Going Paperless in the Device Clinic: Automating Via an Implantable Device Cardiac Observation Workflow

As use of cardiac implantable electronic devices (CIEDs) and remote monitoring continues to increase, device clinics that monitor CIED data are facing cost restraints, staff limitations, and the resulting pressure to do more work in less time. New technologies can help with tasks such as monitoring and managing CIED data. However, when combined with a device clinic’s old system, this can still result in a workflow that is manual, labor-intensive, inefficient, and prone to errors. In this article, we discuss implementing an Implantable Device Cardiac Observation (IDCO) workflow solution for the device clinic at Essentia Health.

Current CIED Challenges in the Device Clinic 

Device clinics currently face several CIED-related challenges. Some examples include: 

Paper processes. Device clinic personnel access CIED data from remote monitoring sites, then print, review, triage, document, and/or provide printed reports to providers for review and signature. Next, they scan and upload each report into the corresponding patient’s EMR before shredding the report. Other device clinics may use paper charts or secure folders to save PDF files or software holding tanks. These processes consume a lot of time … and paper!

Redundancies. This results from the need to document data in multiple device databases or spreadsheets, and schedule in at least 2 places (sometimes more) such as the EMR, remote monitoring site, software system, and clinical scheduling system. Many try to uphold a separate device software database with connectivity that is not standardized among industry practices, thereby making the database inaccurate or incomplete. These extra databases/software systems can require upgrades and yearly fees. The extra system may also lead to protected health information (PHI) security concerns. 

Documentation confusion and errors. There are several forms of documentation tools, including scanning, dictation, typing, voice recognition, or use of website notes. However, documentation scanning can take days to upload to the EMR for review, and result in unclear and inconsistent documentation for the non-expert clinician to decipher. 

Remote monitoring data overload. The many steps required to manage remote monitoring websites add complexity and contribute to resource pressure. Additionally, remote monitoring systems provide a significant amount of information that can cause data overload. As a result, the data is sometimes left in the website rather than added to the patient’s EMR, which in turn, may result in pertinent data being ignored or untreated. 

In-clinic visit documentation paperwork. Health care personnel must print to paper or use a paper-based tool to document current settings and/or changes before sending the data to a second software system. This expected data transfer can sometimes be missing important data, which can cause duplicate work and inefficiency.

Communication gaps. Fractured communication may create patient care delays related to logistical standards involving the use of paper processes, or the need for inefficient communication such as phone calls or face-to-face interactions. Manual entry errors may also result in delays or inaccurate entries. In addition, providers might not have timely access to device information if patient data is not uploaded to the EMR for hours or sometimes even days.

IDCO Solution for Device Clinics

Device clinics can address these CIED-related challenges by implementing IDCO technology and associated workflow to move data and reports from programmers and remote monitoring websites to the EMR. This solution enables device clinics to eliminate most manual tasks related to remote CIED monitoring and in-clinic device visits. It also makes the following possible:

Completely paperless processes. Using the EMR system to receive and store device monitoring information in a single database results in a closed-loop system that allows the device clinic to quickly search for information, including advisories and research. IDCO technology guides creation of standard tools within the EMR, such as common language for visit types and flowsheets, as well as creation of a site for importing discrete CIED data. It enables the device clinic to create a scheduling standard that allows for auto-generated patient letters, as well as to set up a comprehensive device visit section that includes information on visit type (remote or in clinic), vital signs, progress notes, medications, allergies, follow-up, patient education, and billing. The solution can also be used to attach PDF links and flowsheets directly to progress notes in the EMR, as well as standardize clinician-to-provider communication within the EMR tools. It allows reports that track off the discrete data setup for IDCO and the EMR that, in turn, set the stage for optimized staffing volumes, quality, and other important device program operations. As a result, the following benefits can be achieved: 

• EMR is used to its fullest potential. 
• Less staff use is needed for managing industry remote websites and associated data, since information flows instantly into the EMR from remote systems (such as the LATITUDE NXT Remote Patient Management System [Boston Scientific] and Merlin.net Patient Care Network [Abbott]).
• Clinicians can immediately review PDFs of full device data and reports in the EMR.
• The need for paper, printing, and scanning lengthy documents is eliminated. Device data automatically attaches to an arrived visit in the EMR. Furthermore, it correctly attaches to the patient, as it is connected in the closed loop with the implanted device model and serial number match. If a mismatch were to occur, it shifts to a work-edit holder or work que file  to correct the mismatch for verification prior to chart attachment.
• There is a more simplified process of completing clinical assessments/reviews of data changes. Dual computer monitor screens allow health care personnel to review the full industry report on one screen and document in a standardized flowsheet located in the EMR on the other screen. The flowsheet is a discrete data holding tank that allows for quick review of every patient visit over duration of follow-up. It also provides a quick query of each line. 
• There is an added ability for triage to provide bidirectional communication of the report with attached patient assessment in the EMR. The complete report, including rhythm strips and stored electrograms, can be viewed immediately by all who have permission to access the EMR.
• Health care personnel also have the ability to complete the professional review component within EMR using 2-way communication tools, create master device clinic and sub-remote flowsheets for standardized documentation, and build a common area for cardiology reports to present within the EMR. A quick link can open the entire report.
• All created device data points flow directly into the flowsheet for documentation and accessibility. The IDCO process eliminates any transcription errors of copying data from one type of document to another form.
• A closed-loop process confirms that correct patient data is attached to the correct EMR. Protected health information (PHI) security improves with the elimination of paper and an extra device database, as well as the improved accuracy of providing the correct data to the correct chart.

One maintained scheduling center in the EMR. This allows one to create a system that meets the rules for billing components. IDCO permits staff to schedule for an entire year with rules of when the schedule will be reset. The schedule drives the device data attachment similar to a resulted lab result. Furthermore, the solution can be used to create a reporting tool that ties to the billing CPT code rules and visit types, as well as a report that provides a last-visit trigger as a tool to prevent lost to follow-up or unmonitored patients. Benefits can include:

• Decreased repetitive scheduling; scheduling in the separate database is eliminated completely;
• Closed-loop scheduling and follow-up processes;
• Patient error prevention;
• Ease of data queries;
• Ability for patients to view all scheduled visits;
• Streamlined billing procedures.

Streamlined documentation (remote or in clinic). This allows for use of a standardized documentation flowsheet with chart building that includes the device data link or scan. Health care personnel can transfer data and reports from industry programmers to the EMR via tools such as the LATITUDE Link Data Management System (Boston Scientific), which operates in concert with Bluetooth or a secure flash drive. This can result in:

• Seamless data upload into patient charts within the EMR;
• Increased accuracy, since the correct data attaches to the correct chart; otherwise, it is sent to a work que to make corrections;
• Standardized documentation between multiple practitioners;
• The ability to provide discrete follow-up values/data points (eg, shocks, percent pacing, thresholds, etc.), a standard, paperless process for industry that will not participate in IDCO, and physician professional reviews and signatures;
• Non-credentialed staff are allowed to complete chart prep for review by credentialed clinicians;
• An accurate database for advisories or recalls using the implant list and discrete data flowsheet;
• Decreased costs directly related to the ability to sunset optional software systems that may add up to $10,000 or more annually; also, a decrease in staff related to efficiency.

Clear communication with medical teams. By using EMR tools for communication, one can benefit from: 

• Direct data importation that allows for improved communication between the patient, provider, and device clinic; it also provides an electronic trail and sequence for communication to patients;
• Direct scanning into the implant list for importation of implanted hardware including model information; serial numbers trigger the security and accuracy of the system;
• Standard language and workflows that create clear communication.

A standard software language to connect to EMR systems. IDCO implementation offers direct standardized charting related to data points that attach to a flowsheet with the entire report that presents the patient name, model, and serial number match. IDCO demands initial EMR modifications and IDCO design specifications. The IDCO configuration allows immediate connectivity between industries with both programmer and remote monitoring technology that flows directly to the EMR. EMR alterations include new orders and visit types. The key drivers to secure complete accuracy include the closed loop of the implant list and an error work bin. As a result, one can benefit from:

• Increased efficiency and directly decreased costs due to paperless processes that make it possible to accomplish more with fewer staff members;
• Better accuracy and standardization between different manufacturers, as well as multiple industry support for this workflow;
• Decreased costs related to second software databases (eg, Paceart Optima [Medtronic] or ScottCare);
• The ability to allow for all types of remote monitoring, CIEDs, and implantable loop recorders to follow similar workflows.

Our Experience with IDCO Workflow

Implementing the IDCO workflow has helped our device clinic for the past 5 years eliminate patient record errors, remove the need for a separate software database, allow for a discrete data resource section for research, and provide rapid query ability for advisories. In addition, it has allowed us to decrease documentation time and paper use for both in-clinic and remote monitoring. We benefit from 100% accuracy, extensive efficiency, reduced costs, and increased patient safety and data security. The IDCO workflow is a completely paperless system that meets all of our billing requirements when integrated into our EMR system. The true IDCO efficiencies presented with our seamless transition during the COVID-19 pandemic as our team shifted to offsite work completion. With the solution in place, we were able to trim between 10 and 20 minutes off the time it took to document both in-clinic and remote checks, giving us more time to focus on what matters most — providing excellent patient care. We hope that IDCO technology can serve your device clinic too, and be a gateway to standardize CIED processes for all types of device patients within the mandatory EMR systems. 

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