Background

Telehealth facilitates care without the need for a face-to-face healthcare encounter and encompasses 4 distinct domains of application: live videoconferencing, store-and-forward (the storage and transmission of health information such as CAT scans, MRIs,  and x-rays between health providers), remote patient monitoring, and mobile health. RPM collects personal health and medical data in 1 location and transmits it to a provider in a different location. Its applications allow providers to continually monitor health data, including vital signs, blood sugar, blood oxygen levels, weight, and electrocardiogram output. Notably, neurologists are utilizing RPM for chronic conditions in post-discharge or senior care contexts to receive ancillary services and treatment.

Currently 21 million people in the US experience some sort of neuropathy, and demand for neurologists is expected to outpace supply. The American Academy of Neurology forecasts a 19% shortfall in neurologists by 2025, with demand exceeding supply by 20% or more in a majority of states. RPM can provide high value for patients with neurological diseases, particularly because specialists are commonly concentrated in urban areas or near centers of excellence (facilities designated for providing comprehensive care), creating access barriers for many rural patients.

Remote Patient Monitoring Holds Promise for Patients with Neurological Diseases

Neurological diseases affect the central and peripheral nervous system, impacting cognitive function and overall mobility. This is especially true for conditions—like MS, Parkinson’s disease (PD), and epilepsy—that affect the brain, spinal cord, nerves, and muscles. MS, PD, and epilepsy require ongoing care with specialized care teams for diagnosis, treatment, and ongoing evaluation. RPM can help to manage these chronic neurological conditions through:

• Timely specialist follow-up: Identify deterioration in clinical symptoms and subsequent clinical interventions before unscheduled and preventable services are needed
• Improved care coordination: Exchange data and communicate across providers to facilitate condition-specific treatment, including the management of multiple comorbidities
• Enhanced trust: Increase patient satisfaction and feelings of “connectedness” with providers
• Increased clinician productivity: Reduce home visit travel time and automate documentation
• Decreased patient and caregiver burden: Promote independent living, provide automated care management reminders, and relay critical information to prompt caregiver or clinical intervention

Multiple Sclerosis

MS is an immune-mediated disease that affects 1 million US adults and targets the central nervous system. For patients suffering from movement disorders such as MS, RPM can facilitate clinical trial participation and longitudinal symptom monitoring.

• Patient data reporting: During clinical trials, patients may need to self-report data pertinent to defined trial endpoints; a wearable sensor manufacturer is using their product to record vital signs, movement, heart rate, posture classification, and sleep-related metrics for MS patients in clinical trials, reducing reporting burden for patients and improving quality and accuracy of information
• Mobility Tracking: Walking scores are a functional benchmark for MS patients used to assess mobility impairment; these tests are typically conducted at a doctor’s office, but advances in wearable technology permit patients to accurately and precisely track their gait across a range of walking impairment levels

Parkinson’s Disease

PD is a neurodegenerative disorder that affects 1 million people and disrupts dopamine-producing neurons in the brain, which causes mobility issues. Although in-person rehabilitation is required for PD patients, neurologists can also use RPM to provide lifestyle changes and longitudinal care, including:

• Tele-consult with specialists: Patients with PD face mobility issues that can negatively impact their ability to see a doctor; the University of Rochester is providing virtual specialty care in the homes of PD patients using a web-based teleconferencing system to develop a coordinated care plan for each patient; patients with phones can use an application to track and share information about their symptoms with their physicians
• Remote blood pressure monitoring: Orthostatic hypotension (decrease in blood pressure when changing positions, such as moving from sitting to standing) is common in PD patients; one study found that remote blood pressure monitoring for a drug used to treat early PD allowed for faster response to safety concerns of orthostatic hypotension

Epilepsy

Epilepsy is a chronic disorder causing unprovoked seizures that affects 3 million US adults. Although office lab work is necessary for epilepsy, RPM can help neurologists adjust medications, discuss symptom progression, and review diagnostic results, including:

• Care management: Epilepsy management requires care at level 3 and 4 specialized epilepsy centers, many of which are in urban areas. John Hopkins Medicine is tracking seizures and possible triggers, medications, and side effects using a smart watch for epilepsy patients. Researchers are exploring whether a future application could potentially detect seizures, estimate their durations and contact caregivers using a smart watch.
• Wearable technology: Common triggers for epilepsy patients include lack of sleep, alcohol, and medication. A smart watch approved by the FDA is used for epilepsy management to identify seizures, monitor sleep and physical activity, and send alerts to summon caregivers.

Remote Patient Monitoring Is Increasing, but Reimbursement and Coverage Are Barriers to Broader Adoption

RPM continues to gain acceptance as a complement, and in some cases, an alternative to traditional office-based care. Although the federal government, states, and private payers are working to overcome telehealth coverage and reimbursement barriers, there are variations across states and modalities that affect broader adoption.

In April 2019, the Centers for Medicare & Medicaid Services (CMS) finalized a rule expanding coverage for telehealth services in Medicare Advantage (MA), increasing the percentage of MA plans that offer telehealth benefits from 6% in 2019 to 59% in 2020. Furthermore, CMS’ definition of telehealth focuses on rural areas and health professional shortage areas requiring real-time (i.e., synchronous) communication. This definition limits both the location and modality for approved telehealth services in Medicare fee-for-service.

At the state level, over 40 states and DC have passed widely varying legislation since 2017 to expand telehealth coverage for Medicaid programs and in both the individual and group markets. Recent legislation has focused on expanding the scope of telehealth services, ensuring reimbursement parity, establishing telehealth professional board standards, and promoting cross-state licensure. Medicaid programs in 21 states and DC include some form of reimbursement for RPM in their Medicaid programs, but most states have limits on information collection, restrictions on monitoring for specific clinical conditions, and provide reimbursement only for home health agencies. RPM provides an opportunity for patients with neurological conditions, such as epilepsy, PD, and MS to receive high quality care from the comfort of their home.

Telehealth Will Likely Be a Focal Area in 2020

Innovations in telehealth have advanced largely through collaborative research, partnerships, and pilot studies. These efforts contribute to an evidence base that may ultimately inform payer decisions to expand coverage for additional technologies, services, and patient subpopulations. Access to telehealth services remains a legislative priority in many states, but adoption of new technologies by patients and providers has encountered challenges, including:

• Reimbursement variability across states and payment parity with in-person patient visits
• Privacy and patient safety concerns, especially related to data sharing and populations with complex health needs
• Broadband and connectivity issues, particularly among rural populations
• Upfront investments in new technology platforms and operational costs
• Disparities among individuals without smartphone or web access
• Telehealth limitations for both location and modality in Medicare fee-for-service

Continuing into 2020, stakeholders will continue to advocate for high-quality care for patients facing neurological diseases such as MS, PD, and epilepsy, providing opportunities to utilize RPM as a tool for diagnosis and treatment.

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