Empowering CIED Clinics: Navigating Post-Covid Challenges and Data Deluge With Innovative Strategic Partnerships

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EP LAB DIGEST. 2024;24(5):22,24-25.

In the wake of the COVID-19 pandemic and the release of the 2023 Heart Rhythm Society (HRS) guidelines, device clinic managers face extraordinary challenges in adapting to evolving healthcare landscapes. This interview explores how partnerships with specialized service providers are not only harmonious with the latest industry standards but also pivotal in enhancing strategic clinic management. The insights shared demonstrate that such partnerships are not a relinquishment of control but rather an extension of the clinic's capabilities, offering a nuanced approach to patient care and operational efficiency in a rapidly changing environment. Featured is a discussion with David De Lurgio, MD, Director of Electrophysiology at Emory St. Joseph’s Hospital in Atlanta, Georgia, and Devi Nair, MD, Director of the Cardiac Electrophysiology Division at St. Bernard’s Heart & Vascular Center in Jonesboro, Arkansas.

With the complexities brought about by Covid, and in light of the recent 2023 HRS guidelines, what are the key challenges you see for cardiovascular implantable electronic device (CIED) clinic management, and how do you envision these practices evolving?

Devi Nair, MD: Device management is a critical part of any EP program. Regarding device management, approximately 90% of devices are monitored remotely in most clinics. Every clinic is different, and each one has a unique workflow, but remote monitoring for a large volume of patients can be a significant challenge for many clinics. With the recent HRS 2023 guidelines requiring at least 3 FTEs per 1000 patients, it becomes increasingly challenging for clinics to hire trained personnel. Ensuring that you trust your staff to take care of your patients, especially those whom you rarely see in person, is of the utmost importance. That’s why we started looking at opportunities outside of our clinic to partner with institutions like PrepMD.

David De Lurgio, MD: Thanks, Devi. We have had a similar circumstance. At Emory, we follow about 9500-plus patients with CIEDs, and this is in 4 separate clinics, and we are expecting to go to 6 clinics very soon. We found that on a weekly basis, we would get behind by about 300 remote monitors, and to make that up was very challenging. Even before the Covid pandemic, staffing was a big challenge for us. It only got worse with Covid and still has not gotten better, even though the pandemic has subsided. So, we found that we needed help. Having an outsourced remote monitoring only works for us in the positive. It has brought down our back load from 300 a week to less than 10 per week, something we can easily manage and catch up on. It has also increased our ability to respond appropriately. The guidelines told us we would need to hire 27 people just to cover the remote monitoring to satisfy our clinic needs—that is just completely impossible in this day and age. You need to have some help with that.

While technology-based solutions offer significant advancements in data management and patient monitoring workflows, could you elaborate on the aspects of clinic operations that still heavily rely on professional expertise and human intervention?

David De Lurgio, MD: Just monitoring an implantable device now is not enough. Recent published reports have shown us that there are many actionable items. We now know that we have to reduce atrial fibrillation (AF) burden, for example, in our patients. When patients have AF, we have to respond to that. We have to determine the following: Does it meet the requirements for initiation of oral anticoagulants? Should we be considering ablation or other therapies for these patients? When you do not have a system that allows you to quickly and thoroughly assess each and every remotely transmitted monitor, you fall very behind, and I think patients suffer from that. Having the professional input of someone who can actually vet and flag reports is critical. 

Devi Nair, MD: David, you bring up a great point. The data that comes in has to be screened by trained personnel, and having staff who can actually look through this data in a timely fashion and identify problems that need to be addressed is key to remote monitoring. For us, integrating with PrepMD to help us handle this data deluge that we were dealing with was significant because therein, we were also very behind on our remote monitoring and catching up on our patient workflows. We were not delivering care in a timely and efficient manner, and quality care was thus lacking. When the team from PrepMD came in, they helped us in several ways. Firstly, they trained our staff, allowing our staff to improve in their roles. Additionally, they helped us resolve our data management issues to the point where we were down to about 5 to 10 per week, which we could manage well in hand. Our patients also received timely care, overall increasing patient satisfaction. Like I mentioned earlier, every clinic has different needs; what we needed was trained staff who could deal with and manage our data in a timely manner, and through PrepMD, that is precisely what we got. 

David De Lurgio, MD: Yes, we have had a very similar experience at Emory. We had been using contract staff for about 3 years and it has been extremely helpful. PrepMD has supplied us with International Board of Heart Rhythm Examiners (IBHRE)-certified staff. They are excellent. They seamlessly integrate with our staff and really help cover us with the natural turnover we always are going to see in the clinic. Then we started using remote monitoring services, and as I mentioned earlier, it just made a huge difference. Most recently, we have invested in the training modules. This has been really good. It brings our staff together and onboards our staff with training, which is really helpful. We are even using it for our non-clinic staff, for example, with some of our advanced practice providers (APPs) who need to know some of these same things because they are seeing patients in the hospital or outpatient clinic. So, being able to bundle those things together and get a really good deal, something that works financially well for us, and meets our needs has been really helpful. 

What prompted your decision to partner with PrepMD for service solutions like remote monitoring, contract staffing, and continuing education unit (CEU)-accredited online training, and how did you initially envision this partnership benefiting your clinic?

Devi Nair, MD: So, we were not handling the data from our remote clinic in a timely manner. Numerically, we were behind schedule by hundreds every week; we simply were not taking good enough care of our patients. That is what prompted me to get involved with PrepMD and bring in their team. Initially, we definitely had concerns about how an outsourced program was going to work with our clinic team. Were we going to lose control over how we take care of our patients? We had a variety of qualms and fears about this new partnership, but these were very quickly put to rest once we actually got to meet the team and see how well they integrated with ours. PrepMD came in and helped us efficiently clean up our backlog, which in turn helped me show hospital administration the financial benefits of this partnership. They were not realizing what they were leaving on the table due to lack of appropriate and timely billing; however, as PrepMD got integrated with our remote clinic program, they also started seeing the value of actually needing trained staff, which in turn helped me hire more staff into my own remote program as well and train them via PrepMD. So, as we say in the South, our partnership with PrepMD has been a blessing.

David De Lurgio, MD: I could not agree more. I think anyone who is considering using a service that provides remote monitoring and other important services is always going to ask, “Am I losing control of my own patients, and can I afford it?” I think the affordability issue was the easiest thing for us to get past, because we realized that once we were following our patients more thoroughly or being responsive or identifying patients who needed to be brought in for appropriate treatments or adjustments, we really overcame any of the financial concerns. So, the remote monitoring piece has been really easy to gather. I think that the contract staffing has also been something we have really appreciated. We have found that to get good staff and hire and retain them over time is very challenging. These tend to be fairly young individuals who are in the early stages of their career, they wonder what’s next, and they naturally cannot be hired forever and ever, or at least a certain portion of them. Having contract staff to come in, provide full service with excellent qualifications, and even provide the education that we need to keep our staff happy, I think has really worked out really well. 

How do you now perceive the value of partnering with a trusted provider for essential services such as remote monitoring, staffing, and training, and what would you like to see in terms of innovation in this space? 

David De Lurgio, MD: For Emory, the partnership is very effective. We are very happy being able to cover our remote monitoring obligations more thoroughly and effectively for our patients. It is very hard for me to imagine hiring 27 additional employees to cover that role. I am not sure how PrepMD can get better. I do like the training aspect, and I think that we should make it a goal to have everybody certified through the IBHRE as soon as possible, so that means starting the training immediately with onboarding. I am interested in expanding the training to more of our staff. I mentioned it before that APPs are taking the modules. I think that if we make it a goal that everyone becomes device proficient, we are going have a much more effective and long-term solution to CIED management.

Devi Nair, MD: We have been partnering with PrepMD for over a year now, and this is probably the first time in my career that I feel I am up to date on my remote monitoring. I feel at ease, whether I am at work or traveling, knowing my patients are well taken care of in a timely manner. I know my staff feels more comfortable taking care of those patients as well, because they have a second layer of trained professionals they can reach out to at PrepMD, and they look to them for advice in assessing the data that comes from the device, which has also prompted them to seek out better and further education in device management. So, I do appreciate the opportunities that PrepMD provides my staff in the clinic with training and motivation to improve.

Having said that, I do think that there is value in collaborating further with PrepMD to ascertain how this changes the management of our patients in the long term. What is the positive impact remote monitoring is having on the patient? We all talk about remote monitoring, but engaging in it in the proper, right way, will make a tremendous impact on how we take care of our patients and how they are being taken care of. I believe there is value in looking at long-term outcomes in these patients. 

David De Lurgio, MD: One other thing that strikes me is that the software component that PrepMD offers is not something that we have taken advantage of. We use a different vendor for that, because we have been with them for a long time. But every software program that I have seen has some gaps. I think improvements in software can occur through the things we learn in the clinic. PrepMD is uniquely situated because they provide training and all the remote monitoring to learn how to continuously adapt the software to help us identify the actionable items more readily. 

Devi Nair, MD: I would like to add to that point that the real beauty lies in the fact that every clinic is unique, and we each utilize different data management platforms. However, integrating it with PrepMD was remarkably easy because you do not necessarily have to use all their services; you can pick whichever service you want. It is all à la carte. As for us, when the time comes, we would like to consider the software, but currently, we use remote staff and contract staff, along with the educational portfolio they provide.

Some may perceive outsourcing as relinquishing control over certain clinic operations. Based on your experience, has partnering with PrepMD empowered your clinic management team to focus on core patient care responsibilities?

David De Lurgio, MD: When you have a large clinic and a large burden of remote monitors to follow, you must ask yourself an important question: Am I capable of doing it? We found out that we really were not. By analogy, you will not see me trimming the trees in my own yard! We have to outsource the things that we are not capable of doing ourselves. When it comes to remote monitoring, we found that by giving this responsibility to a third party, it improves every aspect of patient care and also improves every aspect of billing, helping us stay current. I think this is what translates into better outcomes for patients in the long run. 

Devi Nair, MD: I will echo David’s points and add that currently, my staff, who were getting absolutely bombarded with all the data that was coming in, and thus lost the ability to spend time with patients, are now able to engage in patient care rather than just looking through paperwork and remote monitoring data. They are actually able to pick up the phone, talk to the patients, see those patients in the office, and deliver better care without worrying about being overloaded by data. This is of paramount importance because you can take the necessary personnel, such as those trained with PrepMD, and achieve great outcomes. Then, you can transfer that to your staff who have a relationship with the patient and deliver appropriate, timely, and personalized care. 

David De Lurgio, MD: I think that is a really good point. 

Based on your experience, what advice would you give to other CIED clinics considering a shift towards a partnership? What factors should they consider to ensure a successful transition and collaboration?

Devi Nair, MD: I think it is important to understand that every clinic is different. It is crucial to know what your clinic can and cannot do; for us, it was a quick realization that we could not adequately conduct remote monitoring without help. We lacked the staff, resources, and trained personnel to perform it in a timely and effective manner. I urge other EP physicians to examine their own clinics and view this as a partnership in pursuit of delivering the best possible patient care. Partnering with the right individuals, such as PrepMD’s trained personnel dedicated to providing device management, and integrating them within your own team, rather than simply seeing them as an outsourced provider, is truly essential. 

David De Lurgio, MD: I think every clinic must look very carefully at what their needs are, what they are able to do on their own, and what they want to be able to do. Devi, you made a very important point earlier that our staff has a unique relationship with the patients, and that is where they shine, and I think that is where they gain the most professional satisfaction. When we divided up the work that had to be done, we found that it was very helpful for us to be able to outsource most of the remote monitoring. It has just worked in so many different ways.

Devi Nair, MD: This is a true partnership. You are genuinely not losing any control of your patients or your remote clinic. Instead, you are collaborating with a team who will help you provide personalized, timely, and efficient care for your patients. 

The transcripts have been edited for clarity and length.

This content was published with support from PrepMD.