off-loading the provider from mundane data collection duties. This is coming in the form of smart software and remote devices to assist us in these historically physician-only tasks.

    If smart systems pass the provider more complete patient information, rich with biometrics, labs, and medical history our new role will emphasize “synthesis to action”…. ideally one that benefits the patient.

    Until 99091 reimbursement strategy becomes aligned with data acquisition innovations, this rocket won’t break gravity.

  2. March 17, 2018 8:15 am

    new codes should go into effect on 1/1/19 and require less time per patient for billing. i hear your concerns but am a glass half full kind of guy. it represents movement in the right direction

  3. April 4, 2018 10:26 am

    I fear the glass is empty. It depends on how you interpret the 99490 code (and 99091) requirement as written. For example, my nurses could perform data collection in under 10 minutes and then present the information to me. I will spend about 2 minutes deciding what to do (10 seconds) and charting (2 minutes) a treatment plan. After that, the nurses see my plan and do the wrap up: e-prescription changes, follow-up, and nursing care plan issues. All together, this many be 20 minutes, thus meeting the time requirement. However, if the provider is expected to PERSONALLY CONTRIBUTE 15 of the required 20 minutes for 99490, we are creating something untenable. Any provider, spending an additional 15 minutes doing CCM for each one of their many polychronic patients is going to be working 70+ hours per week. Brutal, particularly with a burnout rate hovering around 50%. Of course, maybe someone out there can set me straight on what Medicare is really wanting for these time requirements? Like EXACTLY who (by credentials) is responsible for what piece of the total time requirement.

  4. April 4, 2018 3:41 pm

    it is our intent that the new codes include not only Licensed provider time but staff time as well. that said, we’ll see what CMS comes forward with.

  5. October 16, 2018 5:58 am

    Reblogged this on A Girl Disrupted.

  6. ataborsky permalink
    November 28, 2018 2:12 pm

    Can someone please clarify whether 99091 (and the new 99453, 99454, and 99457 taking effect 1/1/19) requires a patient to have at least two chronic conditions? Are patients with one chronic condition eligible? Thanks in advance.

  7. November 28, 2018 7:03 pm

    no requirement for 2 chronic conditions for these codes


  1. Bring Your Own (Health Monitoring) Device: Progress and Challenges | MassTLC

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