Barriers to Incorporating Remote Monitoring into Clinical Practice: Allied Health Professional Perspective

The concept of change is especially important in healthcare. Without change, cardiovascular implantable electronic devices (CIEDs) would not exist today. Without change, we would also still accept sudden cardiac death as a tragic and untreatable event. Yet, in our daily lives as healthcare professionals, we view change as a constant hurdle and not as a beacon of remarkable evolution. Adoption of remote monitoring for cardiac devices has been difficult for many practices despite its proven benefits. Study after study has shown a mortality benefit of ~50%, shorter hospitalizations, faster time to diagnosis, less ER visits, and patient satisfaction.^1,6-8 Yet according to data from the Medtronic CareLink system in 2013, only 55% of eligible patients were enrolled in remote monitoring.² 

Remote monitoring represents a massive paradigm shift in the way we care for our patients. It requires new workflows and responsibilities, multiple systems management, and even new roles and responsibilities for our patients. Implementing change requires “a fundamental acceptance or realignment in thinking, appropriate guidance, and clear strategies and tactics for maintaining long-term results.”³ 

Remote management is a daunting task. North Shore Medical Center (NSMC) adopted remote monitoring in 2007 in order to manage our patients with a Sprint Fidelis lead. We held a large-scale, 1-day class during which we educated, enrolled, and paired patients on remote monitoring with the Medtronic CareLink Network. Next we implemented remote monitoring for patients using BIOTRONIK Home Monitoring^®, Boston Scientific’s LATITUDE^™ NXT Patient Management System, and St. Jude Medical’s Merlin.net Patient Care Network. In November 2007, we had 50 patients enrolled in remote monitoring. Today we have 950 patients enrolled, and nearly 900 of them are successfully transmitting their data. Our disconnected rate is only 6%. We didn’t start out with near-perfect adherence. However, in the last 9 years, we have created workflow efficiencies that benefit both the clinician and patient. This article will identify the barriers we have faced with remote monitoring at NSMC as well as the solutions we have created to improve our workflow.

IT Management: Websites and Monitors

As if our line of work were not complicated enough, with 5 different programmers and multiple tachy and brady platforms, allied professionals are also now expected to monitor 5 remote monitoring websites, multiple home monitors, and become well-versed in telecommunications. Once you become familiar with the websites and how they work, you can easily extrapolate the data needed. However, this takes time, and time is of high value. I recommend starting with one company and enrolling new implants only. Get to know your IT department! They will help you with the data exchange from the website to the EHR. Discuss this with your industry representative and attend any remote monitoring classes they are offering. In addition, reach out to other professionals in the area — they may have some tricks and tips to share.

In my 22 years of nursing, I never imagined I would become so knowledgeable in telecommunications! Currently, only BIOTRONIK and Medtronic offer cellular home monitors. Other companies offer analog monitors with cellular and USB solutions, although sometimes at a significant cost to the patient. Prior to implant, assess patient’s phone status: Do they have a landline? Is it analog or digital? Do they use broadband? Knowing this information can help with choosing the right device for your patient. 

Another key difference with home monitoring has to do with inductive vs radiofrequency (RF) or wireless devices. For example, Medtronic has only inductive pacemakers, meaning the patient must do a manual send when scheduled. There are no alerting capabilities. I often find that doctors and clinics are confused between cellular transmitters and wireless transmissions. Cellular transmitters do not require an active landline. “Wireless” or “RF” refers to automatic daily transfer of device information to the website. An actual manual download is unnecessary. This should also be taken into consideration when deciding on a device for your patient.

Alert Management

The perception of information overload and medical-legal implications still exist. However, in 2014, NSMC’s Medtronic CareLink yellow alert rate (atrial fibrillation, or AF) was 7.6%, and 3.4% for red alerts (shocks and elective replacement).⁴ Information overload can easily be handled by developing streamlined alert management across the 5 websites. Create a structure standard for alert events. In my clinic, shock, AF >6 hours, and lead failures are considered top alerts and require immediate physician attention. Elective replacement, ventricular pacing >40%, and BiV pacing <90% require physician notification within 24 hours. Having this structure improves workflow and communication. We have created standard remote monitoring alerts that are activated at the time of implant. We then tailor the alerts based on patient history and patient needs. We also deactivate alerts that no longer provide benefit. 

Patient Education

Patients also have a responsibility in remote monitoring, but they must be educated on their role. Patients receiving CIEDs are adjusting to a life-changing diagnosis. When is the right time to engage them with the intricacies of remote monitoring? We have tried many different methods, and I will share our best practice for patient engagement.

Patients are enrolled into the remote monitoring website at time of implant by the industry representative. If needed, they are paired at implant. The patient is instructed to plug in the monitor at their bedside when they get home. If a family member is available, they are also involved in this conversation. We assure the patient and family that we will cover remote monitoring in more depth at their 6-week check. 

We allot a 1-hour visit at the 6-week check to discuss remote monitoring. Our patient agreement specifically covers what home monitoring is not. For example, it is not a 911 system. It is not monitoring symptoms. It is not a real-time transfer of information. It covers our hours of operation. It allows for a 24-hour lapse for device review. It is imperative that patients understand these aspects of remote monitoring. We also discuss our policy on patient-initiated transmissions, disconnected monitors, and our communication with the patient regarding the above. The manufacturer phone numbers are listed on the consent. Troubleshooting phone lines, disconnected monitors, and inductive transmissions had been taking away from scheduled patient time; all patients with these issues are now directed back to the manufacturer. This may be a small inconvenience for the patient, but if described during the consenting process, patients are usually receptive. Switching to cellular monitors has also markedly improved our disconnected rates. Patients sign the agreement and it becomes part of the medical record. They are given a copy for their records. Patient engagement is ongoing and not static — you should continue to discuss remote monitoring at each visit. Ask the patient if they have any questions concerning their monitor. Check their connectivity at the time of in-clinic visit. This will allow the patient to see that they are connected, and if they are not, you can then discuss troubleshooting with them at their allotted time.

Final Thoughts

In order to implement successful remote monitoring into your practice, find an ally in upper management. Create a business case supported by sound data, such as citing improved patient outcomes and higher insurance reimbursements.⁵ Is there someone in your practice who is willing to become an expert in remote management, and will your practice support this person in their new role? Slowly build your remote monitoring practice. Start with one vendor and new implants only. Adopt protocols and procedures from successful clinics. And remember, “a fundamental principle of change management is to never tackle a change that’s too complex for your organization.”⁹

Disclosure: The author has no conflicts of interest to report regarding the content herein.

References

1. Slotwiner D, Varma N, Akar JG, et al. HRS Expert Consensus Statement on remote interrogation and monitoring for cardiovascular implantable electronic devices. Heart Rhythm. 2015;12(7):e69-e100.
2. Mittal S. Remote patient monitoring of patients with a cardiac implantable electronic device: an introduction. EP Lab Digest. 2016;16(5):1,12-15.
3. Pexton C. Overcoming the Barriers to Change in Healthcare Systems. iSixSigma. Available online at https://www.isixsigma.com/implementation/change-management-implementation/overcoming-barriers-change-healthcare-system/. Accessed June 16, 2016. 
4. Halligan D. Forging a new frontier: navigating the wild west of remote monitoring. EP Lab Digest. 2015;15(12):28.
5. Saxon LA, Hayes DL Gilliam FR, et al. Long-term outcome after ICD and CRT implantation and influence of remote device follow-up: the ALTITUDE survival study. Circulation. 2010;122(23):2359-2367.
6. Varma N, Epstein AE, Irimpen A, et al. Efficacy and safety of automatic remote monitoring for implantable cardioverter-defibrillator follow-up: the Lumos-T Safely Reduces Routine Office Device Follow-Up (TRUST) trial. Circulation. 2010;122(4):325-332.
7. Crossley GH, Boyle A, Vitense H, et al. The CONNECT (Clinical Evaluation of Remote Notification to Reduce Time to Clinical Decision) Trial: the value of wireless remote monitoring with automatic clinician alerts. J Am Coll Cardiol. 2011;57(10):1181-1189. 
8. Landolina M, Perego GB, Lunati M, et al. Remote monitoring reduces healthcare use and improves quality of care in heart failure patients with implantable defibrillators: the evolution of management strategies of heart failure patients with implantable defibrillators (EVOLVO) study. Circulation. 2012;125(24):2985-2992.
9. Mar A. 5 Barriers to Organizational Change. Simplicable. Published March 29, 2013. Available online at https://management.simplicable.com/management/new/5-barriers-to-organizational-change. Accessed June 16, 2016.