Remote Monitoring, Simplified: Taking a New Approach to Remote CIED Monitoring

Background

The patient is an 80-year-old male with an ejection fraction (EF) of 25% who received an ICD in 2007 and upgraded to a CRT-D in 2014. He recently received an appropriate ICD shock for ventricular tachycardia, failing to be converted with antitachycardia pacing. So far, this is a pretty routine story in a busy device clinic. However, despite the ICD shock, the patient did not call his electrophysiologist or referring physician. The lifesaving ICD therapy was uncovered only through remote monitoring; an alert provided via the cardiac implantable electronic device (CIED) vendor was transmitted to a third-party remote monitoring service, Geneva Health Solutions. This notification resulted in a change in therapy, including programming parameters to optimize the patient’s tachycardia management.

This case presentation is just one illustration of how Geneva’s remote monitoring program has simplified our practice of remote follow-up. This platform has become an extension of our device clinic staff, who interact daily for alert management. With Geneva’s remote monitoring service working in the background, office staff can now focus on the alerts that need our immediate follow-up, freeing time previously spent with routine device management.

Implementing a New Process

Following device recall notices in October 2016, we recognized that our post-implant CIED management was unacceptable. As a result of the recall, we sent a certified letter to each of our patients, notifying them of the issues and stratifying them into various risk categories. Interestingly, of the over 1000 affected patients in just one practice, we found that remote monitoring was being utilized in less than 300. The reasons were varied: some were lost to follow-up or had moved, some had insurance challenges, and others requested only in-office evaluations and then did not return. Many patients understood that they could get device follow-up at the referring physician’s office; however, this communication was often inconsistent.

After an intensive review of our process, the primary issue found was a breakdown in communication. As a result of this realization, we instituted the following policy:

1. All device patients now receive a home monitor at the time of discharge. They receive training (to improve compliance) and are registered immediately with the CIED vendor.
2. All unregistered office follow-up patients are given a home monitor, and are similarly enrolled with the vendor. 
3. We partnered with Geneva Health Solutions, allowing them to have access to our accounts for each of the device vendors.
4. Geneva performs routine device management, following the published criteria (listed below). All of the remote monitoring data streamlines into Geneva’s platform.
5. A notification triage was created with Geneva; therefore, any ICD therapy now results in prompt same-day notification.
6. For the vast majority of patients with routine follow-up, the simplified Geneva website is viewed daily by staff (Figure 1).

Description of Use

The Geneva website is engineered to be a separate electronic medical record (EMR), a portal storing secure HIPAA-compliant patient and device information. While the Geneva report or the device printout itself can be stored in our regular EMR using Geneva’s integration engine, we have found that the Geneva website is easier to use. When seeing device patients in the office, we routinely will use two computer monitors for chart review: one with the EMR open, and a second with Geneva or other ancillary data available. As Geneva is cloud-based, this does not require a server or additional hardware in the office. 

On the Geneva portal, each patient’s display is similarly organized (regardless of CIED manufacturer). As shown in Figure 1, the home page provides a simple summary line for each patient on an easy-to-use dashboard. Patients can be searched by name, record number, or by the time of most recent transmission. By clicking on the “View” tab on the far right, a summary of battery and lead parameters as well as clinical data (e.g., CHA₂DS₂-VASc score or MRI compatibility) can be viewed (Figure 2). The bottom half of this summary shows a “Visualizer” graphic, which summarizes past and future scheduled monitoring windows, whether for HF evaluations or CIED monitoring. In addition, one of the primary benefits of this system is the use of a billing clock that ensures compliance.

Next, by clicking on “MFR Report” near the top of the screen, a PDF copy of the complete vendor’s device printout becomes available for review prior to electronic signature. In addition, by reviewing Geneva’s summary, which includes the discrete data, we can obtain information such as battery life, recent device therapy, manufacturer alert status (recalls), and pacing frequency. This consistent and well-organized format helps the physician or medical personnel reviewing the patient’s transmission to be less likely to overlook an important issue. 

Once reviewed by the clinician, the “E-Sign” tab (Figure 3) provides customizable statements about the CIED interrogation interaction. The findings are reviewed and edited, CPT billing codes and ICD-10 diagnosis codes are chosen, and the signed report is then saved. While we have the option to import every device PDF into our EMR, we generally view the reports on the Geneva portal and import only interrogations of note (such as VT therapy). We believe this simple approach helps to better organize our EMR and can be particularly useful for physicians of other specialties who have previously complained of EMR clutter from device interaction data. After signature, the billing records are then automatically transmitted to our third-party billing service without the need for further steps. Geneva also collaborates with staff to educate our patients on the value of remote monitoring and provides patient engagement to ensure reliable scheduled transmissions.

Benefits of Remote Monitoring

The medical literature supports this more rigorous home monitoring approach. Compared to office follow-up only, the Lumos-T Safely Reduces Routine Office Device Follow-Up (TRUST) trial found that home monitoring resulted in fewer outpatient visits, decreasing in-clinic evaluations by 45%.¹ This and other studies resulted in the 2015 HRS consensus statement with recommendations summarized below:²

• All patients with CIEDs should be encouraged to use remote monitoring as a supplement to in-office visits.
• Decrease routine in-office CIED monitoring to once annually, unless clinical needs dictate otherwise.
• Routine remote device management for all CIEDs should be performed every 90 days. 
• In patients with clinical heart failure, transthoracic impedance monitoring is performed every 30 days.
• Implantable loop recorder follow-up frequency is dictated by clinical need.

It is well documented that home monitoring improves care.³ However, some challenges with remote monitoring still exist.⁴ In addition, it is rare that clinical criteria for decreased utilization also results in improved physician revenue. In our practice, that has definitely been the case. Previous to our policy change, we were monitoring patients inconsistently as well as losing reimbursement when repeated within the mandated 90-day billing interval. Presently, we bill the professional component for clinical interpretation and oversight, while Geneva provides the technical component as an Independent Diagnostic Testing Facility (IDTF). Similar to a rhythm event monitor, after industry overview, physician interpretation is an essential part of the process. Despite that potential loss of revenue inherent with giving up the technical component of CIED follow-up, we noted a fivefold increase in collections while not having to add additional staff to handle the increased data and alert volume. The improved reimbursement was solely a function of ensuring compliance with the remote monitoring standard of care and proper billing for our CIED patients.² By strictly following the published HRS guidelines, we have had few reimbursement denials. 

Summary

In our experience, use of a third-party monitoring service has helped us achieve improved patient care as well as increased practice revenue. Importantly, effective CIED monitoring requires communication between the implanters, hospital, and following office. A standardized protocol, including initiation of home monitoring at implant, should also be implemented to increase compliance. Inconsistent device data reporting from one CIED vendor to another can increase the chance for error, but use of a remote monitoring platform on a cloud-based portal can provide a well-organized summary of CIED data, naive to vendor type, while still allowing traditional device printouts to be available for viewing or for incorporating into an EMR. 

Disclosure: Dr. Higgins is an unpaid advisor to Geneva Health Solutions.

References

1. Varma N, Epstein AE, Irimpen A, et al. Efficacy and safety of automatic remote monitoring for implantable cardioverter-defibrillator follow-up; the Lumos-T safely reduces routine office device follow-up (TRUST) trial. Circulation. 2010;122:325-332.
2. Slotwiner D, Varma N, Akar JG, et al. HRS expert consensus statement on remote interrogation and monitoring for cardiovascular implantable electronic devices. Heart Rhythm. 2015;12:e69-100.
3. Zeitler EP, Piccini JP. Remote monitoring of cardiac implantable electronic devices (CIED). Trends Cardiovasc Med. 2016;26:568-577.
4. Collins J. Outsourced remote monitoring speed traps. EP Lab Digest. 2017;17:1-8.