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AMA and the adoption of digital medicine

There is a lot of hype about digital medicine.  Though the definition of what digitla medicine mans varies, many digital devices are able to monitor patient physiology, medication adherence, or other behavior and communicate that with the patient as well as their provider team. One key barrier to having the provider team actually use these data is reimbursement.  Digital medicine offers physician the possibility of improved care, but spending too long reviewing digital medicine information means that there is less time in the day left to work on revenue-generating activities (like seeing patients).

Last week, the AMA took steps to rectify this issue.  The AMA is adding the following digital medicine related codes to their 2019 Current Procedural Terminology (CPT®) code set.  These codes include:

  • 99453 Remote monitoring of physiologic parameter(s), (for example, weight, blood pressure, pulse oximetry, respiratory flow rate) initial; setup and patient education on equipment use.
  • 99454 Device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.
  • 99457 Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.

While there are a number of other barriers to digital medicine usage (e.g., integration into EMR, long-run patient adherence, easy of use, value of the information created etc.), the AMA decision removes one key barrier to using digital medicine in practice: making sure providers are reimbursed for their time reviewing these data.

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  1. Digital Medicine is Not Enough to Improve Adherence: a response to “AMA and the adoption of digital medicine”

    Is digital medicine the best way to improve medication adherence? Advocates envision a world where doctors have constant feedback on patient health status from the very pills they prescribe. Doctors would know immediately whether patients were unresponsive due to failed treatment or failed adherence. This empowerment would improve dismal medication adherence rates because doctors would know how and when to intervene. The problem is, doctors already know that poor adherence is rampant, but they are failing to fix it. That’s because adherence is a product of healthcare reimbursement that disincentivize adequate doctor-patient time and of broader societal factors that are out of doctors’ control. Flashy digital pills and constant monitoring alone will not improve adherence; instead, efforts need to add components that strengthen the provider-patient relationship.

    Just this week, the American Medical Association (AMA) started the process that would make remote monitoring more readily covered by health insurance. In “AMA and the adoption of digital medicine”, Shafrin describes the three new provider codes included in the AMA’s 2019 Current Procedural Terminology code set (2018). They include the provider time spent showing patients how to use the new technology, receiving information or reports from remote sources, and sharing interpretations of the results with patients (Shafrin, 2018). This information is merely a new tool that providers can use. The real impact of these changes will be the time component of the codes: reimbursing physicians for taking the time to explain the technology and its relevance to patient health.

    Medication adherence is a widespread and dangerous issue. The World Health Organization (WHO) estimates that 50 percent of all patients in developed countries do not adhere to their therapeutic regimen (WHO, 2003). This lack of compliance worsens conditions and puts patients at risk of readmittance to hospitals. Osterberg and Blaschke estimate that poor adherence is responsible for 33 to 69 percent of hospital admissions in the US (2005). Consequently, Haynes et al. claim that improving adherence would be more effective than any other treatment at reducing disease burden (2000). Remote monitoring of adherence technology is one way to address this widespread problem.

    But is information technology the best way to improve adherence? In an Aug. 4, 2016 post, Shafrin details a study that found both providers and patients benefit when they can better track medication adherence with technologies like the sensor pills and patch. But insurers do not see the same benefit. According to a Xcenda survey of 61 leaders in insurance, only 13 percent of insurers covered drug adherence technologies (AmerisourceBergen, 2017). The report cites blames the lag in coverage on lack of data on clinical and cost effectiveness (AmerisourceBergen, 2017). In addition, multiple alternatives to costly adherence technologies already exist. According to Osterberg and Blaschke, there is no gold standard measure, but even simple patient self-report is effective enough at assessing adherence (2005). Providers have the tools to know whether patients take their medicines. The problem is whether they have the time and resources to implement solutions.

    Research shows that patient-provider relationships are critical to medication adherence. In the Mayo Clinic Proceedings, Brown and Bussell extoll the numerous, multilevel factors that drive patient noncompliance, including increasingly complex treatments, poor communication between physicians and patients, and lack of patient participation in treatment decisions (2011). Lack of information on adherence is only one of many causes. As a result, the World Health Organization calls for both improvements in detection of noncompliance and in strategies to address its myriad causes (2003). If the AMA seeks to truly improve patient medication adherence, facilitating use of remote monitoring is not enough: their codes need to be accompanied by support for adherence interventions.

    A better solution to poor adherence is to combine information technology with interventions. To make this change, the AMA should also add code sets for physician activities that address the socio-ecologic factors driving poor adherence. Doctors should be able to charge for (1) time spent discussing adherence barriers with patients, (2) referrals to dietitians and other providers who can provide non-pharmaceutical interventions to chronic diseases when medications show poor results, and (3) pursuing institutional and policy changes that promote medication adherence and general patient health. Using these “solution codes” would empower providers to better address noncompliance when it does occur. Without them, advances in detection through remote monitoring will be ineffective at improving adherence.

    These new codes would be flexible enough to allow for specific patient needs. Just like how the new remote monitoring codes do not specify which technology providers should use, doctors and patients will be free to pursue the adherence improvements that work best for them. The same World Health Organization report recommends providers customize interventions to patients, citing the lack of universal fixes for poor adherence and the importance of individual contexts (2003). Supporting increased patient-provider time to address adherence would better allow for this customization.

    Implementing solution codes is a radical shift from technology- to person-first medicine. Remote monitoring itself is a technocratic solution to medication compliance. An example of a social solution would be the provider asking the patient about expected compliance, probing deeper and discovering that cost is the barrier to expected compliance, then providing information on programs that waive prescription copays. More and more hospitals are adopting these social solutions in general, but the trend needs further support. For example, Deloitte researchers found that 88 percent of hospitals screen for social needs, but only 33 percent have a universal process for addressing needs if patients screen positive (Lee & Korba, 2017). The main barrier was dedicated funding for social needs interventions. The solution codes would create this dedicated funding by starting the process by which insurers could pay for time spent addressing social barriers to poor adherence.

    Shafrin’s post highlights an important step toward improving medication adherence, but expanding coverage of remote monitoring technologies is not enough. Patient compliance depends on more factors than can be addressed under current reimbursement structures. The AMA needs to do more than promote better detection; instead, the AMA should add three more codes that reimburse providers for more time spent addressing poor adherence. In concert with improved monitoring, these “solution codes” would empower physicians to tackle adherence through new channels. Whether the new strategies use remote communication or other methods will be up to the provider and patient. In any case, the improvement in adherence will come from added time to customize interventions to social barriers.

    AmerisourceBergen. (2017, Sept. 25). What do Payers Think About Digital Health Technologies
    [interactive report]. Retrieved from
    Brown, M. T. & Bussell, J. K. (2011). Medication Adherence: WHO Cares? Mayo Clinic
    Proceedings, 86(4). PP. 304-314. DOI: 10.4065/mcp.2010.0575
    Haynes, R.B., Montague, P., Oliver, T., McKibbon, K.A., Brouwers, M.C., Kanani, R. (2000)
    Interventions for helping patients follow prescriptions for medications. Cochrane Database of Systematic Reviews, 2000(2). CD000011. DOI: 10.1002/14651858.CD000011
    Lee, J. & Korba, C. (2017) Social determinants of health: How are hospitals and health systems
    investing in and addressing social needs?. Deloitte Center for Health Solutions. Retrieved from
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    World Health Organization. (2003). Adherence to Long-Term Therapies: Evidence for action.
    Geneva, Switzerland: World Health Organization.

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