Chronic Conditions - Key Activity 24


Develop System to Provide Remote Monitoring


This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; proactive patient outreach and engagement; pre-visit planning and care gap reduction; care coordination.


Remote patient monitoring (RPM) is an innovation that allows for regular updates from patients to their clinician in order to real-time updates. It also allows clinicians to monitor the health and well-being of patients outside of a traditional clinic setting. RPM allows for a closer monitoring of patient’s conditions through regular updates, which can improve overall patient care. RPM devices typically include, but are not limited to:

  • Blood pressure cuff.
  • Weight scale.
  • Thermometer.
  • Glucometer.
  • Pulse oximeter.
  • ECG.

This activity provides an overview of infrastructure and processes required by practices to develop and implement remote patient monitoring programs.

RPM expands the reach of clinicians beyond a traditional clinic setting, which also improves the quality and consistency of care provided to patients.

Due to the geography of the location that the practice services, RPM may prove to be a valuable asset for patients who are unable to reach the clinic for regular monitoring.

RPM improves the equity of care provided by reducing unnecessary barriers to care while also providing real-time feedback to the patient and clinician regarding current health status. RPM also gives the ability to provide continuous data over time, rather than a quick snapshot during an in-person visit. This intervention also helps to improve the health literacy of patients and invites them to be a partner in their care.

RPM assists clinics in addressing social needs by removing potential barriers to accessing care in a traditional setting, such as lack of transportation or distance to the clinic. By making care more accessible, families and caregivers would be better able to monitor their current health status regularly while also receiving feedback from their clinician.

Action steps and roles

1. Determine which types of capabilities are most important for RPM devices.

Suggested team member(s) responsible: quality improvement staff, EHR specialist (or equivalent), medical director and practice administration.

When purchasing RPM devices, determine which types (if any) are compatible with your chosen EHR. This should allow information to be transcribed directly into the EHR. It is also an option to contract with an RPM company, which can assist with developing infrastructure.


2. Determine clinical protocols for determining if an RPM device is appropriate for the patients’ care.

Suggested team member(s) responsible: medical director (or equivalent) and quality improvement staff.
These protocols should be based upon clinical guidelines for diabetes and hypertension.


3. Determine how to properly code for RPM and train clinicians on how to execute proper billing practices.

Suggested team member(s) responsible: billing office and practice administration.


4. Train clinical staff and/or designate a staff member for each clinician to assist patients with setting up and linking RPM devices to the EHR.

Suggested team member(s) responsible: Quality Improvement staff and EHR specialist (or equivalent).


5. Provide the patient with instructions for how often to use the device to obtain the respective diagnostic and how to properly utilize the RPM device.

Suggested team member(s) responsible: medical staff.

Assist the patient with linking their RPM with the EHR to ensure a transfer of information.

The American Medical Association maintains a list of clinically validated blood pressure monitoring devices (see the article to access the list).


6. Assist the patient with understanding certain threshold diagnostics that they should be mindful of, which may warrant medical intervention.

Suggested team member(s) responsible: medical staff.
If practices identify that a patient has a diagnostic that warrants medical intervention, they should reach out to the patient to engage them in appropriate care. Such diagnostics may include, but are not limited to, critically high blood pressures, critically high glucose readings, etc.


7. Designate staff to troubleshoot and assist with RPM-related challenges.

Suggested team member(s) responsible: Quality Improvement staff, EHR specialist (or equivalent) and practice administration.
This can include staff who monitor outputs from remote monitoring to ensure threshold triggers are acted upon (such as high glucose or blood pressure).


8. Considerations for high-risk patients.

Suggested team member(s) responsible: core care team members, care coordinators and navigators, and community health workers.

An alternative that may be available for high-risk patients is to have a community care team, including a nurse and community health worker, that is able to go to the patient’s home on a regular basis and can assist with diagnostics.
An example is Neighborhood Healthcare, which did what many healthcare organizations did during the COVID-19 pandemic – it quickly pivoted to telemedicine. However, some of its ailing low-income patients lacked the technology or digital skills needed for virtual care, so Neighborhood Healthcare decided to bring it to them. This case study outlines how Neighborhood Healthcare accomplished this.


Example workflow

CCI’s RPM clinic workflow journey map: This is a collection of workflows from community health clinics in California that expanded their use of RPM for blood pressure measurements.

Evidence base for this activity

  • Tucker KL, Sheppard JP, Stevens R, Bosworth HB, Bove A, Bray EP, et al. Self-monitoring of blood pressure in hypertension: A systematic review and individual patient data meta-analysis. Rahimi K, editor. PLOS Medicine. 2017 Sep 19;14(9):e1002389.