Aug 6, 2019

COPD, Respiratory Care & Telehealth

Mike Hess

Hopefully, earlier this year you saw various emails and/or social media posts about the “Virtual Lobby Campaign,” AARC’s annual push for legislation beneficial to RTs across the country. This year’s efforts saw the introduction of HR 2508, the “Better Respiration through Expanding Access to Tele-Health (BREATHE)” Act, which called for Medicare to start a three-year pilot program where RTs could, under the supervision of a physician, provide telehealth services to people living with COPD.

On the one hand, this seems like a no-brainer to finally crack the door open for RTs to eventually become full-fledged Medicare practitioners. On the other, I saw a comment this week that “telehealth is a joke.” So which one is the real answer? Who should care about telehealth? From the standpoint of someone working in COPD disease management every day, I can tell you there’s no joke here. Telehealth is going to play a major role in the healthcare delivery of the future, and RTs are ideally positioned to shine in this arena.

Let’s get some of the dry stuff out of the way first. This spring, right about the time the Virtual Lobby Campaign was kicking off, Business Insider forecast that the global telemedicine market is going to rise by 19% annually over the next 6 years (Business Insider: The Telemedicine Boom is Imminent, and It’s Creating Opportunities for Providers). That same article tells us that considering US market share, telehealth will be a $64 billion industry by 2025. At the same time, laws and regulations are still in a relatively embryonic state; there’s plenty of room to influence their development as they mature. I guarantee you every one of our medical and allied health colleagues are doing that as you read this. If we don’t act quickly, we’re going to be left behind.

So why COPD?

Again, it starts with economics. COPD has a $50 billion footprint on our economy, between what we spend directly on medications, hospital stays, etc. and ‘indirect costs’ such as lost productivity and disability (NCBI: The Clinical and Economic Burden of COPD in the USA). COPD is one of the only leading causes of mortality in the US that isn’t declining as we work to improve care delivery (https://www.lung.org/assets/documents/research/copd-trend-report.pdf), telling us that whatever we’re doing, we’re not doing it very well. The National Heart, Lung, and Blood Institute (NHLBI) recognized this a few years ago and developed the COPD National Action Plan in an effort to address it. The National Action Plan was the first large-scale public policy initiative designed to combat COPD, and technology plays a heavy role throughout its five goals.

Why have we made so little progress in COPD?

At this point, you may be saying, “Get to the telehealth part.” Fair enough, but to get there, let’s look at one last preliminary detail and ask, “WHY have we made so little progress in COPD?” Well, think about the two main things we do for COPD: Inhalers and pulmonary rehab, right? Maybe it’s more accurate to say the two main things we THINK we do for COPD. After all, somewhere between 30-50% of all patients use their inhalers incorrectly, resulting in what I call “inadvertent nonadherence to therapy” (NCBI: Systematic Review of Errors in Inhaler Use: Has Patient Technique Improved Over Time?). This number has remained, much like the COPD mortality rate, pretty stagnant over the past 40 years. Why?

Well, think about when we teach inhaler technique. It’s usually either in the ED, when the person is focused on trying to just breathe at all, or it’s at discharge, when the person is focused on going home (and getting a dozen other instructions at essentially the same time). How well would YOU learn under those conditions? We COULD try to do this teaching in the primary care office, but WHEN would we? The median primary care visit is about 15 minutes long and covers 6 topics (NCBI: Time Allocation in Primary Care Office Visits). Can you learn how to use a device expertly in 3 minutes or less? Are you sure? If you can’t, how can someone new to a device, or potentially even new to a diagnosis? And who is going to teach it?

Is Patient Education in Pulmonary Rehab any better?

The situation is no better in pulmonary rehab. A mere 2.7% of people hospitalized for COPD begin a pulmonary rehab program within 12 months of their admission (Pulmonary Advisor: The Challenges of Pulmonary Rehab in Facilities May Be Overcome in the Home). Globally, studies have told us that even when they’re referred (no guarantee there) and when there’s a program nearby (especially problematic in more rural areas of the country), transportation and motivation to get up, out, and moving are major barriers to completion (Sage Journals: Why are COPD Patients Unable to Complete the Outpatient Pulmonary Rehabilitation Program?).

The Power of Telehealth

That’s the power of telehealth. With this model, we can allow patients to contact an office, staffed with an RT expert, and get review and evaluation of their inhaler technique. They can ask questions about coughing and breathing techniques, and potentially get interactive coaching on things like pursed-lip breathing on demand. They can get evaluated for early-warning signs of exacerbation and get immediate rapid-action packs without scheduling transportation for an appointment or setting foot in an ED. At-home pulmonary rehab is showing promise as well, with higher uptake and completion rates as well as non-inferior outcomes with exercise tolerance and quality of life (American Journal of Respiratory Care and Critical Care Medicine: Opportunities and Challenges to Expanding Pulmonary Rehabilitation into the Home and Community).

There are already signs that various healthcare entities, systems, and potentially even payers are already buying into COPD telehealth in a big way. Walgreens just announced a partnership with Propeller Health, makers of inhaler monitor/reminder devices that connect to an app via Bluetooth, to ease refills and provide access to ‘health consultants’ that can (in theory) help optimize care (MobiHealth News: Walgreens adds Propeller Health, Dexcom’s Products to its Health Services Connection Tool); one can only imagine CVS will follow suit pending their potential merger with Aetna. Pennsylvania/New Jersey based Geisinger Health is leading a trial that uses artificial intelligence voice analysis through a cell phone to detect airflow changes that point to impending exacerbations (Ceisinger Caring: Geisinger Launches New Study to Better Treat COPD Patients), right on the heels of developing an entire telehealth platform to enhance home asthma management plans (mHealth Intelligence: Geisinger Builds an mHealth Platform for Asthma Care Management). 

Telehealth & The Future

It’s a cliché that the future is now, but clichés become clichés because they’re usually true. Telehealth will affect virtually every aspect of care delivery, whether it’s remote consultation in the ICU or providing education and remote assessment using smart devices. What was once the realm of Star Trek’s tricorders or other fantastical gizmos is, more often than not, in the rudimentary prototype stage if not even already deployed. It’s still early enough in the game for us to plant our flag on the respiratory elements of telehealth and ensure we keep our seat at the table, but it won’t be for long.

Are you ready?

For more articles by Mike Hess, please visit http://copdnavigator.net/

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Mike Hess

Mike Hess

Mike Hess is the Chronic Lung Disease Coordinator at Western Michigan University Homer Stryker M.D. School of Medicine. He also serves on the Board of Directors for the US COPD Coalition, and was 2019 President of the Michigan Society for Respiratory Care.

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