How To Utilize Remote Therapeutic Monitoring (RTM) In Your Clinic With James Heathers Of Cipher Skin

As technology advances, many things are made more manageable, especially in healthcare. Care strategies and delivery become more effective with easier access to health data that’s been automatically recorded and reported to the care team. Remote Therapeutic Monitoring (RTM) became accepted by the Center for Medicare Services as of 2022. Thus, Physical Therapists can now bill for apps and “wearables” that monitor patient motion (HEPs) between PT sessions. James Heathers , the Chief Science Officer for Cipher Skin , joins the podcast to explain how RTMs can be utilized to benefit patients and providers during the episodes of care. Tune in to this episode for a more comprehensive discussion with James Heather!

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I’ve got a guest, the CSO or Chief Science Officer of Cipher Skin , James Heathers with me in this episode. James, thanks for joining us.

How are you, Nathan?

I’m doing well, thanks.

Thanks for having me. I don’t get to do a lot of shows. I like doing PT shows because people have a tendency to ask questions about things they need to know and not invite me to speculate wildly, which is something that I occasionally do. It’s nice to be able to put the whole thing to rest and do something useful. Let’s be useful.

That’s the whole goal. We’re going to be talking about something that’s relatively new in the physical therapy space and that is Remote Therapeutic Monitoring or RTM because this is relatively new in the space and it’s been recognized by CMS. First of all, tell us about your relationship with remote therapeutic monitoring and where you are coming from.

Let’s do the whole thing from right now working backward. I have been thinking about this well before the codes came out that allowed people to bill remote therapeutic monitoring through the regular CMS mechanisms that hopefully everyone is familiar with. If you are not, you have some pamphlets to read or none of the rest of this is going to make sense. Why would I care about that?

It’s because I work for a medical device company. We explicitly make on-body measurement devices for physical therapists. They measure biometrics and joint angles. They post those directly to the computer, the tablet, or the phone that you use in your practice or at the very least you have in your practice. It cues up all of that data, puts it in the right place, and sends it to your EMR.

Where does that come in? Think of every individual exercise that you do or more specifically everything that you would later bill and justify in terms of how could all of that be written down for me. Also, how could I send someone home with the said device in a context where they were not in clinic the other 165 hours of the week when people are supposed to be doing their home exercise program as might be expected?

Like most digital tools, we offer the ability to be used in multiple different places and we are not tied down to being within the four walls and roof of an outpatient clinic. We think long and hard about what happens when there’s a regulatory unlock. On the 1st of January 2022, the RTM codes went live after a consultation period in 2021.

We were ready. We were waiting because I’m the boring person that reads a Federal register. I strongly recommend that. I do things like that because I suffered through a PhD. It only moderately affected my blood pressure at the time and that thing sets the internal direction that we have within the company when it comes to how PTs are going to use the product later to bill stuff.

That’s the surface-level explanation. Let’s not dwell on the academic background stuff. There are lots of them. There’s psychology, exercise physiology, human movement, digital signal processing, and engineering. There’s a whole lot of physiology and I’ve spent most of that time as a competitive, strong man. I’ve seen the inside of a PT clinic myself.

It is as of January 1st, 2022, these RTM codes came into play and there are five of them, I believe.

Let’s be explicit about this. I don’t know if you’ve got any speech-language pathologists or OTs listening. I would say there are five that are specific to physical therapy. That might be stretching it a little bit. It all depends. There are three that are most important that people understand.

Where would you guide someone who wants to learn more of the details and the ins and outs of each of those codes and how to use them? Do you have some trusted sources to guide them towards?

Anything that comes from a website is written by lawyers because they’re reasonably common in this area. If you’re looking for someone to interpret the law from scratch when something like this happens. As might be expected, everyone with a small legal LLC who has an interest in healthcare, medical devices, etc., immediately wrote about it because changes to CMS are interesting to people like me.

Anyone who’s a law partner or similar will do you proud when it comes to the interpretation of these things. If you want to go deeper than that and I don’t necessarily recommend this for your time and insanity. You will have to read the actual government documents about it and get to grips with it. I know a sigh was heard around the world as all of Nathan’s readers went, “I’m not reading the Federal register. Whom have you got on the show? Who is this guy?” Unfortunately, a lot of the time, there is no other way through.

New codes are scary because a lot of the time, there is a surprising amount of gray area between what is written down and how that is understood. How that is eventually later translated into how should this be built? Part of the lack of aggression about immediately wanting to go, “Here’s a new therapeutic modality. It works. It’s only home exercise but it’s being tracked.” Part of the hesitance around that is the fact that no one wants to be audited. No one wants to be in a position where they have to spend any more time on the phone having another conversation about, “All I did was give him therapeutic exercise and a lollipop. Why can’t you let me build a unit of therapeutic exercise like a normal PT with a normal job?”

I know everyone’s been there. I’ve watched people do this from the other side of the room and gone, “I didn’t think I see anything that made me glad I chose to be a scientist,” which is usually something that I question but it’s a lot. You’ll go to get these drug factors. A lot of information doesn’t come back quickly. I was speaking about this at WebPT Conference in May 2022. Right after that, I saw they released a bunch of figures like how many people are on the platform.

It was public knowledge. You can probably google and find this. How many people on the platform have billed these codes as a basket of codes? I remember it being about 15,000 but you have to go and look, which is very few codes. We’re talking about reimbursements that range from about $19 for the initial code to about $41 for the actual interaction.

15,000 times that for a system that has a big position within an outpatient market means that people did not come out the same way we did on January 1st and went, “New CMS codes. Let’s go. Let’s help people faster for money.” It’s a no. There’s always a feeling out process of something like this but also, there’s another component of responsibility. That’s the thing with people like me who build the products and services that go around something like this has to come to the party and then people need to know about it. That’s slow. Building hardware is difficult. That’s why they call it hardware.

The uptake for new modalities and new codes in the physical therapy realm, I can imagine is slow. As a profession, I believe we’re about 1 decade or 2 behind the curve on most technology. I can see where these new things are, especially if there’s any fear that this newness might lead to audits. We’re going to keep it far away from us.

That’s why I’m excited to have someone like you on so you can tell us, “This is what it is. It’s not a monster in the corner, but it is something that could be useful.” When we’re talking about remote therapeutic monitoring, you can have wearables, if that’s the correct term. People can wear these things to measure their biometrics. What are other ways in which you can utilize these codes outside of wearables? Is it the utilization of an app or something like it that justifies the code?

If you go deep into this, as might be implied by other people who aren’t asked and we’re not here to talk about my company. We’re here to talk about the thing itself. There are plenty of offerings from people who aren’t us that are app-based. In that sense, the therapeutic monitoring section of the code is the continual structured acquisition of PT-specific data over time. It could be as simple as what essentially amounts to a carefully constructed survey that is trying to address all of the questions that you would ask if you called someone on the phone yourself for 30 seconds. That’s the easiest way to think of it.

“Have you had any major difficulties with, at the high end, sport or activity, at the low end, activities of daily living like getting out of bed through to what happened? How does it feel? Pain out of 10, stiffness out of 10, the presence or absence of tingling, pruritus, or whatever.” That also, according to the definition, is part of the potential service that you could provide for remote therapeutic monitoring.

That can be done through an app-based program. That might not be any in your realm, but are apps out there that you know of that you would recommend?

Here’s the thing. I know they’re out there too but I don’t get to use them. We know they’re there. We do our own app development because you can’t just have hardware sitting in the corner doing something without the ability to digitally access that. As might be expected, if you have a Garmin watch, you don’t use all the information off the watch face. Surface skin wearables are the same. It all works through a digital interface that you can see and the important components of that are retrieving the data from the device, sewing it together, structuring it, and turning it into a report that is RTM-capable at the end of that.

As might be expected, we already had the hardware. What we spent a lot of time thinking about is what features does this need to have in order to support the billing cycle? I’m telling you that because I’m 100% certain that anyone who’s releasing an app in that space has thought about that as well but they’re not measuring things like exactly why you’ve got a frozen shoulder seventeen days in, exactly what is your shoulder flexion 12 hours after yesterday’s home exercise program? How much did it hurt? Do you have anything to report? Do you want to request the fact that I’m going to talk to you through a synchronous interaction?

Also, the other way around, if you’re a therapist, you can text message or email people straight out of the app. If you see someone who doesn’t have activity for two days, this is the inside of it. There is a roster. It’s person number three. It’s the 17th. They haven’t recorded any activity since the 14th. There are two problems with that. 1) They’re supposed to be recording their activity because that’s how you help them. They call that healthcare. 2) They could be messing with your ability to get paid.

You are already doing the work. Send the reminder. Those features will be common to any mature app that is available to be able to do this. What you want is something that has all of the available features. We don’t offer that. We probably should. Google until you find one that does it. That’s all you want to do.

I don’t presume you’d be a billing specialist, so I understand where you might have some hesitancy in answering this question. In your situation, you have a wearable. Let’s say a sleeve for someone who has a frozen shoulder like you’re talking about. You set them up. They’re on the app. You’re monitoring them as a physical therapist. At what point do you build the RTM codes? Is it on the data service that they come in for care? Is it a one-time period of care? One thing or is it on the days in between visits?

My understanding is that this is also the conservative approach that after you have done the first series of episodes of service and you get right to the end, you should batch build a whole lot after they’ve been done. I told you that there were elements of this that are unclear. I cannot make a fine determination about it. Let’s say there’s a code that’s for the initial setup. It’s called 98975. One of our devices will do.

If you are a PT and you take a sleeve that is designed to do musculoskeletal monitoring, you show it to someone. You show them the app that they have access to. You put it on them, you have them wave their arm around a bit and they say, “That hurts.” You say, “I know. That’s why you’re here. Stop interrupting me.” Eventually, you get to a point where you feel like they’re going to be okay with using the product that they’ve got while they’re in a remote setting.

That’s a billable episode because it’s not a lot of money, but also, the main CMS had to take into account the fact that you can’t just give someone a box of hardware or install a piece of software and go, “You’ll figure it out.” Generally, that’s not how medicine works. For the people who have been using ours, because it’s impossible to get it wrong this way, we have been recommending that you run the first billing period until you’re done and then you throw the whole lot in at once after the end of a 30-day period.

After a 30-day period, you would go back and add the CPT codes to previous visits or build on that 30th day?

Build on the 30th day.

I’m assuming they’re not timed codes like the other CPT codes we use.

The first one is 98976. I always get 98976 and 98977 confused because they’re pretty much the same thing. The wordings are almost identical, but one’s for respiratory system monitoring, the other one for musculoskeletal monitoring. These are not timed because they are fully remote. For every day in the way that everyone’s familiar with them, one after the other, every time there’s a recording that is giving you usable therapeutic data, the majority of those 30 days in order having data being recorded on them is the center of what makes the code billable. Those are very definite. In that sense, it’s untimed.

It is a small amount of patient time. It’s not any of your time. When we get to the timed code, the timed code is 98980. This is the time that you spent reviewing the data that people send you and must include one synchronous interaction between you and a patient. That can be anything you like, although I would caution everyone at this point in time, please check the legal status of using something like FaceTime to do medical care. Many of these things are not strictly approved. This was a little different during the pandemic and it also changes with the individual rules that individual companies have.

It could be okay now, but it’s not going to be okay if you are reading this in 2024 or the way around.

There are lots of different ways. Use the right platform but also bear in mind, when we talk about sync of communication, and a lot of the time, we’re talking about patients over the age of 65, especially in the post-ortho world as might be expected. Our stuff is for MSK conditions and postoperative recovery. There are a lot of people over the age of 65. As might be expected, you call them on the phone. You’re going to have a little bit better luck than Zoom for business with many of them.

It’s easy enough to schedule as well. Certainly, when I call my elderly parents and I call the actual phone in the house, they pick up with a frequency that would embarrass me in my own daily business life. They’re good at that. They’ve learned. One synchronous interaction like phone, digital, web conference, or otherwise. Asynchronous interactions don’t count. You can’t send a postcard, an email, or a text message. That is not a synchronous interaction. That is an asynchronous interaction.

What we used to call back in the day, talking to people, if you are doing that and the amount of time between you looking at the data and trying to figure out how that impacts their progress over time and the synchronous interaction, that is a timed code. The relevant amount of time is twenty minutes, which doesn’t sound like much until you have a full heavy outpatient schedule and you’re working 4 or 5 days a week.

Let’s say your work can overlap somewhere at a PT clinic. There are lots and lots of people. You could have them. The worst I’ve ever heard is someone said, “I’m trying to do 130.” That was affected by the fact that you weren’t talking about people who were coming in regularly. There wasn’t this 3-days-a-week business or even sometimes 5-days-a-week business. That artificially inflates the number of individual people who are in that bucket, but certainly, it feels like six.

I’m frankly amazed by PTs who can maintain regular visits to 60 people. We’ve only got fifteen people in Cipher Skin occasionally and I’m like, “Who are you again?” You’re treating and trying to maintain rapport, remember names, and not get tired and throw a basketball at 60 individual people. Now, you can’t find 20 minutes for each individual person within the 60.

The people that we talk to, the people that buy our stuff are busier than they’ve ever been because there’s an enormous backlog. Simultaneously, we have a population that because time continues to exist and continues to age. We have this tremendous backlog of elective surgery that was canceled or delayed a lot of the time that’s resulting in people who need post-surgical care and also, people who were manifestly inactive for the last couple of years.

Also, people who’ve been ignoring complaints that they already have over time. That’s obviously tailing down now because in general, the restrictions that we had in 2020 and segments of 2021 are not the case anymore. For most people, it’s a real problem. There’s no question of, “I can’t go outside.”. It’s more, “That’s tailing off, but it’s still happening to a certain degree.” How many 20-minute chunks are we going to be able to add if you’re running in the red?

This is something that you need to be judicious with. There are people who will benefit from it and there are people where I don’t think it’s going to help at all. The whole idea of, “Here’s a thing. This is remote whatever. I can potentially help people build on there and they’re all going to go off and do a thing. It’s not going to be a managed process.” Forget about it.

This is not the right thing to get all keen and mercantile on. Now, there are a lot of people who will benefit from it, but it’s also a matter of your ability to support it as a professional and maintain a standard of care. I hope you could appreciate it. I’m deliberately working against my own interest here. I want you to buy as much hardware as possible and take a whole bunch of measurements but it turns out that the PT market is enormous.

It works brilliantly for us if patients have good experiences and PTs find the use of this straightforward and so they’re not maintaining an inventory of hundreds of devices or something like that. You quickly end up turning into an academic laboratory if you’re going to try and do that. No one’s tried to do that yet, which is why it’s working. It also affords me the ability to be completely honest about it which helps.

To clarify that picture for me at that 30-day mark and I know I’m coming back to the billing, but at that 30-day mark, you could bill for the initial setup. Do you bill a code for each day in which there has been some data accumulated or is there a singular code that covers all the data that’s covering that 30-day period?

That’s a single code and that is one billing period of 98977.

There’s the initial setup. There’s the singular 98977 and there’s also the data interpretation and synchronous conversation with the patient regarding that time and how they used it, right?

You can think of that, yes. There are three important codes, but there’s also 98981. If you are one of those incredibly scrupulous people or you provided a heavy-duty service or you have low patient volume or any number of other things and you’re somehow managing to spend 40 additional minutes, there is a repeat code that’s 98981 but like most repeat codes, the second reimbursement is less money.

You can look all of them up and there’s no point telling you how much money it is because sometimes it’s different between ZIP codes. If you go to the CMS, look up and do that, you can see there and there’s a border there. You can see that the PTs are worth $6 more on that side of the line. I’ve always wanted to find one of those and look on Google Maps just so I could find one that’s on the wrong side and mail them, “Have you thought of going across the street and making 8% more?”

In this situation and if a therapist is thinking, “How can I implement this to benefit my patient?” Who is the ideal PT owner? Maybe a better question is, who is the ideal patient that would benefit from remote therapeutic monitoring?

This is where we move from process-driven discussion of what has to happen with codes for billing and money and the market mechanics of everything, we move into my opinion. I do have one, but I’m telling you, this is my opinion. My mom is doing PT and every single person reading this, my mom is your dream patient. I don’t think she’s ever missed a home exercise program workout ever. She was staying with me in our house a while back and I walked out and found her using my Indian clubs. I have wonderful Indian clubs made out of cast iron that are much heavier than the regular ones. I found her using those as weights to do little old lady deadlifts because she couldn’t find anything else hanging around.

I came out and my heavily-armed mother was standing there doing ski squats in the middle of the floor. She doesn’t need anything I could possibly build her. She got a piece of paper. She printed it out. She had it laminated. She takes it with her on holiday. Does my mom need RTM? She does not. Let’s deal with the convert’s example. There is another person in my family. I don’t think they’ll read this, but I’m not going to say who. They have a variety of musculoskeletal complaints and I don’t think has ever done any home exercise that has been prescribed to them ever.

If you go into the trouble of getting access to something like this, you also have to bear in mind that there is a cost for you. That’s going to be true if you are buying access to the software. That’s going to be something that goes on your license. If you’re buying stuff from us, then the hardware costs money. You get to keep the hardware. You’re not going to throw it away. If you break it, we’ll replace it. You always have access to the hardware if you buy it.

There’s on one side and that’s not free and neither is access over time because there’s an astonishing amount of backend nastiness that has to be maintained to make sure all your data gets to the right place at the right time. It’s not free. You give it to someone who’s not going to do anything with it. They’re going to do exactly the same thing that they did with their Fitbit. They’re going to put it in the kitchen drawer.

If you ask for it back because the patients are not going to buy these, these are entirely reusable and the nice thing about most injuries is that at some point in time, they go away and you don’t have to do regular monitoring on them anymore. It would be irresponsible. If you’ve got audited, can you imagine? Let’s say you’ve got a young, healthy person, 25, with a busted ACL from a mountain bike accident. They are incredibly motivated to get going again because they loathe being injured. It drives them crazy. They don’t even need to do PT because they’re going to push through everything as soon as humanly possible and get going.

Now, they will do a lot better with PT, but it’s not a matter of this being some barrier to access. If you give them measurement stuff over time, what do you think is going to happen after the first 8 to 12 weeks? The answer is that they’re never going to put it on again. That’s why we have the model of it being your hardware that you get to keep as might be expected. There’s no chance we’ve got to go around selling these to people. Only the carbon fiber bike crowd would ever consider buying one of those. It has to be yours.

Now, we’ve dealt with the diligent people and the not-particularly diligent people. I’m not going to put you on the spot and ask you to assign a percentage number for those two groups, but I would say people like my mom at the top, I’d say that’s probably about 5% of all the people. The people in the bucket down the bottom where you can establish all the rapport you want, but they’re not going to do it because human beings are often lazy and self-interested. More than anything, they are capable of the most astonishing amount of short-term thinking.

Human beings are often lazy, self-interested, and, more than anything, capable of the most astonishing amount of short-term thinking.
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We are not designed to plan out twenty-week trajectories. Like me, I had a bowl of chili lime cashews that was sitting here on the desk and I didn’t plan to eat all of them, but I did in the first 70 seconds after I got them. That’s about a third of people and my cashews. We can immediately throw 40% of the individual people away. After this, what benefits from most strongly being monitored over time for progress? Were you sure that if you knew and if you have people who are a participant in the recovery process, it’s going to help? There are a lot of people who are in the middle of that who are essentially pre-converts if you like.

That’s your demographic because they’re uncertain. Every PT knows someone who’s turned up in the first place, who walks into the room, trips over the massage table, gets tangled in TheraBands, and goes, “I don’t even know what I’m doing here. I was told to come here.” Janice at the office gave me a kick and said, “You need to go to PT. My son did. My aunt did. The doctor gave me a solid talking to and said, ‘You don’t need bloody opioids. You need a physical therapist.’”

“I got sent here for my lower back pain but I don’t know where I am. I don’t know what I’m doing and I don’t know what my name is.” That’s your cat right there. The person who is waiting to understand what the process should be like and how it should be structured over time because there’s an element of hand-holding and the introduction to the culture and thought process that goes around how should we be maintaining ourselves over time.

I could see where the competitive person, the person who’s maybe that CrossFit-type athlete or in some sport and sees a wearable in your case or maybe the app that they’re using to interchange or upload their information is a game or a competition. “I got better.” Those people might do well too.

That’s brilliant and you’ve presupposed my second demographic of people but we call this anxiety leverage. I promise you, just so you can sleep at night and because it’s going to work better. You want to be a force for good when it comes to this over time. The last thing you want to do is take someone who is riddled with health anxiety, which is a surprising amount of people and say, “Maintain this daily schedule of check-ins or you are doing it badly.”

That can be a lot for someone. You know those people. David Sedaris wrote a great article many years ago about how he got addicted to his Fitbit. You are not on the side of the ratches if that’s what you are going to do to be able to hand care out to people. You probably want to be on the side of not causing people health anxiety.

There are context and expectations set, and you want to reinforce the good enough rather than the perfection of this over time. The measurements themselves are designed to support that. You’re supposed to take the right daily measurements for the first 30 days. When I say the first 30 days, I mean the majority of it, which means a minimum of 16. That’s a lot of missed days.

When I trained a lot, I trained six days a week. There was a period during my Master’s where I spent a long time trying to get my deadlift over 600 pounds. I thought it would help with the flipping tractor to tires, lifting stones, and stuff. I was convinced it was the key. I always trained six days a week, not heavy stuff every day. Generally, for a strong man, you have event stuff and you have muscle group stuff, a little bit like a bodybuilder and you have powerlifting stuff.

Generally, you think of planes of movement or activities. I think I probably missed 3 workouts in 4 years. Do you know why? It’s because it was super convenient to go to the gym that was 150 meters from my office where I was all day in a building where I had a shower and the ability to wash my clothes. That’s what made the big difference and some dumb obsession with the number. I can’t even remember what I got to. I think I did 585.

I was going to ask you, did you ever get to 600?

I got to 500 on an axle which I was always very happy with. Axle deadlifts for those of you who aren’t familiar with it, imagine a regular deadlift where someone was hitting both of your hands with a toffee hammer. It was horrible.

What are some of the benefits that you’ve seen with either your patients or the test subjects that have used your wearables or have used other apps? Is there data out there, whether within your own company or outside of your company that has shown benefits to using this in patient care and their recovery?

There are two answers. In the sense that we are doing this code right now in this context and measuring it, there are claims of efficacy that other people are making. I haven’t read anything where that’s been split down into numbers. Give me a quick google and you’ll find out what I’ve done in my scientific career when people publish numbers that are occasionally inaccurate. Some impertinent words have been said to that end, but it’s not that. It’s the fact that the eggs aren’t cooked yet.

Someone will get to that in some capacity. I wouldn’t want to try to do that yet, because also you’re proposing. If you’re going to do that in the first place, you have the issue of navigating health data. It’s likely to happen, not in the RTM context, but in something that’s a good analog within a research group at a university. That being said, we get to the second point, which is the fact that there is so much research on reminders and digital interventions, which is essentially what this consists of.

One of the single best-studied things in medicine, if you want bang for your buck, there’s nothing like this in the entire study of the entire clinical pantheon world. There’s nothing better than an SMS. Health text reminder studies, there might be more than 150 reviews on this because it’s everything. Remember to take your PrEP if you’re HIV positive. Remember to take your medicine because we’ve changed the schedule from 2 of those to 3 of those every single day.

There's nothing better than an SMS health text reminder.
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This has been endemic in this research from healthcare for years because researchers love looking at stuff that works. You get a high single-digit percentage change in compliance or adherence depending on how you’re talking about it. Reminding people who forget stuff at the time when they need to do something about it is a great option for anything.

From the perspective of whether we get to see the data over time, I’ll tell you something subjective from this. I’ve had a few of these conversations with the people that have done this or who’ve talked to me about it. I find it a little bit unusual for the first week or so, and then at some point in time, the line starts to go up. It starts changing the way they feel about it. They become a participant in a process.

Once they start seeing that improvement.

We’ve got a problem. We’re abducting their shoulder and it’s not so great. You’re taking a measurement that would be trivial from one of our devices. A regular range of motion test and it’s not so good. You see it get better and then people, “I could see this on the show. I’m waving my arms like I’m doing a semaphore on the deck of an aircraft carrier.” You can all imagine what it’s like when you have problems abducting your shoulder and then it gets better over time. You see that reflected day to day. It’s one of the rare things that you always want when it comes to behavioral entries in medicine, which is a virtuous cycle. There isn’t anything like them.

It’s the same reason that Duolingo will reward you with that annoying bird when you start to hit a streak of multiple things over and over again. It’s the same reason that online games will give you tremendous bonuses for playing 5, 10, 20, or 30 days in a row. It’s why everything that’s got a reward mechanism in something like that has got rewards that are congruent to being able to pay attention over time because people get stuck in the cycle, access, look, and understand. It makes you feel good about it. If you feel good about it, you’re more likely to do it the next time.

We’re all about the reward, the acknowledgment, and the recognition.

Also, it’s you. It’s something you immediately have access to. Let’s say you have some horrible musculoskeletal problem and it’s going away over time. You look at a graph and you remember how you felt when it was 4 out of 5. Now, you are there 3 weeks later looking at 1.5 out of 5 and a line that’s going down and down. It’s got some lumps and bumps and things happen.

There was that time you fell down the stairs and the other time you tried to pick your neighbor’s dog up and you forgot how big he was and then you pulled it a bit but it’s going down. You’re seeing it. There’s a participative element of that when you are generating and looking at this data over time. Whereas if you are using it to defray and not cause anxiety is super useful.

The last question I have is for the provider that’s using it and they’re interpreting the data, how would you coach them if they were looking at this data in front of them to assess it appropriately? Are they simply looking for the trends over time and interacting with the patient to say, “Just so you know, as you followed this program, especially if you did it in consecutive days, you saw great gains.” Is it simply a conversation like that? How should they interpret that and interact with the patient?

It 100% can be. I feel like that’s an easy place to start with. That’s the way that it’s going to happen. It’s entirely out of my hand so I know very few PTs compared to some of the PTs in the market. I don’t have great context here, but I feel like that’s where it’s going to end up a lot of the time. You see someone miss a whole week and maybe you queue them with an email, an SMS, or a phone call and you say, “Get back on the pony,” and they do and it’s the same or it’s worse. You know exactly what to tell them, which is don’t expect yourself to be perfect.

Don't expect yourself to be perfect.
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There’s context involved here. “We made no progress for this week. I want you to take that and I want you to bin it completely, have no emotional violence about it, whatsoever or however you choose to. I wouldn’t say, “Have no emotional violence whatsoever toward a 65-year-old with a knee replacement.” The response would be, “What’s that, Sonny Jim?” if it was me saying it. However, you want to say it to get yourself that context.

Now, if you want to get cute with something like this, you can look at what an expected recovery trajectory would be, either from other people or from the same demographic with the same condition for instance. There are tons of research that’ll tell you what the actual expectations are or something over time or for instance, you’ve got a condition and it’s just stuck and nothing’s changing for three weeks and you’re trying to figure out why.

Also, bear in mind, you rarely have one data set. Wouldn’t it be strange if someone was doing their remote therapeutic monitoring separate from the home exercise that they’re both doing? With RTM measurements, a lot of the time, you’re like 30 to 60 seconds. It’s check-in. Remote blood pressure is a good example of remote physiologic monitoring. You can think of it like that. They’re doing that. They’re also doing the home exercise with that stuff. You can queue and record the home exercise and send that if you want but you’re doing all this and nothing’s changing for three weeks.

I would start asking questions because also bear in mind, the thing that’s going to happen with this and the place where repeat business comes from, the place where reputation comes from, a lot of the time, is built out of the ability to find signals from complex data faster. This is dramatically increasing your at-bats when it comes to, “What can I see within the information that’s been presented to me?” because you are not talking about a very fast Oxford thing once a week to be able to see whatever it is doing.

You throw your arm up. “It still seems like it rotates. It’s still stuck on. Look at that. Fair enough. We’ve got our program. Let’s go.” It’s different from, for instance, this is the last 40 days’ worth of measurements with everything laid out. You can see but a PT with a reasonable degree of experience will tell you what feels right. As a data person, that gives me cold sweats, but that’s only a different perspective.

A lot of the time when you go, “I can feel that. I know it’s working,” but more than that, it’s a subjective perception of someone that you’re dealing with. You’ve got a little bit of range of motion improvement, but a lot of improvement and pain. Also, you feel a lot better about it because it’s being dealt with over time. If you want to do your biopsychosocial, PT is the time. People love saying that word without following through and thinking about all the pieces and what it means. I think they only like the fact that it’s got a lot of syllables.

Thank you so much for taking the time to explain a lot of it, how it could be implemented, and what the ideal patient might be, even down to how it’s built. One of the last questions because we are talking to PT owners out there, what’s the monetary investment in either apps or wearables that you’ve seen that you’ve come across?

I don’t know how a lot of the apps are priced. Knowing the space though, I would think that they’d be bundle priced and that if you put an individual person on it, you would have a licensed tier. That would mean that rolling an individual person would cost money per time, money per person, or money per session. Probably not money per session because the session’s going to be all over the place with different people.

You have to bear in mind at this point in time that for our device, this is about a quarter of all the stuff that it can do. There is a whole range of in-clinic measurements and observations that are designed for regular measurements during the initial assessment, therapeutic exercise, biofeedback, and musculoskeletal testing to a certain degree. Although, that’s an astonishingly complicated and irritating code and I understand why all of you hate it. It’s difficult to build a full servicing that lets you bill it more easily because I know PTs want to do it, but a lot of the time, they can’t access the code because the requirements are so abstract.

I am learning about your world now. This is me over-justifying the fact that I’m going to tell you that they are $499 and there is an access charge over time, which comes up on a monthly basis. The thing that we will do for that is not only to give you the stuff and if it breaks, we will also very definitely get you one that doesn’t as soon as humanly possible because hardware companies loathe that. We want everything to be perfect all the time. We’re all weird perfectionists. The thing that we’ve started doing which has been very well-received is we will help you get to a point of using it where it’s making you money.

It’s a matter of who’s coming in. Even to the grainy level of, “Can you give me advice about how this might be billed? What could we measure? What sort of patients are?” If you try and buy too many of them, we will tell you, you don’t need that many and you should buy fewer because it’s terrible for us. If you stick 5 of them in the corner and you used 3 because you bought 8, that’s a bad thing for both of us. What we want is for you to make money with the thing that we sell you. That’s what makes the world round. If you have a bad experience with it, then you want to turn them on and bill for it, but the whole point is that we need you to be making money with it. That’s what we are designing it to do.

If people want to check it out, videos of it, and your website, where can they go?

CipherSkin.com. It’s that easy.

If people would want to reach out to you, are you on social media, James?

I’m everywhere. I’m one google away from affecting your whole life with my nonsense. You can find me. I don’t use Facebook anymore because I don’t like them much, but I’m on Twitter. You can find me through the Cipher Skin website and other stuff as well. Honestly, it’s one of those things. I have a Linktr.ee. If you find that, you’ll find about twelve different ways to find me. I’m nonymous.

James Heathers, thanks for joining us. I appreciate you taking the time.

This has been fun. I like talking about this. I’ll say something very brief in closing. The way that biomedicine is set up and the ways that a lot of technology has been structured, I feel like both of these things have been quite dismissive of PTs as a profession and as a culture. I get the sense that people feel like they’re being disrespected. I would like to do the exact opposite of that.

I do R&D stuff all day. I think about building things for the government and for private companies, a lot of which I can’t tell you about. I’m glad that I’m helping the people who are probably going to read this because I see a tremendous value in it. As I suppose with scientists, technologists, or whatever you want, I wish people who did what I did respect you more.

I am trying to build something that is going add value to this world that you are trying to work through. I was astonished by how hard it was when I started learning about it in the first place. It was a lot but it also isn’t something that occupies the popular narratives about how medicine and healthcare are hard. I suppose what that amounts to is I hope you enjoyed this and I’m glad I did it.

I’m grateful that you have that mindset for our profession in general. I agree. There are aspects within the healthcare and scientific community that disregard physical therapists and their efforts and their benefits to the community at large. Having you on our side is a good thing. I have faith in you, James.

I appreciate it. It’s good to meet you.

Again, thanks for your time.

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The post How To Utilize Remote Therapeutic Monitoring (RTM) In Your Clinic With James Heathers Of Cipher Skin appeared first on Physical Therapy Owners Club.