The Unfinished Ecosystem: Why Remote Patient Monitoring Has Matured Unevenly, and What Closing the Gap Will Require.

Remote patient monitoring (RPM) is widely framed as a foundational technology for the next generation of chronic-disease care. Specific applications-pacemaker follow-up, hypertension cohorts, structured heart-failure programmes, post-surgical biosensor protocols, and virtual wards-now generate measurable clinical and economic value. Yet a decade of evaluations and implementation studies suggests that the surrounding ecosystem has matured unevenly: working applications coexist with persistent cross-cutting fragility. In this Perspective we argue that four structural gaps continue to constrain RPM's promise at scale: (i) economic models that do not credibly compensate the asynchronous clinical work that RPM generates; (ii) ambiguous frameworks for professional liability and accountability for continuous data streams, intensified by artificial-intelligence (AI)-mediated decision support; (iii) privacy, equity, and benefit-sharing arrangements that do not yet make patients unambiguous net beneficiaries-a gap visible across very different health systems internationally; and (iv) engagement and adherence dynamics that determine whether programmes deliver value at all, but are still treated as secondary outcomes. The COVID-19 emergency briefly suspended much of the friction in this ecosystem and produced a useful natural experiment: what scaled rapidly under emergency conditions, and what subsequently atrophied, illuminates which gaps are technical, which are economic, and which are institutional. We close with a six-point research and policy agenda intended to move RPM from localised successes to a trustworthy, generalisable standard of care.