Care beyond the hospital: The case for digital remote patient monitoring 

Sarah Carroll, Senior Director, Center for Care Transformation 

remote patient monitoring graphic

While COVID-19 has dominated headlines over the past year and a half, there is another health crisis confronting Americans and the health systems that care for them – chronic diseases. It’s estimated that almost 50% of the U.S. population has a chronic disease, and caring for them is consuming 86% of healthcare costs. This crisis shows no signs of slowing down – 83.4 million US adults are expected to have three or more chronic conditions by 2030, up from 30.8 million in 2015. With the current model of care, many people are unable to receive care interventions when they need them, leading to poor quality outcomes, unnecessary ED visits and avoidable readmissions, and negative patient experiences. 

So how do health systems begin to reconfigure their care models to provide better, more proactive care to patients struggling with chronic conditions and other illnesses? Leading hospitals are implementing or expanding their digital remote patient monitoring services in order to provide more robust care and timely care interventions for patients outside of the hospital’s four walls. A recent internal analysis found that an estimated 70% of the AVIA network has adopted at least one remote patient monitoring solution. 

What is remote patient monitoring?

Remote patient monitoring (RPM) is the ability for patients to share biometric and other data from a non-clinical setting, like their home, with their care team as part of a provider-supported program of care. Populations who most benefit from RPM are patients with uncontrolled chronic conditions such as hypertension, congestive heart failure, and diabetes; seniors with multiple and complex conditions; and patients with a rising risk of the conditions listed above. 

Remote patient monitoring can be used for a variety of clinical activities, but the most popular are:

  • Ongoing care management: Symptom surveillance, education, coaching, medication adherence, and regular check-ins
  • Care transitions: Care coordination, care navigation, and medication reconciliation and optimization
  • Post-episode recovery: Care plan adherence, condition/symptom surveillance, wound/pain management, education, clinical interventions, and rehabilitation
  • Hospital at home: Acute care condition monitoring, virtual rounding, education, and clinical interventions 

When implemented well, remote monitoring can have a profound impact on both patients and providers. By removing the need for patients to go to a physical hospital or outpatient facility for routine monitoring, it makes it easier for them to receive the care they need, when they need it, improving their adherence to a care plan and helping them be more engaged in self-care. RPM can also enable the care team to operate more efficiently by enabling lower-licensed members of the care team to monitor incoming data and escalate issues to physicians as needed.

The case for remote patient monitoring

For health systems that operate under a fee-for-service model or are shifting to a fee-for-value model, remote patient monitoring offers unique and substantial benefits, from driving revenue to increasing patient loyalty to reducing the risk of penalties associated with avoidable utilization. 


Health systems primarily using a fee-for-service model are finding significant value in remote patient monitoring due to improved patient experience and increased revenue when implemented at scale. RPM allows patients to have a stronger connection to their care team, driving satisfaction and loyalty, while new reimbursements for RPM services and cost savings can enhance margin. One health system saw an 83% decrease in hospital readmissions among Chronic Care Management patients, resulting in nearly $5.1 million in cost savings, while an RPM digital solution for patients with diabetes reported a 84 NPS for patients on insulin. From a direct reimbursement lens, it’s estimated that the total monthly reimbursement for RPM is up to $120 per Medicare beneficiary.


Health systems that are making the move to fee-for-value are increasingly looking to RPM to help them reduce costs and support people’s best health, using real-time data to prevent or slow disease progression. These systems – and their patients – are seeing value in RPM due to improved clinical outcomes and quality of life, reduced readmissions and avoidable ED visits, and increased use of primary care services. One study found that remote patient monitoring reduced ED visits by 31% for COPD patients and 46% for patients with congestive heart failure. RPM has also been reported to drive $3.6 million in cost savings over 18 months. 

Many health systems operating with more value-based arrangements have been experimenting with a wide variety of RPM capabilities, either during COVID-19 or before. These early adopters are now looking to build an integrated, enterprise-wide RPM strategy to scale what’s working with greater efficiency and impact. 

“At Geisinger, we have experience within the RPM ecosystem, including using connected device and deviceless monitoring for many years,” says Rebecca Stametz, Vice President of Digital Transformation at Geisinger, an AVIA Member. “As the next step towards building comprehensive hybrid care models, we are developing a robust, enterprise-wide RPM strategy using a framework that will support the people, process, and the technology. Geisinger aims to scale our RPM operations, onboard modern technologies, and increase patient-member engagement strategies to gain timely insight of our patient’s health and aid in delivering personalized interventions.” 

Geisinger aims to scale our RPM operations, onboard modern technologies, and increase patient-member engagement strategies to gain timely insight of our patient’s health and aid in delivering personalized interventions.

What good looks like in remote patient monitoring

Beyond device enablement

Point solutions such as connected blood pressure cuffs and glucometers are an essential part of remote patient monitoring, but many of the leading solutions offer more extensive capabilities, including:

  • Multimodal data collection, including connected biometric data feeds as well as patient reported outcomes
  • Configurable alerts to trigger interventions and virtual visits
  • Engaging patient education and intelligent virtual coaching
  • Integrations with EHRs, call systems, physician ordering solutions, and other technologies to simplify enrollment, billing, and evaluation
  • Analytics, such as intuitive dashboards, automated care plans, and other clinical decision supports. 

Creating a remote patient monitoring strategy should start with the questions: “What problem are we trying to solve, and what is the value to be gained for our patients and our business?” Your RPM service can power up several benefits to multiple stakeholders.

“For several years, Presbyterian Healthcare has operated a program of home-based care for its most frail Medicare Advantage members,” says Dr. Nancy Guinn, Medical Director, Clinical Transformation, Population Health at Presbyterian Healthcare Services. “We are always looking for ways to improve the outcomes of that program and turned to the idea of remote monitoring, adding to the extensive in-person services currently offered.

Our goals when looking at RPM solutions were to provide our patients and their families an easy “one button” method to contact our team, and for our team to contact them. We also wanted the ability to understand our patients’ daily needs and receive alerts that might indicate a change in condition, as well as frequently monitor and contact them when they are in transition between care settings. Finally, we wanted tools, like stethoscope and otoscope capabilities, that could serve as ‘eyes and ears’ for our physicians.

Thanks to AVIA’s help, we found a vendor that fits these needs and more, with our pilot launching now. We anticipate being able to expand the population served significantly with the efficiencies from our new program.”

Thanks to AVIA’s help, we found a vendor that fits these needs and more, with our pilot launching now. We anticipate being able to expand the population served significantly with the efficiencies from our new program.

Finding the right remote monitoring solutions

When searching for remote patient monitoring solutions, health systems have three primary options based on their strategic priorities, population health challenges, technology gaps, and operational opportunities: 

Deviceless solutions, including patient-reported outcomes delivered by text, email, and interactive voice response (IVR), are typically lower cost than offering connected devices and provide the easiest access for a wider range of patients. These solutions offer dozens of care pathways and education libraries and are accessible to patients who may have limited technology access or literacy. They are well-suited to larger, rising risk populations. The primary downside of these types of solutions is that health systems are likely to see little to no reimbursement from care management activities that are available through Medicare for use with FDA-approved devices, unless the devices are provisioned by the health system or a health plan. However, a proposed CMS rule on Remote Therapeutic Monitoring could open up new revenue opportunities in 2022.

Condition-specific solutions, including devices and personalized education for perinatal, orthopedic, pediatric, and senior patients, as well as patients with cardiometabolic conditions, may have a higher price tag than deviceless solutions with limited scaling potential due to their targeted nature. However, these solutions are highly engaging for a critical period of time, increasing patient satisfaction and loyalty. 

Enterprise solutions offer 100+ connected devices and a high-touch, high-tech platform for the greatest number of use cases. The major benefit of these tools is their flexibility, accompanied by streamlined integration, although these solutions require a heftier investment and a targeted approach for focused deployment.

Enabling RPM success at your health system

Remote patient monitoring can be a lifeline for hospitals when treating the increasing number of patients with chronic conditions and can be expanded to provide proactive services to rising risk patients from the comfort of their own homes. When done well, RPM can provide significant value for patients, improve clinical outcomes, and serve as a revenue driver for health systems. 

If you’re looking for a partner to help you make sense of the strategic considerations in the complex RPM landscape, the team at AVIA’s Center for Care Transformation is here to help – contact us today to get started.