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Patient and doctor with tablet close up

Cardiac Device Patient Compliance – Keeping Patients Connected

Written by Kent Seckinger, CCDS on . Posted in Articles.

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 a dedicated 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 and distilling 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.

Woman in light blue scrubs working on remote monitoring billing codes

Cardiac Device Billing Codes and Cost Analysis for CIED Remote Monitoring Programs

Written by Greg O'Neal, CCDS, CEPS on . Posted in Articles.

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.

Cardiac Device Patient Remote Monitoring Outcome Benefits

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 Study1 is 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 Cardiology2 followed 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 article3 described 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

ICD Support Group, Patient Education

ICD Support Groups: A Safe Space to Discuss the Lifestyle Adjustments of a Cardiac Device

Written by Kent Seckinger, CCDS on . Posted in Articles.

“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.

Med Device Careers Remote Monitoring Podcast

The Future of Patient Care: A Podcast interview with Beth Davenport, MSN, RN, CNML, and Amy Tucker, BSN, RN, CCDS of Sanger Heart & Vascular Institute

Written by Satya Behara on . Posted in Podcasts.

In this podcast episode, we speak with Beth Davenport, MSN, RN, CNML, and Amy Tucker, BSN, RN, CCDS of Sanger Heart & Vascular Institute in Charlotte, North Carolina, U.S. Beth serves as the Clinical Director of Virtual Care and Cardiac Device Clinics, and Amy is an Advanced Cardiac Device Nurse in their cardiac rhythm device clinic and remote monitoring center. In this conversation, we speak about the success they’ve had at Sanger developing a best-in-class remote monitoring program, the role of the AHP, and the future of collaboration between clinicians, industry, and hospital administration with the creation of HRX, an immersive digital health conference. Sanger Heart & Vascular Institute is a nationally-recognized, top-rated heart and vascular program, where for over 50 years more than 100 heart experts have delivered lifesaving care for every kind of heart and vascular condition.

Visit Med Device Careers Podcasts, brought to you by PrepMD, for more conversations with industry experts across the medical device industry.

Doctor at laptop on phone

Monday Morning in the Clinic – Would some of your device clinic patients benefit from a support group?

Written by Kent Seckinger, CCDS on . Posted in Articles.

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
  • Education on remote monitoring follow up

For additional information on this topic, visit

https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-021-06735-3