Advice on Patient Education and Remote Scheduling of Cardiac Implantable Devices
What is the best time and place for CIED remote monitoring patient education to occur? Keith Nicholson, CCDS, PrepMD Business Operations Director pointed out that the best time for patient education to occur may be at the wound-check appointment:
“Post-op when the device is implanted, the patient has a great deal of information being thrown at them and it can be very overwhelming. Often, we find that at the wound check appointment the patient will be able to process information more effectively, especially if they are provided with helpful written documentation or FAQs to explain how their monitor works and what the frequency of transmissions will be.”
It’s most helpful also at this point if the patient can also be provided a phone number to the specific clinic representative who they can reach out to if they have questions or concerns while setting up their monitor at home.
Patients are oftentimes confused and afraid to ask questions, so having someone who will patiently address their concerns and walk them through setup can quickly result in compliance improvement. It helps to anticipate what the most common patient concerns are that will need to be addressed.
What are typical concerns of a CIED remote monitoring patient?
Is Vendor Technical Service Helpful for Troubleshooting? Some technical issues with the monitors can sometimes require more in-depth troubleshooting just to diagnose the issue. Patients may be confused if they have to deal with multiple individuals for help with their monitor. In this scenario the clinic may find their disconnection rate is occurring more quickly than their recovery rate. Clinics can and should use the vendor technical service departments for assistance. In fact, Medtronic accepts requests for outgoing calls, where they will place outbound calls to patients to help them troubleshoot with real time instruction. With the other vendors who don’t place outbound calls to patients such as Boston Scientific, Biotronik, Abbott or Merlin, they are always happy to help patients who are calling in for help with reconnecting monitors.
Some patients are much more capable of self-help and other patients may not be technically savvy and may require more assistance. When a patient is directed to call the vendor to troubleshoot connectivity over the phone this can oftentimes be a great success. However, in some cases a breakdown can occur when the patient is asked to call the vendor and they either don’t follow through or don’t have success.
Remote Scheduling Best Practices As far as remote scheduling, usually the best practice is to utilize the smart or automatically recurring schedules that exist within the device company websites. This often helps the patient education process, and the patient knows what to expect in terms of scheduled transmissions and copays. Smart scheduling is easily available under the scheduling tab on most vendor websites. Clinics should ideally always use the Smart Scheduling option to ensure coverage of their patient monitoring. Risks of not having patients scheduled include a potential for clinic liability. If a patient is connected but not scheduled the clinically actionable data could be missed. Even with Alerts optimized, summary transmissions sometimes demonstrate something that is clinically important.
Communication and Compliance: Patient Outreach Communication and CIED Remote Monitoring Compliance
In our last blog post, we discussed the potential clinical and economic benefits of remote monitoring for patients with Cardiovascular Implantable Electronic Devices (CIEDs). However, in order to realize these benefits there are multiple processes that need to be functioning at a high level. Several of those processes involve ensuring patient compliance, as both clinical and financial outcomes depend on consistent, reliable monitoring and reporting. Even though contemporary CIED transmitters and apps can be programmed to automatically communicate with devices and send transmission information to remote monitoring software platforms, disconnected monitors and the resultant missed transmissions are common. Scheduling of routine transmissions can also be time-consuming and confusing, with different processes for different manufacturers and devices. Troubleshooting disconnected monitors involves communication with patients which itself requires skill, patience, and understanding.
At a recent PrepMD RMS educational webinar, Dr. Robert Lerman, Former Chief Medical Officer at PrepMD, moderated a discussion on Remote Monitoring Compliance and Patient Communication featuring two members of the PrepMD leadership team – Keith Nicholson, CCDS, PrepMD Business Operations Manager and Amy Harris, CCDS, Lead Patient Outreach Specialist.
The most common causes of device patient remote monitoring non-compliance
Keith Nicholson kicked off the conversation by acknowledging that despite best efforts, it is inevitable that some patient monitors will become disconnected.
“Regardless of best practices, disconnected patient monitors will happen. Patients unplug their monitor and forget about it, they move, or they need their device hardware upgraded. Every clinic should have a plan in place for how to deal with disconnected monitors.”
Benefits of a dedicated team Amy Harris discussed the most common approach to missed transmissions and disconnected monitors where every remote monitoring team member participates and just picks up the work when they can. With minimal staff time available, sometimes patients are simply referred to the manufacturer technical support phone line, but that can be fraught with challenges. Prompt selections or hold times may deter patients or family members, and technical issues with the monitors can sometimes require more in-depth troubleshooting just to diagnose the issue. Remote monitoring staff are typically busy keeping up with reading scheduled and unscheduled transmissions and alert escalations- reconnecting patients is often put on the back burner and addressed in piecemeal fashion.
“Whenever that’s the case, you may find that your disconnection rate is occurring more quickly than your recovery rate,” said Harris. She emphasized what she sees as the key ingredient to patient education success for patients at device clinics, “Clinics will be most effective if they have adedicated person or team assigned to managing effective communication with patients to ensure remote monitoring compliance.”
The inherent difficulties in getting patients reconnected, paired with the overall high volume of disconnected patients are common reasons to designate a dedicated individual or individuals to handle patient communication. This dedicated communication will ensure a better understanding of where each patient is within the process and helps prevent troubleshooting overlap or redundancy by limiting the number of individuals who are reaching out to patients.
“A dedicated staff member(s) will keep the patient communication process as brief and effective as possible for not just the patient, but clinical staff as well,” explained Harris.
Additionally, while on the phone with patients, dedicated outreach specialists can take the opportunity to fill-in any gaps in knowledge that patients may have about remote monitoring, update scheduling and vendor websites, or deactivate accounts of patients no longer being monitored.
Finally, there is a considerable amount of technical knowledge needed for the individual or individuals on the team who will be handling patient education and communication. There are at least 15 different monitoring systems across all the vendors, including bedside units and cell phone applications, and each monitor requires its own troubleshooting process. Familiarity is required in order to recognize each display of the various error codes or light sequences, as well as device compatibility and 4G connection requirements. Taking this wealth of complex technical knowledge anddistilling only the required communication needed to accomplish what each patient needs can be complex and challenging.
What are the most common causes of patient non-compliance with remote monitoring?
Unplugged monitors
Monitor malfunction
4G upgrades
Hardware replacement
Unplugged monitors are the most common cause of non-compliance. They can come loose from the power outlet by mistake. Those are an easy fix! Sometimes however, there are patients who don’t understand how remote monitoring works and may intentionally disconnect the power in between scheduled transmissions. Other issues may include poor placement within the room- such as under the bed- or patients going on vacation or out of town without their monitors. Here patient education is the key. Clearly when monitors malfunction or where there are new 4G connection requirements, detailed product knowledge is needed to troubleshoot. Sometimes our outreach specialists find it helpful to conference in patients and industry technical support staff but they stay on the call as well to facilitate communication. Currently patients who get new devices or replacement devices may have to wait on the shipment of back-ordered monitors. Education of patients on the use of smartphone monitoring apps when available can at times alleviate those supply chain issues, while other times they are unavoidable.
We have a dedicated team. Do we also need formal outreach protocols? We recommend setting up a protocol with clinic preferences in mind for how to optimize the process, to clarify roles and responsibilities so that everyone is operating with the same understanding of who is doing what. Examples of the general protocol for patient communication may detail:
Examples of patient communication protocol
It is also important to properly document and keep tabs on patient outreach, including what was discussed with patients, and noting action and future plans such as patient education sessions.
Patients with Manual Transmissions: While most devices can be set up to send scheduled transmissions automatically, there are still some legacy devices out there that require patients to transmit manually. Some clinics will have to dedicate a staff member to calling the patient to walk them through the process of the manual transmission and explain to them what to expect and inform them of the next transmission date. Many times after doing that once, the patients will be able to handle the manual transmission on their own the next time. Some patients however, will need reminders before every scheduled transmission.
Once a backlog of disconnected monitors is cleared, what does maintenance look like?
Harris: “Once you get the [backlog] volume down to a manageable number, it’ll be much easier to just periodically scan the vendor websites for any connectivity issues or missed transmissions. You can also stay on top of upcoming schedules and proactively keep an eye on that. Depending on the size of the clinic…weekly checks would most likely be appropriate.”
What are some of the most surprising patient misconceptions encountered?
Harris: “I’ve heard some patients have a concern that their electricity bill is going to skyrocket or that even infrequent use of the remote monitor will drain the battery of their device or that the monitor being plugged in at the bedside is emitting harmful rays, or that they are incurring costs in the timeframe in between scheduled transmissions. These are times when education is provided much more thoroughly!”
Finally Nicholson was asked what kind of professional and personal traits he looks for in an outreach specialist in addition to the technical familiarity with the devices and monitors?
“Someone well versed in the EMR and kind of digging through and figuring out what’s going on , but also someone who is just kind of patient because some of these patients are frustrated and it’s not anyone’s fault, they want to get to the bottom of it. And sometimes just kind of having that calming presence to talk to the patient through is gonna be a lot more successful.”
Contact PrepMD to learn more about how they help address common CIED remote monitoring device clinic challenges with regard to patient communication and CIED Remote Monitoring compliance.
The Economics of Cardiac Device Remote Patient Monitoring
Almost universally, Cardiac Device Clinic Managers face many common challenges and need to tackle some difficult questions when analyzing a CIED remote monitoring program. Many of these questions relate to financial considerations.
Dr. Lerman, Senior Cardiologist and Physician Executive with decades of experience in both clinical and business aspects of healthcare, outlined some of the most common questions asked by clinic managers as they consider starting a remote monitoring program, “The discussion should always start with patient care and clinical benefits.
Key factors to examine when considering the outcome benefits for cardiac device patient remote monitoring include: -Reduction in mortality amongst heart failure patients -Reduction in hospitalizations, emergency department visits and office visits -Decreased time from clinical event to clinical decision -Early predictors of heart failure exacerbation -Early detection and quantification of atrial fibrillation”
In 2015, as a result of the many outcomes-benefits studies done over the years, the Heart Rhythm Society designated remote monitoring and interrogation as a Class IA recommendation, when combined with at least one annual in-person evaluation. Furthermore, all patients should be offered remote monitoring as part of the follow-up management strategy when technically feasible.
So, what are the costs associated with achieving the clinical outcome advantages of a remote monitoring program? Any program that enhances patient outcomes should garner support when the economics are neutral or positive. However, programs that significantly escalate costs may face challenges in gaining traction, even if they offer patient benefits.
While cost is important, the overall economic picture depends largely on whether the clinical program exists in a fee-for-service or so-called “fee-for-value” environment (managed care, accountable care organizations, etc.)
In fee-for-service environments, revenue generation is balanced against cost. In fee-for-value, cost reduction is the primary economic driver, as it can lead to shared savings from payors. Complicating matters is that the long awaited transformation from fee-for-service to fee-for-value is still largely a work in progress, and most organizations are somewhere in the middle with participation in both types of financial arrangements. When addressing remote monitoring, it is important to consider the following questions:
Device Clinic Cost Benefit Analysis
One way to answer the first question is through formal health economics research, but those studies can be very challenging, especially when trying to decide how much to value studies done abroad or in a different reimbursement or healthcare climate. The TARIFF Study1is one frequently referenced Italian study published in 2017, which showed that remote monitoring resulted in statistically significant reductions in hospitalizations, emergency visits, outpatient diagnostic tests, and clinical evaluations compared with standard care. The overall mean annual cost per patient in the remote monitoring group was 54% lower than standard care, driven primarily by a lower cost of cardiovascular hospitalizations. This cost reduction is consistent with the hypothesis that earlier identification of clinical or device issues will result in earlier intervention and less complicated hospitalizations.
Another relevant study published in 2021 in the Canadian Journal of Cardiology2followed ICDs and CRT-D patients for an average of 50 months. The data showed that remote monitoring was associated with both a lower risk of death and cardiovascular hospitalizations, with cost savings observed over five years of over $12,000 per patient. In summary, while the evidence that remote monitoring lowers overall costs is not as strong as the clinical outcomes evidence, there is little evidence suggesting that costs will be increased.
“Device Clinic managers can reasonably conclude that implementing a high quality remote monitoring program will result in improved patient care and better clinical outcomes, with a cost-neutral or possible reduction in overall costs to the clinic or hospital,” explained Dr. Lerman
As important as it is to evaluate the economic impact of remote monitoring on the healthcare organization, it is just as critical to consider the impact on individual patients. A 2021 American Journal of Cardiology article3described how cardiac device patients frequently express concerns over remote monitoring, cost transparency, and billing.
Kent Seckinger, CCDS, PrepMD Customer Success Director, discussed how to best approach these common patient concerns. “What it really comes down to is patient education and transparency. Educating the device patients is critical to ensuring that they know that there are real benefits for them with remote monitoring. A discussion with each patient should include the specifics of the billing model and relevant regional reimbursement rates, and most importantly, an explanation of the clinical benefits realized with remote monitoring, such as reduction of hospitalizations and ER visits.”
Patients better understand remote monitoring costs when they grasp the clinical rationale and benefits. Without this patient education, patients often call the clinic in frustration when they receive bills that they don’t understand, increasing staff burden. Even worse, they may decide to disconnect their monitors. It is crucial to discuss remote monitoring with the patient and their family members no later than the very first visit immediately after implantation. This ensures that they understand its importance and implications from the outset
Seckinger explained that the PrepMD Clinic Solutions Leadership Team have found that a little patient education goes a long way. “The patient often feels they’ve taken ownership in the management of their care as well. A critical 30-minute discussion on the benefits of remote monitoring with the patient at their first visit will definitely save time in the long run.”
While the primary motivation to provide remote monitoring services for CIEDs is to provide the highest quality patient care, organizations that participate in fee-for-service environments have an opportunity for increased revenue generation. That is because remote monitoring best practices involve improving patient compliance, which along with a detailed understanding of billing requirements, typically leads to a higher overall volume of billable transmissions. ICD transmissions can typically be billed quarterly, pacemakers every 3-6 months, and ILR and heart failure monitoring can often be billed monthly. This increased transmission volume usually more than compensates for the costs incurred by a third party remote monitoring service if one is utilized. Although there is still a fair amount of regional differences in reimbursement for some remote monitoring services, typically, a well run and legally compliant program is profitable.
It is important however, to be cognizant of the cost burden of remote monitoring on patients, especially for Implantable Loop Recorders (ILRs) and devices where heart failure monitoring can be performed and billed. In both of these circumstances, Medicare allows billing for 30-day monitoring periods, and while such billing meets regulatory requirements when clinically indicated, patient co-payments can add up quickly, especially in regions with high reimbursement.
Greg O’Neal, CCDS, CEPS, PrepMD Director of Technology and Business Development discussed the 2015 HRS Expert Consensus Statement4 of remote interrogation and monitoring for cardiovascular implantable electronic devices. The HRS consensus statement described a cadence of regularly scheduled quarterly remote monitoring transmissions for pacemakers and implantable defibrillators (monthly for ILRs and insertable cardiac monitors) with ad hoc in-person evaluations based on device or patient generated alerts plus a single scheduled annual in-person evaluation, all of which can be potentially reimbursable.
In developing a fee-for-service model, a clinic must be able to optimize the frequency of the remote monitoring transmissions with the appropriate CPT code usage for each device type, including the professional and technical components, while keeping all the patient transmission schedules consistent on each of the vendor websites for all devices.
Greg O’Neal, PrepMD Director of Product & Business Development explained, “In general, we find that many clinics running remote monitoring programs monitor patients less frequently than optimal. This highlights the discrepancy between the ideal monitoring frequency and the actual practices in clinics. The typical reimbursement is often less than 50% of the optimal.”
Clinics should ensure they use the correct CPT billing codes for monitoring heart failure patients monthly, as this could potentially increase their top-line revenue by 30 to 40%.
In addition to making sure that device transmission schedules are optimized, clinics need to carefully track connectivity and quickly move to restore disconnected monitors and minimize missed transmissions. In-person visits need to be coded properly and remote schedules adjusted if necessary.
Dr. Lerman concluded, “No two clinics are the same and this can make effective clinic remote monitoring management a daunting task. It’s clear that there are opportunities here both on the cost saving side and- if you’re in the appropriate model- on the revenue generation side. However, you can’t just roll out of bed one day and realize both these economic outcome benefits as well as the clinical outcome benefits.”
Clinic managers will find that utilizing these best practice principles will help guide them through the process of implementing and managing an effective remote monitoring program at their clinic:
Improving Patient Communication and Education
Monitoring and Ensuring Remote Monitoring Scheduling and Compliance
Ensuring Appropriate CPT Codes, Billing, and Reimbursement
As far as costs are concerned, device clinics may be able to take advantage of appropriate partnerships to optimize their resources. This may be a combination of training, staffing, remote monitoring software and service in the form of a bundled solution that enables the clinics to manage their costs effectively, enhancing their profitability. By strategically partnering with reliable solution providers such as PrepMD, clinics can ensure they are investing in the most efficient and cost-effective solutions tailored to their specific needs. Such partnerships can help clinics navigate the complexities of budgeting and resource allocation, ultimately leading to greater financial sustainability and success.
Explore companies like PrepMD for comprehensive device clinic solutions and discover how highly experienced and certified professionals can collaborate with your clinic to improve patient care, optimize billing, and manage costs with bundled solutions. Additionally, explore the relevant publications below for further insights.
CITATIONS:
1 Ricci, Renato Pietro, et. al, “Economic analysis of remote monitoring of cardiac implantable electronic devices: results of the health economics evaluation registry for remote follow-up (TARIFF) study,” NIH Comparative Study: Heart Rhythm, 2017 Jan;14(1):50-57. doi: 10.1016/j.hrthm.2016.09.008. Epub 2016 Sep 8, https://pubmed.ncbi.nlm.nih.gov/27614025/.
2Abramson, Beth L., et. al., “Canadian Cardiovascular Society 2022 Guidelines for Peripheral Arterial Disease,” NIH Practice Guideline: Canadian Journal of Cardiology. 2022 Jun;38(6):736-744. doi: 10.1016/j.cjca.2022.01.022. Epub 2022 Jan 29, https://pubmed.ncbi.nlm.nih.gov/35537813/.
3Fraiche, Ariane M., ”Patient and Provider Perspectives on Remote Monitoring of Pacemakers and Implantable Cardioverter-Defibrillators,” Research Article: American Journal of Cardiology Volume 149, P42-46, June 15, 2021, https://www.ajconline.org/article/S0002-9149(21)00266-6/fulltext.
4Slotwiner, David, MD, et. al. 2015 “HRS Expert Consensus Statement of remote interrogation and monitoring for cardiovascular implantable electronic devices.” Heart Rhythm, volume 12, Issue 7, July 2015, Pages e69-e100, https://www.sciencedirect.com/scie
“As a healthcare worker I realize that I seriously underestimate the impact on patients receiving an implantable cardioverter-defibrillator (ICD). Besides the patients I have the pleasure of caring for, I do not know anyone personally living with an ICD. Perhaps you do, but I am willing to bet a good majority of clinicians and device specialists do not know firsthand on what life is truly like for ICD patients.”
by Melissa Campbell, CDRMS, PrepMD Remote Monitoring Specialist
According to the JAMA, more than half a million people within the United States have an ICD.1 As common as that may be, I question how healthcare professionals can better understand and serve the needs of ICD patients.
Of course, cardiac device clinics must do their best to provide patient education. Clinics are responsible for patient communication within the brief window of clinic visits and device checks, but that is usually at prompted questions initiated by the patient. How many patients leave their appointments needing more understanding about their newly diagnosed heart condition and their implanted cardiac device?
Recent studies suggest that offering an effective ICD support group can provide patients with a safe space to discuss the emotional impact and lifestyle adjustments from having an ICD.
Benefits of ICD Support Groups:
Improved quality of life
Enhanced communication with healthcare providers
Greater understanding of heart disease and cardiac devices
Education on device follow up via remote monitoring
The value of organizing an ICD support group will not only meet the initiatives listed above but can offer practical pathways for clinics and hospitals to increase engagement and overall patient satisfaction. It is an opportunity to for learning through dialogue while serving a vulnerable patient population.
If your clinic or organization is considering a support group for cardiac device patients, here is a short list of things to bear in mind:
Interest
Subject matter
Access
Promotion
To initially get the ICD support group started there must be some level interest. The literature suggests that patients were more likely to participate in a support group within the first couple of years of ICD implant. A patient survey conducted within device clinics can offer data on general interest of a support group and topics that patients want to discuss.
Another thing to consider is patient access to the support group. Based on the size of the clinic or if the clinic has multiple sites, perhaps a hybrid of in-person and virtual options would permit high participation. The ICD support group is to offer support and not be an added burden. There are many creative options available for clinics to connect with patients.
Lastly, advertise that a support group is available! By enlisting the assistance of discharge nurses, front desk workers or any other healthcare personnel that encounter ICD patients can help promote the support group.
Blog article brought to by the expert staff on the PrepMD Clinic Solutions Leadership Team who provide remote monitoring solutions, including software and service, to cardiac device clinics, enabling excellent care for their CIED remote monitoring patients.
“Setting correct intervals, whether manual or automatic scheduling, in Boston Scientific, Medtronic Carelink, and St. Jude/Merlin/Abbott patient profiles can serve as a resource when determining the best dates for upcoming office visit device checks.”
by Amy Harris, PrepMD Lead Patient Outreach Specialist
Auto-schedules, set to the correct intervals, reduce the risk of scheduling oversight, as well as billing inconsistencies for patients keeping track of their medical balances.
In addition to billing predictability for patients, scheduling pacemaker and defibrillator remote transmissions at the standard minimum interval of 91 days increases the likelihood of obtaining four remotes per year, per patient.
Setting intervals to 98 days to allot more time to initiate the billing process results in fewer transmissions each year per patient, and reduces clinic revenue for remote monitoring.
The same result is true for remote schedules which are skipped or “pushed out” for office visit interrogations. Setting correct intervals, whether manual or automatic scheduling, in Boston Scientific, Medtronic Carelink, and St. Jude/Merlin/Abbott patient profiles can serve as a resource when determining the best dates for upcoming office visit device checks.
Scheduling loop recorder/ICM transmissions each 31 days is the standard minimum, however, intervals of 35 days ensure transmissions arrive on weekdays (for clinics wishing to avoid weekend billing).
Medtronic and Boston Scientific require a few unique steps during the scheduling process
Patient accounts in Carelink with bedside monitors and implanted devices compatible with Smart Scheduling are represented by a symbol . This icon indicates the implanted device is capable of automatic, cycling scheduled transmissions.
The absence of this icon is noted for devices which require patient-initiated manual transmissions, such as with the Advisa, Adapta, Micra, Sensia, Revo, and Versa.
For Medtronic Carelink, there are different scheduling options and requirements
Single
Located under the “Schedule” tab, these one-time schedules are used primarily for pacemakers or defibrillators programmed only to manually transmit. Patients are informed of future transmission date(s), and send data independently.
Single, or one-time scheduling may also be utilized for any pacemaker or defibrillator which is capable of Smart Scheduling, but is opted out of automatically recurring transmissions (e.g., Monitoring physician preference, or report data/billing concerns).
In some cases, both Single and Smart schedules can be used, however, it is more efficient to select one option to avoid scheduling overlap or error.
Series
Located under the “Schedule” tab, compatible pacemakers or defibrillators can utilize a Series, or auto-cycled schedule. This method ensures home monitor transmissions are being sent on time, every time, and provides notification when they have failed.
The earliest possible transmission date is provided, and custom intervals can be selected.
If a bedside monitor experiences connectivity issues, a Series set to transmit on an interval will automatically place that patient within the “Missed Transmissions”, “No Schedules”, and/or “Disconnected Monitors” category for your review.
Summary (Loop Recorders)
Located under the “Overview” tab, “Summary Reports” are clinical reports generated for LINQ devices. These can be set to a one-time or recurring schedule.
LINQ schedules should not be set under the “Schedule” tab. Whether one-time, or recurring transmissions, a Summary Report cannot be generated unless set up utilizing the tools provided under “Overview”
Note: LINQ schedules created under “Overview”, do not populate the date of the next transmission under the dashboard column labeled, “Next Scheduled Send” (for defibrillators and pacemakers). It instead will read, “Not scheduled”.
Boston Scientific provides a link at the top right of each dashboard to toggle between “Clarity” for loop recorders, and “NXT” for defibrillator and pacemaker device transmissions.
For pacemakers or defibrillators, within each patient profile is an option to “Edit/View Schedule and Alert Configuration”.
For Latitude NXT, there are different scheduling options and requirements
Schedules can be set as a clinic default (managed in clinic settings)
Or customized with automatically recurring intervals
Select the next scheduled remote follow up date in blue to view the calendar, and ensure the weekday is matched with the “Day of the Week” dropdown.
NXT provides the option to change or set remote transmission schedules either directly from the dashboard, or within “Schedule and Alert Configuration”.
If electing to set or edit the next transmision date on the dashboard, the date must fall on the same weekday specified under “Schedule and Alert Configuration”, or else the transmission may be “missed” as a result of the date contradiction.
As a method of efficiency, all schedule editing should be carried out under “Schedule and Alert Configuration”
Scheduling in Clarity
Access Clarity using the top right toggle link
Select patient to view profile.
The next scheduled date can be selected from the calendar without an associated weekday dropdown.
“Keep an eye on the leadless pacemaker technology space and watch for upcoming clinical trial data to determine best options for your clinic and patients.”
Most vendors are now offering some form of leadless pacemaker technology, be it a single lead that includes ventricular pacing and atrial sensing, leadless pacemakers, or ICDs with subcutaneous leads. Citing decreased complication rates and easier or fewer extractions, most of the EP world is now getting on board.
As new products continue to hit the market, it’s good to take a step back and look at the data and evidence supporting the use of these novel devices.
Medtronic was the first to release a truly leadless pacemaker in the Micra VR device, released in 2015. Delivered via femoral catheter, there was no need for transvenous leads or a pacemaker pocket. Early data from the IDE (Investigational Device Exemption) and PAR (Post-Approval Registry) studies showed excellent results that met study endpoints. More recently, the Micra excelled in a comparison study looking at large patient populations in real world settings compared to the IDE data (El-Chami et. al, 2018). Successful implantation was achieved in 99.1% of patients with a 2.1% major complication rate over 12 months (95% CI, 2.0%-3.7%), 63% less than patients with transvenous devices (p<0.001).
Also on the market is the Micra AV, which boasts VDD pacing and the ability to provide AV synchrony. The MARVEL 2 trial (Clemens et. al, 2020) showed that with VDD mode and accelerometer-based atrial sensing, the proportion of patients with >/=70% AV synchrony at rest was significantly greater than the proportion of patients in VVI 50 mode (89.2% vs. 26.8%, p<0.001). There were no pauses or oversensing-induced tachycardia. The sample size was quite low at n=75 and only evaluated AV synchrony at rest,, so while the results may not be representative of real-world situations, they are at the very least promising and something to watch closely.
While MDT builds its atrial sensing algorithm, Abbott has recently launched a leadless device as well.Following results of the LEADLESS II IDE study (Reddy et. al, 2022), the Aveir VR system is now FDA approved for implant. Successfully implanted in 98% of patients and able to electrically map before deploying, the Aveir system should serve as a good competitor to the Micra family of devices. What’s more, Abbott recently implanted the first true dual chamber leadless pacemaker in February of this year as part of the Aveir DR i2i study. Contrasting Medtronic’s approach of including atrial sensing in one device, Abbott’s Aveir DR is actually two separate implants, one in the ventricle and one in the atrium. The study has a goal of enrolling 550 patients with primary endpoints focusing on the DR system as a whole (complication rates, acceptable thresholds, etc). Secondary endpoints will look more closely at the atrial implant individually. Primary results are expected November 2023 and study completion is slated for November 2025.
Boston Scientific is taking the leadless trend in an entirely different direction. With the S-ICD successfully on the market for years, Boston Scientific is currently enrolling in the MODULAR ATP trial which involves an EMBLEM S-ICD system implanted concurrently with the EMPOWER MPS (Modular Pacing System) leadless pacemaker. One of the most significant critiques of the S-ICD is that patients who develop a need for transvenous pacing after implant will require an entirely new system. Assuming the Empower makes it to market, a physician can add the Empower leadless device to the already existing S-ICD system with no transvenous leads necessary. Furthermore, a combined mCRM system (S-ICD defibrillator and Empower leadless pacemaker) can provide ATP for fast, organized rhythms in an attempt to convert without the need for a shock. Modular ATP is sponsored by Boston Scientific and will look at primary endpoints of complication rates, communication success between devices, and adequate capture thresholds. Secondary endpoints will examine the Empower’s rate sensor and all-cause survival. If successful, this system will be the first to provide pacing and defibrillation without the use of transvenous leads.
It is truly amazing to see the increased options for patients with pacing considerations even over the last couple of years. We’re no longer tied to traditional RV apical pacing systems. Leadless pacemakers are becoming increasingly popular as a primary pacing option, or especially in patients with limited vascular access, occlusions, or infections. Keep an eye on this space and upcoming trial data to determine what the best option is for you, your clinics, or your patients.
For additional information visit these reference websites:
The learning curve is steep in the cardiac medical device space with effective training programs a necessity. Innovation and advancements in medical devices is constant. The professionals working in the cardiac medical device space rely on clinical and corporate training solutions to ensure proficiency and safe patient outcomes.
Collaboration: Improving Training ROI
Medical device companies and cardiac clinical staff realize a higher return on their investment by embedding employee input and collaboration in the process. To ensure best outcomes and return on training investment, a customized training solution should include thoughtful input from all levels and include training needs assessment to ensure efficacy. Employers who invest in this collaborative approach to a well-trained staff will see better technical and clinical results along with higher morale and job satisfaction.
Clinical Competence: Higher Standard of Care
Any cardiac clinic nurse manager asked will have much to say about the common clinic challenges of an undertrained device clinic staff and continuing education requirements. The cardiac device space is complex with fast changing technologies and products. Hospitals and clinics rely on PrepMD for a variety of our services, including healthcare training, clinic staffing, and remote monitoring services. While there are many positive training outcomes, the priority at PrepMD is to help our clients have more competent staff better equipped to provide a higher standard of performance and patient care.
Building Competent Teams to keep up with Innovation
Nowhere is the importance of clinical and technical competence more apparent than in cardiology and the medical device industry, where new products and innovative therapies are constant! Effective recruitment and retention of a talented team is expensive and time-consuming, and critical to successful patient outcomes. Training is an essential ingredient to building and keeping competent teams who have not only the clinical acumen but also the motivation to keep abreast of the constant stream of new cardiovascular products and therapies.
The importance of Retention
Staff turnover may be one of the biggest pain points for any manager, but especially so in the cardiac space. The importance of new hires and initial training is obvious, but continuing education and coaching of the workforce is where management begins to reap the rewards of staff retention with a competent, satisfied, and well-trained staff. The one-and-done style training investment is not effective for this highly clinical and technical space. An effective training program, positive work culture, and low turnover help contribute to a positive reputation as an employer.
In today’s rapidly evolving healthcare landscape, cardiac device clinics face the challenge of hiring and retaining expert clinical and technical staff who can deliver optimal patient care while improving operational efficiency. The 2023 HRS/EHRA/APHRS/LAHRS expert consensus guidelines emphasize the need for 3 full-time clinical staff members per 1,000 CIED patients to meet the current standard of remote monitoring care. This article explores the significance and influence of highly trained staff in device clinics and introduces an innovative approach that combines outsourcing of both remote monitoring services and contract staffing. Understanding the economic and clinical advantages of outsourcing remote monitoring and utilizing contract staffing helps healthcare providers enhance practice efficiency, financial stability, and reduce the strain of high turnover, ultimately resulting in better patient outcomes. By combining these two strategies, clinics can reap the following benefits:
Cost Savings: Outsourcing remote monitoring services and contract staffing provides significant cost savings compared to in-house monitoring and staffing. Partnering with a specialized remote monitoring service provider and contract staffing organization like PrepMD allows clinics to avoid expenses related to hiring, training, infrastructure investments, and technical support systems.
Expertise and Efficiency: A highly trained and qualified remote monitoring service provider possesses the necessary expertise, experience, and resources to manage and analyze device data effectively. Their specialized knowledge enables efficient data interpretation, timely patient follow-ups, and proactive interventions, leading to optimized patient care and better outcomes. Contract staffing provides access to highly trained professionals, alleviating the burden of recruitment and training for device clinics.
Risk Mitigation: Outsourcing remote monitoring and contract staffing shifts the responsibilities of data management and analysis to specialized providers. This reduces the risk of errors or oversights that could result in adverse events or missed critical patient information. Clinics can leverage the expertise of remote monitoring service providers and contract staff to mitigate risks and improve patient safety.
Financial Transformation through Strategic Partnership: Maximizing Revenue and Enhancing Remote Monitoring Efficiency (A Case Study)
Let’s explore the impact of partnering with PrepMD on a 4,500 patient cardiology clinic to showcase the financial and clinical benefits of outsourcing remote monitoring to leading clinical solutions providers. Prior to the collaboration, the clinic faced resource constraints and struggled with a high volume of transmissions, which hindered their financial performance and remote monitoring operations.
Over a 2-month period, the clinic observed a remarkable transformation. The number of billable transmissions increased by 126%, resulting in a significant 132% rise in generated revenue.
Here is a breakdown of the increase in billable transmissions for specific device types:
Heart Failure (HF): 435% increase in billable transmissions.
Implantable Loop Recorder (ILR): 361% increase in billable transmissions.
Pacemaker (PM): 77% increase in billable transmissions.
Implantable Cardioverter Defibrillator (ICD): 143% increase in billable transmissions.
By partnering with the PrepMD Clinic Solutions Leadership Team, the clinic achieved remarkable financial improvements. The increased billable transmissions and revenue growth during the 2-month partnership period demonstrate the effectiveness of the collaboration. The financial gains realized through this partnership highlight the positive impact of leveraging PrepMD RMS services on both the clinic’s financial performance and patient care.
Addressing Staffing and Remote Monitoring Needs:
Partnering with leading cardiac clinical solutions companies which offer bundled contract staffing and remote monitoring service offerings, enables clinics to address their staffing needs economically and effectively. Clinics can retain staff by implementing 1-year or 2-year clinical staffing agreements providing stability, overcoming high turnover rates, and reducing recruitment and training costs. Longer-term commitments foster a supportive work environment, enhance team cohesion, and optimize patient care delivery.
To address the burden of remote monitoring, clinics can partner with PrepMD for premier remote monitoring services that offer a dedicated team of full-time IBHRE-certified professionals that can seamlessly integrate into their workflows. This collaborative approach allows clinics to become self-sufficient while significantly reducing costs, optimizing billing and revenue, and delivering the highest standard of care to their patients with CIEDs.
Conclusion:
Staffing plays a crucial role in cardiac device clinics for remote monitoring, ensuring optimal patient care and streamlined operations. By adopting an innovative and paradigm shifting approach to CIED clinic management that combines outsourcing of remote monitoring services and contract staffing, clinics can achieve enhanced efficiency, financial stability, and improved patient outcomes. The expertise of specialized providers and the utilization of contract staff empower clinics to focus on direct patient care, in-person device checks, and optimizing clinic operations while maintaining the highest standards of care.
It is Monday morning; the clinic is already buzzing with staff and patients checking in for early appointments. Upon checking the voicemails from the weekend, you hear a distressing message from an established cardiac device patient who states she has received multiple shocks from her ICD. Sadly, this is not the first time you have retrieved this message from this patient.
Although you hope the patient went to the ER, based on her medical history you already know there is not much you or the electrophysiologist can do. That type of response will not give this patient comfort. You are aware that she is not the only patient who has questions and some anxiety about having an implanted cardiac device. How can the clinic assist these patients?
Why should your clinic or organization consider a support group for cardiac device patients?
Improved quality of life
Enhanced communication with healthcare providers
Greater understanding of heart disease and cardiac devices
Watch the video by Matt O’Neal, Co-Founder & Chairman of PrepMD here.
Five phases of the Interview: Interview preparation can be overwhelming and anxiety-producing! Prepare, anticipate and practice are the over-arching principles to help ease the anxiety and successfully close an interview. The initial preparation for an interview involves researching the company, the industry, and the interviewer(s). You should know your key selling points that directly address why you want this job and what makes you a good fit. Prepare well for each of the five phases of an interview which are outlined in this article. Anticipate what your interviewer is looking for and specifically identify any potential concerns he or she may have about your candidacy so that you are prepared to respond to those concerns. Be sure to practice what you will say to CLOSE the interview and role-play with someone.
Phase 1 is the Introduction and Connection phase. It is critical to make a connection with the person you are interviewing with. Use resources such as social media as a way to learn more about the person you are interviewing with. Ideally, you will be able to find some common ground. Research indicates that the longer the introduction/connection phase of the interview, the better the outcome of the interview. The rationale behind this is that people naturally feel a connection and a sense of goodwill and obligation to give that person a chance.
Phase 2 is the Review phase. “Why don’t you tell me a little bit about yourself” indicates a transition to the review phase. A common problem in this phase is the tendency to ramble on, say too much, and not feature the important facts. A lot of people may naturally present themselves and their background in chronological order. However, this may tend to take too long to get to the assets you should be featuring. Rather, you should try to frontload or feature several key things the person needs to know about you. So you could say, “before I go into the details of my background, let me give you 3 key points about myself which I think are critical to the position you are hiring for.”
Your preparation for this phase of the interview is to identify and practice introducing yourself and how you plan to explore for common ground.
You don’t need to go through every aspect of your resume. Your preparation for the review phase should be to identify and practice what you will need to say to highlight and punch up your most relevant experience and qualities.
Phase 3 is the Assessment Phase: You’ll know you are in this phase of the interview when the interviewer has started to ask more questions. What is your best job? What is your greatest strength? What is your biggest weakness? You should try to anticipate the types of questions this hiring manager may ask you. The hiring manager wants to determine if you are appropriate for this role and for their team.
Your preparation for the Assessment phase of the interview is to take a good inventory of your objective and relevant experiences. What is it that you objectively bring to the job? An engineering degree with a 3.6 gpa is an example of an objective asset. Your work ethic or organizational skills are subjective. The way you can bring those skillsets to the conversation is to qualify those subjective qualities. For example, “I achieved success in my career as a sales associate and I’ve been praised by colleagues and supervisors for my superior communication and organizational skills, along with a strong work ethic. All of these skills contributed to my successful career progression at XYZ corp.”
Phase 4 is the Job Fit Phase: the interviewer will tell you about the job description, requirements, roles and responsibilities and overall what a day in the life of this role looks like. Hiring managers want to see that you have prepared well by researching as much as possible about the roles and responsibilities of the job. It can be tremendously helpful if you are able to speak to someone who works or previously worked in this role or a similar role, so you have some personal “day in the life” understanding. During this phase of the interview you want to take a very active listening role. Active listening involves asking reflective questions to demonstrate that you are actively listening to what they are telling you about the job. This active listening should provide you with key points to respond to during your interview close so that you can clearly communicate what makes you a good fit for this role.
Phase 5 is the Close Phase: Telltale sign that you are nearing the end of the interview is when the interviewer asks, “Do you have any questions for me?” Prepare questions! As you ask these questions you want to keep an inventory of the answers so that you can use them in your summation close. Categories of questions include people, team, products, services, market, and position or role.
Most people find the Close to be the most challenging and awkward part of the interview, so the general advice is to practice, practice, practice. The more you hear yourself saying a close during practice, the less anxiety you will have over executing the close during the interview. A direct closing statement example would be “Do you think I am a good fit for this role?” or “Do you have any concerns about my ability to do this role?” and be sure to meet those concerns head on. Finally, ask the interviewer “Do I have your support for this role?” Be prepared to respond. At this point you may need to summarize your key attributes for this role and how they confront and respond to those expressed concerns. Finally, you should prepare a follow up question, “What are the next steps in the interview process and what is your expected timeline for making a decision.” Be sure to ask the interviewers for their business cards and email addresses so you can send each person a short personalized thank you email, where you should remind them of why you are a good fit for this role and to address any concerns he/she may have about your candidacy.
We use cookies and similar technologies to improve your experience on our website.
“Post-op when the device is implanted, the patient has a great deal of information being thrown at them and it can be very overwhelming. Often, we find that at the wound check appointment the patient will be able to process information more effectively, especially if they are provided with helpful written documentation or FAQs to explain how their monitor works and what the frequency of transmissions will be.”
At a recent PrepMD RMS educational webinar, Dr. Robert Lerman, Former Chief Medical Officer at 
“Whenever that’s the case, you may find that your disconnection rate is occurring more quickly than your recovery rate,” said Harris. She emphasized what she sees as the key ingredient to patient education success for patients at device clinics, “Clinics will be most effective if they have a dedicated person or team assigned to managing effective communication with patients to ensure remote monitoring compliance.”
Kent Seckinger, CCDS, PrepMD Customer Success Director, discussed how to best approach these common patient concerns. “What it really comes down to is patient education and transparency. Educating the device patients is critical to ensuring that they know that there are real benefits for them with remote monitoring. A discussion with each patient should include the specifics of the billing model and relevant regional reimbursement rates, and most importantly, an explanation of the clinical benefits realized with remote monitoring, such as reduction of hospitalizations and ER visits.”
Greg O’Neal, PrepMD Director of Product & Business Development explained, “In general, we find that many clinics running remote monitoring programs monitor patients less frequently than optimal. This highlights the discrepancy between the ideal monitoring frequency and the actual practices in clinics. The typical reimbursement is often less than 50% of the optimal.”
“As a healthcare worker I realize that I seriously underestimate the impact on patients receiving an implantable cardioverter-defibrillator (ICD). Besides the patients I have the pleasure of caring for, I do not know anyone personally living with an ICD. Perhaps you do, but I am willing to bet a good majority of clinicians and device specialists do not know firsthand on what life is truly like for ICD patients.” 
. This icon indicates the implanted device is capable of automatic, cycling scheduled transmissions.
“Keep an eye on the leadless pacemaker technology space and watch for upcoming clinical trial data to determine best options for your clinic and patients.”
