How can RPM be implemented for a remote facility?

Answer 1

Introduction

Advancements in technology provide new opportunities for different industries and sectors to improve quality of products and services offered. Similarly, the health care sector has access to diverse technological devices that may improve the quality of care services provided to patients when executed effectively. The use of technology in health care is increasingly becoming popular. In health care, most advanced technological systems are utilized with the objective of improving health outcomes, enhancing coordination and in making communication more effective (Lesser et al, 2012). Communication in this context involves transference of information from a care provider to another provider and from a care provider to a patient and vice versa. For a technological system to be implemented effectively in a health are institution, it needs to operate under a common health information system that will create interoperability and compatibility (Lesser et al, 2012). Advancements in technology bridge barriers that may be posed by physical distance or lack of adequate skilled staff in a facility among other barriers. Remote patient monitoring is one such technological system that enables health care professionals to educate, communicate with and monitor the progress of patients remotely (Lesser et al, 2012). This paper discusses the adoption of remote patient monitoring as a common health information system for two merging organizations in order to improve care delivery and health outcomes.

Analysis of technology

Federally mandated requirements are linked with quality improvement and adoption of best practices in health care. Technological advancements can help achieve these objectives. Remote patient monitoring is one such technological system that is expected to enable providers to bridge the barrier of physical distance that may hinder patients from being monitored continuously until their condition is treated completely or effectively managed. Under the FDSAIA (The Food and Drug Administration Safety Innovation Act), a key focus is on promotion of use of quality management principles (Health IT Report, 2014). The regulation encourages health care institutions to develop systems that facilitate identification, prevention, tracking and monitoring of safety hazards as well as in reducing risks to patients. Patients who live in remote regions are exposed to diverse risks including possible worsening of their health condition if they are not monitored continuously. The merging organizations would be able to pursue the FDASIA focus on quality management by adopting remote patient monitoring as it would make it possible for the physiological parameters of patients to be measured regularly and possible alerts passed on to skilled staff at the main health facility (Health IT Report, 2014). The satellite facility may face shortages of staff and equipment based on its distant location from urban centres and the patients may not be able to visit the facility frequently due to challenges such as poor infrastructure. Additionally, if they visit the facility, the quality of care they receive may be hindered by the shortage of staff and lack of advanced technological equipment. Consequently, adoption of a technological system that facilitates monitoring of patient's conditions remotely is a beneficial approach that would meet federally mandated requirements on best practices and quality management.

Remote patient monitoring is a system that contains four core components that enable it to perform its functions. While devices that are used in remote patient monitoring are diverse and may contain different features, the four core components are found in almost all RPM devices. The four components are sensors, a centralized repository, a diagnostic application software and local data storage (Lesser et al, 2012). Each of these components plays a significant role in the functioning of an RPM system. Sensors are placed on the device and used in measuring physiological parameters of the patient. The information collected is then passed on to the provider using wireless communication. Local data storage refers to an interface that connects the sensors to providers. The interface also connects the sensors with a centralized data repository. The centralized data repository is a device that stores the information that sensors send and that may be transferred by health care providers or the local data storage. The final components - diagnostic application software - refers to a tool that analyses the information that has been collected and provides recommendations for treatment as well as intervention alerts (Lesser et al, 2012). An RPM system takes place in four main phases. The patient uses peripheral devices that have sensors to measure physiological parameters associated with their health condition. The data that is collected is then transferred to providers of health care services through wireless communication. Once the information is received by the health care providers, they may manually assess it for potential problems or utilize decision support algorithm that is applicable in a clinical setting to identify potential problems (Fensli and Oleschuk, 2011). In case a problem is detected, an alert is made to inform the health care provider and appropriate interventions or treatment options are taken. In this way, intervention is performed in a timely manner and the health of patients is able to be maintained at a stable level without the patient necessarily visiting the health care facility physically on a regular basis for check-up (Fensli and Oleschuk, 2011). The technological system is especially beneficial for health condition that require regular monitoring such as Diabetes and congestive heart failure. In managing diabetes, many physiological parameters of the patient need to be controlled including the patient's blood pressure, their blood glucose and their weight (Fensli and Oleschuk, 2011). Use of RPM would ensure that the physiological parameters of the patient are checked continuously to facilitate identification of possible problems that may require intervention before the patient's condition worsens. The functions performed by an RPM system reflect the federally mandated requirements associated with quality management and best practices. The system enhances the quality of care, improves health outcomes and represents a recommendable practice in health care as it enhances patient welfare and safety.

Quality management principles as is described under the FDASIA involves processes that are aimed at identification, prevention, tracking as well as monitoring of safety hazards and in mitigating risks. There are diverse approach to quality management but the underlying factor is for safety hazards to be identified and eliminated and for risks to be mitigated. In this context, the welfare of the patient is a priority and this framework is reflected in the RPM system that monitors the physiological parameters of patients to anticipate possible problems and ensure that risks are mitigated. Based on quality management principles, detection of tracking and prevention of safety hazards as well as mitigation of risks should only be narrowed down to a specific area of a patient's treatment process but should be integrated in their social, psychological and physiological dimensions (Fensli and Oleschuk, 2011). This means that the technological advancements made to improve the quality of health care services offered to patients should strive not to compromise the patient's ability to engage in other aspects of their lives.

With regards to identification and adoption of standards as well as best practices, the priority is on improving patient safety through promotion of innovation. Standards, though, are developed through an evidence-based system that is open, fair and impartial. In this dimension, the development of innovative products that enhance service provision and conformance with specific guidelines to uphold quality of health care services are performed (Fensli and Oleschuk, 2011). Best practices are approaches that have been shown to create superior results in a consistent manner. The use of RPM may hence be perceived as a best practice because previous studies on the use of the technological device have illustrated its consistent effectiveness in improving quality of care as well as access to health services. Best practices are applied with the primary objective of promotion as well as maintenance of consistency and quality and these objectives are similarly sought by an RPM system. Herbert and O'Donough (2012) explain that remote patient monitoring the information they generated from 3 case studies conducted on health institutions revealed that use of RPM reduced operational and health costs in addition to improving health outcomes and making health services more accessible to patients (Fensli and Oleschuk, 2011). The same observation was made by Huston (2013) who determine that remote patient monitoring is one of emerging technologies that is greatly facilitating provision of health care services across distant locations. This is especially important in the context of remote health facilities that may not have adequate skilled staff or advanced equipment and which could utilize the effective communication system created by remote patient monitoring to coordinate with a larger health care facility in offering quality health care services.

Team members

Adoption of remote patient monitoring by the merging organizations constitutes a practice change therefore there needs to be a structured model through which the new practice is implemented. An important step is in creating an appropriate team that will be actively involved in executing individual roles to promote achievement of effective implementation. Team members that would be on the project committee come from different disciplines and are namely; medical practitioners or physicians, technicians and a representative from top management (in this case a medical director). A lawyer is also needed in the committee as this project involves compliance with federal regulations and industry standards therefore there will be need for legal counsel to mitigate legal risks.

The medical director (MD) can also hold the vice president position in the organization and is usually tasked with overseeing clinical activities as well as patient care policies. Additionally, the MD is actively involved in development and implementation of strategies associated with clinical services. The MD is a member of the top management in a health care facility and would hence be needed in the project team based on the need for administrative authority in the committee and their skills in overseeing patient care policies. Physicians are involved in diagnosis of patient's diseases, prescription of appropriate medication, determination of whether medicinal therapy is required, provision of information to patients regarding diagnosis and treatment and in monitoring the manner in which the patient responds to medicinal therapy. Based on the progress made by the patient, the physician may choose to alter the treatment approach or therapeutic plan. In implementing RPM, the physician would be actively involved as the new practice would require them to rely on the technological devices to receive patient information and in coordinating care of the patients remotely.

Technicians are the staff in an organization who develop a strong information and communication system that facilitates smooth operation of processes in the organization. Additionally, the technicians regularly review the IT systems to repair areas that are worn out. They also anticipate and are prepared to respond to possible glitches in technical equipment in a timely manner. Since the new practice involves introduction of a technological system, technicians within the merging organizations would be needed to help in duties such as installation and in familiarizing the stakeholders with the technological devices.

A lawyer is an essential staff member or consultant in a health care facility as there are national, state and industry regulations that need to be complied with hence requiring the involvement of a professional in legal matters to provide counsel. Similarly, this individual will be needed in the project committee as the new practice is expected to match particular standards associated with patient safety, federal regulations and health outcomes.

Roles of team members

Each of the individuals identified to be included in the project committee will be assigned a particular role. The lawyer will be charged with identifying legislations, policies and industry guidelines (or standards) that the merging organizations are required to comply with as they adopt a remote patient monitoring system. For instance, under the HITECH and FDASIA regulations, there are provisions that highlight best practices as well as industry standards that should not be compromised as technological innovations are adopted in health care service delivery. Consequently, there is need to have an individual who is adequately informed and skilled in legal matters to guide the project implementation team in complying with all regulations and avoiding legal risks that are associated with possible non-compliance.

The MD would be needed creation of strategic approach that will be involved in implementing the new system. For instance, when adopting a new practice in a health care setting, the top management sometimes employs the lewin change model in order to facilitate effective implementation of a change. Lewin's model is a model that divides the implementation of a change in an organization into three phases. The MD would be tasked with making decisions such as this one and also in ensuring that the other members in the top management are aware of the importance and necessity of the new practice. By creating support for the new practice from top management, a major barrier to effective implementation would be eliminated as the project would receive adequate resources and approval to be executed.

The physicians would be involved in applying the new practice by providing patients with appropriate RPM devices to be used in measuring their physiological parameters and conveying collected information to the health care institution. A training and education program would also be essential for the physicians to ensure that they are adequately skilled and knowledgeable in use of RPM systems to monitor the health condition of patients. It should be noted that RPM is one of many emerging technologies and innovative products may contain features or processes that a professional may not necessarily be familiar with. Consequently, a short training period for physicians would be recommendable to familiarize them with the technological devices and their use. Regarding provision of a training program, the MD would have to provide their approval and pass on the matter to other members in the administration for consideration. Once trained, the physicians would be expected to offer services to patients in a manner that integrated RPM systems. The idea is to ensure that health care services in the health facility for patients who visit the facility physically is not compromised by focus on remote patient monitoring but rather that a balance is created.

The role of technicians would be a major one given that the smooth operation of RPM devices within the system wound influence the outcomes of the change initiative. Technicians would be required to evaluate the context of the health care facility, the satellite facility and the priority health needs that require monitoring. Once this is performed, the technicians would have to recommend an RPM system and product that has particular features suited to address the priority areas identified for the health care facility. Additionally, the input of technicians regarding the appropriate product and vendor is necessary to facilitate interoperability. Lack of interoperability would hinder the new practice from being effectively executed therefore it is very important that the devices procured achieve interoperability. The technicians would also form part of the team tasked with educating or training physicians on use of the new technological system.

Importance of interoperability

While there are some core features (such as the four core components) that different RPM devices have in common, the products come from different vendor and may have varying features. These variations are largely introduced in a bid to develop competitive edge as vendors seek to introduce more features that create added value. However, variations in features and device components create a major challenge based on lack of interoperability. When interoperability is lacking, the manner in which physiological parameters is documented and shared becomes complex. Conn (2016) provides an example of the challenge faced by healthcare providers who are in the accountable care organizations (ACO) and those who are not with regards to sharing of essential patient information. According to the author, interoperability lacks between providers of health care services who work in a health IT systems that is within the ACO and those that do not. One such challenge is created by variations in interfaces as well as information-sharing agreements hence developing a complex web of hurdles that take up time, effort and other resources to overcome. The importance of interoperability is hence evident in the major hurdle that develops when information cannot be shared smoothly between providers to facilitate effective delivery of health care services to patients.

Conn (2016) explains that there are some providers who have yet to receive federal HER (electronic health record) incentive payments. The author further clarifies that these providers are especially facing a challenge when attempts are made to connect them with ACOs. The categories included in this context are hospice organizations, long term as well as behavioural health institutions. In the survey conducted by Conn (2016) a majority of the ACOs had yet to integrate data from behavioural health providers therefore creating a significant hurdle when providers from ACOs attempt to connect with behavioural health providers. Similarly, in the context of RPM, the information for the distinct health conditions that will be addressed under the new practice will have to be integrated in the individual departments that will interact with the information in order to ensure that effective coordination is achieved. In remote patient monitoring, more than one staff member from a specific department are involved as the patient is required to connect the device to their body for sensor to measure physiological parameters and the information generated may pass through one or more departments before it is stored. For instance, if the information collected regarding the physiological parameters of the patient (such as blood pressure) raises an alert, the physician may find that they need to refer the patient to a specialist hence requiring transference of the collected information to the specialist. Consequently, when the department of the specialist and that of the patient's physician have varying interfaces or cannot share information on the patient, the system exhibits a glitch that may use up time, human resources and compromise the safety as well as well being of the patient.

Standardized nursing terminology

When capturing information in a health care system or data that is nursing-specific, use of standardized terminologies is beneficial. When standardized terminologies are used in such cases, consistent as well as coherent communication is supported. Additionally, documented across settings and from one specialty to another becomes enhanced. A third benefit is in facilitating evaluation of nursing activities with the objective of ensuring that care that is person-centred and cost effective is delivered. There is also the issue of interoperability and as has been determined, interoperability is a very essential factor when using information technology in health care. When standardized terminology are used, mapping and harmonization of terminology is created therefore the stakeholders from different departments would be able to share information, communicate effectively and coordinate care. Schwirian and Thede (2014) in a survey conducted in various health institutions regarding the helpfulness of standardized terminologies determined that when standardized terminologies are used in health care service delivery, care gets planned efficiently, patient care becomes organized, appropriate health outcomes are generated, and appropriate interventions are generated for the patients. The rationale is that harmony and understanding of terminologies used during service delivery reduces the possibility of misunderstandings or miscommunication occurring between health care providers and enables the care providers to develop appropriate diagnosis (Schwirian and Thede, 2014). Development of an appropriate diagnosis facilitates recommendation of an appropriate intervention hence facilitating realization of positive health outcomes. However, when different terminologies are used across departments or health care institutions, interoperability lacks. Consequently, providers have a difficult time sharing information, understanding shared information and developing accurate interventions (if the interpretation of shared information is wrong).

Federal regulatory requirements

Health information technology is a development that has created opportunities for improvement of quality of health care and in reducing health care costs among other benefits. Based on the significance of use of information technology in health care, national and state governments have made effort to promote the adption and effective use of technological innovations in improving quality of health care. The FDASIA and HITECH are two recent federal regulatory frameworks that support the use of information technology in provision of health care services.

FDASIA

The Food and Drug Administration Safety Innovation (FDASIA) is a regulatory framework that supports the use of IT in health care delivery and that focuses on developing strategies or action plans that will reduce possible risks on patients' safety created by use of IT systems. The regulatory framework highlights the areas that IT in health care is expected to improve. Quality management and adoption of best practices are areas that the regulatory framework argues benefit greatly from use of IT systems in health care. The regulatory framework encourages health institutions to adopt use of technological innovation to improve the quality of care offered (Health IT Report, 2014). The requirement stipulated is hence for health institutions to create an open environment that accommodates suggestions for improvement through implementation of technological innovations. Remote patient monitoring is one such technological innovation that matches the focus of FDASIA in improving quality of care for patients while mitigating risks that IT systems may have on patient safety (Health IT Report, 2014). In this regard, the FDASIA recommends that quality management principles be adopted when using IT in health care and that standards as well as best practices be created and practiced. The rationale is that the principles developed would relate with the security and safety risks that patients face based on the type of health IT system that is in use hence facilitating reduction of risks and improving health outcomes (Health IT Report, 2014). The same applies to use of standards and best practices because the primary objective of best practices is to promote maintenance of consistency as well as quality in the nature of services offered and their outcomes. The requirement is for health institutions that are using IT to follow quality management principles and create as well as adopt best practices that will support achievement of expected outcomes while mitigating risks to patient's safety (Health IT Report, 2014).

HITECH

A second federal regulatory requirement is contained in the Health Information Technology for Economic and Clinical Health Act (HITECH Act) that is mainly focused on providing incentives for health institutions to adopt use of IT systems (HHS, 2016). The regulation aims to encourage providers to adopt electronic health record systems at a faster rate through provision of incentives. Based on the focus of the legislation in driving health institutions to adopt exchange of health information through electronic platforms and through means that protect such information from theft or wrongful use, 'privacy' and 'security protections' are areas that the legislation prioritizes (HHS, 2016). Within the legislation it is stipulated that failure to comply with relevant security protections as well as privacy issues when handling and sharing health information puts the provider at a high potential legal liability. This legislation requires the national government to allocate as well as make available funds to the health care sector that will be solely used as an investment to proliferate use of electronic health records in health institutions. Upon signing of the ARRA (American Recovery and Reinvestment Act) in the year 2009, the amount that was required to be allocated for use in promoting increased use of electronic health records was $ 19.2 billion (HHS, 2016).

Components for federal regulatory requirements

A major component of an RPM system that reflects the HITECH requirement to increase use of electronic health records is the centralized repository. This component stores the information that has been sent from providers of health care and from the local data storage. It is an electronic feature and stores information in digital form therefore illustrates that the RPM system meets the HITECH Act requirement for health care institutions to increase their use of electronic health records.

A component of the RPM system that meets the FDASIA requirement to improve quality management principles and adopt best practices is the device sensors and their ability to transmit information through wireless communication. Sensors are designed in a manner that enables them to measure specific physiological parameters associated with the patient's health condition and pass on the information collected to a third party through wireless communication. This component meets the requirement for best practices to be adopted and quality management principles to be applied when IT is in use in health care. Quality management involves identification of safety risks and resolving them and in this case, the sensors are designed to facilitate collection of accurate, reliable and necessary information on physiological parameters of patients without compromising the safety of patients. Unlike the local data storage and diagnostic application software which do not necessarily have to get into contact with the patient, the sensors are required to be in contact with the patient's skin. In this regard, they possess high potential of threatening the safety of the patient and appropriate measures have to be put in place during design of the sensors to ensure that any risks are mitigated.

Security threats and potential impacts

When information technology systems are applied in health care service delivery, some privacy risks arise. In the case of remote patient monitoring, the sensors that are used to collect information on physiological parameters of the patient may be used by people with sinister motives to collect private information regarding household activities. Such a development would put the household of the patient at risk of harm that may be take diverse forms including threat of physical attack or wrong use of the collected information targeting the owner's social and economic lives. Transmissions that are made from medical devices may be captured, stored as well as shared by a third-party advertise who are linked with the manufacturer of the technological device. The advertiser may then use the information that they have collected to target the patients by offering products and services that address their needs or exploit their health condition. A third security threat is on the burden of privacy responsibility that is transferred to the patient if the patient provides consent for a health device to be implanted in them and fail to read the fine print on any issues associated with privacy. This security threat largely affects the patient who wound develop distrust towards technological devices that are being adopted in health care service delivery. The trust of patients would also be lost in the case of transmission of information to a third-party advertiser. Another security threat posed is vulnerability of technological devices used in telehealth to hacking. For instance there are specific insulin pumps whose PHI can be breached and in the process, medical identity theft conducted. Given such vulnerability, patients are prone to raise concerns over security, privacy and safety hence requiring health institutions to put in place stringent measures that will uphold security and maintain positive perceptions of patients regarding medical devices.

Patient privacy features

There are technical solutions that can be created to enhance the security and privacy of users of medical devices under remote patient monitoring systems. A major solution would be development of a strong data policy in the health care institution that limits the use and transmission of patient information for medical purposes only, to the right or intended party and with little room for breach (Kara, 2011). To avoid breaches, the patient can be made aware of ways in which they can enhance the privacy of their information by changing consumer privacy preferences in the security and privacy settings link in the medical device or the computerized devices used. The devices used in RPM and that are capable of transferring information using wireless connection have a section in the settings link that allows consumers to highlight their preferences regarding privacy (Abraham et al, 2015). Within this section, the patient can limit access to their information to only specific parties.

Encryption of information is another alternative but this approach is too technical and would require the technical team at the health care facility to integrate an encryption system to enhance security and privacy (Abraham et al, 2015). Encryption in this context means that the information that is stored and transferred holds specific security measures that can only be overcome if the interested party has appropriate authorization.

Industry standards

The HIPAA (Health Insurance Portability and Accountability Act) under its security rule has outlined several minimum standards that health institutions and care providers need to meet with regards to protection of ePHI that may be created, received or transmitted by an organization (Hall and McGraw, 2011). The safeguards that have been put in place encompass diverse dimensions including administrative, physical and policy dimensions (Hall and McGraw, 2014). An example of an administrative safeguard is the requirement for all organizations to conduct a security risk analysis aiming to identify as well as analyse risks that ePHI may be exposed to. Once this is performed, the organization is expected to implement security measures that will mitigate the risks that have been identified.

Clinical and non-clinical emerging technology

Non-clinical

Teleconferencing is communication technology that facilitates electronic communication between two or more parties in an interactive manner. Voice transmissions are applied in this context and the mobile device held by one party in a satellite facility transmits audio messages to another party at a different facility (ACA, 2015). The technology is more complex than a common phone connection that support two-way communication and may accommodate multiple parties (ACA, 2015). This technology facilitates sharing of information and discussions between physicians or other medical staff from different health facilities.

Apart from transmission of audio data, emerging technology has created video conferencing. This communication system is more sophisticated than basic teleconferencing and involves use of the internet, a computerized device and cameras to link different parties in a communication platform where they can see and hear each other (ACA, 2015). Consequently, it is often used in high profile meetings that require input of top management and effective coordination that cannot be supported through audio communication alone.

Clinical

A remote patient monitoring system is an emerging technology that supports as well as facilitates assessment as well as delivery of patient care in health facilities that are located in remote locations (ACA, 2015). The technology can measure physiological parameters of a patient and pass on this information to a health care provider using wireless communication. The patients connects sensors to their body and these sensors measure specific physiological parameters before transmitting the collected information to a health care provider (ACA, 015). The physicians in the remote facility may also pass on this information to other providers in a main health facility.

A different technology is the eMR and it refers to a database that singularly contains information that has been entered on patients and that can be accessed by all treating clinicians as long as they are authorized (ACA, 2015). This system creates convenience and efficiency in storage, retrieval and transference of patient information.

Conclusion

Adoption of a remote patient monitoring system is a recommendable change for the two merging organizations as it would improve the quality of care offered to patients in the remote location where the satellite facility is found and with the main health facility. Remote patient monitoring meets federally mandated requirements regarding improvement of health outcomes, quality of care and costs of health care among other aspects. The FDASIA and HITECH are federal regulations with requirements that support use of IT in health care.