How mobile check-ins can nudge patients to healthier behaviors and better outcomes
New remote patient monitoring (RPM) codes added to the Medicare fee schedule for 2019 finally attach a definitive payment for general physiological remote monitoring of chronic conditions. This new, long-overdue reimbursement, and the fact that services from clinical staff—and not just physicians—can now be reimbursed means providers and health plans will undoubtedly launch new RPM programs in the coming year.
As healthcare organizations introduce these programs, they will likely notice an unexpected but powerful benefit: improved patient engagement. That’s because the simple act of reminding, or “nudging,” patients to report their outcomes via mobile-enabled RPM (mRPM) on a consistent, unobtrusive basis can elicit new, often positive, health behaviors.
This repeated contact can be subconsciously interpreted as “health coaching,” although it is not really instruction at all. Reminders, inputting data, and receiving feedback from a provider can simply activate the patient’s imagination towards what is possible with their health.
The “nudge theory”
The phenomenon of improving patient adherence to a care plan through repetitive gentle reminders is based on the nudge theory, a Nobel Prize-winning behavioral economics theory. It contends, in part, that indirect suggestions and positive reinforcement can influence people’s actions. The theory offers numerous societal applications, including politics, business and criminal justice, as well as healthcare.
The main principle behind the nudge theory is we do not always make decisions in our best interest, and trying to change our behaviors based on rational evidence often doesn’t work. We tend to make decisions based on habit and whatever we interpret as the easiest option available. That means physicians and organizations need to make it easy for patients to create and follow new healthy habits; not by explaining the potential adverse outcomes that could otherwise occur, but rather by conveniently integrating them with their lifestyle.
For example, telling a patient they should take their hypertension medication as prescribed to avoid a heart attack or stroke may concern a patient enough to follow that recommendation for a week or two. But if the medication has unwanted side effects, the patient may choose to stop taking it, or she might just forget about it. Chances are the physician will not find out about the patient’s nonadherence until the next appointment, which may be months away. However, if this situation is flagged early though mRPM, her doctor can intervene and develop a new care plan.
Once the revised care plan is developed, the provider can “nudge” new behavior simply by asking the patient how regularly they took their medication and its specific side effects and having each patient report their blood pressure using an inexpensive home device. These replies are recorded for use by both the patient and their physician.
Ideally, the patient can see the positive trend the prescribed medication is having on her blood pressure, which will encourage adherence to the hypertension therapy and potentially encourage other lifestyle changes. For example, a patient checking and reporting her blood pressure might start reading nutrition labels on food packaging for sodium content, or a patient with type 2 diabetes who is tracking blood glucose levels might lose weight due to better dietary and exercise choices. Neither of these behaviors needed to be overtly prescribed as part of the mRPM program, but they become a natural benefit of patients’ greater mindfulness about their health.
Mobile offers convenience and simplicity
Here’s why reporting simple biometrics such as blood pressure and answering related health status questions can have positive, ancillary patient engagement effects:
1. Reporting on a consistent, but unobtrusive, schedule requires the patient to regularly consider their condition(s) and their health-related choices;
2. Patients are reminded that their physician is monitoring their behavior and desires their success year-round. This “sentinel effect” could also be characterized as a “cared about” effect, developing a patient’s sense of responsibility in their own care plan;
3. Consistent data-sharing opens the door for enhanced communication with the provider, which deepens the trust that is essential for engagement.
According to the tenets of the nudge theory, physicians need to make adherence as convenient and habit-forming as possible. In 2019, nothing is easier or more habitual for patients, including senior populations, than to communicate and share the data for mRPM using their smartphones or other personal mobile device.
Mobile-enabled RPM, and mobile asynchronous communication in general, offers numerous advantages over telephonic approaches for several reasons:
• Omnipresence: Smartphones and mobile devices are rarely far from reach; one analysis suggests that Americans use their smartphone five hours a day on average
• Convenience: Data can be shared at any time and anywhere through wi-fi or cellular reception. If the mRPM program is designed appropriately, reporting and answering clinically relevant questions takes a patient less than five minutes, typically only a few times a week
• High adoption: Smartphone adoption has reached 77 percent of all Americans, including 46 percent of seniors
• Minimal learning curve: Patients are already familiar with their smartphone or mobile device’s features and functionality. To leverage this familiarity, the supporting mRPM app should be highly compatible with the mobile device’s operating system and offer mobile-optimized educational resources, such as short videos, to support patients need for orientation and support.
Tracking progress ideal
According to the nudge theory, positive reinforcement is an important element to encourage desired behavior change. That is one of the reasons why the mobile technology used for an mRPM program should include report-presentation capabilities. Key trends should be presented graphically through highly visual, intuitive methods that allow patients and providers to rapidly interpret progress or abnormalities. A positive trajectory tacitly encourages patients to continue existing adherence behaviors and other positive choices, whether dietary, exercise or other lifestyle decisions.
As patients become more engaged in their care, however, a risk of over-reporting emerges: patients may want to share updates with their physician too often. Being deluged with irrelevant patient-reported data numerous times per day is not helpful for patients or providers and can derail any well-intentioned mRPM program.
Providers can control the quality and quantity of data and information from patients through a disciplined, automated and scheduled data-collection process using mobile devices. Although tightly controlled, the data capture process should always allow providers to review the patient-reported outcomes before they are entered into the electronic health record.
Finding a sustainable outreach balance is key. Most patients will respond well to mRPM reporting and surveys that take place a few times a week. A small number will benefit from more frequent interactions, and even a smaller minority will not communicate at all. As organizations implement and refine their mRPM programs, they are likely to discover a balance that delivers both the needed data, stronger patient engagement, and positive behavior change to achieve the best possible care outcomes.
About the author
Harry Soza is CEO of CAREMINDr, a health IT company based in Silicon Valley that provides mobile-enabled remote patient monitoring (RPM) solutions that give doctors the ability to check in on patients in between face-to-face visits.