Bringing Cardiac Telemetry and Event Monitors “In-House”: Interview with Kenneth Johnson, MD, MBA, FACC

Dr. Johnson completed his Internal Medicine, Cardiovascular Disease, and Interventional Cardiology training at Baylor University Medical Center in 2001. He later devoted his personal time from the rigors of a busy practice to pursue and complete an MBA at Kellogg School of Management at Northwestern University. Since then he has successfully transitioned into the role of Chief Strategy Officer (CSO) at Cardiovascular Provider Resources in Dallas, Texas. He oversees the strategic development of over 83 cardiologists at 25 different clinics while maintaining an active and vibrant medical practice. One of his first decisions as CSO was to transition cardiac telemetry and event monitors “in-house.”

In this interview we explore the various salient features of successfully reclaiming this cardiac service line, as illustrated by Dallas-Fort Worth HeartPlace.

As Chief Strategy Officer for Cardiovascular Provider Resources, one of your first decisions was to bring cardiac telemetry and event monitors “in-house.” Can you tell us why you chose this?

It comes as no surprise that we are in an ever-challenging healthcare reimbursement climate. At HeartPlace, we are constantly looking for ways to deliver superior patient care while maintaining good stewardship of our organization’s financial strength. One of our cardiac electrophysiologists and I were exploring the event and telemetry business model from two different directions, and soon discovered that we were really working toward the same goal. By taking ownership and additional responsibilities with cardiac monitors, we were able to effectively bring this service “in-house.” We have been able to deliver excellent care to our patients with our own devices, while billing globally for the entire scope of the cardiac monitoring service.

Can you briefly explain the “basics” of transitioning cardiac telemetry and event monitoring in-house?

Traditionally, cardiology practices prescribe cardiac event and/or telemetry monitors for patients with arrhythmias, syncope, dizziness, palpitations, or for post-ablation procedures/antiarrhythmic drug initiation. Typically, the physician would be responsible for the medical interpretation of the data, and an Independent Diagnostic Testing Facility (IDTF) would provide the cardiac monitoring service. HeartPlace was not the first group to adopt an “in-house” event and telemetry model, as several large clinics have successfully set the precedent and transitioned cardiac event monitoring and telemetry monitoring into their practices. After extensive research into the matter to ensure compliance with all applicable healthcare regulations, we decided to purchase the cardiac event and telemetry monitor hardware and perform all the necessary maintenance of the equipment. We contracted with a cardiac monitoring company to provide the remote cardiac monitoring service.

How many vendors did you vet, and how did you select your current vendor?

We meticulously vetted four different companies and settled on one vendor, MedTel24, as our preferred equipment and monitoring services provider. When selecting this vendor, several elements were necessary for us to award the contract: clinical excellence, customer service, and competitive pricing. Initially, we assessed MedTel24’s performance in these arenas by undertaking a pilot phase before rolling out to our entire organization. The pilot was handled professionally with excellent customer service, and we discovered that all cardiac monitoring personnel with MedTel24 are certified cardiac technicians. Secondly, we had to be sure that we were getting the latest in hardware features with reliable device performance. From our experience, several patients have had difficulty with traditional landline-based cardiac monitors. Today, more and more of our patients are transitioning away from traditional analog telephone lines to digital systems. Furthermore, battery longevity has been an issue in the past. MedTel24 offered cardiac monitoring hardware for both event and telemetry monitors that worked on a wireless platform, and demonstrated excellent performance characteristics. Finally, we had to ensure that we were receiving competitive pricing, and based upon discussions with their competitors, we found that MedTel24 had a cost structure that was more economically favorable to our practice.

What corporate integrity policies has HeartPlace instituted to ensure appropriate clinical utilization of cardiac monitors?

HeartPlace prides itself on ensuring policies have been put in place to ensure appropriate clinical indications are employed when utilizing cardiac event monitors and telemetry monitors. This is quite easy since the indications for monitoring under this new business model are no different than they were previously. We devised a checklist that allows our physicians to determine the proper device for the appropriate clinical situation. For example, if a patient complains of palpitations on a daily basis, a 24- to 48-hour Holter monitor would likely be sufficient to diagnose the palpitations and is considered the first-line monitor of choice. However, if a patient experiences palpitations only few and far between, an event monitor or telemetry monitor would be more appropriate. Additionally, our electrophysiologists are increasingly utilizing telemetry monitors pre and post atrial fibrillation ablations to document the clinical burden of the arrhythmia.

What difficulties were encountered during this transition?

Traditionally, physician practices have not been responsible for the maintenance of these devices, as these were handled by the IDTFs. During the training phase, we had to ensure that our employees understood how to: 1) hook up these devices on patients; 2) provide appropriate instructions to patients for device utilization; 3) download the data from the device for physician review; and 4) reclaim the device at the end of a prescription period, wipe the memory clean, and return the device to the circulating inventory. General device maintenance was also performed. Overall, these new skill sets were easy to adopt. Additionally, with the secure web-based platform provided by our vendor, accessing patient records and cardiac rhythm strips has never been easier for our office personnel.

Has there been any feedback, positive or negative, from your patients?

Interestingly enough, in the past, patients would have their telemetry monitor shipped to them by an IDTF and then would have to figure out how to hook up the units at home. Some IDTFs do provide Internet-based instructional video clips to assist these patients. However, for our elderly patients, this has been especially difficult. On several occasions patients have come back to the office exasperated because they could not figure out how the device worked. By bringing this service in-house, we take the responsibility of ensuring the device is hooked up appropriately the first time, and that patients are educated prior to leaving the office so we get accurate medical data in a time-efficient manner. 

Has there been any feedback, positive or negative, from your office staff?

From an organizational perspective, our office staff have been delighted they now only deal with one cardiac monitoring hardware platform as opposed to several different vendors. This increases efficiency with our office staff. They find the process generally easy and efficient, and can register and hook up a patient in a matter of minutes. Having the equipment in-house ensures patient monitoring begins before they leave our office. Additionally, the web portal has made it easy for our office assistants to download the appropriate reports for the physician to review prior to seeing the patient. Finally, our billing department is able to obtain the patient enrollment forms that facilitate prompt coding and billing.

Has there been any feedback, positive or negative, from your physicians?

Having access to a web portal allows the physicians to view/edit raw ECG data (full disclosure) in addition to the reports generated by MedTel24. Reports can be retrieved from any Internet-ready computer. Several physicians have commended MedTel24 on the quality of their tracings.

What specific healthcare laws were evaluated prior to bringing cardiac event and telemetry monitors “in-house?”

Our executive team and legal department vetted the proposed service line. Any organization considering bringing this cardiac service line in-house should pay special attention to various proposed arrangements that are currently being recommended by various cardiac monitoring vendors. From a standpoint of Stark Laws, Anti-Kickback Statutes, and Anti-Markup laws, our legal department felt that the model proposed by MedTel24 was responsible and compliant with prevailing healthcare regulations. 

What specific criteria does the physician have to meet in order to be permitted to bill the technical components of event and telemetry monitoring?

Physicians must own the monitoring devices via purchase or lease, and must have appropriate documentation to prove ownership. The physician’s staff must perform the patient hookup and instructions, and prepare the device for use. The physician must provide all supplies required to utilize the device, such as electrodes, batteries, and prep pads. The physician’s staff is responsible for receiving the monitor at the conclusion of the session, clearing the memory, cleaning the monitor and lead wires, and returning the device to the physician’s inventory. In addition, the ordering physician must perform the administration of the monitoring services under the conditions of “general supervision.” General supervision requires the physician to be immediately available to the monitoring vendor’s technicians through telecommunicative means. If the ordering physician is unavailable, the ordering physician must have another physician providing call coverage.

With all the added responsibility a physician practice takes on, is it worth the time and financial investment to bring this service line in-house?

Given the current climate of reduced medical reimbursement, any opportunity that allows us to enhance quality, maximize revenue, and minimize operational disruption in our clinics is worth investigating. The operational disruption with these devices is certainly minimal, especially considering our medical assistants were already performing Holter and event monitor hookups in many of our offices. Clinically, the web access allows physicians real-time access to high-fidelity tracings that certainly provide the opportunity to enhance the quality of care we deliver to patients. In many cases, we have made diagnoses earlier in the monitoring period, allowing us to initiate prompt treatment. Finally, depending on the payor, the break-even point for owning one of these devices is anywhere from four to eight uses, which is easy to achieve in a short amount of time.