The Challenge It has been shown that implantable cardioverter defibrillators (ICDs) significantly lessen mortality rates due to sudden cardiac death among patients at risk for recurrent heart arrhythmias.1 However, as the number of Americans with ICDs grows in the United States because of both the increased 50-plus population and the 2004 recommendations by the Center for Medicare and Medicaid Services (CMS) to cover more of these procedures in at-risk patients the challenge and demand to safely monitor and manage hundreds of thousands of ICD recipients by a small number of electrophysiologists and their practices increases. According to the Heart Rhythm Society, the U.S. averages just 3.79 electrophysiologists per 1,000,000 people, with many of these specialized doctors located only in well-populated cities, causing rural and suburban patients to drive sometimes hundreds of miles for routine monitoring once their device is implanted. At the same time, recent reports of device malfunctions have heightened concern among implanted patients, who now require additional counsel and care in addition to regular device monitoring in order to make them feel more at ease with their ICDs. These and other issues have short-staffed electrophysiology practices facing challenging times when it comes to monitoring their patients' ICDs and pacemakers. Our practice at Asheville Cardiology Associates was dealing with increasing numbers of patients and strained profitability, as our patient pool stretched beyond 3,000 implanted device patients. In response to this pressure, we looked to outsource our routine ICD monitoring in order to free up doctors and nurses for more acute patient care. In December 2004, after interviewing several monitoring companies, we chose Raytel Cardiac Services to handle follow-up for our ICD and pacemaker patients. Raytel's service provides our clinic's staff with detailed reports and emergency physician notifications to ensure that Asheville patients' clinical needs can be addressed quickly and effectively. The Issue Asheville Cardiology Associates was forced to re-evaluate its monitoring practices after losing a significant portion of our clinical staff to nearby hospitals. During the transition, nurses at the clinic had to work overtime to monitor patients' ICDs and pacemakers. Having quality nurses onboard to assist doctors is imperative given the nationwide shortage of electrophysiologists; however, our clinic's specialized nurses were being pulled away from their other important functions to handle routine implanted device follow-up. Patients were walking in unannounced needing his or her pacemaker checked. Our staff was running on overload, and our practice feared that this overload would cause additional staff turnover. While patient demand was at an all-time high, profitability didn't match up to it. Insurance carriers will not compensate practices enough to do monitoring the old fashioned way in person yet our practice couldn't bill the patients enough to cover the costs or else they would complain to the billing department. While the patients appreciated the in-person contact and monitoring, upon a full review, we realized that it was a huge financial burden for us, and something had to change. Insight and Strategy Making the switch from in-office implanted device monitoring to outsourcing for remote monitoring, while a successful decision, proved to be difficult at the onset, particularly since we were switching monitoring practices under duress (rather than planning ahead, as Raytel would recommend other practices do). Two key issues arose, one being system compatibility with our electronic medical records, and the other being patient education and satisfaction to ease the transition, since our clientele enjoyed the face-to-face experience of in-office monitoring. To deal with the medical records compatibility issue and to streamline the transition, an implantable device specialist employed by Raytel served as liaison with Asheville Cardiology Associates during the transition period; he continues to oversee the practice's needs to this day. The liaison's role was pivotal to the switch, since he was able to blend what Raytel does on a daily basis with the type of data that we generate in our own system. It also gave our practice a single point of contact within Raytel, which helped streamline the process and avoid any communication lapses. Secondly, patient support of this new system was key. We wanted to make the whole implanted device monitoring process easier for everyone, but not lose our patients as a result of their dissatisfaction with the concept of remote monitoring. The key was communication and reassurance to our clientele, and we set up various ways to do this. The patient/practice communication outreach included: Classes were held for patients to learn how to use the new technology. Brochures about Raytel's services were distributed for patients to read and learn more about remote cardiac monitoring. Patients were educated that Raytel works directly with the clinic's insurance companies and HMOs; this relieved the clinic's billing department of a lot of data entry work and insured the patients received accurate billing. Small groups of ICD patients were transitioned one at a time to avoid unfavorable scenarios. The Results Asheville Cardiology Associates has used Raytel's remote ICD monitoring system for months now, and we have streamlined our device follow-up considerably. Our practice's specialized nurses now focus more on acute patient care as opposed to routinely monitoring ICDs and pacemakers. Patients who live some distance from the practice no longer have to travel for routine monitoring since they can have their devices tested from the comfort of their home at a time convenient to them. Raytel's computer records cleanly interface with our practice's medical records, avoiding additional data entry that would have defeated the timesaving purpose of the monitoring changeover. In addition, in an effort to ensure patient satisfaction, Raytel periodically surveys patients to uncover and address any issues that may have surfaced. The additional benefit of working with Raytel is that their monitoring service is available 24/7, 365 days per year, so patients who have a shock episode can call into Raytel's trained technicians any time, day or night, and their condition can be assessed. If the assessment meets criteria designated by Asheville, a physician is immediately notified in order to actively manage the patient's condition. It really has been a win-win situation for all involved. It was well worth the effort to turn this cost center into a revenue center that everyone the staff and our patients benefits from. References 1. Joseph GK, Wilkoff BL, Dresing T, et al. Remote interrogation and monitoring of implantable cardioverter defibrillators. Journal of Intervention Cardiac Electrophysiology 2004;11:161 - 166.