Taking Care of Patients Beyond the Confines of the Traditional Office Visit

— Home monitoring can offer a great way to extend our services

 A photo of a woman sitting on her couch during a telehealth visit with her male physician.
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    Fred Pelzman is an associate professor of medicine at Weill Cornell, and has been a practicing internist for nearly 30 years. He is medical director of Weill Cornell Internal Medicine Associates.

Built into the heart of the patient-centered medical home is the idea of extending care beyond the limits imposed by an in-person office visit.

I've written before about how 20 minutes just isn't enough, either for us or for our patients. There is so much we want to get to, and our patients surely have multiple issues they want to address, that the need is there to extend care beyond the walls of our office.

The Opportunities of Telehealth

Video visits and other telehealth opportunities certainly broaden available options. For example, seeing a patient with new mental health issues such as depression or anxiety, and after a decision is made to start them on a medication, there is no real reason for them to come back into the office to see me to check on how they're doing, and to monitor for side effects and check on efficacy.

Seeing them on the video and talking to them can give us a good sense of how they're doing -- maybe not quite as good as in person, but you can tell if their mood has lifted a little, or whether nothing much has changed. And this probably saves them the couple of hours needed to take off work, arrange childcare, and come all the way into the office and sit around in our waiting room.

Beyond telehealth with the provider, having additional team members help out in the ongoing management of acute and chronic problems can extend care massively. For example, starting an outpatient on a new medication for diabetes, remote care can add depth and power to the care we provide when multiple members of our team -- from nurses to social workers to nutritionists to pharmacists to care managers -- can reach out and add to the management of this condition, check on side effects, encourage diet changes, dose-escalate medication, and ensure that patients are checking their glucose levels and taking their medication correctly.

Spending Enough Time?

But all of this, at its best, adds up to only a fraction of the time our patients spend out in the world living their lives and having their medical conditions affect them. For our most complicated patients, we may see them a couple of times in succession, and then maybe a few more times over a year, but is this enough time for us to really make a difference for them, to make the maximal impact and give them the best chance for improving their health?

Twenty minutes, maybe a maximum of 10 to 12 visits a year (roughly once a month, pretty intensive)? That's 3-4 hours total time in care. So, 4 out of the 8,760 hours in a year (not counting leap years), comes out to 0.045662% of their life directly involved with us.

That's where I think remote patient monitoring can really make a difference. There have been multiple efforts through the years to build up programs for this, some with a great deal of success, others with limited value and benefit.

It's only worth monitoring something if we're going to do something with the data, if it can provide useful information, if it's going to change our management or empower patients to do more of the things they need to do -- like take their medications regularly, exercise, or change their diet, when they can see the results of these actions almost immediately. But sometimes it can go too far.

The Case for Remote Management

I remember one patient I saw with very mild type 2 diabetes, who had started on a low dose of medication by their choice. They were sent home with a glucometer and instructions to test blood glucose levels occasionally when fasting, or after big meals to see the effects of what they had eaten, or after exercising, or else when they had any symptoms of hypoglycemia or hyperglycemia.

When they came for a follow-up appointment several months later, they brought in a blood-spattered logbook, which showed that they had somehow decided on their own to check sugars five times a day. There was page after page of glucose readings, all hovering pretty much around the same almost normal values. I tried to explain to them that this much testing was more likely causing undue pain and discomfort from pricking their finger so much, or risking an infection from stabbing themselves so often, or more likely they could become anemic from all those hundreds of tiny little drops of blood (just kidding), than impacting care or changing management with those readings.

But for certain patients, remote monitoring can help intensify therapy, improve compliance, and hopefully lead to better outcomes. Programs of home blood pressure monitoring offer a prime opportunity to extend the care and actively engage our patients in self-management. This feedback, this data on how they're doing during all that time between our office visits, will likely be as valuable (if not more so) than just a blood pressure check when they come back in after a few months on a medication.

I've had numerous patients tell me how much they've enjoyed doing it, how engaged they felt, how it helped them stick with their medicines, stick with their exercise, stick with their diet changes. We need to ensure that we build a safe system for this data reporting, a way to spot trends and catch emergency situations before they cause a problem, without overwhelming the providers with massive dumps of data every day to their electronic health record in-baskets.

Another area of disease management that holds great promise with remote patient monitoring is the use of continuous glucose monitors for our patients with diabetes. Patients love them, they are less invasive and less painful than fingersticks, and they've become so sophisticated that they are starting to recognize trends, such as when patients are heading for dangerously low levels of glucose in their blood. The feedback patients get on their phones or the monitor's device can show them time in-range and time out-of-range that can be very powerful for them, as well as for us.

Possible Role for AI

Once again, we don't want to get all this data all day long; we don't have the bandwidth for it, and most of the time we're not going to change management based on the day-to-day numbers we get. But there may be a place for artificial intelligence (AI) here, to take a first look at the data, help spot trends, and push us and our patients to make changes in medications or other non-pharmacologic interventions.

There are probably countless illnesses and conditions for which remote monitoring by patients may prove invaluable, from mental health issues, to pregnancy, to heart failure, and more. While we are just starting to get data on the short- and long-term benefits of these programs, and many research projects are still ongoing, it makes sense that a rigorous program of patients checking a condition's status at home and reporting these back to the team would do a lot to improve short- and long-term disease management, complications, and other outcomes.

We need to embrace these systems, make sure our patients have access to the devices and the technology and the resources they need to do these self-monitoring programs at home, so we can fully engage them and help them gain control. It's more than remotely possible that this is going to make a big difference for everyone involved.