Western AF Symposium 2023: Session 17 Roundtable

Implementing Digital Health in the AF Practice: Health Care Provider Perspective

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Featured is the Session 17 Roundtable entitled "Implementing Digital Health in the AF Practice: Health Care Provider Perspective" from WAFib 2023. 

Moderator: Brent Wilson, MD

Discussant: Monique Mones Young

Discussant: Jill Schaeffer

Discussant: Will Cho

Discussant: Erica Zado

Brent Wilson, MD: I'm Brent Wilson, and I'm filling in for Chris McGann, who was unable to make it. It's my pleasure to be here with this panel discussion. We're going to talk about the implementation of digital health in the atrial fibrillation (AF) practice. I'm here with a fantastic group of panelists. These are all advanced practice providers (APPs), who as you all know, form a crucial role in any cardiology practice that provides high-quality patient care, but they often do not get a lot of the credit. A lot of the credit goes to the physicians, but these people are the ones who actually do most of the work. So, I'd like to introduce them briefly. I'll start with Monique Young. Monique is from the University of Tulane. She works with Nassir at the University of Tulane, where she is involved in lots of the great things they have going on in advancing artificial intelligence. Next to her is Jill Schaeffer. Jill has been at Lancaster General Health in Pennsylvania for 24 years and she served previously on the board of trustees for the Heart Rhythm Society (HRS). She has done a lot of great things there, so it's a privilege to have her with us. She has a lot of experience in electrophysiology and managing AF clinics. Then, I'd like to talk about Erica Zado. Erica joins us from the University of Pennsylvania, where she also is heavily involved in their managing their AF database in the cardiac electrophysiology (EP) practice there. She is a current HRS board member, and she is also an editor for the Heart Rhythm Journal. Last but not least, I'd like to introduce the incomparable Will Cho. Will is also at the University of Utah, and he is a phenomenal advanced practice clinician. Will is the head of our advanced practice group at the University of Utah, and I can truthfully say I don't think I have met a better leader APP leader anywhere. So, it's a privilege to have Will with us here. We're going to go through each of our APPs and have them talk about how they implement digital health in their AF practice, what they're currently doing, and if they have thoughts about what they may do in the future, because I know many groups, including the group at Tulane, are looking at some future applications. With REACT-AF, this is only going to grow. It’s going to really change the face of care for arrhythmia patients. So, to start off, I looked up digital health on the FDA's website and they define it broadly as including several large groups, such as mobile health, health information technology, wearable devices, telehealth, and telemedicine. They say that digital health technologies use computing platforms, connectivity software, and sensors for health care and related uses. So, maybe we'll start with Monique. Can you tell us about what your team is doing with digital health?

Monique Mones Young: So, we've had an abundance of speakers today about digital health. Who doesn't have a watch and who doesn't have the Kardia (AliveCor) app? Patients come into our clinics every day, and we all can probably say that they're detecting AF earlier. I've had so many people come into my clinic now who are aged 25 to 30 with detected AF, and it's true AF. It's not atrial tachycardia, it's AF. So, who and when do we treat? We have the MRIs, we have early ablation, and EAST AF. I think digital technology will absolutely change how we look at and prevent strokes down the way. In my population, a lot of times I’ve had patients tell me that they cannot do digital health because they're not savvy enough. But I have 85-year-olds who send me Apple tracings. Sometimes I have to teach the younger ones. With APPs, including medical assistants (MAs) to nurses, if they can teach patients how to measure a pulse, they can teach them how to export a text message. I use Hurricane Katrina as an example. Back then, Hurricane Katrina was a part of my life. I didn't know how to text, but texting became a priority in 2005 because I couldn't reach my family. Now, text messages are something we don't even think about. We now have a population who knows how to email, text, and send tracings. In our clinic, we have patients who are hours away. I have people who travel 2 hours to our clinic, and I think a lot of people do that. But I also use a lot of telehealth because of that, because for those patients to come to me, they either have to take off of work or have to inconvenience a family member to bring them to me. So, I will do a telehealth visit or have them send me a tracing because I still have a dedicated email. I have thousands AF and arrhythmia tracings. So, it's kind of like my digital health platform that we use for all our implantable loop recorders (ILRs) and such. The patient will message me and I'll say it looks fine. They'll think they are back in AF and I can message them back. So, that is how I utilize it. I use it a lot after our ablations as well. Some patients don't want a use a monitor because they have reactions to it. The REACT-AF trial is going to be huge for when to stop an anticoagulant if possible. So, that is how we're utilizing it, and we have great AI and engineering teams. It has opened up a whole platform. 

Jill Schaeffer: I agree with Monique. I live in Lancaster County. It is a very nice place to retire because of affordability of housing and health care, so the average age in my clinic is in the 80s. I deal with a lot of elderly patients, but we also deal with younger patients. Two years ago, I would have said we were doing more pulse checks and pulse oximeters to help patients monitor their own rhythms post diagnosis. That is really changing. It's not uncommon now with a consult in the hospital for the children to ask, “should I buy dad a watch?” Or “what about this Kardia that I saw on TV?” So, there's a very heavy interest in what we can do to monitor our health and how we can use that. That opens up a lot of good things as well as challenges. Again, in my population not only are we dealing with AF, but a lot of tachy-brady syndrome. Yes, we move people onto ablations, but many folks, for various reasons, choose antiarrhythmic drugs. We use our nurse practitioners to help follow those patients serially, so that the physicians can continue to meet new patients, have access to those patients, do ablations, and keep them in the lab. I would say my job is to keep them in the lab. So, we do a lot of follow-up. I may see a patient in the clinic once a year, but what is happening the other 364 days of the year? How are patients able to monitor themselves whether they're too fast or slow? So, we often use low-tech options such as teaching pulse checks and pulse oximetry versus the high-tech options. I shared a story the other day of an elderly patient of mine who very proudly brought me a spreadsheet of the blood pressures that she takes every day. She also now has the Kardia app, but she said, “Jill, it's always green.” So, it just goes to show that folks really can learn and you have to meet them where they are. That being said, I think there are some challenges, because on the opposite end, sometimes you have to ask, what am I looking for? I really don't need you to send me an Apple tracing every other day or 5 times a day, because there is a component where some folks develop anxiety. With quality of life in AF, one of the biggest fears is “when is the shoe going to drop? Am I going to have AF during my daughter's wedding, as I'm walking her down the aisle?” There is always a constant worry. So, setting up a recurrence plan is a big part of what we do in the AF clinic, saying this is how we manage it, you're anticoagulated and rate controlled. I spend a lot of time educating our patients, because as we all know, if they call their primary care physician (PCP), they might be told they are in AF and must go to the emergency room (ER). That is what we are trying not to do. We try to keep patients in an outpatient approach. But then what happens is I can see the patient as an add-on. If somebody calls in, we focus on access to the therapies that they need. So, sometimes I'll see a patient who had been recommended an ablation. They say, “maybe if it happens again, I'll do it, but not now.” Then they call me and they have their Apple Watch tracing that shows recurrence. I see them and we start talking about it. I reserve a date for the ablation and we start that process. They still come back and meet with the physician, because it might have been 2 years since they met with them last. But by meeting with the APPs in the clinic, we can preserve that access. So, I think it has been a wonderful thing. Like you, we are exploring more telehealth opportunities to do that. In my area, certainly Covid did that. It wasn't our patients’ fault. Our platform wasn't the best with supporting the video visits, mostly because the Wi-Fi was weak. We often had to convert to telephones, but our system is working on that. So again, we can see patients when they need to be seen. Using these technologies, it's really an exciting time to do that.

Will Cho: At the University of Utah, years ago, when Kardia mobile and ECG Check initially came out, we had kind of a prehistoric way of trying to gather this data. We had a shared email address where all the patients would send their PDF tracings to. There wasn't a really systematic way to interpret or look at the data. Whoever was available would randomly check it. Through the years, we've evolved that process. We use Epic at the University of Utah and have a function called MyChart where patients can directly send an email to their provider, so patients are now able to attach up to 3 PDF documents to a MyChart message and it gets directly incorporated into the patient's medical chart. So, that has been a huge improvement in terms of consolidating the data. We still have a ways to go to better manage and keep the data. However, we see a lot of patients from out of state. Remote areas in Wyoming, Idaho, Nevada, New Mexico, and so forth. So, for these patients, it can be kind of a hassle to travel to their PCP’s office just to get an electrocardiogram (ECG). It can be a 1- to 2-hour drive in some instances. What these mobile ECG tracings allow these patients to do is save a trip, save an ECG bill, and it also allows for more efficient patient throughput at the time of treatment. So, it has definitely been a game changer. Everybody in our practice uses the Apple Watch or Kardia mobile, etc, but a lot of our younger folks under age 65 are heavily leaning towards that direction. It's definitely simplifying the care process.

Erica Zado: I want to echo a lot of what everybody else has already said. At Penn, Covid was a game changer. They quickly pivoted to telehealth visits, as we all had to, and we learned very quickly that you can effectively take care of arrhythmia patients with video visits. Especially device patients, you get their data, have their visit, and actually diagnose heart failure just looking at patients. So, that really made a huge difference. Of course, now with insurance reimbursement being what it is for video visits versus in person, we've backed off from that. But it's still a great adjunct, and as far as the Apple Watch, I now spend a fair amount of time teaching the patients who have Apple Watches how to set it up, spending time to set up their irregular heart rate and high heart rate notifications and showing them how to record an ECG. We also have Epic and we have MyPennMedicine, which is basically MyChart, where people can upload. We can send the patient instructions on how to upload from their Apple Watch. It’s an incredibly effective tool as long as you tell patients, “if you want me to see this immediately, you need to then call the office and tell me you’re having this symptom and that they need me to look at this,” because I won’t see it unless I’m on Epic. The other spin that is a little different from everybody else is we had an observational study a number of years ago with PRM and NOACs post AF ablation, very similar to the REACT-AF trial, but we were using pulse checking with the Apple Watches. I cannot wait to see how the Apple Watch PRM works, but to segue, we would always augment those pulse checks with routine monitoring and things like that to make sure we're not missing asymptomatic AF. But now all those patients either get a LINQ (Medtronic) or we tell them they need to get the Apple Watch or Kardia and check that way as opposed to only pulse checks. I'm looking forward to how the Apple Watch study works. But that was the extra thing that we were already doing as far as digital health—we were segueing into it being an access issue since not everybody can afford an Apple Watch or Kardia. But for those people who can, we're getting as many patients with AF with those devices so that we can follow them closely whether they're on anticoagulation or not.

Brent Wilson, MD: Thank you. It's curious how much patients do on their own. For example, I'll frequently have older patients come in and show me their Kardia device or new Apple iPhone and say they researched this. They’ll say “You've talked about AF in the past, so I got this.” I think maybe Jill mentioned this, that occasionally you get concerning messages that the patient doesn't understand. With physician burnout, one of the causes, to use an Epic term, is “managing the in-basket” of all these messages from patients. All these digital health technologies are for sure increasing patient messages to providers. What has been your experience in dealing with that and what kind of systems have you built to address these common patient questions that will come as we use more and more digital health technologies?

Jill Schaeffer: I can answer what we do. I think that is where you set up the expectations when you talk about it. As long as your heart rate is okay, you feel okay, and you're anticoagulated, I may not need to know that. Even if it comes up unclassified or whatever. I spend time saying that I want to know if your heart rate is less than 50, or if at rest, your heart rate is over 100. I cannot say that I'm inundated with tons of messages like that. I think in the future though, to that point, we need more artificial intelligence that will help classify that and provide feedback to patients. I think it'll get better and better. Including the family is really important. Now, if you feel poorly and you understand that you don't, that is different. It's not uncommon for me to get a message from a patient that they have been in AF since Friday and they are rate controlled but don't feel the best. They are waiting it out over the weekend. If it is paroxysmal it will go away, but if it doesn't go away, I tell them to come on in and we’ll talk about next steps. The other part of a lot of this is the tachy-brady syndrome. I have a lot of patients who, because they're older, their renal function and heart rate changes, so a lot of times these are clues that we need to see them more frequently than what was thought. An annual follow-up is maybe not enough. A lot of times, the patients give us the information to let us know that. Setting that up with them the first time you meet them, or at repeat visits, to say, “I want to know if you have congestion.” Especially our folks who have heart failure, when is it time to go to ablate and pace using a lot of conduction system pacing? We end up having those conversations on when is it time to move to the next step in AF care.

Nassir Marrouche, MD: Question to the panel: Are you challenged by your administration on how much time you spend with your patient on the phone or online? Are they challenging you with views that this interaction is billable?

Will Cho: In this era where our nonclinical administrators are pushing us to be more productive clinically, right now the mobile ECG volume is not an issue in terms of burnout, but I could see it being an issue 5-10 years down the road. My understanding is we need to spend at least 30 minutes a month—I could be totally wrong—per patient to be able to bill for this. We've thought of coming up with some sort of subscription package where patients can log into this mobile ECG interpretation service that we provide, but nothing is finalized yet. But it is in the back of our minds for sure. 

Erica Zado: We're not billing yet. Again, I've heard through the rumor mill that there is a way to bill for ECG interpretation and phone visits. But I think for the most part this is sort of a freebie part of the part and parcel of the whole taking care of the patient, at least at Penn. They haven't figured out how to bill it.

Jill Schaeffer: I think that is where the video visits come in. You can bill video visits and at least what I'm told in our institution is the video visit is the same as if it would be an in-person visit. That's not the case with a telephone visit. But again, we must have patience and understand how to do that. So, simplifying and using Epic; we’re switching to a different platform to do our video visits that is supposed to make it a little easier through Epic, and we look forward to that. So, that is a way to recoup at least some. But by and large, a lot of the work we do with the in-basket similar to positions is not reimbursed at this point, but it's something that is on everybody's mind. With off-hours calls that come in, we have nurse practitioners 24/7, 365 days a year. Not necessarily EP, that comes into general. Burnout? I worked night shift one time, and I had a lady call me with her blood pressure at 3 in the morning. I had to wonder, why are you checking? But these are the phone calls that come in, and a lot of times patients know that it's free advice. It's not like a lawyer where you get billed for every email. 

Monique Mones Young: I'll echo off of Jill. I’ll use a televisit if I get an email saying a patient is in AF. I had 3 of them yesterday and it was almost 5 o’clock on a Friday. So, I thought, if you don’t feel bad, then I’ll make a visit next week. The patient asked, “did you see my heart rate?” I said if you feel okay, then that is okay. But I do see where it can become cumbersome. I tend to make my personality very nice and I’m sure you all do as well, that is our job. But I think the thought that comes to mind with billing is that a lot of PCPs are able to bill for blood pressure checks in these post visits, and as an EP team, we have to look at. We are looking at this and it is preventing stroke, whether they're off anticoagulation or they need to go back on anticoagulation. I think we should be able to bill for this. I think there is a way if we really look at it as a team. The dietitians and endos can do blood sugars and blood pressures and bill for it, so I think we have to push to get our billing for the effort that we do on the side of ECGs and tracings.  

Brent Wilson, MD: And while this gets figured out, the video visit is a good way to perhaps do that. You can bill by time. It doesn't have to be a conventional “how are you doing?” focus on that target visit. As long as you document the time, you should be okay. 

Rod Passman, MD: Quick question: I think to engage properly with this type of strategy, you need the technology, and that means money. So, how do we ensure that we're not worsening inequities in health care when people who can afford these technologies get remote care, avoid coming to the office, and reduce hospitalization, and things don't get worse for those people who can't? What kind of data are we going to need to prove to insurers that it’s actually cheaper to give someone a Kardia then to let them go without one? I know in 3 minutes it's a lot to answer, but I’d love to hear your input. 

Jill Schaeffer: I’ve heard from other centers—we do not do this—but some centers are purchasing several Kardias like a library card and using that method. Because you're absolutely right, it’s for the folks who cannot afford that, and it's something that truly will help. That is why I say that sometimes I will go to low tech. That being said, and maybe it's the area I'm in, almost everyone has a smartphone. But I wonder about people who aren't making it into the office. I live in Amish country and I cannot tell you the last time I had an Amish AF patient come to me. So, I think they're staying with their PCPs, I think they're not getting EP care, though it's something where we must be very cautious about so that we don't forget about folks who cannot do it. That being said, I'm really glad that Kardia is a lower cost option. For implantable cardiac monitors, patients complain about the copay. But that is a monthly report that we get reimbursed for. So when I tell them Kardia is a one-time cost and you attach it to your smartphone, it’s viewed quite positively by most of my patients. 

Monique Mones Young: Regarding who can afford and cannot afford it, most people come in with their family, so I tell them, “when people ask you what you want for Christmas or your birthday, get something. It may not be the $500 watch, but they can afford $69 or $100.” Patients ask me, “Which one should I get?” I always say it's patient dependent. What are you going to use? Because you can have all the devices in the world to measure and monitor, but if you don't use them or know how to use them, it’s no good. 

Will Cho: Very quickly, I think it'd be interesting to look at time to treatment and ER visits between the 2 groups.

Brent Wilson, MD: That is a great point, because all my patients who come in with the watches and devices that they researched on their own, they are all of higher socioeconomic status. I think it's very rare that you'll find someone who is indigent who comes in with a device like this and says, “This is great. How do I use this?” 

Erica Zado: There are a lot of people who have smartphones who cannot afford an Apple Watch or even Kardia but who can get the free app. The problem with that is that they're not great at detecting an irregularity. But at least they would know if their heart rate is 120. 

Monique Mones Young: It’s socioeconomic. Where I’m at, there are a lot of highs and lows and mixed. So, you're correct about the diversity. But if you teach them and they feel like you're watching them or can send something to you and have confidence, they'll get it for their mother. Again, I go back to education and tell them this can prevent a stroke. When you say the word stroke, they’re suddenly more aware. They don’t want to have a stroke or another stroke. 

Brent Wilson, MD: That’s a great point. Hopefully we’ll soon get to a point where flexible spending dollars can be used on watches and these devices without much question. Right now it’s challenging, but hopefully that day is coming soon. 

Audience question: I have a question for the panel. How do you determine if a patient will be able to use the device? Do you have certain criteria, like are they able to measure every day or connect to Bluetooth or understand what to do? Do you have a checklist if you meet a patient and say there will be additional literature for this?

Erica Zado: I know my patients. There are ones that we know for sure. They'll even tell you. For example, when I say I'm going to put a Zio patch on them, they’ll ask, “how do you do that?” There are instructions in the box and it's super simple to do, just put on a patch. Those patients are not going to be able to do a watch. Sometimes I teach them how to do pulse checks and go super low tech with some of the older people, but I don't think there is necessarily any criteria other than knowing your patient and knowing what they're willing to do, because there are some people who would. But most of my patients, if they don't think they can do it, they'll tell me as much. I'll show them my watch and they’ll say, “Look how easy this is!” but later say “I don’t think I can do that.” So, I tell them that is fine and show them how to check their pulse.

Jill Schaeffer: I have a team of folks, just like Will, and I find that we have to be cognizant of all the stuff that is out there, too. I have a watch and I bought a Kardia to better understand it, so that we could show examples to say this is what it looks like, it connects to your phone, and go through that way. So no, we don't have checklists either, but it's patient choice. If they say that it is not for them, then I tell them to let me know if their heartbeats go over 100 at rest or under 50 and they’ll stay on anticoagulation. 

Brent Wilson, MD: It's really interesting how our enthusiasm for this technology really rubs off on patients. I've seen many patients come in with a new Kardia device and be really excited about it. I tell them that is great, I'm glad they got it and go into how to use it. You see their face light up and they really get excited about it. Another interesting thing is that it doesn't seem to corollate with age, like you all have mentioned. My mother is in her mid-80s, and she has an Apple Watch and does great with it. She’ll show me messages and what ask what they mean, like “This says something about a rhythm issue.” So, it's fun to see that there is really no age barrier. It's more about a willingness to learn and the excitement. Maybe family members can provide support if the patient cannot do it on their own.

Erica Zado: I frequently ask patients if they have a 13-year-old grandchild!

Brent Wilson, MD: That is a good point! That is who resets grandma's device. Her 18-year-old grandson can do the software updates and everything for her. 

Monique Mones Young: One other thought I had about selection and choice: you also have older generations who are not as steady on the hands. So, that also makes a difference. The day before I left to come here, my cousin was actually in AF. He had been telling his provider that his pulse rate was in the 50s. They took him off his metoprolol and amiodarone. I went over there with my Apple Watch. He has a little Parkinson's and he had been through another system prior to coming to us. So, I think patient selection is also knowing your patient, knowing what they can do, and looking at them. But his heart rate was in the 50s. He was using a blood pressure cuff and pulse oximetry, and neither of them worked. Neither was accurate. When I showed him the watch and was able to put my watch on his wrist, he saw his heart rates were in the 130s. So again, patient selection, knowing who they are, and what they can do is a huge thing of advancing what we can do with them with monitoring.

Brent Wilson, MD: Those are great points. Yes, there is nothing like when that patient comes in and says they had symptoms the other day, and then they pull up the rhythm strip from that on their watch. It’s just fantastic, it really makes it all worthwhile. 

Erica Zado: That brings up another point about education, which we spend a lot of time doing. It may sound counterintuitive, but you have to tell them they have to get you a strip. With the LINQ, a patient might say “I had this episode 2 days ago,” and you ask, “Did you record on your phone?” and they'll say, “no, it didn't catch any. Can't you look at 4:30 on Thursday?” We have to tell them, that is not how it works. You didn't have anything that the device thought was a problem, but that doesn't mean you didn't have anything. So, I spend a lot of time educating people on how to use these things. To Jill's point, there are some people who will literally send you 50 strips a day, and you finally have to tell them to stop and set the expectation for what you're going to respond to. You also have to set the expectation with the device, whether it's an Apple Watch, Kardia, LINQ, or implantable loop. You must tell the patient how to use it appropriately to help you make the best decisions for them. I spend a lot of time doing that.

Brent Wilson, MD: That is a great point. I just noticed that all the panel participants, except for the incomparable Will Cho, have a watch that is capable of recording tracings, so I'm not sure if we're supposed to be worried about that or not! Are there any other questions from the audience? We have just a few minutes left. Okay, I think we'll probably wrap it up then. Thank you to our wonderful panelists and their great comments. I’m looking forward to implementing more and more digital health in the future. Thank you very much.

The transcripts have been edited for clarity and length.