As a result of the data presented by studies such as MADIT and SCD-HeFT, which support prophylactic implantation of ICDs, the device patient population at Cardiology Consultants (Newark, Delaware) continues to grow at a rapid rate. Close to 30% of our device patients have ICDs today, compared with just 3% when I first started 17 years ago. We currently follow 1,680 pacemaker and 660 ICD patients. The rising influx of patients, as well as the need for us to be mobile and serve patients at statewide clinics up to 100 miles from Newark, requires the highest degree of efficiency in how we manage our scheduling and resources. Before we implemented the Medtronic CareLink^® Network remote monitoring service over two years ago, we were facing typical follow-up challenges: too many patients, too few follow-up staff. We either needed to hire additional staff or reduce responsibilities.

Adopting Remote Device Monitoring vs. Hiring Staff
       At Cardiology Consultants, there is no such thing as a "typical day at the office." Our 26 physicians practice across the entire State of Delaware, as well as some rural areas of Maryland and New Jersey. Our clinic staff includes two advanced practice nurses (Rita Lucey, RN, MSN, APN, and myself), one registered nurse, three cardiovascular technicians, three electrophysiologists, and one administrative assistant. Rita and I jointly log approximately 330 miles a week within a 120-mile radius to cover all clinic patients. Certain days of the week are devoted to seeing patients at our Implantable Device Clinic for routine evaluations and troubleshooting. When not in the clinic, we assist our physicians with inpatient physical assessments, patient teaching, discharge planning, as well as interrogations and reprogramming of implantable devices at three area hospitals.

Figure 1.

Leigh Sibert, RN, CS, APN (right) and Rita Lucey, RN, MSN, APN (left), Co-Managers of the Implantable Device Clinic at Cardiology Consultants, view remotely transmitted device data on the secure Medtronic CareLink Network Clinician Website. By generating "batch-processed" or summary reports of multiple device patients, the clinic managers can provide follow-up in much less time, using fewer resources than needed for in-office follow-ups.

       When remote device monitoring for Medtronic ICD patients was first introduced to me, I recognized that this technology could provide an immediate solution, and I presented it to our business manager. Internet-based remote monitoring was a new concept, and little practical experience was available on which to base our decision. However, we decided to try the system, expecting that the time-savings would allow us to avoid hiring additional staff and to invest additional effort in critical priority care. Since we implemented the Medtronic CareLink Network in February 2003, we have enrolled 230 (more than 75%) of our Medtronic ICD patients.

Comments:

- “Medtronic CareLink monitoring has been a good addition to our follow-up protocols because it allows my nurses more time to devote to problem patients in the office without compromising safe and efficient care of our ICD patients. I can also reassure physicians who refer patients to me in remote areas of the state that we will follow-up their devices closely and make any EP recommendations efficiently and promptly.” -- Piamsook Angkeow, MD, Cardiology Consultants, Newark, Delaware

Sidebar photo.

Clinic Efficiency Test Compares In-office vs. Remote Device Clinic Efficiency Test Compares In-office vs. Remote Device Follow-up.

Clinic Protocol for Remote Monitoring
       In over two years’ experience with the Medtronic CareLink Network, this technology and the processes we developed have helped us remain highly efficient. The protocol for our Medtronic ICD patients using remote monitoring prescribes four quarterly routine checkups: three pre-scheduled remote transmissions and one in-office follow-up for threshold testing. The patient transmits device data via a standard telephone line from home or from anywhere in the continental United States, Alaska and Hawaii following a prescribed schedule. A typical transmission takes about 5 minutes — a significant time-saving for our patients, compared to the time they otherwise spend traveling and waiting at the office to be seen, not to mention travel costs and caregiver burden. We download the transmitted data from the secure Medtronic CareLink Clinician WebSite and batch-process the reports, usually 8–10 patients per batch.
       "Batch processing" refers to a feature of the Medtronic CareLink Network that allows us to print many patients’ reports at once, instead of each patient individually. The data include device parameters such as battery status, arrhythmia events since the last in-office or electronic visit, system alerts, lead failure and diagnostics. If we see a problem, we troubleshoot and, if indicated, get the physician involved. We ask all of our Medtronic CareLink patients to transmit on the weekends, and our staff strictly adheres to a policy of responding within two business days.
       The weekend transmissions make perfect sense for us. Monday is the only day all of our staff is present at the Implantable Device Clinic: one of our three EPs, the two APNs, our RN, and the CV technician. When Rita and I arrive on Monday morning, we bring up the Medtronic CareLink data from the secure Internet site, batch process the reports and print them out. While the reports are printing, we are able to perform other tasks. We transfer the data onto a pre-formatted electronic form that is sent to the referring physician and added to the patient chart. This also saves time compared with dictating the information. If the checkup is routine, we are both licensed to sign off on the form. If there is an issue, we ask the doctor to review the data and decide on further action. By splitting up the batch-printed Medtronic CareLink reports, we are able to multitask, taking care of "the CareLinks" in-between seeing patients.
       Our well-trained support staff maintains a current list of the pre-scheduled Medtronic CareLink transmissions. If we discover on Monday that certain patients forgot to transmit over the weekend, our staff calls them within the next two days to request transmissions by Thursday. We tell patients not to transmit on Friday (unless they call with an issue and we are expecting their transmission) because we may not get the report until Monday. Compared with rescheduling a missed in-office appointment, it is much easier to reschedule an electronic transmission. Weekend transmissions are also advantageous for some of our elderly patients who may need assistance from a family member.

Clinic Efficiency Test Compares In-office vs. Remote Device Follow-up

- Human Factors International conducted a comparative analysis1 on behalf of Medtronic, Inc., in May 2004, measuring average times required for in-office device checkups vs. processing device data downloaded from the Internet-based Medtronic CareLink Network at four cardiology clinics. Times were recorded for a total of 27 in-office visits and 30 remote Medtronic CareLink follow-ups at Cardiac Diagnostics (York, Pennsylvania), Cardiology Consultants (Newark, Delaware), Mid-Ohio Cardiology (Columbus, Ohio), and Northwest Florida Heart Group (Pensacola, Florida). In-office visits were organized into seven process steps: pre-visit, check-in, initial exam, triage, charting, checkout and physician procedures. Medtronic CareLink follow-ups consisted of pre-visit, batch selection of patients and reports, batch printing, data review, charting, patient calls and physician procedures. On average, Medtronic CareLink remote follow-ups took 7.8 minutes vs. 22.2 minutes for in-office visits, an average efficiency increase of 65% at all sites. The time reduction varied between 44% and 80% depending on specific factors: patients with episodes, 44%; patients without episodes, 77%; single-chamber devices, 70%; dual chamber devices, 71%; and CRT patients, 80%. If only the routine Medtronic CareLink follow-ups are considered (not patients with episodes), the average efficiency increase is 74.5%. Editor’s Note: This summary of the June 2004 clinic efficiency test was provided by: Trevor McCaw, Sr. Product Marketing Specialist, Patient Management, Medtronic, Inc. 1. Falk D, Straub K. Practice efficiency improvements resulting from the use of Medtronic CareLink Network remote monitoring service. Fairfield, Iowa: Human Factors International, 2004.

Test Confirms Efficiency Gains at Four Clinics
       Within weeks of the Medtronic CareLink Network implementation, Rita Lucey and I knew that the quarterly electronic visits were not only saving us many hours, but that we were actually able to use the time saved to see patients who required extensive device troubleshooting and clinical assessment and treatment. For our Medtronic ICD/CRT patients, remote monitoring took routine follow-ups out of the traditional system. In simple math, that replaces 3 follow-ups x 230 Medtronic CareLink patients = 690 potential in-office checkups per year replaced with much less time-consuming electronic visits. Even if unscheduled visits and transmissions are added in, the time-savings are significant.
       A clinic efficiency test conducted at four cardiology clinics on behalf of Medtronic in May 2004, including ours, confirmed the time-savings in hard numbers. The test compared the time and process required for in-office device checkups versus remote Medtronic CareLink Network transmissions. An average efficiency increase of 65% was observed at all four clinics (see sidebar: “Clinic Efficiency Test Compares In-office vs. Remote Device Follow-up”).

The Patient Experience
       Our device patients often experience high anxiety levels. Having a remote link to their doctor has reduced that anxiety and added a new degree of freedom and convenience to their lives. Most of our Medtronic CareLink patients continue to work, travel and lead busy lives. Knowing they have a convenient means of communication with us gives them peace of mind. Some patients who were afraid to travel before using the Medtronic CareLink Network now have the confidence to travel again, which greatly improves their quality of life.
       Remote monitoring has enabled us to ensure quality follow-up for many of our patients in distant rural areas who were having difficulty traveling back and forth to our clinic. Before remote monitoring, if patients were unable to drive or get a ride, they simply didn’t show up for appointments. Patients living in rural areas greatly appreciate remote follow-up via telephone.
       A recent patient experience illustrates the potential life-saving value of remote monitoring. One of our Medtronic ICD patients, a young mother, experienced a "dizzy spell" at home and was unsure if she had lost consciousness during the spell. Her young child was napping, and she did not want to wake the child up and find someone to drive her to the doctor’s office. She was without symptoms when she called us, and we had her send a Medtronic CareLink transmission. The data revealed that she had experienced a shock following rapid, life-threatening torsades de pointes rhythm. She had not felt the shock because she was unconscious at the time. We immediately contacted her husband, asking him to bring her into the office for further evaluation. Our patient did not have to panic, call 911, or leave her child unattended. She told us that without the Medtronic CareLink Monitor, she may not have pursued medical attention that day.
       Remote monitoring has also served as a diagnostic tool to monitor a patient’s response to medication. Medications can be titrated on an outpatient basis using the data provided by the Medtronic CareLink Network. For patients diagnosed with paroxysmal atrial fibrillation or increasing episodes of ventricular tachycardia, for example, we can adjust medications and perform more frequent follow-up via the Medtronic CareLink Network, checking their response with the VT and mode switch counters. The remote monitoring system acts as a kind of continuous Holter monitor, aiding the physician in choosing the right drug at the right dose.
       Phantom shocks can plague any ICD patient who has been through the trauma of repeated defibrillation. Prior to remote monitoring, we would check these patients at our earliest convenience at the office just to tell them it was not a real shock. If a Medtronic CareLink patient is stable, we can ask the patient to transmit and then provide reassurance that it was a "dream shock." That saves the patient a sometimes embarrassing trip to the office, and gives us the opportunity to discuss their current health and anxieties.

More Comments:

- “The Medtronic CareLink Network is a major advance in ICD follow-up. Our patients love it, which improves their satisfaction and our ability to care for them.” -- Henry L. Weiner, MD, Cardiology Consultants, Newark, Delaware

A Domino Effect of Benefits
       We observed a domino effect of benefits after adopting remote monitoring with the Medtronic CareLink Network. Considering our highly mobile work schedules, the greatest benefit for Rita Lucey and me is that the Medtronic CareLink Network keeps us all linked, no matter where we may be at any given time. When I am at a downstate location and need a quick decision on potential action, I am able to send patient device data to one of our physicians at another location for prompt review.
       The batch-processing feature of the Medtronic CareLink Network saves us considerable time compared with reviewing each case individually. Moving from manual dictation of patient information to easily moving electronic data from one file to another has provided huge time-savings. These efficiency gains have eliminated the need to hire additional staff.
       Remote monitoring with the Medtronic CareLink Network has increased our referral base, particularly with downstate physicians. The fact that the referring cardiologist remains the patient’s post-implant physician while we take care of remote monitoring and provide an EP report is a benefit to both the patient and primary physician.
       The Medtronic CareLink Network has been a valuable addition to our EP clinic. As we experience rapid patient growth, we can handle the increased number of follow-ups without compromising quality of care. We and our patients have peace of mind knowing we can connect anytime, no matter which site we are visiting or what constraints our schedules place on us. Also, the technology allows our practice to stay on the cutting edge, benefiting our patients by providing them with convenience and quality care.