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Can Remote Patient Monitoring Have An Impact For Patients With Diabetes?

Technology and its ability to connect health-care providers with their patients have become increasingly important during the COVID-19 pandemic. Accordingly, this author assesses the potential of remote patient monitoring to prevent lower extremity complications in the at-risk population of patients with diabetes and offers practical insights on implementation and reimbursement. 

As clinicians continue to modify their practices in order to stay viable during the global COVID-19 pandemic, the ability to collect and monitor patient information outside of the four walls of the office or clinic is more important than ever. With an increasing number of patients staying away from doctors’ offices and hospitals due to concerns about catching the novel coronavirus, the need for innovative solutions that allow for continued care of the at-risk patient population is essential. 

Tissue Analytics, a wound care electronic health-care software company, estimated that there was a 40 percent decrease in wound care center patient visits during the early onset of the coronavirus outbreak in comparison to the same time frame in 2019.1 Over the past several years, remote patient monitoring emerged as a promising area of medical advancement and technology. The global pandemic only helps to accentuate its importance and utility as many clinicians are now taking advantage of this opportunity to adopt remote patient monitoring into their practices. 

Remote patient monitoring is the use of any digital technology to collect health-related data from patients in one location (i.e. home or skilled nursing facility) and securely transmit that information electronically to the health-care provider in a different location. The purpose of this information transfer is to allow health-care providers to obtain physiologic assessments, evaluate this information and subsequently make care recommendations back to the patient. In contrast, “telehealth” is a broad category that consists of all health-care-related activities conducted through telecommunications technologies. 

Remote patient monitoring is a specific subcategory of telehealth that involves collection and transmission of patient health data through the use of electronic devices. Unlike telemedicine, remote patient monitoring services do not require interactive audio or video. 

Some examples of remote patient monitoring devices include wearables such as temperature-sensing socks or pressure-monitoring insoles, fitness trackers and a wide variety of other devices that one can use to collect medical data. 

What Are The Benefits Of Remote Patient Monitoring? 

Remote patient monitoring can provide benefits to both patients and health-care providers alike. With the assistance of remote patient monitoring, it is possible to virtually complete medical assessments that professionals historically performed in person. Implementation of remote patient monitoring into a busy medical practice can enhance physician workflow, allowing clinicians to dedicate office time to patients needing more complex intervention while still keeping tabs on more stable patients within the practice. 

Implementation of remote patient monitoring can also help physicians collect better quality data. At times, patients may not be the best historians or may even stretch the truth when it comes to adherence to medical treatment plans. Data from remote patient monitoring, on the other hand, is not easily manipulated. 

For patients, it can offer increased access to care, especially in more rural areas. The convenience of being able to obtain health-care services from the comfort of their homes is a big advantage, especially during the current COVID-19 pandemic. A benefit of remote patient monitoring is that it helps limit direct person-to-person contact, thus potentially decreasing the spread of COVID-19. 

Additionally, many elderly patients have limited transportation options and/or limited physical function that may cause them to skip important medical appointments. Using remote patient monitoring can decrease the need for hospital admissions by catching changes in health early and ultimately may lead to better patient outcomes. 

When using remote patient monitoring devices, patients become more accountable and engaged in their care, which may lead to improved patient adherence to treatment plans. This empowerment may also help to strengthen the physician/patient relationship. 

Can Remote Patient Monitoring Help Prevent DFUs And Related Complications? 

The development of a diabetic foot ulcer (DFU) has a considerable effect on patient morbidity and mortality, contributing to high health-care costs.2 It is well established that DFU formation is multifactorial. Long-standing diabetes and the resulting increased blood glucose levels contribute to neuronal damage.3 This damage causes a decrease in the ability of nerve fibers to transmit adequate signals and results in neuropathy.3 When patients develop sensory neuropathy and lose their protective response mechanisms to pain, they are unable to detect changes in temperature or minor trauma such as blisters or abrasions.3-5 Decreased motor nerve fiber densities can detrimentally affect balance and spatial awareness that impact ambulation.3 

As a result, this abnormal gait can create additional areas of pressure on already vulnerable tissue, leading to callus and subsequent ulcer formation (see photos above). Microvascular dysfunction contributes to reduced tissue perfusion, leading to reduced oxygenation of the tissues, which may result in an increased vulnerability to mechanical stress.3 All of these pathophysiologic changes can contribute to the development of DFUs and their subsequent failure to heal. 

Diabetic foot ulcers are one of the most common preventable complications in patients with diabetes yet patients with diabetes have a 15 to 25 percent lifetime incidence of foot ulcers.6 Currently, the standard of care for DFU prevention consists of patient education, systematic foot exams and therapeutic shoes with multidensity pressure-reducing insoles.7 Although studies show that these therapies can reduce the incidence of DFU formation and recurrence by about 50 percent, they are still heavily dependent on patient adherence.6 Perhaps the implementation of remote patient monitoring in this patient population can lead to a better standard of care for DFU prevention as the early data appears promising. 

There is mounting clinical evidence showing that daily temperature monitoring of the feet can be a beneficial tool to aid in DFU prevention and recurrence. A prevailing hypothesis is that skin temperature is a marker for tissue inflammation and injury in the neuropathic foot, and can be an early signal alerting to potential areas of skin breakdown and ulceration. Changes in temperature of greater than four degrees reportedly had a positive predictive value for skin breakdown in previous dermal thermometry studies.8 

Temperature monitoring has become an area of increased interest among podiatrists, spawning at least three randomized controlled trials and multiple other clinical studies. Researchers have noted anywhere from a three- to tenfold decrease in re-ulceration when patients utilized remote patient monitoring devices for temperature assessment along with standard of care versus standard of care alone.9-11 It seems that temperature monitoring is a simple mechanism by which to identify early signs of tissue pathology in order to avoid DFU formation. 

A recent study in the Journal of the American Podiatric Medical Association reported that the odds of having a diabetes-related amputation increased three to 10 times since the onset of the COVID-19 pandemic.12 Coronavirus infection is particularly dangerous for patients with comorbidities such as diabetes but the need for proper foot evaluations continues to be an essential part of diabetic foot management. Keeping the at-risk patient safe at home while providing critical health screenings through remote patient monitoring allows clinicians to safely monitor patients, decreases the risk of exposure to COVID-19 for patients and providers, reduces health-care utilization, increases access to care in urgent cases, and has a positive impact in reducing diabetic foot complications. 

Implementing Remote Patient Monitoring: What You Should Know And What You Should Ask 

With so many providers and hospital systems looking to adopt remote patient monitoring, it is imperative to monitor what matters. Given this increasing interest in remote patient monitoring technology, many companies offer an array of devices and services. It is crucial to formulate a protocol for prioritizing which patients to monitor in order to amplify patient benefit. Patients at increased risk for complications or hospitalizations should be the focus. Correct device and patient selection will help drive adherence to data collection and make the most impact in reducing high-dollar health-care services such as wound care emergency room (ER) visits, hospitalizations and surgical interventions. 

A 2019 survey conducted by a wearable health-care solutions company found that two-thirds of patients 40 years and older would agree to utilize a monitoring device if it meant they could reduce the number of times they had to physically visit a doctor or hospital.13 

Determining the specific health parameters that will make the most impact on your patient population is an essential step in ensuring a successful remote patient monitoring program. For instance, monitoring plantar foot temperatures of patients with diabetes is a preventative measure to help thwart DFU development. In order for an office to successfully implement a remote patient monitoring program to monitor plantar foot temperature in those with diabetes, diabetes must be a relatively common comorbidity among patients in the practice and the development of a DFU must be a concern among these patients. 

Aside from determining what physiological parameters you wish to monitor, there are some other crucial factors to consider prior to implementing a remote patient monitoring program. How does the system fit into the practice workflow? Ideally, remote patient monitoring is most efficacious when one uses it simultaneously with a customized patient care plan. Programs can monitor and manage a variety of chronic health conditions, but the best remote patient monitoring care management plans are those designed to suit the patient’s personal needs and conditions. If one detects a concern virtually, physicians can see the patient in the office for expedited consultation and treatment, potentially preventing serious complications. Accordingly, leaving designated appointment spaces on the schedule open for these instances is a good idea. 

Remote patient monitoring technology can be an asset in streamlining practice operations but pairing with the right technology partner and asking the right questions are important keys to success. 

What is the overall cost? Some remote patient monitoring platforms demand that practices lease the devices or incorporate device costs into their platform fees. Others require payment for devices upfront. 

How does the remote patient monitoring platform relate to your current electronic medical record (EMR) system? Some remote patient monitoring platforms mesh well with current EMR systems while others function completely separately. 

Who is responsible for data interpretation and communication with the patient? Will a dedicated staff member perform this in-house or will the practice farm this out to a support service? Some practices find it helpful to contract with a third-party partner to keep track of incoming data as well as billable time to facilitate the submission of claims to payors each month. 

Lastly, keep in mind that the functionality and quality of the patient device are just as important as the office software platform. Is the device easy enough for patients to use at home without assistance? Integrating an easy-to-use device will help to ensure the overall success of your remote patient monitoring investment. Assessing the tech savviness of each individual patient is a step one should not overlook. A device is only as good as the patient’s ability to successfully operate it. 

Pertinent Insights On Reimbursement 

It is pivotal to understand all the requirements and guidelines for providing and billing remote patient monitoring as well as the charges associated with delivering theses services. 

Practices can submit billable time to Medicare and other private payors for reimbursement. Remote patient monitoring became a covered service by Medicare in January 2018. The Centers for Medicare and Medicaid Services (CMS) recently revised the remote patient monitoring guidance in response to the COVID-19 public health emergency.14 The CMS agrees that this type of patient care is an integral part of the management of chronic disease states in order to effectively track physiological changes and symptom progression. 

Several CPT® codes exist for the provision of remote patient monitoring. Codes are specific to different remote patient monitoring activities. Onboarding a new patient onto a remote patient monitoring platform or device, setting up the equipment and educating the patient on its use fall under CPT code 99453. Reimbursement for providing the patient a device for 30 days is covered by CPT 99454 and can be billed every 30 days. CPT code 99457 covers interpretation of data and interactive patient management via telephone text or email communication. There is an add-on code (CPT 99458) covering additional 20-minute follow-up conversations with the patient in a given 30-day period.14 

When one monitors a patient remotely and the collected data indicates no abnormalities, the code CPT 99091 will apply as there is no necessary modification in the care plan. These codes can be billed and reimburse separately. One can submit CPT codes 99457 and 99458 as “incident to” and under “general supervision” rather than direct supervision. This means that performance of remote patient monitoring services can occur via the direction of the billing physician without the physician being physically present or in the same location as the person who is collecting and interpreting the medical information.14 

However, one cannot charge patients for the devices themselves. Also keep in mind that medical necessity is critical for coverage of remote patient monitoring services. Correct ICD-10 codes must be part of the claim. One should note that physicians must also obtain advanced patient consent and document this in the patient’s medical record. Clinicians must also detail the justification for the use of remote patient monitoring in the medical record for compliance purposes.14 

In Conclusion 

Even before the COVID-19 pandemic hit, I had conversations with many health-care providers who had already made or planned on an investment in remote patient monitoring. In light of the global health-care crisis, there is an apparent technological tsunami in the remote patient monitoring space. With so many companies introducing remote patient monitoring devices, it is sure to drive competition. The most effective devices will be economical, easy to use and will seamlessly integrate into current EMR systems. 

Several companies have launched devices aimed at improving diabetic foot care in particular. Some of these technologies to keep an eye on are temperature-sensing socks that may predict ulcer development, custom diabetic inserts that can measure pressure points and patient adherence, and offloading boots that can track patient activity and adherence. 

I believe remote patient monitoring will become increasingly pervasive and may change the way we care for our at-risk patients. When it comes to your individual practice, make sure your remote patient monitoring model meets your specific needs with help to ensure success for you and your patients as well. 

Dr. Cole is the Medical Director of the Wound Care Center at University Hospitals Ahuja Medical Center in Beachwood, Ohio. She is also an Adjunct Professor and Director of Wound Care Research at the Kent State University School of Podiatric Medicine. 

By Windy Cole, DPM

1. Tobe M. Wound care is an essential service! Available at: 6654464277728022528-4S2U . Published April 2020. Accessed February 10, 2021. 

2. Nussbaum SR, Carter MJ, Fife CE, et al. An economic evaluation of the impact, cost, and Medicare policy implications of chronic nonhealing wounds. Value Health. 2018;21(1):27–32. 

3. Jeffcoate WJ, Harding KG. Diabetic foot ulcers. Lancet. 2003;361(9368):1545–1551. 

4. Ndip A, Ebah L, Mbako A. Neuropathic diabetic foot ulcers - evidence-to-practice. Int J Gen Med. 2012;5:129–134. 

5. Colagiuri S, Marsden LL, Naidu V, Taylor L. The use of orthotic devices to correct plantar callus in people with diabetes. Diabetes Res Clin Pract. 1995;28(1):29–34. 

6. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA. 2005;293(2):217–228. 

7. van Netten JJ, Price PE, Lavery LA, et al. Prevention of foot ulcers in the at-risk patient with diabetes: a systematic review. Diabetes Metab Res Rev. 2016;32(Suppl 1):84-98. 

8. Armstrong DG, Lavery LA, Liswood PJ, Todd WF, Tredwell JA. Infrared dermal thermometry for the high-risk diabetic foot. Phys Ther. 1997;77(2):169- 177. 

9. Lavery LA, Higgins KR, Lanctot DR, et al. Preventing diabetic foot ulcer recurrence in high-risk patients: use of temperature monitoring as a self-assessment tool. Diabetes Care. 2007;30(1):14- 20. 

10. Lavery LA, Higgins KR, Lanctot DR, et al. Home monitoring of foot skin temperatures to prevent ulceration. Diabetes Care. 2004;27(11):2642-2647. 

11. Armstrong DG, Holtz-Neiderer K, Wendel C, Mohler MJ, Kimbriel HR, Lavery LA. Skin temperature monitoring reduces the risk for diabetic foot ulceration in high-risk patients. Am J Med. 2007;120(12):1042-1046. 

12. Casciato DJ, Yancovitz S, Thompson J, et al. Diabetes-related major and minor amputation risk increased during the COVID-19 pandemic. J Am Podiatr Med Assoc. Available at: https://doi. org/10.7547/20-224 . Published November 3, 2020. Accessed February 10, 2021. 

13. Hennick C. How remote monitoring programs are beneficial. HealthTech. Available at: https:// . Published April 27,2020. Accessed February 10, 2021. 

14. Bryant G. CMS guidance for remote patient monitoring. ICD10 Monitor. Available at: https://www. . Published June 29, 2020. Accessed February 10, 2021.

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