Perspectives on Device Clinic Management and Remote Outsourcing: Experience With CV Remote Solutions

In this article, we feature the physician, nurse, and administrator perspective on device clinic management and remote outsourcing. EP Lab Digest talks with George H. Crossley, MD, Director of the EP Lab at Vanderbilt Heart and Vascular Institute in Nashville, Tennessee; Torrie King, RN-3, BSN, Assistant Nurse Manager, Patient Care Service, Arrhythmia/Device, at Vanderbilt Heart and Vascular Institute; and Austin T. Reed, MBA, Director of Physician Services at Centennial Heart, about their experience collaborating with CV Remote Solutions.

What challenges have you found in recent device clinic management?

Crossley: I think the main challenge we’ve had is our ever-increasing volume. We have about 16,000 patients on remote follow-up. As the population ages and we have more baby boomers getting devices, the total number of devices in our clinic has gone up and our ability to find trained staff has decreased. By and large, the challenge in the device clinic is that we hire a new person, put a good year into training them, and then often lose them when they either move on or are employed by industry. It’s a difficult thing. Since we have a finite number of technicians and nurses doing device work, when we lose one for whatever reason, we don’t have the flexibility to scale up and down quickly to meet that.

Which stakeholder in your organization was first to consider remote outsourcing, and why?

Crossley: I think all of us came to this together. The ability to have an outside resource that could scale up and down each year was very appealing.

What were your concerns about outsourcing?

Crossley: Being in a university, we’re very concerned about quality, and giving up control over that was something that was outside our comfort zone. We also didn’t want to create a model that changed it from being a financially positive service to a financially negative service. Some of the other opportunities to outsource elsewhere certainly did that, and that was not appealing to anyone.

For others considering outsourcing, what are your recommendations when looking for a partner?

Crossley: My advice to my young trainees when I’m training them is that culture eats strategy for lunch every day, meaning that you’ve got to find the type of culture that is going to fit with your organization and you have to make sure you’ve got a partner who is going to view it the same way you do. There are different approaches to this. There are ever-increasing numbers of outsourcing options. We found somebody who is very committed to their monitoring quality and interactive with us in terms of feedback on quality and opportunities for improvement. Of course, part of that is making sure you understand what their training is of their staff and what their go-forth monitoring is of their quality. It is very important to understand the quality and training aspects of any vendor on which you depend.

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

Crossley: The thing that has been most valuable to us is we don’t have the challenge anymore of having to scale up or down as we have staff issues. We’ve converted our staff that was doing all the remote monitoring with our in-center follow-up to just doing the in-center follow-up, and doing it in a much better way than we could have done it before, because we now have the bandwidth to do it. We’ve been very happy with the quality, monitoring, and feedback. The response to our feedback has been received in a manner exactly what I would hope it would be.

What challenges does your clinic face with device management?

King: The biggest challenge we face is the volume of patients that we have. Our clinic has about 9,000 device patients. Just being able to keep up with the transmissions that were coming in was all we were really able to do, but then we were missing out on the patients that weren’t being followed. Part of that challenge came because we’ve had the same staff for many years, and one moved on and another passed away. So just bringing in new staff and getting them fully trained to do in-clinic device checks, but then also keeping up with this work, was a big challenge.

Why did you decide to pursue remote outsourcing?

King: We really needed help cleaning up our vendor websites to ensure that we had all of our patients on the proper cadence of care and to be sure that all of these patients were being monitored remotely every 91 days.

For others considering outsourcing, what are your recommendations when looking for a partner?

King: I would recommend finding someone that fits in well with your team and feels like they can be a part of your team. We are still very much involved in our patient care and we communicate a lot with the CV Remote Solutions team, so it makes us feel like we’re all one big team working together.

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

King: The quality of care that we are able to bring to our patients while using CV Remote Solutions has significantly increased. We’ve also increased our patient transmissions by about 80%, so we’re really getting to monitor more patients than we had been in the past. It has also allowed our staff to use this time to further their knowledge and get the training that they need in the clinic so they can be more resourceful to our clinic.

In addition to remote outsourcing, what other services has CV Remote Solutions provided for your team?

King: We’ve been doing monthly education with our staff. One of their nurses, Jenny, does a monthly Zoom educational session with staff about patients that we have seen in our clinic that have had a problem with a device. We have also had help with some new protocols that we’ve been writing for our device clinic, and so I’ve been able to bounce off some ideas with them and get their guidance on helping to write these protocols.

What challenges have you found in recent device clinic management?

Reed: The biggest challenge that we have had in device clinic management is having adequate staffing with the right skill set to support the overall volume. Finding nurses or technicians that have a data analytics skill set and an EP/device clinical skill set has been very difficult over the past two years. As our volume of device patients has increased year over year, we have had a difficult time managing those device transmissions due to limited staffing.

Why did you decide to pursue remote outsourcing? When did you know it was the time to outsource?

Reed: Quality of care and patients always come first. From an administrative side, we always try to look at cost efficiency, patient outcomes, and quality. Looking through these key metrics, I quickly realized that where we were prior to outsourcing was slowly declining in regards to being able to support the volume that we had. We were adding two more electrophysiologists over the next 18 months and knew that we needed support to continue the level of care that our patients were accustomed to. The current staffing and scalability of our model was insufficient to support the projected growth. At that point, we opened up the market to look at different outsource options and figure out the best fit for our group. We were confident in our processes and nursing skill set, so we had a certain expectation that we were seeking in order for this outsourcing to fit into our model.

When looking for a remote outsourcing partner, what qualities were you looking for?

Reed: First and foremost, we were looking for a monitoring service that had the same level of skill set that we had in the practice. This included having registered nurses, preferably with at least five years of experience on the EP side, and specifically with direct device experience. We were looking for a partnership that was willing to analyze our current workflow at the practice and be able to tailor their support to our workflow. We were also looking for a team that had the experience and credibility to provide feedback and best practices with our team to help optimize our current program.

For others who may be struggling with the burden of device follow-up, what are your recommendations for evaluating current status and creating goals for the future?

Reed: For us, I would always look at the current quality of service that you’re providing. That’s difficult, because I think everyone believes that they’re providing the best quality of service to their patients. But it’s important to do more of an economic analysis on your device clinic. For example, what were your charges the prior year for your remote monitoring checks? How many active patients do you have that are on devices? Then, look at the compliance rating from those. You could find a financial opportunity, or more importantly, you could find there is a quality of service or patient outcome opportunity. This is just one example, but I would recommend doing a deep dive on the economic analysis of your clinic and being honest about where you are from a cost efficiency standpoint. Where are you with patient outcomes? Then, dive in from a quality of service standpoint. Are you where you want to be? Finally, always look at the future. What is your 3- to 5-year plan? Naturally, the number of your electrophysiologists as well as the number of patients with devices will grow. If you have enough staff and your service is top-notch at this exact moment, are you still vulnerable so if you continue to grow at a certain rate or you’re adding positions, can you still provide the same level of support that you’ve always been able to provide your patients? That is what we did. From a practice standpoint, you have to look at where you are currently and then look to the future. Is your staffing model and workflow scalable to the growth that you’re going to expect? Part of looking to the future is knowing how difficult it is to hire this type of talent to review and analyze this data. So, getting in front of it prior to the need is the important part of this.

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

Reed: I was personally impressed with their ability to document our current workflow and build processes to help support our remote monitoring team. The level of expertise that the nurses at CV Remote Solutions have is exactly on par with our standard of care in the clinic. All of their nurses have at least five years of EP experience and they’re all IBHRE certified. It’s important to note that making this change for our practice, which was independent for so long, was scary. The willingness of CV Remote Solutions to understand our workflow, our physicians and clinicians and how hard they all work, and really become part of our team and give opportunities, is probably what I was most impressed with. After outsourcing with CV Remote Solutions, we noticed a reduced alert burden as well as improved quality of life for our current nurses, who no longer felt the guilt of taking a vacation because we were understaffed and our device patients wouldn’t be supported. CV Remote Solutions has brought a lot of positives outside of just the improved revenue streams. They’ve improved patient care and increased our compliance. From my standpoint, we feel like they are a part of Centennial Heart. They are an outsourced company, but from a practice standpoint, we consider them our teammates, and they are just an extension of our remote monitoring team. That is not the same impression I got from other companies. At least for our group, we have seen the willingness of CV Remote Solutions to adapt and tailor to our workflows, and their nurses have gone above and beyond. We have a certain sense of ownership and loyalty to our patients of going 110%. In the two and a half years we’ve been with this group, we’ve never had concerns with quality of care. CV Remote Solutions adheres to our values and mission and more. Our patients also ultimately benefit from it because they’re getting the care that they deserve.

Disclosure: The authors have no conflicts of interest to report regarding the content herein. Dr. Crossley reports consulting, teaching, and research for Medtronic, and consulting and research for Boston Scientific. 

This article is published with support from CV Remote Solutions.