Community-Based Collaborative Vascular Disease Detection: How one center utilized the PADnet Disease Management System to grow its service line

Could you tell us about your position as CV Service Line Director of Development?

The department assists with developing a vision for the Cardiovascular (CV) Service Line based on forecasted trends in the CV market, which ultimately drives the addition of new services. The development department also helps design and implement the framework to support the new services. The position was created about six years ago as West Georgia Medical Center (WGMC) expanded its CV services to include percutaneous coronary interventions (PCI). Diagnostic caths had been performed since 1975. A few examples of other expansions are the electrophysiology program (which has been basic pacemakers for the past 30 years) to include implants/defibrillators, and the vascular interventional program.

Can you tell us more about your vascular program?

We actually have been doing vascular diagnostic arteriograms and vascular interventions since the 1990s. In 2006, cardiac interventions became feasible at our hospital when the state approved PCI at select facilities without onsite cardiac surgery through participation in the C-PORT trial. Needless to say, our single interventionalist became very busy and unable to manage the volume of both cardiac and vascular interventions; therefore, vascular interventions had to be put on the back burner.  During this time frame, the vascular volume fell dramatically, and in fact, we had dropped down to as low as 40 vascular interventions per year. As a result, our physicians got accustomed to sending vascular interventions out of the area because we simply were unable to handle the volume. And once referral patterns change, it can be very challenging to reverse the trend. 

Why were you interested in the PADnet and the PADnet Disease Management System?

I first heard about PADnet from a vendor booth at a workshop about a year prior to implementation. Our CV program had successfully recruited two additional interventionalists to bring our total to three. We were now able to handle the vascular volume and bring those services back home for the patients in our community.  Our challenge was letting the physicians and community know we could now manage both their vascular and cardiac needs. We had all the ingredients for a successful program:  three interventionalists, a new state-of-the-art lab, and a well-trained staff. The addition of the PADnet Disease Management System (PDMS), was a great way to communicate the expansion of services to physicians. We rolled out the BioMedix PDMS System at the same time as the new interventionalists joined our community. They were a perfect complement to each other.

Can you describe PADnet and the tools it provides to physicians?

The PADnet is an in-office test for all physicians, but especially useful for primary care physicians and podiatrists. It measures the ankle-brachial index (ABI), and also gives you the pressure waveform of the blood flow through the vessel. So the PADnet not only gives blood pressure, but also the actual pulsatile waveform, and both of these measurements are used to diagnose the presence or absence of peripheral artery disease. The system measures the pressure in the arms and legs with sequential cuffs down the leg from the thigh to the calf to the ankle, and it even records the blood flow in the toe. 

Would interventionalists provide consults on the results?

Our interventionalists and cardiologists both interpret the tests. That is the beauty of PADnet. It provides choices.  It organically encourages collaboration between the testing physicians and the interpreting cardiologist. West Georgia Medical Center serves as the central hub for the network, which facilitates rapid interpretation of the test. The primary care physicians and podiatrists offices choose to be a testing site and have a contract for rental or lease of the PADnet with BioMedix.  The interpreting physicians are also in contract with BioMedix for interpreting the exam. Each test site and interpreting physician has the option to be a part of the PDMS network. The network allows the physician office test site to immediately send the exam to be interpreted by the cardiologist of their choice, and results can be returned in as few as 10 minutes, depending on the availability of the cardiologist. The exam comes across the Internet into the chosen cardiologist’s access-protected computer and/or smartphone for interpretation and recommendation.  The primary care physician then decides the treatment option to be utilized. We have had cases where the primary care physician had a patient in the office for testing and wanted to tell the patient the results during that visit. The primary care physician was able to call the interventionalist, ask him to take a look, and within 10 minutes, the primary care physician had the ABI and PVR waveforms back with an interpretation. Our goal is to have a less-than-24-hour turnaround on all the tests. The vast majority are read by our cardiologists and returned to the primary care physicians or podiatrists within 24 hours.

How many testing sites does West Georgia Medical Center work with right now?

We currently have eight offices in the community in the network, plus two additional offices in surrounding cities.

What has been the impact for your three interventionalists?

With the addition of the two interventionalists, there has been a 300 percent increase in our interventional vascular volume from the base year to where we are now, keeping in mind that we previously had one interventionalist and were referring our vascular cases out. The demographics for our service area includes a high incidence of diabetes, coronary artery disease and hypertension. We also knew the prevalence of PAD was high in the community, but wasn’t getting treated. The PADnet Disease Management System has been a great tool for the cardiologists to provide efficient interpretation and feedback to the primary care physicians. We have been able to track these metrics through the system and use the data to provide excellent service to the physician offices and to grow our CV service line.

When was the PADnet Disease Management System implemented?

October 2009.

Was the hospital the champion?

West Georgia Medical Center was the facilitator and let the offices know of the new services available through the PADnet Disease Management System. It should be noted that anyone can purchase the PADnet and not be in a network; BioMedix sells a freestanding unit. Physicians can independently own the device and complete vascular testing in their office. BioMedix provides many options for the offices to choose from.  But, by choosing to be in the West Georgia Medical Center network, it allows these physicians to be part of a collaborative healthcare model which decreases exam turnaround time, time to treatment and improves patient and physician satisfaction. When BioMedix visited each primary care physician and podiatrist, these options were presented to them. 

Was adding the PADnet Disease Management System a way to bring the patients to your lab that had been previously sent out to another facility?

I think that over time, the program would have recaptured the market, but having the PDMS made it easy for the physicians and interventionalists to communicate. It gave them the opportunity to build relationships and work closely together for the greater good of the patient, and to realize the benefits of this type of collaboration. The bottom line is this: It was good for the patient.

Has there been an impact on diagnosis in your community?

Yes. I would say we are still in the infancy stages in terms of getting the word out on the prevalence of PAD to both physicians and the community. For example, at West Georgia Medical Center, we present a yearly program called “The Heart Truth for Women,” with an attendance of about 550 women each year. One year, we spotlighted PAD and offered a screening exam for PAD with 85 slots available, and within two weeks, every single slot was booked. In that month, we definitely saw a spike in our volumes, both cardiac and peripheral, as a result. Normally, about 25% of the testing volume from the general population will need further medical attention and an even smaller amount will actually need an intervention.

What were the challenges of implementing the program?

The system works very well. The test is performed in the primary care or podiatrist’s office and once they hit “Send”, it is in the hands of the cardiologist within minutes. Depending on how quickly the cardiologist reviews the data, results could actually be back in the physician’s office within 10 minutes. The system itself was not an obstacle to overcome; rather, our biggest hurdle was educating the physicians in our community that we were once again able to perform vascular interventions in a timely manner and that patients would no longer have to drive out of the area for treatment. Given any market, you will need an understanding by physicians that peripheral artery disease is prevalent, and if treated early, it can improve long-term outcomes. The progression of the disease can be significantly delayed by encouraging exercise and if necessary, giving medications to improve circulation. We have the mindset that says, “If the patient has symptoms and it limits activity, then there is a treatment that can potentially improve the quality of life.” When a patient presents with one or more of the symptoms of PAD, testing is usually covered by Medicare or insurance.

Any other challenges?

Making sure the test turnaround time is 24 hours or less. Initially, the test turnaround was more than 24 hours. The first obstacle was fine-tuning the process. We initially experienced some issues with information flow to the cardiologist interpreting the test, but BioMedix resolved the set-up issues. The next hurdle was to get the cardiologist in the habit of interpreting the test quickly. The best way to ensure a quick turnaround time is to communicate with the cardiologist whenever we have any test turnaround time that exceeds 24 hours. The better you communicate, the better the turnaround times will be, and the more satisfied the primary care physicians and patients will be.

Do you have any recommendations for other health systems that might be interested in trying something like this?

Know your service area and where your patients are receiving care. Know the incidence of PAD and the utilization rates for your area, because it will vary depending on the age ranges of your service area. If you are well below the normal utilization rate for your population, it definitely would be an opportunity for education and screening. 

Do you feel that the PADnet Disease Management System has achieved what was originally expected?

Absolutely it has met our expectations. It has created a bridge between the cardiologist and the physician’s office. It was good for the primary care physician, and it was good for the cardiologist as well. But most importantly, it was good for the patient. It keeps the patients close to home for their intervention, and it gives them a fast turnaround time for their tests or procedures.

Our experience has definitely been very positive. There is such an emphasis in today’s healthcare for providing appropriate care in the appropriate setting, and the PDMS is a seamless flow of information across the care continuum that helps achieve this goal. It definitely feeds into where healthcare is going.

Jane Bower can be contacted at: bowerj@wghealth.org.