As the rate of insertion and prevalence of implanted cardiac devices continues to rise, so does the burden of managing the collected data. The amount of physiologic data that can be gleaned from one device will progressively increase with each subsequent generation. Further, as privately owned clinics begin to merge with larger healthcare organizations, the quantity of patients that fall under a collective umbrella increases markedly.
For clinics that already use electronic health records (EHR), it can be difficult to incorporate data from an electronic device database and then transfer that to the patient’s EHR. For clinics that do not use an electronic device database, the burden is significantly larger. Patients’ charts become filled with printed remote reports and endless programmer strips, creating multiple volumes of records that must be stored in file cabinets, taking up valuable real estate. Oftentimes, the printed reports include handwritten notes that may or may not be decipherable and do not carry forth into the patient’s medical record. In addition, industry representatives or clinic staff must fill out homemade flow sheets. This manual transfer increases the risk of incorrect information, such as wrong device or lead information or omitted arrhythmia episodes, being entered into the patient’s record. When manufacturer alerts and recalls are issued, there is not a centralized place to query impacted patients and transfer that data into their EHR. Finally, with the mandated use of EHR, all of the paper documents must then be scanned into the patient’s chart, utilizing resources and personnel that could otherwise be focused elsewhere.
In the inpatient setting, the risk of misplacing or omitting device interrogation data increases exponentially. In a typical hospital device interrogation, an industry representative will check a device and place the paper record in the patient chart for the clinician to review. In some cases, the industry representative will commute to the outpatient clinic to drop off a duplicate copy of the interrogation that, again, must be scanned into the patient’s record. This is a significant gap in the continuity of care for that patient. In a field that prides itself on technological advances, this process of managing information is borderline archaic.
Our Clinic’s Solution
Our practice, Norton Heart Specialists, is part of Norton Healthcare located in Louisville, Kentucky. Our clinic, the Heart Rhythm Center, has one centralized location which staffs 4 EPs, 2 APRNs, 7 device programming specialists, and 3 cardiac device techs. We also have 13 outreach locations within a 100-mile radius. In total, we manage approximately 6,000 patients across our organization. Norton Heart Specialists partnered with our organization, Norton Healthcare, as well as Medtronic in an effort to optimize our workflow. As our patient volume began to increase, we recognized the need to have device data more readily available to our clinicians. We use the Paceart Optima System with SessionSync (Medtronic) to manage device follow-ups across our organization. We began using Paceart in 2009 and Paceart Optima in 2014. Paceart Optima organizes and archives data for cardiac devices across multiple manufacturers and serves as a central repository for our patients’ cardiac information. The system acts as a gateway through which data flows from programmers, remote monitoring websites, and transtelephonic monitoring to our clinic’s EHR. The Paceart Optima also simplifies workflow — with bi-directional HL7 integration — to help improve workflow management and save time. We previously used other electronic device databases, but made the decision to change to Paceart due to lack of 24/7 technical support, frequent system failures, and suboptimal data fields.
With Paceart Optima, we are able to manage clinic schedules for our multiple locations and resources within those locations. Patient encounters can be routed to our EHR (Epic) as discrete data, and a PDF (from any location) can be sent directly to the provider for review. We are able to attach documents, including PDFs of electrocardiogram waveforms (EGMs), from any manufacturer to those encounters. In particular, for most Medtronic devices, we can import and view the EGMs associated with any arrhythmia episodes.
When manufacturers issue device alerts or recalls, we are able to query Paceart Optima to identify those patients affected. We can then disseminate that information quickly and efficiently not only to our clinic staff, but also to the patient. The ability to query our database is also helpful in obtaining reports for programming, trend analysis, follow-up data, rhythm strips, appointments, and more.
We have streamlined our scheduling process by utilizing the scheduling function within Paceart Optima. This one-stop function saves time and reduces errors by utilizing one system. For example, when a patient appointment is scheduled through our EHR (Epic), the appointment is automatically sent to Paceart Optima via an HL7 scheduling interface, and then into the CareLink Network remote monitoring system for Medtronic devices via the One-Stop Scheduling feature of Paceart. The One-Stop Scheduling feature allows for scheduling in just one system, instead of having to arrange the appointment in both the device database as well as the EHR. If the patient is enrolled in another remote monitoring system, the appointment must be manually entered after it is initially scheduled in Epic. The push from Epic to Paceart Optima remains the same.
The Medtronic 2090/Encore programmers have a unique feature, SessionSync, which can transfer device data directly from the Medtronic programmer to the patient’s record within the Paceart Optima system. The data in Paceart Optima is then pushed directly into the organization’s EHR (Figure 1). We have found the benefits to using this system to be significant, both from an outpatient and inpatient perspective. We achieved this functionality by working very closely with our organization’s IT and security teams. Because the Paceart Optima database lives on our organization’s mainframe network, we can access Paceart Optima on the same secure network. We accomplish this by using a secure dedicated IP address that sends the interrogation directly into Paceart Optima by the clinician, who creates the encounter for that acute event and sends it into Epic via an HL7 interface. We use the Encore programmers in the inpatient setting with SessionSync because of the stable and secure connection standard built into these programmers. We can use either a CAT5 Ethernet cable and a dedicated computer port in the hospital or the Encore’s MAC address for wireless access. We can now replicate the clinic process in the acute hospital setting by sending all of the device information with SessionSync during an interrogation for implants as well as inpatient and ED interrogations. This includes all of the current settings, saved device information, real-time EGM of the patient’s presenting rhythm, complete episode information with EGMs, and threshold/sensing tests. For new patients, it is important that all of the patient’s identifiers that Epic uses match the patient’s record that is created in Optima.
In clinic, utilizing SessionSync increases our workflow efficiency. Diagnostic data for Medtronic cardiac devices transfers directly from the Medtronic programmers (2090 and Encore) into the patient’s Paceart Optima record, which then transfers to our clinic’s EHR after being reviewed. We no longer need to transfer from the programmer to Paceart, and then print out paper reports to manually scan into the EHR. Patient quality of care is also improved. By using SessionSync, providers are able to rapidly review the patient’s device check within the EHR system and not spend time looking for device printouts or waiting for the staff to upload data into Paceart. The elimination of handwritten notes reduces the risk of error in interpretation and also creates a consistent report format for providers to view. This allows our providers to promptly address the patient’s situation and make treatment recommendations, as test measurements and previous arrhythmia history are readily available. There is the option to add personalized electronic interpretations or comments to the interrogation, as well as comments on the patient’s account that can be carried through on each report. There is no longer a need to go back into the remote monitoring website to view previous interrogations or episode history.
SessionSync has also allowed us to go paperless, or at times, “paper light”. This helps us mitigate data loss, reduce potential errors as a result of data loss, eliminate paper and related printing costs, and minimize chart storage space. Data security is also becoming an increasing concern across healthcare in the United States. SessionSync lessens the data security concerns of printing or using USB storage devices, reducing the potential for HIPAA violations that can occur with the transfer of patient data.
In the hospital setting, patients’ device printouts can frequently be misplaced during their stay or sent to medical records to be scanned into their chart, along with a myriad of other paper documents, causing a delay in accessing important information. SessionSync is an underutilized tool for patients with implanted cardiac devices that are interrogated during a hospital stay. Medtronic allows for a programmer to be readily available, enabling either a Medtronic representative or hospital staff to complete an interrogation in the facility. By using SessionSync, patients’ device data can be directly transferred from the programmer (2090 and Encore) into their Paceart Optima record, which is then transferred to our outpatient clinic EHR. This includes standard inpatient interrogations as well as new device implant data, device changeouts, and upgrade information. For a new patient without a Paceart Optima record, the device check information is held in a queue until our clinic staff member creates an Optima account for them. The encounter data from the interrogation, including all documentation and attachments, is then pulled into their Optima record and directly into the EHR. Certainly, this process is expedited if the patient already has an established record within the Paceart Optima system.
In addition, our organization utilizes CareLink Express for device checks in the emergency department. Device data from checks using CareLink Express reside on our organization’s CareLink website. If the patient is enrolled in CareLink, this data is automatically imported into that patient’s CareLink record, which then feeds into Paceart Optima and ultimately into our EHR. If the patient is not enrolled in CareLink, then the device data will stay in CareLink Express until it can be matched to the patient after enrollment in CareLink remote monitoring. Currently, 76% of our patients with cardiac devices are actively enrolled in remote monitoring, including CareLink.
Perhaps the most critical benefit of using SessionSync in the inpatient setting is rapid access to pertinent information. Our organization has 5 local hospitals, but an electrophysiologist (EP) may not always be on site. The provider in the hospital caring for the patient can have the device interrogated and information directly imported into the patient’s chart. The EP can then immediately access the interrogation and advise on interventions and treatment recommendations. Device reports and programmer strips no longer need to be faxed to the location of the EP. This digital workflow eliminates HIPAA concerns over where information is carried or faxed, as well as who has access to the information. Staff efficiency is increased, freeing them for more direct patient care.
Challenges and Clinical Outcomes
As with any change in workflow, there were challenges to implementation. Creating the workflow for each of the systems to “talk” to each other required a lot of effort between our clinic, Norton IT/Security, and Medtronic. It also required extensive training with our clinic staff as well as the providers. The location and display of device information within the patient’s chart was different and took some time for us to be able to quickly find the information we were looking for. We also noted that if we had a patient that was not yet entered into Paceart Optima, but had a chart within Epic, there were difficulties matching them across the two systems. This does slow our workflow a bit and we are working with Medtronic to find a solution to streamline this process.
However, once we were able to fully execute the new workflow, we noticed significant improvement in workflow efficiency. We are able to more quickly respond to our patients if they have issues that arise outside of normal clinic hours. Our clinic staff is now available on the weekends to address alert events that occur and assist our providers in quickly getting the information they need to care for the patient. In addition, by capturing all of the discreet data that is transferred electronically, we don’t run the risk of missing vital information related to their device.
The need for a more streamlined approach to the collection and management of data from implanted cardiac devices is evident. The problems with our previous solutions included data overload, gaps in pertinent information, delays in patient care, higher potential for error, and security breaches. By utilizing Paceart Optima with SessionSync, we can seamlessly integrate device information directly into the patient’s EHR and eliminate the need for cumbersome and inefficient workflows. Paceart Optima also allows us to manage multiple clinics across a wide geographic area and rapidly address patient safety concerns related to device alerts and recalls. The partnership between our organization, Norton Healthcare, our practice, Norton Heart Specialists, and Medtronic has been fundamental in establishing this first-of-its-kind program.
Disclosures: The authors have no conflicts of interest to report regarding the content herein. Outside the submitted work, Dr. Morris reports personal fees from Medtronic and Boston Scientific.
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