Letter from the Editor

The Future of Cardiovascular Healthcare Delivery (Part 2 of 2)

Bradley P. Knight, MD, FACC, FHRS, Editor-in-Chief

Bradley P. Knight, MD, FACC, FHRS, Editor-in-Chief

The following are thoughts on the future of how cardiovascular healthcare will be delivered, from the perspective of a clinical electrophysiologist. This first installment of this series, featured in last month’s issue of EP Lab Digest, was devoted to anticipated national changes. This second part proposes five strategies that leading medical centers should consider to stay in front of the curve (Figure).

The first strategy that a medical center can take to be competitive is collocation of invasive services. As cardiac surgeons continue in the direction of minimally invasive approaches, and electrophysiologists develop relatively more invasive procedures for patients with multiple comorbidities and complex problems, it makes sense that the venue for each patient is similar. The current separation of medical procedures and surgeries in hospitals is based on antiquated models. Why is it that when a surgeon implants a pacemaker, the procedure is done in an operating room with an anesthesiologist, but when the same procedure is performed by an electrophysiologist, it is done in the EP lab? Why is administration of anesthesia for an epicardial VT ablation considered “off-site” or “Non-Operating Room Anesthesia” (NORA)? There are many benefits to geographical proximity for the cardiovascular service line. One benefit is the ability to share resources. These resources include shared nursing, anesthesia support, scheduling, and supplies. Other benefits include professional collaboration, sharing of ideas, development of interdisciplinary research projects, and proximity of surgical backup in the event of a complication. Some collocation is already occurring in centers where, for example, lead extractions and convergent procedures for atrial fibrillation are being done in hybrid operating rooms, but this needs to be done on a larger scale to fully take advantage of the benefits that collocation offers.

One of the most important strategies that will separate the leaders from the rest of the pack is a focus on physician efficiency. There is no other profession that would tolerate the current model, where the most highly trained members of the team are performing tasks that require the least amount of training. The time has come to take better advantage of the proven benefits that mid-level providers bring to the cardiovascular healthcare delivery system to improve physician efficiency. A concrete example is the development of a program where cardioversions are performed autonomously by a credentialed Advanced Practice Provider.1 Dr. Christine Sinsky, Vice President of Professional Satisfaction at the American Medical Association, makes a strong case that improving physician efficiency is not just a way to improve professional satisfaction, but is a better business model (www.stepsforward.com).2 She has made it clear that the delivery models of the future cannot be managed with the staffing models of the past, that we need to develop more meaningful and manageable measures of good care, rethink documentation to avoid the many hours that physicians spend on documentation that adds no value, and align with team-based care. She has recommended avoiding compliance creep where federal regulations are exacerbated at the local level by overly conservative interpretation of policies, reducing the ratio of mouse clicks per task in the electronic health record, developing the field of Practice Science to optimize delivery models, and incentivizing administrators based on metrics that include physician satisfaction and efficiency. 

A more controversial approach is a closer partnership with industry. No one can argue that nearly all of the advances over the past three decades in cardiac implantable electrical devices and catheter ablation tools have come from collaborations between physicians and the medical device industry. Transparency, ethical behavior, disclosure, and compliance with AdvaMed guidelines are assumed, but the assumption that relationships between electrophysiologists and medical device companies are inherently nefarious is unfounded and interferes with what logically has the potential to lead to important advances for our patients. Institutions should be streamlining their processes to bring novel therapies to patients, as well as encouraging their physicians to be more engaged with industry to make better devices and provide physician input during the early development phases.

Expertise will continue to be important. Although there has been a lot of interest in continual formal validation of one’s clinical knowledge and skills, demonstration of lifelong learning, and maintenance of board certification, competence alone will not define a leading medical center. Expertise defines excellence. Expertise, clinical volume, reputation, and quality are directly dependent on one another. Recruitment of experts will continue to be a highly effective way to establish and maintain a leading program. Top programs must continually put themselves in the position of being the place physicians first think of when they need to refer a patient to a tertiary care center.

The fifth strategy that centers need to work on, as the delivery of cardiovascular healthcare evolves and healthcare systems consolidate using a prototypical hub-and-spoke model, is triage. As unstable patients are being evaluated for transfer to the hub hospital, and as more outpatients are calling to schedule a clinic appointment, only a person with a healthcare background can properly triage patients based on their medical problem and acuity level to appropriately bring those patients into the system. A centralized call center staffed by operators cannot overcome the importance of proper triage.

There are many pressures in the modern healthcare system that will change how cardiovascular care, including the care of patients with heart rhythm disorders, is delivered. Healthcare systems can react to these changes as they occur, or work proactively to geographically bring their cardiovascular service line together, make physician efficiency a priority, partner more closely with the device industry, recruit and develop expertise rather than just competency, and invest in ways to better triage patients trying to enter the system.


  1. Strzelczyk TA, Kaplan RM, Medler M, Knight BP. Outcomes associated with electrical cardioversion for atrial fibrillation performed autonomously by an advanced practice nurse. JACC: Clinical Electrophysiology. 2017 (In Press).
  2. Sinsky CA, Willard-Grace R, Schutzbank AM, Sinsky TA, Margolius D, Bodenheimer T. In search of joy in practice: a report of 23 high-functioning primary care practices. Ann Fam Med. 2013;11(3):272-278.