Remote Monitoring Workflow in EP: Challenges and Opportunities

In this episode of The EP Edit podcast, we’re featuring a discussion about remote patient monitoring in cardiac electrophysiology. Martha G. Ferrara, DNP, FNP, CCDS, FHRS, Assistant Director of EP Services and Practice Manager at White Plains Hospital Center in White Plains, New York, and Anthony Mercando, MD, FACC, FAHA, from White Plains Hospital Physician Associates in White Plains, New York, and Associate Clinical Professor of Medicine at Columbia University Vagelos College of Physicians and Surgeons, will be discussing how remote monitoring has evolved over the years, their own experience and best practices in their remote monitoring clinic, and the latest technological remote monitoring tools.

You can now listen to this episode on Spotify and Apple Podcasts.

Martha G. Ferrara, DNP, FNP, CCDS, FHRS: Thank you so very much, Jodie, for inviting us to be part of this podcast. My name is Martha Ferrara, I am the Assistant Director of EP Services at White Plains Hospital in New York. We have a remote monitoring program for cardiovascular implanted devices that is very robust. We follow the 2015 Heart Rhythm Society (HRS) consensus, which has given us a guideline for remote monitoring of patients with pacemakers, defibrillators, and loop recorders, and it is standard of care. We are following close to 1000 patients and it is a full-time job. I have an infrastructure that has different team members that allow us to do this every day. Remote monitoring is very different from when I started many years ago and it has evolved very much so — the technology and connectivity gets better. So the challenge is being safe when we follow data that is [coming in on] almost a continuous basis. I'm not sure if there is a way that we can staunch the data deluge that we get, but I think that we are trying to address this, not just from our healthcare system, but I know HRS also has very much vested in keeping up with the technology, especially now that we are not just talking about pacemakers, defibrillators, and loop recorders, but we are talking about other data that comes from wearable devices. I'm going to let Dr. Mercando tell us the way that he follows, the amount of patients he follows, and what sort of infrastructure he has in his clinic. For me, I have a remote monitoring team, so it's about five to six of us that do this daily, including weekends.

Anthony Mercando, MD, FACC, FAHA: Jodie and Martha, thank you very much for inviting me to be part of this conversation. I'm a little unique in the field of remote monitoring. I am a general cardiologist in practice in Westchester County, which is north of New York City. I've been doing pacemaker monitoring now for over 35 years, including 33 years in clinical practice, and I've seen it evolve a lot over that time. But the majority of my time, about three-quarters of my time, is actually spent still taking care of patients.

I'm in a practice of five cardiologists. We follow about 450 to 500 pacer, defibrillator, and loop recorder patients. They're mainly patients of the five of us in our practice, and so that makes it a little bit easier logistically. Communication is completely open. I just walk down the hall if I find a problem with somebody's pacemaker or defibrillator that is being managed by one of my partners. We follow these patients both in the clinic and remotely.

Right from the beginning, I've been a big advocate of remote patient monitoring. We started out many years ago with transtelephonic monitoring, so I've been pushing remote monitoring for many years. In my practice, it's the norm to recommend remote monitoring to every single one of our pacemaker patients, so we follow between 90% and 95% of them remotely in addition to in the office, and I think that that is key.

The way our clinic is set up is I usually see patients in the office for in-office interrogations a half day a week. I have the assistance of company representatives, although I see every single patient after they have seen the patients first and checked thresholds, etc. I talk with every patient and go over the results with every single patient, but the assistance of the company representatives really helps to leverage my time. In my clinic, I have one nurse who spends about one-quarter of her time assisting in the clinic. She assists by making appointments and by following up after I have read a remote follow-up. I see every single one of the remote follow-ups in my office. She will then call the patients back to let them know that everything is okay. Obviously, if there is an emergency, we handle that differently. I might give the emergency to whichever one of my partners is following that patient, or I will deal with the emergency myself.

We use a data management system, which I think is key to being able to leverage my time to follow this many patients. We happen to use Paceart (Medtronic), but there are several other ones out there on the market, and I would highly recommend using one of these management systems. It certainly makes the follow-up a lot easier and more uniform from company to company.

Ferrara: I agree with that, Dr. Mercando. It sounds to me like the infrastructure that you have is similar to mine. We presented an abstract at Heart Rhythm 2019 on the staff ratios needed for safe remote monitoring, and there is positive data in that respect in our field. The technology in remote monitoring, especially with the past year that we have had, has become even more important, I think, to be able to be connected in one way or another. Now, we had a real pandemic that occurred globally, and so those patients that were remote monitored, we did not skip a step in following those patients — quite the opposite — and I think that that is the experience of most of us who are in this space. It reinforced just how incredibly important it is for the technology to be leveraged. I think that the pearl is that patients get the importance of remote monitoring more than they have in the past. The infrastructure that we have is pretty much what you are reflecting from me, and it’s very reassuring to hear that you are the red-alert, clinician manager of all the data that comes in. So you have about 400 to 500 patients, you, and an admin, whether that admin is the nurse, clinician, or also the person that will schedule patients. So there are two people doing your remote monitoring program, which I've heard so many great things about.

I'm so glad that you accepted this invitation, because I want to know best practices from all of us who work here. Sharing best practices throughout the country, about all that we do, also gives ideas to others. I mean, there is always someone acting exactly the way you are acting. For example, when I am the red-alert manager, I disseminate that information to either my attending EPs, the patients we follow, or the cardiologists that allow us to follow their patients. I think it's an incredibly high-level, important job, because you have to now decide whether you are having a pacemaker implanted in this patient because of a symptomatic pause or there is ventricular tachycardia or atrial fibrillation. So it's a really important job. The infrastructure will save you. The data management system that I call an electronic pacemaker record (EPR) is crucial, because automation of getting the data in so that you can actually follow your clinical pathway is important.

There was a great paper written by Dr. Sei Iwei from Westchester Medical Center called "Remote Device Monitoring: Be Careful What You Wish For."¹ I highly recommend that paper to everyone, because he is expressing and putting down on paper everything that we go through. There is another paper that I think is also very crucial in this space. It was written by Amber Seiler and colleagues, and it's called “Clinic Time Required for Remote and In-Person Management of Patients With Cardiac Devices: Time and Motion Workflow Evaluation.”² I think we will be seeing more of those papers and I would love to write a paper with you on how we do what we do, because the more we inform those of us who are here, I think the better we all are as team members trying to service our patients.

Mercando: Yes, those are all good points. I think the first thing about remote monitoring is you have to buy into it and realize that although it does seem to increase the workload, it's actually reducing the workload. There have been several papers that have shown that over the years. We are actually leveraging our time better by having fewer in-office visits and by being able to quickly read a report that is presented to us by whatever data system we're using, whether it's a data management system such as Paceart or Murj. But it does result in fewer visits by the patient in the office. It also results in faster response time to problems and alerts, especially with wireless telemetry, which has evolved over the years.

We could talk about the way that remote monitoring has evolved over the years. It allows us to use pacemakers and defibrillators for other things, rather than just monitoring the leads and batteries. Remote monitoring could also be used for arrhythmia and heart failure monitoring, and these are benefits that we didn't even imagine in the early days of remote monitoring. It allows for earlier event detection and proactive changes in medical therapies, including heart failure therapies in a lot of cases.

Also, I think patients benefit, because they feel they're in touch with their physicians at all times. I think most patients like the follow-up and the knowledge that their physician can find out if there is a problem or an arrhythmia, and I think this increases patient satisfaction.

I can give you many examples of these benefits. For instance, a patient that I follow was discharged from the hospital after surgery. He was in the hospital for prolonged surgery. He went home and within minutes of his getting home, I had a text message on my phone. The representative had a message and my fax machine had a message telling me that the patient's defibrillator had been turned off. So we were able to immediately bring him into the office and turn it back on. This is something we never would have had without wireless telemetry. In addition, patients are amazed when I might call them up and say, tell me what happened to you just now, and they say, "I was in bed and I felt a jolt in my chest." I just told them about the shock that they just received — this is all made possible through remote telemetry.

Several studies have shown that there is a reduction in the time to diagnosis of arrhythmias, reduction in emergency room visits, reduction in overall healthcare costs, reduction in time spent by clinic staff following patients, and even reduction in all-cause mortality. So I think that all of these benefits accrue when we adopt remote monitoring as uniformly as possible. I think that most electrophysiologists have bought into this. Many of the physicians who do general cardiology, who also follow pacer patients, have started to fall into this too. I think it's a real benefit to our patients.

Ferrara: I agree. Many years ago, the norm was to bring patients in every three months. I think that having the capacity and the technology that we have now with wireless telemetry, any alerts (such as advisories) from the companies while the patient is on remote monitoring is an added safety net that the patient feels. Because when you tell them, "The company has issued an advisory regarding the battery longevity of your pacemaker, and we know you're dependent," they truly do get frightened by that. So when you have that added educational piece that you can provide for the patient regarding how important remote monitoring is and how it can inform us, they feel they have an extra safety net. If there is an issue, I will know about it.

That is why I think that when we do remote monitoring now, it is a complete job description. It is no longer something that we can do in-between patients, during lunch, just pick it up an hour before you leave — it no longer is that. It's exactly what you and I do. Every day, I log into my electronic pacemaker record in the data management system that we follow. We have all the companies dropping data into this one system — that is crucial for anyone doing this. So you go in and look at your alerts, and that is what you address first thing in the morning. When patients get that phone call and they haven't felt that atrial fibrillation [episode], now you have to say, "Well, you do need to speak to your cardiologist, because we're now looking at blood-thinning medication." It gives me an opportunity to educate that patient, and not only on the importance of having kept that monitor connected. I always thank the patient for doing that, because none of what we do is possible at all without that connectivity being live. For me, with nearly 1000 patients — I just actually ran the numbers before we started the podcast — and it's about 91% to 92%. I don't think that's good enough for me — I’d prefer it to be more like the connectivity that you have, Dr. Mercando. I think yours is way higher than that, and that's what I'm aiming for. Something over 95% to 98% would be fantastic. That is basically what I drive my team to do every day, because patients don't know if they're not connected. That is changing now with telemetry and the patient apps that we're starting to see from companies. I don’t know if this has been your experience lately with the new apps?

Mercando: Yes, it is. One other point I wanted to make about something you mentioned is recalls. Of course, it certainly allows us to follow patients who have either recalled devices or alert generated transmissions from recalled devices. The next step, and we're already seeing this with at least one of the recalls, is to proactively analyze the data over time to try to predict when a device will fail based on one of these alert problems, to inform us ahead of time that this is a device that may be subject to a recall or may have a problem in the future. I see at least one of the recent recalls is utilizing that, and they're utilizing data management on the company's end to alert us to potential problems. In other words, predictive analytics based upon the data that's coming in. What do you see as some of the challenges to remote monitoring that we are facing right now?

Ferrara: I think some of those challenges are from old history and patients not knowing what remote monitoring is. I work in a very underserved, underinsured population, and so I have found that invariably, it is just having that dedicated time for the patient, even if it's 15 minutes, to educate them about remote monitoring. The other challenge that I find is the billing aspect of remote monitoring, more especially, with loop recorders. That is a work in progress with my healthcare system and our billing department, because I find that I need to educate the billing department as well as the patient as to what this is, because billers don't know. So it is a bit challenging, but I've never disconnected a patient for billing issues. I'm always trying to find solutions for this, because if the patient had a stroke and they're 75 years old, I then have to educate them about what that means and what we're looking for.

I find that patient education is crucial and that is the issue sometimes. I've spent an inordinate amount of time with some patients who call because they're disconnected, because back when they received this device, either by another physician or someplace else, that educational piece was missing. As a nurse practitioner, that is a fantastic way to bond with the patient.

The other challenge that I find is trying to explain the technology, because we are in such influx now from the different companies. They're all trying to navigate the same way we are — this remote monitoring will work but it won't work if it's this way, or if it's that way, then try the app. Some of these patients are elderly and they don't want to deal with the app, but the families do. So I just think it's a challenge for all of us, not just clinicians, but for patients and companies as well. Let's find something a little more uniform and let's just stop changing so much, but I think it's just to do with the technology.

Mercando: Right. I think that one of the biggest challenges that goes along with what you just said is the data management and the sheer volume of data that's coming in. That's why I find that using a data management system, such as Paceart, really helps a lot, because it's presenting the data to me in a uniform fashion. So I know where to look to see the automatic threshold that was just determined, I know where to look to see what the battery issues are, and I'm very familiar with every company's report, but I don't need to be as familiar with each individual report if I'm seeing the patient aggregated to me. I think in the future, we really need to address how to manage all this data, especially with implanted loop recorders.

As people who follow remotes know, there are many false positives with implanted loop recorders. We receive many alerts that are really noise or inadequate sensing of QRS complexes. This is something which needs to be addressed by the companies, and we need some help with this. I do feel that artificial intelligence (AI) is the next step and will need to be built into a lot of what we do here in order to help us to get out of this mountain of data that we have.

The other thing that you mentioned, of course, is the billing. A lot of people shy away from remote follow-ups because of the complexity of the billing. A lot of people don't understand the billing. Remote follow-ups are really billed on an interval basis rather than on a one-off or two-off basis of reading a report. So it is possible and allowable to bill as a monthly interval, let's say, for patients who have a loop recorder or who have heart failure devices. That means that the bill is sent once a month, or every three months for other devices, and it doesn't matter when or how many reports came in during that interval time, if you're billing for intervals. That is really the correct way to bill.

I think a lot of us have challenges dealing with billing departments, whether it's in our own private practices or whether it's in my group, for instance. I've really had to spend a lot of time with our billing people, because almost no other procedure is billed in this fashion. But it does reduce the complexity of billing if it's done on an interval basis, which is allowed by Medicare. It's something that I would highly encourage you to all take a look at and try to get your billing people into that kind of format.

Which brings me, I suppose, to the protocol for follow-up. I think different people use different protocols for follow-up. I'll tell you what mine is, which pretty much follows the 2015 HRS guidelines, and maybe you can comment on yours. We standardize it pretty much for pacers and ICDs. Although the guidelines suggested that pacers don't need to be done as frequently, for standard purposes, we pretty much do it this way in the office every year and remotely every three months. For heart failure patients, the follow-up is every month. Although again, the interval billing is different than for two of those three months, and there is a bill that would be generated for the remote follow-up itself every three months and then the monthly follow-up for heart failure is generated slightly differently with different codes.

Implantable loop recorders are monthly. We follow those patients monthly, but of course, if an alert comes in, it comes in. Most of the transmissions I receive on loop recorders are not the monthly transmissions, they're actually the alert transmissions. But theoretically, wireless devices are being followed continuously, and we can receive an alert any day of the month or quarter, so you need to have of a way of dealing with this and of following alerts that come in. I literally have received alerts when traveling abroad and I deal with those alerts by sending them to my associates who are working at those times, and that is how we deal with it. But again, every practice will be different. If you are a practice following patients from many different cardiology practices, you have to have a way of reporting these alerts to the cardiologist so that he or she can follow up on the patient in a clinical fashion. Do you follow these guidelines pretty much?

Ferrara: I do, that is exactly the best way to do it. I find that patients are now more savvy to address one of the bullet points that we had discussed about the data that we receive and the data that we send to the referring cardiologist or primary care doctor. That data is blinded to the patient, and patients getting more and more savvy about this, saying “You are charging me on a monthly basis and I don't even know why I'm getting this bill.” I think that's a fair point. I really believe that if you are going to follow patients and bill them, but they are blinded to what you're doing, it shouldn't be an esoteric concept — they should know why this is happening. So I think that those patients that are more savvy want to see their data.

When that has happened with the patient, that bill suddenly becomes something that is not irrelevant, but not as important, because they see the report that we post to our electronic medical record (EMR), which is the way that I communicate with patients now, because it's truly impossible for my healthcare system, my team, and the infrastructure that I have in place for my remote monitoring team to call every single patient or to generate a letter. What I'm trying to leverage is the technology that we are all now accountable to, especially with the CURES Act that was passed, so that patients have access to their data.

So I ask patients to please become part of the patient portal. We ask patients for their demographics when they come to our office, including their email addresses. The system automatically sends a link where they can become part of the portal. When they do that, they are able to look at that report that I post, and I tell them that. I say, you won't get a letter from me, but this is the only time.

I don't know if you do this, Dr. Mercando, but the way that I still work with my remote monitoring system program is when I see something, I say something. Because this way, you will never miss my call. You know, if I'm calling you, I have seen something that we need to speak about, and you will still have access to your data. If you become part of the portal, you can see all the normal reports that I send to the physician that you've asked me to involve in your care.

With patients, I see their demeanor changing. So, I like the fact that you're a great advocate of patients having their own data. I think that it just makes that relationship a little more trustworthy for patients that we are doing what we are doing and that it should not be a concept that they're not a part of.

Mercando: Absolutely. I have some patients who, if we don't inform them either through the portal or by telephone within a few days of their scheduled appointment — and they get a schedule from us, even though we're literally monitoring in real time, we tell them when we're going to be doing the official transmission in that three-month period — I'll get a call, email, or message on the portal from them saying, "Hey, what did my report show?" I think that they really do like to know that everything is going okay with this device, which they can feel, but they have no idea of whether it's working or not.

That's one thing that I believe that the future is going to be more remote monitoring through cellular phone app-based technologies, for a couple of reasons. First of all, assuming that the app is activated, most patients walk around with their phones at all times, so there's no problem such as, “did you unplug the device accidentally to plug in your hair dryer or another device in the wall? The phone is there with you all the time and will always send back. The other thing is the opportunity to be two ways with the patient, so that we could send information to the patient through the apps. Thirdly, in some cases, with select patients who really want to know and can use the information appropriately, we can actually have the app alert them to problems. For instance, if this is a patient with known paroxysmal atrial fibrillation and they're having an arrhythmia, to let them know right away that they're having the arrhythmia. It’s sort of like the Apple watch, but this is much more accurate. That alert can be sent to them immediately on their phone. I'm a big believer in giving this data to the patient as soon as possible. Again, although some patients would prefer not to have the data — they'd rather talk to someone in real time or later on after the event has occurred — I find most patients really do want their data.

Ferrara: I agree with that. I think that the challenge for us clinicians, our healthcare systems, and the companies out there is to help us do this job better by allowing the redundancy of false alerts or data that we have. Be minimal, because there are too many barriers to get to the real events if you have 100 false alerts on the same patient. So I think companies are working very hard on AI, like you were mentioning. I think that we all know now that this is not an answer that will come from one person, one team, one healthcare system, or one company. The answer that needs to come has to be a team approach answer. It will take all of us at this stakeholders table to come up with an answer that will allow us to do what the goal of remote monitoring was 15 years ago when we started to do this, in that it will allow for action on this event that was real, to then deliver better patient care, to not burden our healthcare systems so much, and deliver quality of life for our patients. I think that that really is the goal and it's an achievable goal of remote monitoring. We can do it.

Mercando: I agree. As you know, Martha, artificial intelligence is a passion of mine. I'm an electrical engineer. I am a geek from way back, and one of the things I do in my free time is artificial intelligence. I really think that applying machine learning and predictive analytics to the data that we're acquiring through remote telemetry, especially wireless remote telemetry, holds a lot of promise in terms of diagnosing problems with the devices, diagnosing arrhythmias in a more intelligent and expeditious manner, and also in communicating the information to the patients and also to the physicians and clinicians caring for the patients, so that we can act faster. So, I do think that is the future of remote monitoring. If we want to talk about this in five years, I'm sure we're going to have a lot more to say about this.

Ferrara: I agree.

Mercando: Martha, thank you very much for inviting me to do this, and Jodie, thank you also. It's been a real pleasure. I love talking about this. This is one of my passions and something I've been doing for a long time, and hopefully will continue to do for a long time into the future.

Ferrara: I'm incredibly honored that you agreed to do this podcast. I'm very thankful for Jodie, who is always out there for clinicians to bring the best and latest practices that we have into EP Lab Digest. It's a magazine that I read every time it comes out. It's fantastic, it really is. It just informs us all in a very digestible way, because you just want to know what everyone else is doing out there, what are best practices. I'm incredibly honored that you are going to do this with me, Dr. Mercando, and I will be a geek in this space with you. Let's regroup in three years to talk about it again and see what we're doing then!

Mercando: Yes, that's a deal!

Editor's note: This transcript have been edited for clarity.

References

1. Iwai S, Frenkel D, Jacobson JT. Remote device monitoring: be careful what you wish for. JACC Clin Electrophysiol. 2021;7(2):235-237. doi: 10.1016/j.jacep.2020.09.033  

2. Seiler S, Biundo E, Di Bacco M, et al. Clinic time required for remote and in-person management of patients with cardiac devices: time and motion workflow evaluation. JMIR Cardio. 2021;5(2):e27720. doi: 10.2196/27720