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An Innovative Model for Practicing Cardiac Electrophysiology
In this episode of The EP Edit, we’re featuring a discussion on an innovative new model of care for cardiology and cardiac electrophysiology (EP). Dr Moeen Saleem and Dr Kanwar Singh discuss the independent private practice care model at the Midwest Cardiovascular Institute in Naperville, Illinois, and Cardiovascular Institute of the South in Houma, Louisiana.
Listen to this episode on Spotify and Apple Podcasts!
Transcripts edited by Jodie Elrod
Dr Moeen Saleem: I’m a private practice electrophysiologist based in the Western suburbs of Chicago, and I have been in practice for about 18 years. I started off in private practice, and around 2012, we were acquired by a hospital system. More recently, in 2021, we decided to form an independent private practice group. We have about 24 physicians and 14 nurse practitioners (NPs) practicing within 2 hospitals.
Dr Kanwar Singh: I’ve been a cardiac electrophysiologist for more than 4 years, practicing since 2017 at the Cardiovascular Institute of the South. I finished my cardiology fellowship at Tulane in 2015 and followed with EP training at Aurora St. Luke’s program in Milwaukee.
MS: The Cardiovascular Institute of the South has become a national model of independent private practice for cardiologists. Around 2020-2021, our group of cardiologists at the hospitals that I practice at started looking at options to become independent. This was for a variety of reasons, including that it seemed to be a better fit for us long term. My senior partner, Dr Mark Goodwin, who is an interventional/structural heart specialist, had a relationship with the founder of the Cardiovascular Institute of the South, Dr Craig Walker, as well as its CEO, David Konur. They served on an advisory board for Philips, the triad model of health care providers, hospital administrators, and industry specialists. It was a think tank advisory board for solutions to make health care more efficient. That is really the goal of private practice: to optimize operational efficiencies, deliver high-quality care to patients, and have good work-life balance. Dr Goodwin, with his contacts at the Cardiovascular Institute of the South, made a couple of visits to the practice and said, “This is the model that we need to implement in Chicago.” I went on their website and realized I already had a digital world connection with one of the EP doctors (Dr Singh). I messaged him that we would be coming to visit, and asked if he had time to talk about his perspective and experience with Cardiovascular Institute of the South, including what attracted him to join that practice out of fellowship.
KS: To give some background about the group here, it was founded in 1983 by Dr Walker, and has since spread to about 10 locations in Mississippi, Louisiana, and the Midwest. The total number of cardiologists is close to 64 overall. In my group, we have about 9 cardiologists and 2 electrophysiologists. It is one of the biggest private groups at present in a herd of groups being overtaken by hospital employees, and that model has been shifting throughout the country. It’s a unique practice group. When I started the EP practice here, we had mostly cardiology, interventional, and a significant volume of peripheral arterial disease cases. Complex EP procedures were being sent out. Since then, complex EP procedures are now being done locally in Houma—from ablations to lead extractions, epicardial ablations, and left atrial appendage closures—the whole gamut of EP procedures.
MS: What intrigued me about the practice model and what prompted me to call Dr Singh was when my partner, Dr Goodwin, came back from the site visit and reviewed our workdays, workflow, and the efficiencies of our work. For example, we would see 25 patients and be lucky to be done by 6:00 PM with the electronic medical record (EMR) and clerical work that came along with routine clinic care. He asked, “What if I told you that you could see 40-50 patients and be done sooner?” I said, “There is no way that’s true. I don’t believe it for a second.” We also take general cardiology calls, and some nights we can take 25-50 phone calls. Dr Goodwin said, “What if I told you that you could be on call and take 0-3 phone calls?” I responded, “That’s impossible. That does not exist.” When I called Dr Singh and asked about his workdays and clinic days, he said he usually sees 30 patients and is done before 5 o’clock. I asked how he did that—he had just completed a full week of call. I asked, “Did you work during the day?” He said, “Yes.” I then said, “How many calls were you getting per night?” He just laughed and said, “Between 0-1 phone calls over the course of the week.” So, everything that Dr Goodwin had said was 100% consistent. There were clearly some operational efficiencies and an improvement in work-life balance as well. Time is a fixed commodity, and for health care providers, it can be difficult to have extra time with our family. Yet, they had cracked the code and were still able to maintain an efficient care model. That was my initial impression and everything was confirmed on the site visit. Dr Singh, can you elaborate on what your experience was coming out of fellowship and now 4 years into a busy and successful EP practice?
KS: In 4 years, there have been more changes that we have made to the practice as well. When I started, efficiency in the clinic was already one of our big priorities. Patients were seen with a rapid intake, quick visit with the physician, and a rapid discharge with the help of the whole team. One of the things I found was important in improving efficiency was how many people were working in the background to help quickly get the patient in and out. Two licensed practice nurses work with the medical technician to get the patient triaged, doing the electrocardiogram device check and getting the device programmer in the room, so by the time the physician enters, the device is already checked. Then, when we make our assessment and plan, and the nurses take over from there and follow the orders. Billing is done at the same time as the clinic visit, so you are not left with any work at the end of the day to bill the patients or do the rest of the orders. Once you leave the room, you are done with that patient and can move on to the next room to see the next patient. It is a very efficient model.
To follow a similar efficiency in the hospital setting for call, we had to make a transition there as well. In our first year of practice, we had a different model, which was NP based. That model worked fine until requirements and the availability of NPs changed. That led to the creation of a virtual care center, which we will talk about in more detail in a minute.
I think one of the main challenges faced is that it’s a very different training model during fellowship. We have more procedure-based fellowship training. Many times, the continuity of care in EP fellowship is not the same as we will have in practice. Once you’re in practice, you encounter the challenges that are going to be faced in clinic. EMR is one of the key factors in efficiency. The medical record system was designed by one of our cardiologists in collaboration with his software team from India. With medical record systems, you can often ask any doctor and get the same answer: there are so many clicks and so many options to go through, that at the end of the day, you are still asking “How do I figure this out?” The medical record system that we use is being designed specifically for the cardiology and EP practice, and it’s very intuitive. There is a limited amount of data that is presented to the user to improve efficiency. The system is designed to meet requirements in probably 10-15 clicks, and then you’re done. When you finish the patient chart, the visit is complete. The nurses will let you know at the end of the day if you missed anything. Combining the EMR with the team of nurses and medical technicians underscores why our clinic is so efficient.
MS: One of the points I wanted to focus on was metrics and what was being tracked by our management team. One of the important metrics is the number of patients who are seen in a clinic day and how much staff is needed to make that happen. There is a lot of staff work that happens in the background in preparing a clinic for a given day, preparing patients and getting ready for discharge. In our previous practice model, we would see 25 patients in a day, we were lucky to be done by 6:00 PM, and there would be 50 patients in a week. Now, we are routinely seeing 80-90 patients in a week. That is a 60% increase in productivity and throughput into my clinic, and I’m finishing by 5:00 PM—an hour and a half to 2 hours earlier than before. Regarding the EMR, computers are set up in the clinic so there is a workstation in every room. I use my badge to sign in and out of every workstation. When I leave one room and go to the next, I use my badge and the computer automatically opens to where I left off in the other room. Without having to log in and open up a chart each time, that translates to about 40 minutes saved per day. And each note is done by the end of the clinic visit.
Continuity is another aspect I want to comment on. In the past, if I would see an initial consult for atrial fibrillation, I would order some testing and then a nurse would call the patient to review the testing, discuss treatment recommendations, and schedule a follow-up. We now have the clinical capacity, staff, and efficiency that when I order testing, I can bring the patient back in 2 weeks later to review in person. That helps tremendously in continuity. Many times, follow-up visits become high-level visits, because based on testing, we initiate a new treatment plan, recommend a procedure, or do additional follow-up tests. All this is possible because of an efficient EMR and appropriate staffing for that capacity. Patients are also happier.
As Dr Singh mentioned, the virtual care center is a 24/7 operation. It’s staffed by NPs, nurses, and telemetry techs. They take our first call at night, so 25-50 phone calls are now down to 0 to 2-3 phone calls. The management team tracks all the metrics, evaluating how many phone calls the virtual care center takes, where the phone calls come from, and the staffing needed according to traffic. For example, there may be one day or certain hours of the day when a lot of phone calls are coming from pharmacies. They’ll understand that they need to staff the refill team to make sure there is enough staffing to cover all the refill phone calls. In the evenings, there may be a lot of phone calls from hospitals about postop orders or test results from inpatients. Based on this, they can develop protocols to make care more efficient, minimize the number of phone calls the nurse has to make, or build protocols to help with decision making. The other thing that the virtual care center does is active management for the patient throughout the night, rather than calling a doctor and waking them up to notify them of a rhythm change or test result. The virtual care center actively manages the patient throughout the night. Testing is ordered earlier as well as completed earlier in the day, and as a result, many patients can be discharged ahead of time if it was an overnight observation. So, metrics that we follow in the clinic and virtual care center can help with efficiency in hospital care.
KS: The virtual care center model was especially beneficial in these last 2 years, during which time we encountered a pandemic as well as a massive hurricane in Louisiana. As a group, we were prepared for these challenges and adapted very quickly. For example, in our medical record system, there is a one-click video or a voice call set up directly to the patient’s cell phone, so it’s easier for patients who cannot physically come to the clinic to set up a virtual televisit. You open the patient chart and click the link, the patient gets the phone call, and you are connected directly with either a video or phone visit. We had this in place during the pandemic when the clinics closed.
During hurricanes, when clinics are closed and patients are evacuated, we can still virtually reach out to quickly fill medications or have virtual doctor visits. The virtual care center is linked to all the patient charts, so even if the patient is displaced, you can quickly reach their charts and establish continuity of care. n
KS: Regarding day and night coverage from the virtual care center, the doctors are available 24/7 as well. But at the end of the day, having a wakeful doctor during the day for those 7 days of call is much better than an overburdened doctor during the day and night. Taking away the burden of phone calls helps a lot. We have guidelines and standard of care protocols for more critical patients, such as established patients with an implantable cardioverter-defibrillator (ICD) who experience a shock. However, most patients will fall into a standard category that can be treated based on an algorithmic approach. Clinical judgment is still needed, and that is why having experienced NPs is important—they know when to contact the cardiologist on call for a critical patient. But for a relatively stable patient, care can be instituted right away and the patient can be stabilized by the time the cardiologist arrives in the morning.
MS: We are always available for any emergency. The difference now is that we get a phone call with all the information ready to be shared with us. When the NP calls us, they have all the patient information readily available.
One of the other ways the virtual care center translates to efficient rhythm management is that we have our own telemetry technicians. Dr Singh has a larger team of telemetry technicians since they have 60+ cardiologists. We have 9 telemetry techs that provide 24-hour coverage for outpatient mobile cardiac telemetry, event monitoring, and Holter monitoring care, so we can provide real-time monitoring for our patients. Last month alone, close to 380-400 monitors were placed on our patients. We track how many monitors were ordered, how long the patients were prescribed to wear the monitor, and if patients wore the monitor for 7, 14, or 30 days. Every month, we know how many monitors were ordered and the average time was 10 days based on the ordering pattern of all the different physicians. We have our own telemetry technicians providing real-time monitoring, and if there is an arrhythmia of concern that takes place overnight, they can review it with the NP on call and contact the physician if needed. It’s an in-house model of providing efficient care and optimizing operational efficiency to give the highest level of care.
KS: In discussing this care model, I think Dr Saleem will also agree that we have better work-life balance having more efficient and less frustrating days, not just at the hospital and in the clinic, but when coming home at end of the day and not having to think about what you missed or could have done differently.
MS: Yes, as someone who has been in practice for 18 years, I have the “before and after” perspective of what it was like to be in private practice for a brief period, then transition to employment by a hospital system, and now I’m back to private practice. I think that corporate systems are here to stay. They’re very big and have to be focused on many things—general surgery, medicine, hospitalists, staffing, and all the strains associated with the pandemic. By becoming independent and having a successful relationship with the hospital administration, we have consolidated and concentrated the voice of cardiology in a true and meaningful team partnership with the hospital. Rather than being individually employed by the hospital, we are now a collective group trying to make the cardiovascular program of the hospital successful. And if they’re successful, we’re going to be successful.
The virtual care center’s coverage of overnight call and helping to lift some of that burden off the physician can also can go significantly toward preventing health care provider burnout, which has certainly been an issue. This model gives us the opportunity for all of those things.
MS: If we can improve operational efficiencies to make the hospital cardiovascular program successful and increase patient access to our clinics—especially as so much cardiology care is shifting to the outpatient side with ambulatory surgery centers (ASCs) and office-based labs (OBLs), which they have experience with in Louisiana and we are in the process of planning here—to have those operational efficiencies and then be able to get home at a reasonable time to be with our family is incredibly fulfilling.
Kanwar, would you like to comment on anything about OBL or ASCs? It’s not a direct aspect of the model, but it’s something that the Cardiovascular Institute of the South has been very successful with.
KS: Right. I think it’s mostly less complex device implants, pacemakers, ICDs, and some less complicated cardiac resynchronization device therapies. It’s still more in line with interventional cardiology procedures, which are more readily available to do in an OBL and ASC. The reasons I think the ASC model works well in EP as well as cardiology in general is because of the efficiency, cost savings for the patient, and for overall health care for insurances, Medicare, and other private insurances. The patient cost is decreased because the hospital cost for procedures is different than the ASC and OBL costs. For patients, I believe out-of-pocket and overall costs are less. There is more efficiency because it is our own staff operating and we are very familiar with the workings of the whole team, physician scheduling is easy to manage, and there is clinic in the same building, so you can have a clinic/procedure day in-between the clinic patients or sometimes in-between the morning and afternoon clinic. So I think the ASC and OBL practice models are here to stay.
MS: Yes, at the moment, it is mostly for peripheral vascular interventions and maybe some coronary angiograms, catheterizations, and such, but EP is moving into that space.
I want to thank the team at EP Lab Digest as well as Dr Singh, my partner in this cross-country practice relationship. I really enjoyed this discussion. It reminds me of the excitement and enthusiasm that we have for making this model successful, not just here in the Chicagoland area, but partnering with you so that we can show everybody in the country that there is something to be said about this strategy.
KS: Thank you, Dr Saleem, and thank you to the EP Lab Digest staff as well. It was a good discussion and thanks for having us today to talk about our model.
