In this interview with Seth McClennen, MD, FACC, FHRS, Director of Electrophysiology of South Shore Hospital, and Bridget Murphy, RN, a cardiac device/heart failure nurse, they discuss their use of RemoteMD at Harbor Medical Associates in South Weymouth, Massachusetts. The RemoteMD service is a new resource that helps practices to effectively transition into cardiac implantable electronic device (CIED) monitoring, eliminate CIED backlogs, provide real-time reporting on the CIED population, and train staff. RemoteMD, established by PrepMD in 2015, is currently monitoring patients across 4 states within both academic and private practices, and is inclusive of pacemakers, ICDs, and ILRs.
You previously mentioned to me that remote monitoring has been integral to the growth and development of your practice, and that you have one of the highest utilization rates of this technology in the country. What clinical benefits has your practice derived from remote monitoring?
McClennen: In regards to growth and development, RemoteMD and remote monitoring has made it possible for a busy cardiology group, with only one electrophysiologist and one device clinic nurse, to handle a higher number of patients than we might otherwise be able to. We no longer have to see every patient in the office as often, because we’re getting comprehensive detail on those patients. The clinical benefit to patients, especially for those with an automated device, is they’re getting daily monitoring on a number of device parameters. If there is an abnormality, we pick it up within 24 hours (as opposed to 10 years ago, when it was every 3 months that we would get an assessment).
Murphy: On average, we see 40-50 remote monitors per week.
McClennen: Of those cases, Bridget will specifically flag 2 or 3 that need to be addressed. The most common example is when a device picks up atrial fibrillation, which as you know, is the most common cause of stroke. Normally we would have had to wait 3 months until the patient’s next regular office check to pick up the AF episodes; however, knowing about those episodes as they happen, especially if the heart rate is rapid, makes remote monitoring a pretty powerful tool. Even if the patient says they’re feeling fine, we can tell them we’ve found a problem and come up with a treatment plan.
What were some of the challenges (regarding patient volume, staffing needs, and workflow) that your practice faced when implementing a remote monitoring program?
McClennen: We have used remote monitoring from its beginnings over a decade ago. I’ve always seen its potential. The only challenge is in converting the theory (regular automated physician-reviewed device checks from home) into practice, given the logistical challenge of uploading and reviewing the volumes of data available.
What were some of the difficulties associated with remote monitoring before RemoteMD?
McClennen: I’ve always felt that remote monitoring is incredibly useful, especially when it is automated and not patient dependent. However, it can sometimes be more cumbersome than you’d like it to be, from pulling the data off the company-specific websites, to appropriately reviewing the data in a format that is easy, to billing, and then creating an electronic medical record (EMR) translation of that data. From my sense, RemoteMD takes away those first onerous tasks, which are to get the information off the website and do a first-pass review.
Murphy: I agree. The original reports themselves are also cumbersome — they can be anywhere from 12 to 36 pages. RemoteMD provides a valuable service going through that data.
McClennen: If you pulled 100% of the information from the reports, only about 10% of it is useful, and the rest you have to dissect through. Therefore, you need a number of filters to get through all the information. RemoteMD provides the data upload and initial review, and Bridget looks through it, so by the time I see the data, it has been distilled down into only the parts that I need to know about.
How did your practice manage remote monitoring of device patients prior to using RemoteMD?
McClennen: I was here before Bridget came into the practice. There was a device clinic nurse at Harbor Medical before I came here 14 years ago. When that nurse retired, Bridget came on. It was the exact same process described before, except the device nurse at the time pulled the technical information off the internet, reviewed it, and created an initial assessment before I saw it. These tasks became physically impossible with the size of our practice. As a clinician, you then have a couple of different options. You can either close down your practice because you aren’t able to see more patients (which of course we’d never do!), or you can get more help (internal or external). We chose external, which is where RemoteMD fit in. We could have also hired someone and taught them to do it, but it’s difficult to find people with expertise like Bridget who understand this stuff.
Bridget, tell me more about your role in the clinic.
Murphy: I manage the whole device practice from office visits to remote monitors. I cover every aspect, including triage to workflow of the device clinic.
McClennen: As far as triage, Bridget is our first line of defense managing any symptomatic patients. She also tracks down any patients having clinical problems; we first identify the patients, and she will give them a call. In addition, Bridget manages certain device patients who don’t see me for a few years in a row. Another example is if a patient has another cardiologist and they need a device expert to see them — Bridget will manage that visit on her own.
How do you utilize RemoteMD?
Murphy: The remotes are all on the website, and RemoteMD generates snapshots of the interrogations and provides a technical summary of each interrogation report for billing and documentation.
McClennen: RemoteMD coordinates and gets the information off the internet, makes sure patients are doing their appropriate downloads, and puts a basic report into our electronic health records.
When did you begin using RemoteMD at Harbor Medical for your cardiac device and heart failure patients?
Murphy: We began using RemoteMD in September 2015.
What were your reasons for choosing RemoteMD?
McClennen: It was too overwhelming — if you’re having a nurse spend their time doing secretarial work, you’re not appropriately and effectively using their skillset. We knew we needed help! As I said before, we were either going to be training someone new or getting external help. We were familiar with PrepMD’s capabilities and with cofounders Matt O’Neal and Bob Mattioli, so we reached out to them and asked if they could help us out. From our standpoint, it was a manpower issue. We didn’t have enough personnel to complete all of the different tasks associated with remote monitoring, including getting the monitor done and scheduled, pulling the monitor results off the internet and getting it into the EMR in a transferrable format, having both Bridget and myself interpret that data, and then doing the billing. The most time- and labor-intensive aspects were with those first tasks, which included getting the patients to logistically participate in remote monitoring. While most of the remote monitors are automated, others require the patient to manually press a button on their monitor; also, physically getting the data off the website can take some time. We chose to farm out these initial steps to RemoteMD. We tried having our previous device clinic nurse do everything from scheduling to pulling data, and it didn’t work.
Tell us about some of RemoteMD’s organization, monitoring, and reporting services and capabilities.
Murphy: Aimee Bollentin, a nurse practitioner on the Remote MD team, handles the download and the first pass at the report. They also track all the patients, so if any are missed, they will compile a list for us. RemoteMD provides a weekly list of the patients that are expected to come in, so we can follow up if those patients do not show. It’s a tag team effort to get all the scheduled remotes to come in, as well as ensure that all the reports are completed.
What types of monitoring do you use RemoteMD for?
McClennen: We use RemoteMD for alert monitoring and routine long-term monitoring on all of our implantable cardiac devices (pacemakers, implantable defibrillators, and implantable loop monitors).
How has your workflow changed since utilization of RemoteMD?
McClennen: Workflow has changed because the logistical aspects are now taken care of, such as tracking down patients, pulling reports, doing a first pass look at the reports, and billing. Therefore, the best way that RemoteMD has helped is to make Bridget’s life tolerable, because it’s physically impossible to do everything herself. It essentially takes over the tasks that a secretary and second nurse might, because it handles secretarial issues as well as navigates the websites, pulls the data, does an initial analysis, and gets a customized report to us.
How has RemoteMD changed your time management?
Murphy: I’m lucky, because I’ve used RemoteMD from the beginning — therefore, I didn’t know a world without RemoteMD!
McClennen: RemoteMD has made the job go from impossible to possible. Our clinic volume became too big, so we needed help. I wasn’t against hiring people to do the extra work — either a service or a dedicated person can help manage the first pass of the data and help with monitoring and scheduling of patients.
In what other ways has your practice customized RemoteMD for your needs?
McClennen: RemoteMD is responsive to feedback in its reporting. For instance, we are always interested in quantifying mode switch (atrial fibrillation) burden as duration under 5 minutes, or over 5 minutes — this has direct bearing on the need for systemic anticoagulation. We’ve asked RemoteMD to always quantify duration of longest mode switch episode for every report, which they now do.
How specifically has RemoteMD helped optimize billing?
McClennen: RemoteMD does not have anything to do with our billing — we do our own internal billing. However, RemoteMD does keep a log of our patients and notify us of any patients who miss their routine 3-month remote check. Keeping patients to a regular schedule helps both patient care as well as optimizes reimbursement per patient.
Was there a learning curve involved in implementing the RemoteMD service?
Murphy: Not for me — it was pretty straightforward, and we were operational right from the very beginning.
McClennen: The only thing we needed to do was tell them how we wanted the data to get to us so we could then edit the reports and get them into our EMR. It was simple. The reports are electronically transmitted to us, then Bridget makes edits, puts them into our EMR, and I edit and sign them. It’s not difficult to figure out or use, and if there is ever something that needs to be further customized, RemoteMD will adjust it.
Seth, how has your caseload grown since utilization of remote monitoring?
McClennen: RemoteMD is like an electronic “physician extender” because it allows a physician and device nurse to monitor and manage far more patients. We see the patients in person once a year, but we’re getting multiple interrogations in between that time that are very comprehensive. Therefore, the volume in our device clinic has been continuously increasing since I’ve gotten here, and the only reason we’re still able to keep afloat with all the work is because of remote monitoring.
Is there anything else you’d like to add?
McClennen: Based on the value we receive from the RemoteMD service, I expect more competition in this area over the next 10 years. Today, the RemoteMD service is essential and has expanded our capabilities.
Disclosures: The authors have no conflicts of interest to report regarding the content herein.
This article is published with support from PrepMD.