Remote patient monitoring: A current concept update on the technology adoption in the realm of orthopedics

1. Introduction

Remote patient monitoring (RPM) although conceived many decades earlier has witnessed rapid and wide spread adoption in the healthcare delivery model since the advent of the COVID-19 pandemic.^1,2 The need for remote monitoring was urgently recognized and swiftly ushered in the health care delivery during the pandemic and post-pandemic era and this decade has been game-changer for the RPM.3 The pandemic has helped to refine the RPM to the extent that today, RPM health solutions stand at the cusp of being a part of standard healthcare practices rather than a mere add-on feature being offered by Health Care providers (HCP).

RPM technology collectively, refers to monitoring, assimilating, integrating, and transferring patient data remotely, allowing a continuum of care or serving as an innovative stand-alone healthcare delivery model.³ The scope of RPM has expanded from web-based telemonitoring of patient outcomes⁴ and web-based remote rehabilitation solutions⁵ to wearable devices for home-based continuous monitoring and implantable devices for joint replacement and other hardwares.^6,7 RPM solutions have been slated to assure timely intervention, enhance treatment adherence, facilitate access to healthcare at an equitable cost, and decrease the burden of medical services by cutting down hospitalization rates.⁸

RPM has received a renewed focus in research studies, with several studies indicating its cost-effectiveness and effectivity. Therefore, this narrative review and current concept update is aimed to synthesize and present the various modalities and types of technologies in RPM healthcare delivery.

2. Material and methods

Our narrative review was synthesized after a literature search on PubMed using the terms "remote," AND "patient," AND "monitoring". The retrieved articles underwent a further detailed review to include the articles that were pertinent to orthopedic surgery and related care.

Our review was structured to comprehensively outline the prevailing RPM technology.

For better understanding and clarity of the subject, RPM were divided into following subcategories.

• 1.Digital Platforms
• 2.External Medical Devices
• 3.Implantable Devices

For each of the subcategories, a detailed literature search and review of literature was done. This included the current state of adoption, user feedback where available, the positive and negative aspects of the technology and likely future development in the arena.

3. Results

The concept of RPM unifies the paradigms of digital healthcare monitoring with E-treatment and E-health solutions. Traditionally, the RPM term has been used for electronic monitoring, but experiences from the COVID-19 pandemic have helped to expand and integrate tele-consultations with the all-encompassing RPM technology. The umbrella of RPM now includes all forms of telecommunications and electronic information processing technologies used to monitor a patient's status at a distance, measure specific medical parameters remotely, and facilitate remote consultations between the beneficiaries and the providers of health care (Fig. 1)

Fig. 1.

Current scope of telehealth.

Professionals and institutions can interact with patients on virtual audiovisual platforms to curate and titrate management plans and provide self-care awareness.⁹ The Advantages of RPM solutions for both patients and healthcare providers have been illustrated in Table 1.

Table 1.

Table 1 illustrates the advantages of remote patient monitoring solutions for health patients and healthcare providers.

Patients	Activity tracking: Orthopedic remote patient monitoring solutions typically offer activity tracking features, allowing patients to monitor their movement and exercise levels, which is particularly important for orthopedic patients who are recovering from surgery or managing chronic conditions.
	Symptom tracking: Patients can input their symptoms and pain levels into the monitoring system, giving healthcare providers real-time information about their condition and adjusting treatment plans accordingly.
	Communication tools: Many remote patient monitoring solutions provide secure messaging and video consultation features, allowing patients to communicate with their healthcare providers without needing in-person visits.
Health care Providers	Remote monitoring and alerts: Healthcare providers can receive real-time data and alerts about their patients' condition, allowing them to intervene promptly in case of any concerning changes or issues.
	Data analytics: Orthopedic remote patient monitoring solutions often come with data analytics tools that enable healthcare providers to track patient progress, identify trends, and make informed decisions about treatment plans
	Integration with electronic health records (EHR): Many remote patient monitoring solutions can integrate with EHR systems, streamlining the process of reviewing and documenting patient data for healthcare providers.
	Customization and personalization: Healthcare providers can customize monitoring parameters and alerts based on individual patient needs and treatment plans, ensuring a personalized and proactive approach to patient care.

RPM technology can be broadly divided into three modalities: digital platforms, telehealth audiovisual technology, wearable external medical devices, and implantable devices.

• 1.Digital Platforms

A digital platform is typically a mobile/handheld device application, built-in with a parametric workflow of pre-, peri, and postoperative maps(Fig. 2). The currently available RPM solutions are Wellframe, OrthoLive, TracPatch, BePatient, and KinetiGraph.^10,11 These seamless interphases allow communication, data exchange, healthcare-related information, hospital registration platform, payment gateway, and facilities for one-on-one interaction during remote monitoring. Telemedicine apps may allow synchronous or real-time data sharing or asynchronous data sharing that allows for later exchanges. Telemedicine via apps in total joint arthroplasty and shoulder surgery¹² has been reported to increase patients' compliance, decrease cost, and increase time efficiency.¹³ Engaging the patient in the confines of their home has reduced costs and resulted in a better overall satisfaction rate.¹² Some commonly available orthopedic remote monitoring apps are My Mobility, HIUMA, and Orthotracker app.

• 2.External Medical Devices

Fig. 2.

Workflow of remote patient monitoring app.

Approximately 90 % of recovery from TKA occurs outside the clinic when a patient's activity level and exercise regimen play a significant role in the rehabilitation process. The proprietary RPM system gives real-time motion feedback through an avatar. It allows for charting the progress made daily, sending notifications, and reminding the users to exercise or take the weekly self-assessment¹⁴ (Fig. 3). The app is downloaded preoperatively, and the baseline data is obtained. The knee sleeve is paired with the patient's device in the postoperative period before discharge.¹³ The patients are instructed to perform daily rehabilitation exercises and to complete a weekly survey. Two sensors on the knee sleeve transmit spatial orientation changes, reporting daily compliance with a home exercise program and the range of knee motion. When combined with the app, the RPM system collects additional data points such as mobility, defined by steps/day, weekly patient-reported outcomes (PROMs), and analgesic consumption.¹⁵ The patient application gives patients full access to their data and an avatar illustrating the patient's range of motion while performing the exercise sets.

• 3.Implantable Devices

Fig. 3.

Dynamics of a Wearable remote patient monitoring device.

An IMD (Implanted Medical Device) is surgically implanted in the body and provides valuable data on certain systemic conditions. An IMD has sensing capabilities and telemetric link functionality that could provide a means of continuous monitoring¹⁶ (Fig. 4). This would enable clinicians to track the postoperative recovery process, enhance guidance of personalized postoperative care,^10,11 and empower patients to review and manage the health of their implants. The system could provide alerts on the occurrence of adverse events to give an early indication of the need for further investigation or modification in activities.

Fig. 4.

Data acquisition and transmission of an implanted medical device.

The implantable devices may prove helpful in total hip replacement (THR).¹⁷

The data gathered by an instrumented implant in case of THR surgery may include metrics on the performance of the implant or activity of an individual patient, such as daily steps, range of motion, and condition of the bone-implant bond or wear of the bearing surfaces. Furthermore, this data would also be valuable to researchers in order to understand better the overall use and performance of THRs across a patient population.¹⁸ The use of in vivo sensing, capable of real-time condition monitoring of the implant's performance, the occurrence of adverse events, and patient health metrics offers a potential solution.¹⁸

4. Discussion

The RPM application is a dynamically evolving field, but the possibilities for the near and distant future are infinite. The intended benefits chiefly include ensuring a timely intervention, improving patients' adherence to treatment, improving access to healthcare, reducing inequalities, reducing hospital stays and hospitalization rates, and effectively reducing the cost of healthcare. Additionally, the RPM apps may provide several benefits to healthcare providers, such as increased patient engagement, better insight into adverse outcomes, and a cost-effective and user-friendly means to collect, store, and share information.^3,7,14 The RPM platforms also offer solutions that can be tailored to orthopedic care. It allows providers to track patients' progress, communicate with them, and collect real-time data from connected devices.^10,15 The EMD has found valuable applications in the form of a remote hybrid monitoring wearable sleeve during postoperative rehabilitation. The implantable devices may provide solutions in some areas concerning the complications of THR surgery.¹⁸ Despite the success of THR surgery, complications are known to occur. The current techniques of diagnosis often prolong the detection of the underlying causes, resulting in primary failure of the prosthesis, which may result in revision surgery. The use of in vivo sensing can provide real-time monitoring of the implant's performance and the occurrence of adverse events. Patient reported outcome Measures (PROM) has recently gained attention as the new benchmark for the successful outcome of any surgical intervention.¹⁹ RPM will offer a unique opportunity for real-time and accurate update on these PROM. Similarly metaverse in healthcare is increasingly being adopted for enhanced patient experience in pre and perioperative period.²⁰ RPM will without any doubt be a key element in these metaverse user case scenarios.

5. Limitations and challenges

However, there are several limitations and challenges in the use of RPM technology. Despite their promising application to improving outcomes following arthroplasty, privacy issues remain. A recent Delphi statement encompassing the emerging concept of "Digital surgery" concluded there are "no guidelines concerning data ownership, and the international legal requirements concerning data sharing are unclear".²⁰ With the rapid increase in the number and type of wearable devices, the data generated is being integrated to form what can be described as intelligent healthcare systems. For the benefits of this technology to be realized, there needs to be a focus on data protection and confidentiality.

Globally, different pieces of legislation exist for data protection because much of the data generated can be identifiable, such as GPS tracking data.¹³ In Europe, the General Data Protection Regulation (GDPR), since May 2018, has stressed the need for strong privacy guarantees for users when gathering and analyzing their usage data. Similar laws exist in the United States, such as the Health Insurance Portability and Accountability Act (HIPAA). However, the HIPAA governs data that is identifiable only. Although legislation is required to regulate the collection, storage, and use of wearable device data, it is hoped that technology will overcome these barriers.²¹

There are also some additional challenges in the implementation of RPM technologies. These challenges chiefly include technical challenges regarding the interoperability and integration of diverse technologies, regulatory challenges that include compliance with regulatory standards and policies,²² ethical challenges concerning the responsible use of patient data and informed consent,²³ and human factor challenges that include patient adherence, healthcare provider engagement, and usability of monitoring devices.²⁴

Declaration of competing interest

I, Dr Swapnil M Keny, the corresponding author of this manuscript hereby declare that there was no potential competing or financial interests on behalf of all authors in writing this manuscript.