Cover Story

The Future of Remote Patient Monitoring

Jonathan P. Piccini, Sr., MD, MHS, FHRS 
Electrophysiology Section, Cardiology Division, Duke University Medical Center
Durham, North Carolina

Jonathan P. Piccini, Sr., MD, MHS, FHRS 
Electrophysiology Section, Cardiology Division, Duke University Medical Center
Durham, North Carolina

Remote monitoring has evolved significantly since its inception. Not too long ago, remote monitoring represented a convenient alternative to frequent visits to the arrhythmia clinic. However, now remote monitoring is a class I recommendation across several indications. The HRS Expert Consensus Statement1 on remote interrogation and monitoring for cardiovascular implantable electronic devices (CIEDs) recommends that remote monitoring and interrogation is recommended over a calendar-based schedule of in-person CIED evaluation alone (whenever feasible). Moreover, the consensus statement also recommends remote monitoring for several specific clinical situations, including patients with CIED components that are advisory in order to facilitate early detection of device malfunction. The development and subsequent arrival of remote monitoring as a class I recommended treatment represents a significant evolution in clinical practice. 

However, remote monitoring will continue to evolve. We can expect significant growth and innovation over the next five years. 

While the utilization and innovation of remote monitoring may not be completely predictable, there are several areas where change is most likely to occur. These potential changes include: (1) greater incorporation of remote monitoring data in practice management and research, (2) consolidation and integration of software and information technology platforms, and (3) increasing patient participation and access to remote monitoring data and practices. 

Early clinical studies of remote monitoring helped establish that remote monitoring reduces time to clinical decision making.2 Additionally, remote monitoring has been shown to reduce inappropriate shocks and improve survival.3,4 Prior studies have also shown that remote monitoring is associated with significant reductions in healthcare utilization and hospitalization. Recent nationwide data suggests that remote monitoring may reduce hospitalization costs by 30%.5 For every 100,000 patient years of follow-up, remote monitoring is associated with 9810 fewer hospitalizations, 119,000 few days in the hospital, and $370,270,000 lower hospital payments. These benefits are even more substantial in heart failure patients with CRT-D devices, in which remote monitoring is associated with a 36% lower rate of readmission following heart failure hospitalization (Figure 1). Given the existing consensus recommendations for remote monitoring and the emerging outcomes data, it is increasingly likely that health systems will pay more attention to remote monitoring. In order to maximize benefit from remote monitoring, health systems will need to place continued investment in the infrastructure and clinical staff needed to facilitate efficient and high-quality remote monitoring care. However, these commitments should lead to improvements in clinical efficiency, outcomes, and cost savings. Finally, it is not out of the realm of possibility that remote monitoring will become a reportable performance measure in the near-term to intermediate future. 

While remote monitoring utilization will continue to grow in clinical practice, it will become an essential research tool. For example, remote monitoring systems and databases offer the potential for improved collection of outcomes in pragmatic clinical trials. One could easily envision a clinical trial of device programming or other intervention with online consent, minimal clinical visits, and remote data collection via the electronic medical record and CIED monitoring data. 

Despite the increasing use of remote monitoring in clinical practice and its emphasis in long-term patient management, there are some aspects of remote monitoring that have not improved. Among these are the need for clinicians and practices to access, review, and manage several remote monitoring programs and databases. Furthermore, these multiple, vendor-specific databases do not exchange data or interface with current electronic medical record systems. There is a clear unmet need for information technology and software programs that can import data from diverse remote monitoring systems and provide clinicians with centralized arrhythmia and device monitoring evaluation and management. There are already several efforts underway to try and develop such software programs in order to further streamline remote monitoring management. 

While the future will bring greater incorporation of remote monitoring data in practice management and research, the patient’s relationship with remote monitoring systems will also evolve. There is increasing demand for improved patient access to their own device data and a desire to empower patients to take a more active role monitoring their health status and participating in their arrhythmia care.6 While there are challenges to improving patient access, there are several emerging technologies that may make it more feasible. In 2015, the first Bluetooth-based remote monitoring platforms were approved by the FDA and are now available for use in clinical practice in pacing systems. For example, the MyCareLink Smart Monitor (Medtronic) allows pacemaker patients to transmit data in real time to their healthcare provider using a handheld device reader and a smartphone application (Figure 2). Future iterations of Bluetooth-enabled pacemakers will communicate directly with the remote monitoring system without the need for a handheld wand. 

There are also emerging data that suggest remote monitoring can be harnessed to help patients actively manage their own medical care. At present, patients with atrial fibrillation and risk factors for stroke take their oral anticoagulants on a chronic basis. However, the recent REACT.COM pilot study tested the feasibility of an implantable cardiac monitor-guided intermittent anticoagulant strategy — so-called “pill-in-the-pocket” anticoagulation. In REACT.COM, patients with nonpermanent AF and a CHADS2 score of 1-2 were randomized to daily non-vitamin K oral antagonist anticoagulation (NOAC) versus remote monitoring-guided intermittent NOAC therapy. In the interventional arm, patients with more than one hour of AF on their implanted monitors were switched to active NOAC therapy, but could also discontinue NOAC therapy after 30 consecutive days without AF. In 59 subjects, the REACT.COM investigators demonstrated that implantable cardiac monitor-guided intermittent NOAC therapy resulted in a 94% reduction in the total time on NOAC therapy.7 The REACT.COM pilot study is just one example of how remote monitoring technology can be used to guide remote patient management. There are many more, including the use of handheld electrocardiogram recordings to guide corrected QT assessment for class III antiarrhythmic drug monitoring.8 

In summary, the future of remote monitoring is now. Clinical practices and healthcare systems should invest in remote monitoring infrastructure and utilization to promote improved efficiency and outcomes as well as reduce hospitalization. Remote monitoring platforms will eventually be integrated and increasingly used to guide research. Finally, remote monitoring will also serve as a mechanism to engage patients in their care, including remote management.

Disclosures: Dr. Piccini reports that he receives research funding from ARCA biopharma, Boston Scientific, Gilead, Janssen Pharmaceuticals, ResMed, and St. Jude Medical. He also serves as a consultant to Johnson & Johnson, Laguna Pharmaceuticals, Medtronic, and Spectranetics.

References

  1. Slotwiner D, Varma N, Akar JG, et al. HRS Expert Consensus Statement on remote interrogation and monitoring for cardiovascular electronic implantable devices. Heart Rhythm. 2015;12(7):e69-100.
  2. Crossley GH, Boyle A, Vitense H, Chang Y, Mead RH, CONNECT Investigators. The CONNECT (Clinical Evaluation of Remote Notification to Reduce Time to Clinical Decision) trial: the value of wireless remote monitoring with automatic clinician alerts. J Am Coll Cardiol. 2011;57:1181-1189.
  3. Guédon-Moreau L, Kouakam C, Klug D, et al. Decreased delivery of inappropriate shocks achieved by remote monitoring of ICD: a substudy of the ECOST trial. J Cardiovasc Electrophysiol. 2014;25:763-770.
  4. Hindricks G, Taborsky M, Glikson M, et al. Implant-based multiparameter telemonitoring of patients with heart failure (IN-TIME): a randomised controlled trial. Lancet. 2014;384:583-590.
  5. Piccini JP, Mittal S, Snell J, Prillinger JB, Dalal N, Varma N. Impact of remote monitoring on clinical events and associated health care utilization: a nationwide assessment. Heart Rhythm. 2016 Aug 17.
  6. Krieger LM. Man with defibrillator wants to know what his heart is saying. The Mercury News. Published January 29, 2012. Available online at http://www.mercurynews.com/2012/01/29/man-with-defibrillator-wants-to-know-what-his-heart-is-saying/. Accessed October 26, 2016.
  7. Passman R, Leong-Sit P, Andrei AC, et al. Targeted Anticoagulation for Atrial Fibrillation Guided by Continuous Rhythm Assessment With an Insertable Cardiac Monitor: The Rhythm Evaluation for Anticoagulation With Continuous Monitoring (REACT.COM) Pilot Study. J Cardiovasc Electrophysiol. 2016;27(3):264-270.
  8. Chung EH, Guise KD. QTC intervals can be assessed with the AliveCor heart monitor in patients on dofetilide for atrial fibrillation. J Electrocardiol. 2015;48:8-9.
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