The Iowa Clinic, P.C. is among the most respected multi-specialty clinics in the Midwest. Heart & Vascular Care, a division of the Iowa Clinic, conducts more than ten outreach clinics throughout Central Iowa and has a satellite clinic in southwest Iowa staffed by two cardiologists. The physician referral base covers a large portion of central Iowa, including small county hospitals as well as internal medicine physicians within the Des Moines metro area. Heart & Vascular Care sees approximately 20,000 clinic patients per year and is the primary or consulting physician on approximately 3,000 hospital patients per year in the Des Moines metro area.

Figure 1.

Frank Haugland, MD, PhD.

Figure 2.

Pamela Nerheim, MD.

       As Heart & Vascular Care expanded, the need was identified to serve the pacemaker and electrophysiology patients in the practice more efficiently. The physicians wanted to maintain an excellent level of patient care and maximize reimbursement. As such, they decided to develop their own Arrhythmia Service Program rather than outsourcing these services. The partners at Heart & Vascular Care believe that problems were often delayed due to the turnaround time of the scanned reports; the quality of the tracings were also difficult to interpret. The services they planned to offer included in-office pacemaker and ICD evaluations, transtelephonic pacemaker checks, and Holter and cardiac event monitoring.

About the Iowa Clinic

- The Iowa Clinic is comprised of more than 125 physicians and healthcare providers representing over 30 medical specialties. They serve a population area of 1.3 million and average more than 400,000 patient visits per year. Heart & Vascular Care is made up of eleven cardiologists, two electrophysiologists, and a cardiovascular clinical nurse specialists.

       As Heart & Vascular Care began to develop their own Arrhythmia Services Department, they determined the number of pacemaker patients was approximately 800. The ICD or device patients numbered to close to 250. In total, the Arrhythmia Services Department would be providing care to 850–1000 device patients, excluding new implants. In addition to these patients, the physicians needed to provide for an ever-changing electrophysiology/pacing venue to include the CRT patients and allow for new research projects. They also needed to identify those patients who qualified for new studies or fell into the MADIT or other device criteria.
       In preparing for the new Arrhythmia Services Department, other matters also had to be taken into consideration, including staffing, equipment, etc.:

Staff
       The staff of Heart and Vascular Care Arrhythmia Services includes a supervising nurse manager, an office manager, a cardiovascular clinical nurse specialist who is NASPE-certified to manage the device and heart failure patients, an EP staff nurse dedicated to the electophysiologists, and three experienced and well-trained arrhythmia technicians. The staff also includes an electrophysiology tech/paramedic specialist to oversee the day-to-day operations of Arrhythmia Services Department.

Figure 3.

Cardiology Tech Nathan Benn places a Holter monitor on a patient.

       Many of the Arrhythmia Services technicians are cross-trained to provide coverage for diagnostic testing areas within Heart & Vascular Care, including nuclear and echocardiography.  These technicians have elected to cross-train for these other testing areas so that they can enjoy a variety of work experiences. They also place and help instruct patients regarding Holter and event monitors, as well as perform transtelephonic pacemaker checks. Arrhythmia services are staffed 10 hours each day.

Figure 4.

Cardiology Tech Jodi Fisher scans a Holter monitor.

       The Arrhythmia Services Department is supervised by a nursing manager. Clinically, we are guided by a nurse practitioner as well as two electrophysiologists in the practice.
       Our call center is a division of Arrhythmia Services and is staffed by Heart and Vascular nurses and a paramedic specialist. Call can be taken from home; each person on call is provided with a laptop computer and a cellular phone to take patient phone calls. The event or tracing then can be taken over the phone line from home and triaged appropriately. Protocols have been designed by the electrophysiologists to help with the triage process. Taking call is elective; it is compensated at a market competitive rate.

Figure 5.

The Arrhythmia Services Staff (left to right): Jodi Fisher, Cardiology Tech; Joan Shannon, Cardiology Tech; Steve Loveland, ARNP; Julie Routh, Arrhythmia Services Team Leader; Nathan Benn, Cardiology Tech; Jill Torres, Cardiology Tech.

Education
       Vendors will provide staff continuing education on all new pacing and electrophysiology products. Monthly meetings are held with the electrophysiologists to further define the procedures and goals of the Arrhythmia Services Program. Other continuing education opportunities are available to all staff members and encouraged by the practice.

Reimbursement
       The challenge of reimbursement is a high priority in every medical practice, and it’s no different at Heart & Vascular Care. The practice is fortunate to have a top-notch coding team to coach and educate the medical staff daily in the changing world of reimbursement. They utilize a team approach to optimize payment of all procedures performed. Audits are conducted, and checks and balances are in place as education and performance tools for the staff and physicians.

Equipment
       After reviewing several vendors for the purchase of a Holter system and event monitors, as well as a transtelephonic system and transmitters, Heart & Vascular Care selected Mednet Healthcare Technologies, Inc., a New Jersey based manufacturer of the Cardiostation™ pacemaker, ICD and arrhythmia follow-up systems, Heartrak™ cardiac event recorders and Pacetrak™ pacemaker transmitters. Mednet provided all the monitoring systems, including satellite office systems, as well as the monitoring devices given to patients. Mednet Healthcare Technologies also provided two laptop computers.
       The medical staff has found the quality of products and pricing optimal for their practice. The staff was impressed with Mednet’s commitment to provide service around the clock and with the experience that the vendor brought to the table in order to set up such a large center. Mednet’s technology enabled the staff to offer 24-hour arrhythmia monitoring services for any emergency patient calls. In addition, the staff asked Mednet to add customized features to the Cardiostation™ program in order to research particular fields, i.e., the number of patients with primary ventricular tachycardia, atrial fibrillation, heart block, etc. Mednet quickly delivered on these requests, facilitating abilities to query demographics, referring physicians and types of procedures, etc.
       The cardiovascular nurse specialist has been provided with a laptop to take to the outreach pacemaker clinic in order to enter the pacemaker/ICD data directly into the laptop computer. Through Cardiostation™ technologies, this information can be viewed at any time from the main office or the satellite clinics. With Cardiostation™, it is not necessary to access patient charts in order to retrieve settings whether it is a pacemaker, an ICD or an arrhythmia patient. This is a valuable time saver to staff members as well as physicians. No longer is it necessary to waste time looking for which device was actually implanted in emergency situations, when that data can be easily recalled through the ‘follow-up’ system.
       Initially, fifteen Holter monitors, 30 event monitors, two receiving centers, one satellite receiving center and one laptop computer set-up were ordered. As the referral base grew, the monitoring services also grew and as of this date, Heart & Vascular Care has expanded their services to include 40 Holter monitors, 85 event monitors, two laptop monitors, three receiving centers and one satellite review station. In the near future, a fourth receiving center will be purchased.
       Two full-time staff members are scheduled to receive event monitoring transmissions, place monitors, scan Holters and do transtelephonic pacemaker phone checks. The tech hours are staggered to provide coverage 10 hours per day. The other two technicians assist with EKGs, treadmill and other diagnostic testing in the office.
       Even though the number of monitors has doubled, there are still clinic days in which most of the monitors are in use. Utilization and placement of monitors, scanning and event calls in an unpredictable business is frequently “feast or famine.” Flexibility and good teamwork play an important role in obtaining the promised 24-hour turn-around on all Holter monitors as well as handling the other testing.
       With an eye to the future, this system will work well for expanded services to other outreach clinics. It is extremely user-friendly and requires little training for the user. Staff has the ability to download monitors into the system, which allows for quick monitor turn-around. The monitor may be used again immediately and saves the clinic from purchasing a larger quantity or monitors. The physicians and staff recognize that an accurate diagnostic test can be a useful tool in the treatment and diagnostic considerations of each patient, and missed or inaccurate tests can result in the inappropriate diagnosis and wrong treatment for the patient.

Call Center
       The call center is staffed by clinic nurses and a paramedic specialist. The goal to provide quality services to both the patients and the physicians has been met, and the Heart & Vascular Care staff has even exceeded their own expectations. Any patient identified as having a significant arrhythmic event is contacted immediately and managed according to protocol or instruction from electrophysiologists or cardiologists. Often they are scheduled to see an electrophysiologist the same day or within a few days, depending on the severity of the event. The referring physician is contacted, so he or she can make patient care decisions in conjunction with the cardiologists.
       Patient care and reimbursement improvement has exceeded expectations as well. Staff has been added in order to accommodate the new Arrhythmia Services Department, but it is a win/win situation, because the employees have become very dedicated and vested in patient care and the success of the practice.

Conclusion
       Since the Heart & Vascular Care Arrhythmia Services Department opened in late October 2003, over 1,500 patients have been served. Physicians and staff handle approximately 350–400 transtelephonics, eighty Holters and 60 events per month. The arrhythmia services hours are from 7am to 5pm, Monday through Friday. When the department closes, a staff member takes call, enabling Heart & Vascular Care to serve their patients 24 hours a day, seven days a week.
       In summary, Heart & Vascular Care has successfully optimized reimbursement while providing outstanding patient care. The members of the practice continue to look to the future with optimism and the ability to change and tailor patient and practice needs to the ever-changing growth in the electrophysiology and pacing fields.

Perspective from Frank Haugland, MD, PhD

- **i**The dominant driving factor for our decision to expand our arrhythmia services and to bring our Holter, cardiac event monitoring and cardiac device monitoring ‘in house’ was to improve the quality of patient care. **i**For Holter monitor recordings, the biggest single factor which influences quality is the skill of the technician performing the scanning. We have been extremely pleased with the quality of the Phillips-Zymed Holter scanning and reporting system provided through Mednet Healthcare Technologies, Inc. It is, however, the skill of our arrhythmia technicians who scan the Holters which allows us to optimize the accuracy and integrity of arrhythmia documentation and interpretation. **i**As an example, one frustrating and commonly observed error in Holter scanning is failure to adequately display the onset and termination of any sudden arrhythmia for the interpreting physician. In addition, when there is a rapid supraventricular tachycardia, it is critical to know whether that was of gradual onset, which might be expected for simple sinus tachycardia with increasing activity versus a sudden onset. **i**Having this sort of personnel perform my Holter monitors scanning gives me the utmost confidence that the high-resolution traces, which I am being presented with for final Holter interpretation, include all of the critical information needed for accurate diagnosis and interpretation as well as subsequent recommendations regarding electrophysiologic testing, possible ablation procedures, and possible ICD implantation procedures. **i**Looking towards the future, we plan to develop this type of database, which will allow us to verify appropriate diagnosis and documentation as we subject out practice to internal quality review measures regarding diagnosis, treatment, and long-term outcomes.