Device Clinic Optimization With CV Remote Solutions: Remote Outsourcing, Consultation, and Heart Failure Management

In this interview, EP Lab Digest talks with 3 clinicians about their use of remote monitoring outsourcing, device clinic consultation, and remote management of heart failure (HF) devices through CV Remote Solutions. John Rogers, MD, associate chief of cardiology and director of cardiac pacing and tachyarrhythmia device therapy at Scripps Clinic Medical Group in La Jolla, California, shares his experience with remote monitoring outsourcing. Cheryllynn Waymack, MS, associate director of the Heart Institute at UW Medicine in Seattle, Washington, discusses device management from an administrative standpoint. Beth Davidson, DNP, ACNP, CCRN, CHFN, FHFSA, is the immediate past president for the American Association of Heart Failure Nurses, and director of the Center for Advanced Heart Failure Therapy at HCA TriStar Centennial Medical Center in Nashville, Tennessee; she describes the value of remote monitoring for HF.

When you decided to outsource, what made you decide on CV Remote Solutions as your vendor?

John Rogers, MD: We decided to outsource when our device clinics expressed concern that they were understaffed. In recent years, we lost 2 of our 5 physician assistants in the device clinic—one moved away and the other decided to work somewhere else. We began seeing a backlog, which concerned us. In assessing different outsourcing companies, I was looking for one that I had some experience with and that also stood behind their work. Most importantly, I wanted to make sure I could trust them with the remote monitoring of our patients. We decided on CV Remote Solutions because of the longstanding work of James Allred, MD, and Amber Seiler, NP, who are the founders of that company. All it took was a simple phone call, and they immediately began working with our team to assist in our remote monitoring needs.

What were the top considerations when choosing a remote outsourcing vendor?

Rogers: One of the first aspects we looked at was the vendor’s track record, including how successful they were with other practices that were similar in size. We knew we were going to be needing some help following approximately 4000-5000 patients, so it was important for us to know if the remote outsourcing company had that kind of experience.

The second consideration was open communication. Knowing the people at the company and having the ability to communicate back and forth was an important factor for success.

Finally, since we’re used to running our device clinics in a certain way, we wanted to be able to articulate that to the vendor in the hope they would be able to accommodate how we like things done. We did not want to give up complete control. That is why we ended up choosing CV Remote Solutions—they were able to meet all of these considerations.

Do you feel that a clinician-owned remote outsourcing company is important? If so, why?

Rogers: Yes. Knowing that the clinicians who own the company have experience, credibility, and reputation is important. I believe a clinician-owned remote outsourcing company is focused on not only the business aspects of the company, but also the quality of their services. Other companies may not be as invested or have the same understanding of our needs. A clinician-owned company has typically been in the trenches and understands what needs to be done.

What have you found most valuable in a remote outsourcing partnership with CV Remote Solutions?

Rogers: Having open communication with the CV Remote Solutions team has been so helpful—we can go to them with any questions and they are always willing to help. CV Remote Solutions is not a cookie-cutter remote outsourcing solution—they really do help develop solutions with the people they’re working with. When I started talking with them about helping us do remote monitoring, they came up with solutions based on our practice situation.

Another valuable aspect about our remote outsourcing partnership with CV Remote Solutions is that it feels almost as if they’re an extension of our team. From a team standpoint, they have been a lifesaver in terms of staffing, because while we’re now trying to hire more device clinic staff, it can take some time to onboard people. Remote outsourcing with CV Remote Solutions helped us not only with a temporary fix to get us through this rough patch, but we’re also now seeing the advantages of remote monitoring of our patients, allowing our team to focus on in-office patient evaluations and follow-up checks.

What have been the biggest opportunities with device clinic management in your program?

Cheryllynn Waymack, MS: Northwest Hospital and the main campus of the University of Washington Medical Center integrated as one hospital with 2 campuses in early 2020. As an integrated academic medical center, we needed to manage implants from 3 hospitals, including UW Medicine-Harborview Medical Center, UW Medical Center-Montlake, and UW Medical Center-Northwest. So, one of our challenges was learning how to successfully manage patients in a high-volume setting across multiple locations.

We also found it difficult to find training for the monitoring services of these implanted cardiac devices. It takes about 6-8 months of training before staff are able to get some of their foothold in this skill. There were not a lot of schools providing this specialized training, so it fell on individual institutes to train and develop their staff. As you can imagine, taking 6-8 months to get that support was too long of a time period. As we trained people, we realized we were competing with industry as well, because they also use those same individuals for their support of implanted devices.

We knew that “home growing” these opportunities was not going to be a sustainable solution, so we started researching different options to find out what else was out there and how other groups were taking on this challenge. That is when we started looking out to the market to see what companies were out there and what other academic medical centers similar to our program were using.

What were the deciding factors when choosing to pursue an outsourcing partnership?

Waymack: We were looking at a couple of different components. We were looking for outside support that had worked in a similar environment such as an academic medical center, but also that had experience with our clinic size, volume of patients, and type of patients we manage. We wanted a company that would be a good match for us.

References were also incredibly important, as we wanted someone who was established. It was important for us to know where else they were being used, how they had proven to be successful, and the lessons they had learned. Coming from an academic medical center, we have unique needs, so we were interested in knowing the size of programs that they have managed before and hearing reviews on the services they offer.

The other factor that we looked at was the software platform that would be used. There are multiple vendors with implanted devices, and we needed a company that would work with one platform, since going through all of the different vendor sites daily is not very functional. We wanted a vendor with a standardized solution that could pull that information into one platform to allow us to look at trends, patient tracking, and analytics. We didn’t have a specific platform in mind and were open to what was out there. CV Remote Solutions was able to meet each of these 3 deciding factors, including the type of monitoring services, how the information was pulled into a platform for us, and how that platform would then integrate into our Epic system.

What top 3 considerations would you recommend to other clinics who are exploring the option of outsourcing?

Waymack: First, I would recommend that clinics have a good understanding of their program and know what services they’re looking for support in from their vendor. There are a lot of different choices available. For example, do they need customer service support to contact patients who’ve been disconnected, or are they looking for a company that can help with remote reads and provide support with transmissions? Are they also looking for a company that will clinically step in and help establish clinical protocols for their program? It is important to start with an understanding of where the gaps are in the current program, as we found the services offered and cost varied by company.

From there, I would recommend looking at the quality components. When looking at the references, find out if the company provided good support from a clinical point of view in addition to customer service metrics.

Third, look at your cost structure and what you financially hope to achieve. Evaluate whether the current financial model of your program is sustainable and if the cost of outside support will be financially sustainable.

When thinking about navigating change within your team, what has been most successful?

Waymack: When we started this process, it was natural to want to hold onto the way things had always been done. We questioned whether we could trust in a different way of doing things. What really made this change successful is that the decision was made not only by administration, but with the help of our team. We brought them into the decision-making process by asking them about where the current gaps were and what could be improved. By including them in this process, they were able to see that this would be an addition to our team and that their ideas were valuable. We included them in the selection process so they were able to ask questions and provide feedback. Our team also participated in all the implementation meetings. We did this across all of our campuses, bringing in key stakeholders for each one. Therefore, it was not only our administration driving it, but our team as well, and this helped pull everyone together. As a result, we had a lot more standardization at the end. Previously, we had been doing things slightly differently at each campus, so this change really helped us come to a more standard approach with communication and documentation of patient care.

What is most valuable about the collaborative care between EP and HF in the care of your patients?

Beth Davidson, DNP, ACNP, CCRN, CHFN, FHFSA: The complexity of HF care is increasing with the advent of both new medical and device therapies. HF does not occur in a silo—patients have multiple comorbid conditions requiring care by many different providers, including EP. Patients are often confused about self-care directions—who do I call if my weight goes up, if I get short of breath, or if my ICD fires?

EP and HF are so connected, therefore, care coordination or collaboration can “streamline” workflow and communication for both groups, which also improves the patient experience and patient outcomes.

I believe we have made some valuable progress between the EP and HF communities. However, we still have work to do to figure out how to make that easier for both groups.

What benefit have you seen to having HF diagnostics available for review for your patients?

Davidson: Two of the most commonly reported symptoms of HF are shortness of breath and fatigue. These nonspecific complaints can be due to HF or from a variety of other issues. We know that congestion or volume overload is the most common reason these patients are admitted to the hospital.

Eliciting the most accurate history and performing the physical exam, even for expert clinical teams, can be really challenging. HF clinicians are always trying to measure jugular venous pressure and assessing for other clinical signs. Clinical trials have shown that even HF teams can sometimes misread these signs and symptoms.

Remote monitoring of HF gives us valuable insight into objective (vs subjective) parameters such as changes in intrathoracic impedance, day and night heart rate, heart rate variability, and many others. We may see those changes 30 days or more before a patient ever develops symptoms, so this helps us to be proactive as opposed to reactive. We can quickly identify signs of decompensation, adjust therapy, and reduce overall HF hospitalizations. During the pandemic, the added benefit of remote monitoring also offered a great way to supplement virtual visits when the physical exam was essentially impossible.

What were the barriers prior to CV Remote Solutions providing this data?

Davidson: I think the biggest barrier was that while clinicians knew this was valuable data, we still had to get buy-in from administration about outsourcing and why it was needed. I explained to them how it was valuable for the patient, what the limits were in our current workflow, and how this could be used to help manage volume and resources in the clinic. I discussed how this was similar to what our EP counterparts were already doing in helping to manage their device diagnostics. I made sure that administration understood the logistics, such as how we would schedule the remote checks, how we would bill and document, and how this would be incorporated into the electronic health record (EHR). In addition, I demonstrated how we needed better access to this data in real time, since not every patient seen in clinic can be sent to EP for device checks without also significantly impacting the EP workload.

Once we had buy-in, we had to figure out the logistics of how this solution was going to look for our practice. How would we know who was getting a device check that day? How would this be pulled into the EHR? Our vendor, CV Remote Solutions, had a lot of experience with this and made it really painless for us. We met with them a couple of times to figure out a workflow that not only worked for us, but also gave us the information we needed and met the billing and documentation requirement. It will not look the same for every clinic. CV Remote Solutions can customize a solution that works for your specific team.

What have you found most valuable in CV Remote Solutions helping with HF remote monitoring?

Davidson: Having an experienced, skilled set of eyes to review the HF diagnostic report makes us more efficient. The diagnostic reports are sent electronically to our team, and if everything is within normal limits or the patient is at baseline, we simply sign the report. For patients who are highlighted as having high-risk markers or changing parameters, we know to provide these patients with immediate attention. This is essentially serving as a risk stratification tool for our patient population.

I think teams sometimes get worried about having more data than they can handle. However, having a remote monitoring solution in place helps us focus on the 10% of patients that need closer attention. We feel like we are in better control.

An unexpected benefit is that patients love it. They see it as an added layer of protection. It creates trust and helps them feel connected to our program. This has enhanced the patient-provider relationship.

What would your advice be to clinics who are struggling with logistics of HF remote monitoring?

Davidson: My advice would be to remember that you do not have to know it all. Whether it is the EP or HF team, you can divide and conquer the work. For example, a device diagnostic report can be routed to the EP team and the HF diagnostics will be routed to the HF team. This can be easily organized so that both the EP and HF teams get their own report tailored to their needs. This allows us to focus on what we do best, and we collaborate with EP when there is a problem. We do not have to sort through EP-specific data in the report, and EP does not have to sort through HF-related data. For the HF team, we trust the data is there and act on it appropriately.

It is also important to establish a workflow that makes sense for your practice. The workflow should be methodical and efficient, and part of the routine. Collaborate with the remote monitoring company to determine the best workflow, because one size does not fit all. We went through a bit of trial and error until we figured out what worked best.

Finally, do not try to manage this all by yourself. I do not know how large programs do that, especially if there are limited resources and staff members. CV Remote Solutions can help manage this piece of the puzzle in a much more efficient way so you are not having to hire one or more staff members. CV Remote Solutions has made this really manageable for our HF team. It has been a win-win for our colleagues as well. If another clinic is interested in outsourcing remote monitoring, they should ask for references and talk to clients who are using it. This is something that is very integrated into your system, so you want to choose a vendor that you consider a true partner. 

This article was published with support from CV Remote Solutions.

Disclosures: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors have no conflicts of interest to report regarding the content herein. Beth Davidson, DNP, ACNP, CCRN, CHFN, FHFSA , reports she is the Immediate Past President of the American Association of Heart Failure Nurses.