July 4, 2023
A while ago, Spritely posted a blog about something we called “remote-first thinking”. In essence it stated, if a patient’s care can be delivered remotely, and there is no worse outcome for the patient and it is no more difficult for the clinician, then it should be delivered remotely. If, for no other reason than to free up car parking space, although it achieves a lot more than that.
It seems obvious. The hard part, for clinicians, is knowing whether care can be managed remotely with ease, and with no worse outcome for their patients. That’s where RPM trials come in. Successful trials create new models for remote care that are proven to be engaging, effective, and efficient. These trials should advance our understanding of what can be achieved remotely, empowering clinicians to confidently implement new models of digitally enabled care. The key word here is “advance”.
To avoid an endless cycle of trials we need to ensure that each new trial delivers new learnings and that each subsequent trial takes those learnings into account, where relevant. I once had a Great Uncle who used to say upon return from his gold panning adventures in Central Otago – “I know where there ain’t no gold”. Double negatives aside, the point is, failure can create progress if we learn. Knowing what doesn’t work gets us closer to sustainable models of remote care for more patients in the health system.
Hospitals should start by identifying the patients and clinicians who could benefit from RPM. Be sure to understand what has already been done and learn from that, just like my Great Uncle. Don’t repeat trials only to learn what you already knew. Ask clear questions that need answering and set goals that you can evaluate. And if the trial is successful, make the product available to others, with all the information they need to use it without going through another trial.
When Hato Hone St John trialed telemonitoring as part of their commitment to health equity for Maori and Pasifika they set out to answer three distinct questions
1. Will GPs refer patients with uncontrolled hypertension to a remote care program managed by Hato Hone St John?
2. Will Maori and Pasifika patients that are referred, engage with the remote care program?
3. If GP’s refer people and if those people engage, will the program measurably reduce their risk of having a heart attack or stroke?
No one knew the answer to these questions, but now Hato Hone St John can confidently affirm all three and the trial (known as Manaaki Mamao) is a growing in scale and importance.
From our experience, the single most important goal to evaluate when it comes to RPM is patient engagement. If patients find it difficult to participate, then engagement will be low. If engagement is low, then there won’t be much for clinicians to monitor. If an RPM program has low engagement for any reason, then it can’t be effective, or efficient. Make patient engagement the first goal of every RPM trial, then go from there.
In healthcare, engagement should be equitable. It should be just as easy for one patient to engage as another, regardless of their specific circumstances. Take time to understand, based on experience and research, what you need to do to make it easy for your patients to engage with your RPM trial.
Listen to the clinicians on the front line. They are the ones relating to patients and can explain why they are not engaging. If we want to advance, to make progress, we must stop doing what we know doesn’t work and try something new. Trials only fail when they repeat the mistakes of previous trials.
Make it easy for as many patients as possible to participate. Then continuously evaluate the trial based on the level of engagement achieved (number of patient interactions, type of patient interactions, quality of patient interactions etc….). The importance of engagement cannot be overestimated, but on its own it isn’t enough to make a successful trial. It’s not enough for patients to just be engaged. They must be engaged with something that works. Something that is measurably effective.
Effectiveness is another key evaluation measure. We don’t want patients engaging with new models of care that don’t work – no matter how new, shiny, trendy, or digitally enabled they are. By setting clear goals related to improved patient outcomes, the team running the trial should be able to determine if the new model of care they are trialing is effective.
Effectiveness measures can include clinician-reported, and patient-reported health outcomes. They can also include measures relating to everything from clinic room capacity to car park availability and compliance measures to climate goals. We must take the time to clearly define what effectiveness means for each trial, then set measurable goals related to this and regularly evaluate them so we know if the trial is working. In addition to this, we must also know what the trial is costing and the value it is delivering.
Every model of care has cost implications, and this brings us to another important pillar of evaluation, efficiency. How efficient is it? Some things are easier to demonstrate than others, but as always, we must listen to the clinicians on the front line and their patients. Does the new model of care enable them to safely care for more patients. Or does it enable them to provide more care to the same number of patients. If so, then there must have been some efficiency gains.
Other evaluation points can be harder to measure. Does it reduce hospital admissions/readmissions? Does it reduce length of hospital stay? Attribution can be tricky here, but these measures aren’t impossible to prove. Many international studies have been published, which can inform local RPM trials. Proving the efficiency of a new model care is an important part of the equation when obtaining funding for it. Ultimately, RPM must increase the capacity of our workforce and our facilities.
When evaluating RPM trials, it’s important to establish the key questions you are trying to answer and to build on previous research. Key measures should relate to engagement, effectiveness, and efficiency. These are the things that ultimately determine the value of remote patient monitoring. We can’t expect new models of digitally enabled care to be funded and adopted by the health system without evidence of how it improves outcomes for patients and capacity for clinicians.