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Closing Gaps in Care with Remote Patient Monitoring

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Gaps in patient care —the difference between the care a patient needs and the care they receive— have far-reaching consequences that contribute to deteriorating patient health, preventable diseases, and millions in costs annually to the U.S. healthcare system. As healthcare moves towards value-based care, understanding these gaps is essential for effective and efficient care management.

Understanding Gaps in Care

Gaps in patient care have been on the rise. According to The Centers for Disease Control and Prevention (CDC), 41% of adults delayed or avoided care in 2020. Now, more than three years later, care gaps continue to compromise patients’ health and increase care costs.

The consequences of care gaps result in worsening conditions and illnesses that lead to poor outcomes, unnecessary doctor’s visits, and hospitalizations. From undiagnosed diseases and a lack of access to effective treatments to medication non-adherence and geographic barriers, all are drivers in the creation of gaps in care. Gaps in care can also occur due to infrequent communication or a lack of adequate care coordination. Identifying and understanding gaps in care is necessary to make care more accessible and convenient for patients.

Examples of gaps in care include:

  • A patient does not adhere to their medications as prescribed.
  • A patient does not undergo recommended screenings such as colonoscopies, mammograms, or cardiovascular screenings.
  • A patient fails to receive the testing necessary for managing a chronic illness.
  • A patient does not schedule recommended appointments like annual wellness visits or misses recommended vaccines.
  • A patient is unable to arrange transportation to appointments.
  • A patient cannot find the care they need within their network or area.

How RPM Closes Gaps in Care

Connected health technologies such as remote patient monitoring (RPM) can help address many of these gaps by enabling better access to care, engaging patients in their own health, and providing a bridge to manage patients’ health conditions from the comfort of their homes. The following are a few ways that RPM is helping to close gaps in care:

Bridging Geographic Barriers

In rural or underserved areas, access to healthcare can be limited. Patients in these areas often face barriers to timely care. Consequently, these patients often have worse outcomes and experience lower-quality healthcare scores compared to urban and suburban populations.

RPM helps bridge geographic barriers by enabling clinicians to manage a patient’s care outside brick-and-mortar care settings, often reducing the need for regular physical visits, especially in remote areas. Patients use RPM devices such as glucometers, blood pressure cuffs, pulse oximeters, and digital weight scales to collect essential health data, which is then transmitted to healthcare providers for analysis. This data is invaluable for diagnosing and managing conditions, regardless of the patient’s location.

Continuous Monitoring and Follow-Up

Delays in preventative care—such as mammograms, colonoscopies, or well visits— can result in missed or delayed diagnosis and subsequently lead to more costly and potentially invasive treatment down the line.

RPM allows healthcare providers to have access to real-time patient data that helps them to identify and address health issues promptly. RPM platforms can send alerts when certain vital signs or health metrics fall outside acceptable ranges. This proactive approach enables providers to intervene as soon as the problem arises and deliver earlier interventions that prevent the worsening of chronic conditions.

Promoting Preventive Care

Many conditions can worsen unnoticed without proper monitoring or follow-up, resulting in disease progression and more severe complications.

RPM platforms provide clinical insights while the patient is at home in their natural environment, allowing providers to view trends and changes in metrics before a problem escalates. Additionally, RPM platforms that include an AI-virtual health assistant, such as Esper, help support patient engagement and adherence with regular SMS communications to encourage healthier lifestyles. For example, Esper provides 24/7 support by answering patient questions and sending reminders for medications and daily vitals collections to ensure patients adhere to their care plans. This encouragement and support help motivate patients to take preventive measures to maintain their health and well-being.

Supporting Care Management for Aging and At-risk Population

As patients age, their need for medical attention increases, in addition to their likelihood of having chronic conditions. Nearly 80% of senior patients have two or more chronic diseases, leading to an increased demand for healthcare services.

RPM enables healthcare providers to manage the needs of the growing aging demographic more efficiently. It can be particularly beneficial for at-risk patients, allowing clinicians to monitor their health closely and ensure timely interventions. Additionally, RPM can be helpful in post-discharge monitoring, reducing the likelihood of hospital readmissions, which is a common issue among older patients.


RPM is addressing longstanding gaps in patient care by bridging geographic barriers, prioritizing prevention, and supporting care management for at-risk populations. As healthcare organizations and providers continue to adopt and implement remote patient monitoring, patients can look forward to a future where healthcare is more accessible, proactive, and patient-centered.