Remote Monitoring Saves Dollars, Makes Workflow Sense
As the number of people with implantable cardiac devices increases, wireless telemetry will grow in use. Studies have shown economic and practical value associated with using remote technology.

Wireless monitoring of cardiac patients is poised for a perfect storm. In 2008, Bruce L. Wilkoff, MD, director of cardiac pacing and tachyarrhythmia devices at the Cleveland Clinic, presented a paper at the Heart Rhythm Society meeting predicting that remote monitoring could become the standard of care by the end of the decade. The rationale is simple. Research shows that remote monitoring effectively supports increases in the number of patients served without directly increasing demands in clinic staff time and resources (see sidebar).

Demographics certainly favor expansion of remote monitoring. The number of follow-up visits for patients with a cardiovascular implantable electronic device (CIED) exceeds 5.8 million visits each year, and will continue to increase as more CIEDs, such as pacemakers, implantable cardioverter defibrillators (ICDs) or cardiac resynchronization therapy (CRT) devices, are implanted. Technology is keeping pace, with vendors introducing and investigating a host of devices to help clinicians virtually monitor cardiac metrics and hemodynamic measures. The Centers for Medicare & Medicaid Services (CMS) also is facilitating the move toward more remote monitoring; new codes that reimburse remote monitoring at the same rate as in-office monitoring went into effect in January 2009, which could encourage more sites to adopt remote monitoring technologies.   

The trend carries multiple benefits. Remote devices may not shorten the initial length of stay for the target population, but they could keep patients out of the hospital for subsequent events, says J. Thomas Heywood, MD, director of Heart Failure Recovery and Research at Scripps Clinic in La Jolla, Calif. That’s because remote devices supply an early warning system to help cardiologists better manage their patients. Plus, remote monitoring can help ICD patients avoid three out of every four annual office visits, which translates into an efficiency incentive for cardiologists because remote management reduces office staff time dedicated to patient monitoring. At the patient level, remote devices translate into fewer office visits and a higher level of involvement in managing his or her own cardiac disease.

Remote monitoring at a glance

George Crossley III, MD, president of Mid-State Cardiology and St. Thomas Heart in Nashville, Tenn., uses Medtronic Paceart clinical database in conjunction with Medtronic CareLink Network remote device management system to better manage congestive heart failure and atrial fibrillation (AF) in ICD patients.

How does it work? When a patient receives an ICD, the physician pre-programs the device to regularly check specific parameters at three-month intervals, and a bedside monitor transmits data to the office for review. Review of the wireless data downloads replaces three of the four annual office visits for ICD patients.

“It’s a way to provide good care remotely,” sums Crossley. Typically, Mid-State Cardiology patients connect to the device on a Friday afternoon, and a nurse reviews the data early the following week, with the cardiologist following up with the patient by mid-week. In contrast, conventional monitoring requires scheduled office visits. With remote monitoring, a nurse can review data when there’s time between cases or bundle the review of several patients. “It’s a huge benefit to the practice,” Crossley says.

The remote system may be particularly beneficial to patients prone to AF. “We want to limit atrial fibrillation because it increases the risk of heart failure and can lead to stroke,” says Crossley. For such patients, the physician programs the device to transmit an alert if the patient’s heart rate crosses a certain threshold. The monitor sends a message to the cardiologist’s cell phone if it detects a new onset of AF or atrial tachyarrhythmia. The alert facilitates compliance with the standard of care calling for blood thinners within 48 hours of AF to decrease the risk of stroke. The remote monitoring system informs Crossley about AF within 24 to 30 hours, providing him the clinical data necessary to order blood thinners. In contrast, standard scheduled downloads occur every three months, meaning a cardiologist might not know about AF for three months.

Finally, patients can send data manually, which reduces costs and increases convenience. Take, for example, the issue of a 3 a.m. shock to the patient. Conventional processes may entail an ambulance trip to the local ER followed by transfer to a referral center at a cost of $5,000 to $6,000. In contrast, if one of Crossley’s patients feels a 3 a.m. shock, he connects to the monitor and transmits the data to Crossley. The cardiologist reviews the data, often conferring with the patient by phone and scheduling an appointment. The cost drops to a few phone calls, says Crossley.

Scripps Clinic Heart Failure Recovery and Research program uses Medtronic OptiVol Fluid Status Monitoring with CareLink remote management to follow 100 heart failure patients. OptiVol measures changes in electrical impedance in the chest, which corresponds to the amount of fluid in the chest cavity.

Heywood, who is studying the clinical impact of OptiVol, says the system provides several pieces of information. Most importantly, it indicates patients at high-risk for heart failure. Data, however, is sensitive, but not specific. That is, a patient might cross the threshold if he ignores dietary recommendations or forgets to take medication. “Early data show that cardiac events take longer to build than previously thought. In some cases, we’ll observe a long, gradual worsening of the signal for up to eight weeks,” notes Heywood. Currently, the FDA has not approved an OptiVol alert, so data must be downloaded manually. Studies of OptiVol alarms show the alarm would go off up to 10 days before an event, which could keep patients out of the hospital, says Crossley.

Mid-State Cardiology also uses remote technology to manage patients with pacemakers. Although wireless monitoring technology for pacemakers is not yet available, the system does allow providers to complete regular downloads from home rather than the office. The capability allows cardiologists to look at the battery and other technical components of the pacemaker.

Experts foresee that remote monitoring will continue to increase, particularly for ICD patients. The technology delivers multiple benefits: better utilization of staff resources, enhanced communication and clinical responsiveness, and reduced costs.  

Grow Clinic Traffic Without Adding Staff
Home monitoring of devices via wireless technology can increase the number of patient evaluations without directly increasing demands on clinic staff time and resources, according Elizabeth Ching, RN, from the Cleveland Clinic.

Ching and colleagues tracked ongoing implantable cardioverter defibrillator (ICD) device follow-up patient visits over a four-year period. Each ICD patient was offered the option of in-person device follow-up or device follow-up supplemented with remote monitoring. She presented the study at the 2008 Heart Rhythm Society meeting.

During the study time, the overall number of ICD evaluations increased by 164 percent, while remote evaluations jumped from 94 patients to more than 5,000 patients,

“We increased our total number of patient evaluations over the past five years, without as much strain as seeing all of the patients in clinic,” Ching said. “The growth is a direct result of the clinic’s incorporation of ICD follow-up through remote monitoring evaluations, allowing for better time management and overall improvements in resource allocation.”