Sunday, October 23, 2011

The 3 Legged Stool of Telemonitoring: The Device, A Non-Physician Professional and the Patient

Just when the Disease Management Care Blog has barely learned to control itself when it's in the company of clueless electronic health record (EHR) techno-weenies, enter the equally intolerable "telemonitoring" enthusiasts. Their jargon-laced claims of pan-medical and cost efficacy is enough to give the DMCB a migraine.

Their bombast is easy to spot.  According to this new class of leprechauns, small wearable telemonitoring devices for blood pressure, temperature, breathing, heart rate, weight, calories, blood sugar, cholesterol, brain waves, nail length, eye-blinks and minutes spent in the bathroom upload the data to the doctor who, thusly armed with critical insights of well-being, can do more of their... doctor stuff like... give out some prevention and stomp out disease.

For the best example of how that is simply not true, the DMCB is reminded of this negative December 2010 heart failure symptom telemonitoring study that alerted the patients' physicians about "variances."  The DMCB readership already knows that physicians are already busy and just don't have the time to fit one more task into their busy days.  That's doubly true if the data is unfiltered and without any context.

Yet, while the DMCB is unwilling to hop aboard the telemonitoring train, that doesn't mean that this has nothing to offer.  In the DMCB's estimation, it'll increase quality and probably lower costs if it is combined with two other key ingredients:

1) a non-physician professional being in the loop, who can a) monitor the information and b) contact the patient with significant variances and c) use a combination of clinical judgement and standing orders/protocols to guide a patient response (which, by the way, doesn't have to include seeing the physician).  An example is here.  They're usually nurses and they can be part of the Patient Centered Medical Home or as part of a population health management program (or both).

2) an empowered, engaged, enabled and educated patient who understands the "output" of the device and can respond autonomously, confidently and collaboratively.  While some readers may pooh-pooh the DMCB's unrealistic idealism, the DMCB has found that most patients are smarter than they are given credit for.  As far as the DMCB is concerned, if a patient can manage a telemonitoring device, they can usually deal with the non-physician professional and also have some insight about what the device is "saying."
The DMCB thinks of it as a three legged stool.  Having telemonitoring patients be 1) passive and 2) unsupported bystanders while their data uploads scramble their overburdened physicians' workflows isn't health reform, it isn't cost saving and it isn't quality. 

Image from Wikipedia

1 comment:

Anonymous said...

I use remote telemonitoring of HF patients' weights on a daily basis. In my opinion, it is simply a TOOL, not a solution.

We enroll patients deemed high risk for exacerbation; it works well for some, not so well for others. Yes, we have DTP's to use when necessary, but it also provides a feedback mechanism for the patient when their Na intake is too high. In some, it does cause them to change their eating behavior, in others, it doesn't. However, in most, they are at least cognizant of the effects of dietary indiscretions, which is a start.

Overall though, our Medical Home program has used it successfully to curb exacerbations (double digit reductions in HF hospitalizations).