By: Amit Shah, MD, MSCR
The high-level concept of remote patient monitoring (RPM) isn’t new, but the ways the technology is being used in specific medical specialties are becoming more diverse, more expansive and more creative.
As an early advocate of the viability of RPM technology in cardiology before COVID-19, I foresee a broad variety of use scenarios in clinical practice as well as clinical trials.
The ability to assess patients in their home setting with clinically actionable metrics on a more frequent basis than every three months in a regular exam offers a higher-resolution insight into what’s happening with a patient. Broadly speaking, I also think there’s a substantial insight that we can gather with patients by talking to them and assessing them in their home setting as opposed to a 15-minute clinical visit. Physical activity and sleep are two examples of important health behaviors that are extremely difficult to evaluate in a clinical setting without direct measurements. Psychological stress is another important measure of health that impacts many underlying risk factors and health behaviors; major life events may also accompany the onset of new symptoms such as chest pain or fatigue that may not have a good explanation.
The data gathered through RPM technologies that measure heart rate and activity are emerging as methods to fill gaps in available clinical guidance. This type of knowledge, especially pertaining to behavioral biomarkers that the patient can’t readily describe, can be invaluable to a provider. While blood pressure monitoring is a well-known use for RPM because patients can self-deploy the data periodically and well-established clinical pathways are available, this is just the tip of the iceberg when considering the opportunities to measure lifestyle factors on a more holistic level.
Another emerging role in RPM is in arrhythmia surveillance. Home monitoring for atrial fibrillation is increasingly available. The possibility of a low-cost continuous home-ECG monitor with FDA clearance offers an exciting dimension in health tracking that combines lifestyle management and atrial fibrillation monitoring with a patient-centered approach. As the cost, size, and burden of ECG monitors are reduced, and FDA-cleared, clinically actionable algorithms are applied, remote tracking may become mutually beneficial to both patients and providers as stakeholders in wellness and cardiovascular disease management.
Diverse Implementation of RPM Technology
That need has been even more evident during the COVID-19 pandemic, where telehealth has been the mainstay of care for lower risk COVID-19 positive patients and patients under investigation. The unpredictable nature of the COVID-19 disease course has underscored the potential role for home monitoring programs, although we, as a scientific community, are still figuring out the best practices for which monitoring strategies are the most effective for reducing the risk of adverse outcomes in those undergoing home monitoring. As RPM in COVID improves, and more patients can be successfully monitored/treated at home, rather than the hospital, fewer people will be exposed, fewer hospital beds will be used, and less personal protective equipment will be needed.
During the pandemic, we have also had to explore alternative models for cardiac rehabilitation, a comprehensive lifestyle change program for patients with a recent cardiac event. We have a program at the VA for home-based cardiac rehabilitation where we are coaching Veteransremotely for a comprehensive lifestyle change. For them, remote patient monitoring technologies are also vital for safety monitoring. In particular, ECG is vital for exercise-related arrhythmias and evaluation of chest pain at home
As part of the Medicare response to the COVID-19 public health emergency, they have approved remote home ECG monitoring of exercise as an extension of on-site hospital exercise programs that are otherwise closed because of COVID-19 transmission risk. This is because exercise causes aerosolization of virus particles and is considered a high-risk activity. In addition, the impact of mask-wearing on the efficacy and safety of exercise is not clear. As such, continuous ECG monitoring is an essential component of the cardiac rehab RPM solution during the pandemic. Although the hospital staff has limited capacity to respond to cardiac emergencies during exercise sessions when monitoring remotely, the risk of sudden cardiac death during exercise is exceptionally rare, especially when proper risk stratification is performed and the highest risk patients are excluded. Thankfully, this group comprises a very small percentage of all patients who undergo cardiac rehabilitation.
Finally, certain well-staffed high-risk cardiac clinics such as heart failure are likely to benefit from RPM technology that includes ECG. Many heart failure clinics are managed by multidisciplinary teams that have the resources to manage a dashboard of patients and proactively intervene when abnormalities are detected to avoid readmissions. Integration of ECG into current RPM programs offers an opportunity to include arrhythmia and other behavioral outcomes into their clinical management pathways, especially for patients without implanted devices. More work is needed, however, to assess patient volume status remotely, since the current gold standard is a physical exam.
Actionable Clinical Trials
An emerging aspect of home ECG monitoring is the ability to evaluate autonomic function. At Emory, we are evaluating autonomic function as measured through heart rate variability as a way to investigate coronary artery disease (CAD), depression, and the risk of long-term adverse outcomes. The study builds upon previous work by our team titled Circadian Autonomic Inflexibility: A Marker of Ischemic Heart Disease, which found an association between lower heart rate variability (HRV) and subclinical myocardial ischemia, as well as lower coronary flow reserve, in a cohort of male veteran twins.
As a follow-up to this study, we are usingVivaLNK medical wearable ECG sensors to remotely monitor patients who are undergoing coronary angiography to better understand the role of autonomic function in their risk. We have enrolled over 70 participants and are primed to further explore the space of ECG RPM in these individuals who are at high risk of arrhythmia and ischemic heart disease events. By collecting data from the sensor patch prior to their angiogram, we can better understand the role of the autonomic nervous system in predicting their heart symptoms, coronary anatomy, coronary physiology, and quality of life.
Overcoming Obstacles to Implementation
Although RPM has promise in disease management across several disciplines, the onboarding process for new providers can be an obstacle that prevents its utilization. Although reimbursement models are in place to financially sustain RPM in clinical practice, many times a clinical champion is needed to innovate and start a new program and bring the best evidence-based practices into reality.
As we network and learn best practices from each other, we may find more providers interested in starting RPM program onboarding can be daunting. The technology behind the RPM must also offer provider dashboards so providers can track the health status of their panel and including integration with billing to reimburse them for their time This is an important difference with certain standalone consumer devices that are not integrated with clinical management systems and do not have a payment model and may lead to false alerts and anxiety for patients who otherwise do not have proper support mechanisms in place to manage unexpected alerts from their devices
Looking to the Future
Opportunities abound to implement the technology of wearable medical sensors and remote monitoring solutions in cardiology. Areas of emphasis and innovation include sleep monitoring for insomnia and sleep-disordered breathing, cardiorespiratory fitness tracking, psychological health, autonomic dysfunction, arrhythmia, and overall cardiovascular risk. Novel algorithms and mechanistic insights are possible through additional research and can be integrated into existing billing structures to improve health tracking and the quality of disease management from a public health perspective. Pragmatic and/or randomized clinical trials will be imperative as we embark on this new journey and integrate these technologies into our preventive care
Amit Shah, MD, MSCR is an Assistant Professor of Epidemiology with an adjunct appointment in Medicine (Cardiology) and is Chief of Preventive Cardiology at the Atlanta Veterans Affairs Healthcare System. His areas of expertise include stress psychophysiology research, ECG signal processing, cardiac physiology, arrhythmia risk, population-level risk prediction, mobile health technologies, vascular biology, genetics, and risk prediction. Dr. Shah has been funded by the National Institutes of Health, American Heart Association, and Veterans Affairs Administration.