With the Affordable Care Act and other paradigm shifts to the healthcare industry, clinical and operational efficiencies are more crucial than ever. The old cardiac rhythm management (CRM) device paradigm allowed for extensive industry participation in the follow-up of patients, but manufacturers have been forced to look hard at existing service models as a result of device price erosion. The average selling price of a pacemaker fell 26% from 2007 to 2011 (Medical Device Business, September 23, 2013; adj. for inflation); implantable-cardioverter defibrillator prices declined similarly. The CRM device industry has responded to this price decrease with increasingly automated devices that record, store, and transmit large amounts of data directly to the clinic. This influx of data continues to overwhelm clinics and clinicians.
To add to the difficulties, burgeoning numbers of device patients, greater device complexity, and declining reimbursements have created a collision course for many cardiac implantable electronic device (CIED) clinics that find themselves stretched too thin to provide crucial services with efficiency. In this article, we showcase two practices that in recent years have implemented a virtual labor source for cardiac monitoring.
Both practices discussed here chose ScottCare’s Ambucor Health Solutions, a virtual labor service that provides consultative and contractive ambulatory electrocardiographic and remote cardiac device monitoring services. With Ambucor, a CIED patient is registered by the manufacturer at the hospital and Ambucor is then advised of the patient’s schedule. Ambucor’s service professionals use state-of-the-art monitoring technology to follow the patient.
Main Challenges Faced
“We simply could not manage all of the incoming data from all of these devices,” stated Dr. Suneet Mittal, Director of Electrophysiology for the Valley Hospital Health System, which operates offices in New York and New Jersey that treat nearly 1,100 patients and 4,500 device encounters a year. “We were not even able to open up a monthly heart failure clinic for devices because we could not handle the load of quarterly device checks. We had come to the recognition that we were appending the remote responsibility of the workload to a nurse practitioner, which was not feasible. It was at that time we decided we had to look at alternative models.”
Over in the Delaware area, Cardiology Physicians, PA (CPPA) reports it was experiencing similar issues: because it was not always able to keep up with the patient load, some patients were not followed in a timely fashion or were missed entirely. CPPA employs eight physicians and three physician extenders to manage the 200-300 patients visiting the clinic each day. Obstacles to optimal care included in-clinic patients who preferred very early or late appointments (causing an uneven workload distribution), as well as disjointed follow-up procedures due to multiple clinicians who used different approaches — some embracing new technology options (remote monitoring), some favoring transtelephonic monitoring (TTM), and others scheduling only in-clinic visits. Finally, outpatient telemetry was handled by different systems and different colleagues. All of this not only affected patient care but had a trickle-down effect on clinic billing and the overall financial health of the clinic.
As a result of these myriad concerns, both clinics investigated multiple options to manage their heavy patient loads. In CPPA’s solution search, a major requirement of outsource solutions had always been access to complete patient and device data. “The issue that drove me was that some of these independent companies are like a black box,” stated Dr. Brian Sarter, an electrophysiologist at CPPA. “You only get the information they send you.” Dr. Sarter did not consider an independent diagnostic testing facility (IDTF) in his search because he believed it would preclude or greatly limit his access to all patient data. In addition to requiring that patient data be timely, accurate, and reliably transmitted, Dr. Sarter insisted that patient data be available to him with no restrictions; he wanted alerts from remote monitoring to be captured, accurately interpreted, and then appropriately forwarded.
Over at Valley Health, Dr. Mittal agreed. “We do not see an IDTF being able to do these things. It would have to be a cloud-based architecture that would allow us to communicate or pull data from all of our patients, irrespective of whether it be in New York or New Jersey.”
In concert with the data issue, it was crucial any contracted solution keep pace with changes in the practice of medicine, technological innovations, reimbursement challenges, and growth at the clinic itself. For example, CPPA has grown about 10% in the past two years. Every year new devices with updated technology come to market. Equally challenging, payers change their regulations; for instance, payers now require complete Holter monitoring before advancing to other therapies. As these and many other changes impact real-world clinical practice, the contracted solution must work with the clinics, step by step, to manage these changes.
About four years ago, Ambucor became the solution of choice for CPPA. Dr. Sarter recollected their initial decision-making phase, stating, “CPPA needed uniformity but without sacrifice in quality. So we explored certain vendors offering relevant services.” CPPA learned about Ambucor through its use of ScottCare’s TeleSentry™ mobile outpatient telemetry technology, a real-time monitoring service for patients with atrial fibrillation or syncope. Their use of the TeleSentry system, which provides live patient visibility, analysis, and wireless transmission of arrhythmia events, changed CPPA’s ideas about what was possible with remote monitoring and virtual labor. “The introduction of the TeleSentry technology was impressive to us because it was the first solution that was able to do real-time monitoring,” said Debbie Falkenstein, Clinic Manager at CPPA.
Valley Health more recently signed on with Ambucor. “In 2012, we took a hard look at where we were in-clinic versus where we should be. We really demonstrated that we were missing the guideline-based device care in the majority of patients, which was adversely affecting both patient care and in-clinic revenues,” stated Dr. Mittal. “We had to look into alternative models, and the labor model that Ambucor provided fit nicely.”
Both organizations had similar goals in gaining uniformity and thus streamlining their workflow to reduce costs. Both groups were also adamant about maintaining quality.
An equally important factor for both clinics was to provide care for patients beyond routine office hours. “We started to see the observational data come out of the ALTITUTE registry and a number of studies from Europe, including ECOST, COMPAS, and IN-TIME, which showed that morbidity and mortality of patients from remote monitoring is reduced substantially compared to our usual methods of follow-up,” Dr. Mittal commented.
Remote follow-up performed by the clinic requires a highly trained nurse practitioner or physician extender; however, the flow of patient care can be disrupted when personnel take time off. The nature of Ambucor’s 24/7/365 services eliminate concerns over insufficient staffing.
About 80% of Valley Health’s device patients, representing devices from multiple manufacturers, are enrolled in remote monitoring. Those not enrolled in remote monitoring are exempted because they are either not deemed suitable candidates or because patients are unwilling to participate.
Clinicians at both organizations agree that response times to alerts have been excellent and that patients are receiving more comprehensive care. When alerts or remarkable conditions arise, Ambucor notifies the clinic so the physician can make the appropriate clinical decisions. When things are going well, the clinic can be assured that the patient is still accurately and reliably followed, all without adding to the already hectic workload. Kelly Vance, Marketing Manager of CPPA, noted, “We expected Ambucor to help with staffing and reduce the load in the monitoring center, and it did.”
Debbie Falkenstein of CPPA said, “We love the fact that patients with syncope have immediate follow-up with Ambucor. As soon as they see something such as a patient having syncope, they reach out immediately. We are not just a number.” Falkenstein added that there is good rapport between Ambucor and CPPA, particularly when there are software updates or troubleshooting issues emerge. “The issues with managing patients are just the logistics of the different steps that are involved with the process,” Dr. Mittal explained. “Prior to the use of Ambucor, there were challenges in the system.”
By streamlining the workflow, Ambucor has enhanced patient care simply by allowing follow-up to be performed more consistently and reliably. “The patients are being cared for in the time frame that is recommended,” Falkenstein added. This has led to more systematized and timely billing and a lightened burden for staff. Ambucor also provides clinicians with full access to all data.
“In terms of operational efficiency, Ambucor has been very successful,” Dr. Sarter said. In the past, staff was overwhelmed with follow-up. Even the use of an IDTF contributed to a backlog of follow-up because information had to be interpreted and, in some cases, acted upon. The Ambucor team not only could read patient data, it created a more straightforward workflow and billing system so the clinic was not faced with a sudden unexpected bolus of work or payment troughs. Dr. Sarter explained, “It improves our workflow because we can better dedicate our physician time.” Dr. Mittal shared similar thoughts: “Ambucor allows us to relegate the billing function. That is making clinical sense as well as financial sense.”
Ambucor also helped bring together all of the external ambulatory ECG monitors under one roof and offered cloud-based architecture for faster data management even across multiple physical offices in different states. This has paved the way for expansion to better meet patient needs. “Ambucor allowed us to expand to the point where we can offer monthly checks of implantable loop recorders and implantable cardiac monitors, in addition to quarterly checks of pacemakers and defibrillators,” reported Dr. Mittal.
By better managing the avalanche of data, Ambucor allows clinicians to focus on relevant data in clinically meaningful ways. “The quality of the information we are getting in terms of atrial fibrillation duration and frequency of events is helping our management and decision models,” Dr. Sarter concluded. “Patients who have serious arrhythmias are alerted right away, reliably, 24/7/365; most importantly, I have access to all of the data. This benefits the patient. And since we provide the service, we are receiving full reimbursement.”
Dr. Sarter described a typical workflow at CPPA for a new CIED patient: the patient is registered by the device manufacturer at the hospital (and Ambucor is notified of the patient’s schedule), then CPPA staff educates the patient about remote monitoring and trains the patient on the setup of their equipment/device. The patient is then followed by Ambucor.
As much as possible, new device patients at Valley Health are paired with the remote monitor system upon hospital discharge, and the first “handshake” between device and remote transmitter occurs at the wound check about seven to ten days post-implant. “The first portion has gotten a little easier, as the companies have been giving us the transmitters to give to the patients at implantation,” stated Dr. Mittal. “Knowing that the patients are going to come back in seven to ten days for a wound check, and having Ambucor there to ensure the patients receive the ‘handshake’ transmission, has been a real value because it removes that responsibility from the nurse practitioner.” Both methods equip patients very early with remote monitoring tools and help them view remote monitoring as a normal and essential part of their care rather than an optional function.
An unexpected benefit has been positive patient response, even though the average patient is not cognizant of the behind the scenes activities of a busy device clinic. According to Debbie Falkenstein, patients at CPPA no longer feel hurried because someone has to run and do something else. “We have had only positive feedback from our patients.”
“We’ve been very happy with Ambucor.” Dr. Sarter concluded. “It offers a more robust system, in that if a patient alert comes through, it goes to Ambucor and we do not rely on a staff person here to promptly relay it. Ambucor has all the skills there.”
Dr. Mittal has been equally pleased to offer the full benefits of remote monitoring to the clinic’s device patients. “I am a firm believer that remote monitoring is critical to delivering care. I say that with the caveat that if it cannot be done within the confines of a small clinic managing its own patients, then it should be done in a large data center. Within those data centers, models like Ambucor are integral to managing the data quite well.”
Darren Selsky, MS, MHA is a twenty-year veteran of the medical device industry. Mr. Selsky is President of the Medalytics Group, LLC and a recognized consultant of the Heart Rhythm Society. Prior to his entry into the consulting business, Mr. Selsky held numerous positions for St. Jude Medical, including Director of Product Marketing for Remote Patient Management and Programmers. He has degrees in both Biomedical and Electrical Engineering from Temple University as well as a Masters in Health Administration and a Master of Science in Healthcare Finance.
Disclosures: Darren Selsky, MS, MHA reports receiving consulting fees from ScottCare Corporation for conducting interviews. Dr. Sarter has no conflicts of interest to report regarding the content herein. Outside the submitted work, Dr. Mittal reports EP fellowship grants and personal fees from BIOTRONIK, Boston Scientific, Medtronic, and St. Jude Medical; he also reports personal fees from Greatbatch, ScottCare Corporation, and Sorin.