RPM or Bust

Having a Covid-19 re-emergence strategy will be a critical aspect of the upcoming flu season (September 2020 – March 2021) and a large component of that strategy could be accomplished throughremote patient monitoring (RPM). All networks of care delivery should pivot digital therapeutic (DTx) research, implementation, and deployment to fully focus on this unique global challenge. The care paths ways of Covid are well known and new capacity building in acute and ICU beds is being undertaken. However, it is also possible to enhance capacity by better patient management and more real time data as to potential cases. This latter strategy is tailor made for DTxintervention as it allows networks to better manage chronic risk patients at a physical distance while also giving more timely population level data directly to the organization helping to align resources to locales of need. Finally, this approach will lead to increased satisfaction with the organization handling of the crisis as well as limiting liability/concern of community spread originating from physical care facilities. This paradigm shift in the delivery of healthcare can only be achieved through rapid transition to a primary delivery of non-emergent healthcare through virtual means.

Goals

Create an RPM program at mass scale which augments the telehealth/virtual triage strategies that are currently being developed/employed by your organization. This site will lay out a few options for this delivery, but the goal is the same: to better manage patients and guard emergent lifesaving hospital capacity for a major Covid spike. Additionally, these measures must be in place by the late summer in order to be prepared for the next wave in Covid infection curve which will likely occur during the flu season. This tactic is the only tool left in the arsenal as herd immunity is being suppressed by quarantine and vaccines will still be half a year away in the fall. The RPM approach will require significant resource deployment from the organization to catch up and surpass near peers in terms of digital engagement and care giving. However, Federal overtures to virtual care reimbursement couple with a public health remit to care for an ageing population in a geographical footprint with an opportunity to lead the transition into the new post-Covid paradigm.

Solution

There are a variety of vendors offering remote patient monitoring platforms enhanced with FDA approved hardware, or pending full approval, which your network could leverage to create a public health monitoring paradigm. The leaders in this field are BioIntelliSense, and Current Health . Additionally, there are a variety of Bring Your Own Device (BYOD) vendors, such a Valdic, that would allow rapid transfer of remote patient generated data, upstream into a Banner monitored feed. Or, there are entirely homegrown solutions which could piggy back off the enhanced fhir protocols being enacted by ONC concurrently to this pandemic.

Regardless of tact, these avenues of incoming data could be monitored by a centralized/decentralized team which acts in a manner similar to our current call center. Or, simply absorbed into the telehealth teams as a force augmenter. This paper will lay out a few scenarios and estimated cost of each. This is especially likely as CMS has loosened rules surrounding billing/filling of reimbursement codes for RPM and telehealth. A network could, theoretically, leverage a few ordering Providers, into a massive population health delivery team that is mostly staffed by an analyst team and recuperate the majority of that cost directly while have the simultaneous network improvement impact of aligning in-person care to the neediestpatients.

Project Outline

Quickly identify a preferred RPM monitoring vendor. This vendor should be FDA approved, and simultaneously (infernall) begin to stand up an RPM monitoring team. This could branch into either a subcomponent of the telehealth team, an expansion of a current call center, or a truly unique hub that is either physically housed, or remotely managed, by a new department. The version one of this new entity would be continuously refined as lessons were learned about the capability to monitor at this scale; however, a basic breakdown of the project would have roughly 120 days to be well prepared for the incoming Flu season spike:

The immediate steps would be to re-organize into a dedicated confederation of assets to quickly do an intake of RPM vendors, begin the contracting phases, and secure funding for this transition. The next steps would be operationalization of this new wing of care continuum and folding it into the virtual care umbrella with an escalation strategy to telehealth when ordering providers may be necessary or funneling to the proper in-person care facility if deemed appropriate. Finally, training of new staff + communication to the greater patient population would be necessary to build demand for the new capability. This site will also consider the possibility of a subscription service for this product line in the era of Stark and HIPPA waivers. (CMS Responds to COVID-19 National Emergency Declaration, 2020)

Background Covid-19 originated from the city of Wuhan in the People’s Republic of China on, or around mid-December 2019. The virus is from the same family as the SARs infection but is of a novel structure which has never before infected humans (Scripps Research Institute, 2020). This distinction makes the virus especially difficult to control as there is no legacy of herd immunity in any human population.

Structure Modeling by University of Washington School of Medicine Virology Lab

The coming of warmer months in the Northern Hemisphere is traditionally associated with the suppression of flu cases. This phenomenon is well studied and suggests that there may be a window of opportunity to regroup during the summer months, but flu season will come back into focus by the late summer for most of the hemisphere, and spike in the early Winter in North America. (The Flu Season, 2020)

CDC modeling of Flu season spikes for The United State for year 1982 – 201

Responses

Various world governments have met the challenge of Covid-19 with suppression tactics in a technique known as “flattening the curve”. In this model the majority of governments seek to limit exposure to the virus during defined periods of time in hopes that spread will not only be artificially suppressed, but that cases loads will remain at levels that don’t overwhelm the healthcare capacity of local hospitals. (Specktor, 2020). The primary tactics in this strategy are quarantine/shelter in place/closure of large civic events.

That said, these tactics have finite time periods that they can be employed as shelter in place orders have proven to be disastrous to the world economy. Unemployment is spiking as bars/restaurants/sporting arenas are forced into indeterminate periods of closure, and international supply chains are in taters due to factory closures (Conerly, 2020). Additionally, these tactics have the consequence of elongating the duration towards herd immunity.

Herd Immunity

Herd immunity is the concept of population resistance to a bacteria or virus. The basic theory is that people who are immune to the virus, or at least exposed to the degree of severe mitigation, must hit a specific percentage with relation to the overall society. The percentage of the population that must be immune to supply herd immunity is a sliding scale based on the infectious rate of the vector in question. The Spanish Flu had a herd immunity level around 55% of the overall population, whereas Measles has a herd immunity level of roughly 90% of the population. (Regalado, 2020).

MIT Herd Immunity Infographic

Vaccines and natural exposure are the two avenues to reach herd immunity. Given the current suppression tactics, and flattening the curve responses by various world governments, there is a low possibility that herd immunity will be achieved naturally by the start of the next flu season given naturally occurring transmission.

Vaccines

Vaccines are a population health tool which allow for rapid gains towards herd immunity levels by safely exposing recipients to a similar vector structure which will allow the host’s immune system to create a natural resistance to full infection. (Public Health.org, 2020).

A worldwide race is underway to develop safe and effective vaccines to combat covid 19. Many unique approaches are underway for the harvesting of the vaccines. These include, but are not limited to, growing covid vaccines in plants to speed up from the traditional egg incubation method, to deploying RNA only injections to rapidly get testing into humans. With all that said, traditionally vaccine trial to clinical validation and approval is at least 12 months. (Terry, 2020). Even given extreme expedience of testing; it is unlikely that a working and commercial vaccine for Covid will exist before Q1 2021. This exacerbates the artificially depressed spread of natural immunity discussed in herd immunity to suggest that the incoming flu season will again prove to be a difficult fight against Covid.

Remote Patient Monitoring

RPM offers the best bet of better patient management for chronic ailments as well as the potential to more quickly address flare ups of Covid outbreaks as we monitor patient temperatures/shortness or breath/and potentially oximeters remotely. RPM also piggy backs off digital engagement tools which will allow us to better communicate essential information about Covid preparedness directly to patients. This layer of care will fit squarely between patient sought education, RPM, and then the escalation to telehealth visits directly. A healtchare network approach should be to move into a digital first posture where our education, monitoring, and telehealth (scheduled and ad hoc) are the primary focus of the ambulatory delivery network. There will continue to be in-person specifc visits for types of ailments that cannot be handled remotely, but this hybrid model will begin to move the infectious spread risk out of the care giving facilities.