A confluence of new trends is directly impacting cardiac implantable electronic device (CIED) therapy in the U.S. Expanding device indications, shifts in population demographics (the graying of America), and new technological innovations have resulted in more CIED patients. The fee-for-service reimbursement model of the Centers for Medicare and Medicaid Services (CMS) has shifted reimbursement paradigms so that both the remote and in-person monitoring of CIEDs are now grouped into one “family” of physician services.1 Additionally, the Patient Protection and Affordable Care Act (“Obamacare”) has mandated many changes, including adding insurance coverage to more patients and requiring the migration of medical records to electronic systems.2 Thus, the management of this burgeoning CIED patient population has required busy device practices to consider and, when appropriate, integrate remote care efficiently into their practice models, especially as their patient load increases.
Remote monitoring clearly has the potential to significantly reduce the number of in-office visits and facilitate the management of device advisories and unscheduled events. Despite these obvious advantages, remote monitoring was not always easy for busy practices to manage. For one thing, manufacturers had different systems.
“Remote monitoring can be harrowing,” stated Dr. David Harnick, Assistant Professor of Cardiology at Mount Sinai and head of the Heartwise Cardiology Clinic in New York City. “With many patients and many different systems, it can be very complicated.” In his busy New York City electrophysiology practice, Dr. Harnick treats hundreds of device patients with different types of devices from all of the major manufacturers. In order to take advantage of what remote monitoring has to offer, physicians must leverage its strengths and integrate it optimally into their workflow. “BIOTRONIK Home Monitoring® has really streamlined our practice by allowing us to set up templates for common patient types. Applying this base template to new patients and further customizing only where needed saves us a lot of time and effort. It’s also a scalable system.”
For patients with BIOTRONIK devices, Dr. Harnick and his team also use the batch follow-up capabilities of BIOTRONIK Home Monitoring using a fixed calendar schedule. On a specific day (first Monday of the month, and so on), all of the BIOTRONIK devices transmit reports into a single batch file that Dr. Harnick and his staff can then review. Then, 31 or 91 days later (depending on type of device), another automatic transmission occurs and the data are put into a batch file.
“We batch everything together on 31- and 91-day schedules, and we set them up to be organized by device. BIOTRONIK Home Monitoring automatically batches all patient files and prints out a report, which we can then organize as we wish, in this case by device type. My staff sets aside specific time on that day for billing purposes. The batch report allows a very efficient means for me to review large numbers of device reports. A report is then produced as a PDF file, which can be uploaded to our electronic medical records,” Dr. Harnick explained.
The remote monitoring schedule is fixed so that specific calendar days are set aside for transmission of certain devices. With BIOTRONIK devices, this transmission can occur automatically and patients need not be notified. (With some devices and manufacturers, patients must be called first and then take specific steps to transmit reports.) For Heartwise Cardiology, using BIOTRONIK Home Monitoring in this way began as an experiment but soon emerged to be a proven and efficient model.
“This model works, because BIOTRONIK Home Monitoring is a truly remote wireless system. The patient does not need to do anything to transmit. In fact, the transmission occurs without the patient even being aware of it,” continued Dr. Harnick. While all CIED manufacturers offer a version of remote monitoring, Harnick points out that BIOTRONIK works best because the transmitter device is very simple (no patient interaction required beyond plugging it in), no landline is required, and patients come to understand and accept the technology. In fact, compliance with BIOTRONIK Home Monitoring is high.
“With BIOTRONIK Home Monitoring, we have been able to achieve about an 85 percent rate of transmittal success in our practice,” Dr. Harnick stated. “That far exceeds what we have been able to do with other systems.” Part of this high compliance rate may owe to the fact that Dr. Harnick tries to acquaint his patients with Home Monitoring at the time of implant, so that patients come to view remote follow-up as an essential part of their new life as device patients. However, the ease, convenience, and automatic transmissions of BIOTRONIK Home Monitoring assure high compliance rates even among patients who might otherwise be a bit technophobic. The remote monitoring systems of other devices may require the clinic to first contact the patient by phone and then walk the patient through certain steps (such as turning on the transmitter, placing a wand over the implanted device, etc.) to conduct remote follow-up. Not all patients are willing or able to take these steps.
With BIOTRONIK Home Monitoring, patients are not individually notified for each transmission. “Of course, patients are instructed as to how Home Monitoring works and they know that we are downloading reports periodically. Our clinic does not need to call patients individually if the reports show that everything is working appropriately. We tell our patients that if there is a problem, they will hear from us, but if they don’t hear from us, their device is working fine.”
The staff at Heartwise Cardiology sets aside specific hours to handle the billing work based on the transmission days. “The batch programming we do with BIOTRONIK Home Monitoring generates a legal, billable report,” Dr. Harnick explained. Furthermore, this report can be appended to the electronic medical records with no special steps other than creating a PDF document.
When new patients come into the practice, they are absorbed into the existing schedule. “That may mean that a new patient may be included with just 40 days of data on the first report instead of the full 90, but we keep a fixed schedule. It works very well this way,” Dr. Harnick said.
“BIOTRONIK offers truly remote wireless Home Monitoring for high- and low-voltage devices,” Dr. Harnick added. For pacemaker patients, the clinic looks at battery status, impedance values, and device settings. For ICD patients, Dr. Harnick’s staff also reviews heart failure monitoring parameters, respiration rates, and defibrillation parameters. “Additionally, the newest pacemakers from BIOTRONIK are unique in that they incorporate thoracic impedance monitoring, which may ultimately prove to be a useful marker for managing diastolic heart failure in pacemaker patients.”
Dr. Harnick explained, “This practice model means that we don’t have to expend too much of our resources on remote monitoring. For example, we can do the transmission, reporting, and billing — all in one day. The system can be scaled to meet our needs as our practice grows.” Other advantages of the scalable BIOTRONIK Home Monitoring system include simplicity, efficiency, and speed. The use of this model based on transmission schedules can help patient care better align with current guidelines for CIED patients,3 and can streamline hectic clinical practices to accomplish more with fewer resources.
Compliance may be one of the biggest obstacles preventing the widespread use of remote systems. A database study of 269,471 consecutive U.S. device patients (all manufacturers, all types of CIEDs) revealed that more than half (53%) never used remote monitoring features.4 While there may be many reasons for this low level of patient compliance, the database study could not associate sex or age with compliance. In a meta-analysis of remote monitoring outcomes, remote monitoring did not confer mortality benefits to patients compared to conventional in-person care, but did offer earlier event detection and had the potential to reduce inappropriate shock therapy from an ICD.5
Increased challenges to EP practices in the wake of expanding patient populations and the concomitant administrative burden have underscored the importance of forward-thinking device technology that can not only provide care for the patient but can support the clinical team as well. The BIOTRONIK Home Monitoring system is an important feature for device patients and the clinics that care for them.
Disclosure: The author has no conflicts of interest to report regarding the content herein. The author is with LeQ Medical, and discloses she received a fee from BIOTRONIK as a freelancer for this article.
- Slotwiner D, Wilkoff B. Cost efficiency and reimbursement of remote monitoring: a US perspective. Europace. 2013;15(Suppl 1):i54-i58.
- U.S. Congress. One hundred eleventh Congress of the United States of America at the Second Session: An Act Entitled the Patient Protection and Affordable Care Act. 2010; H.R. 3590: http://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf. Accessed 27 September, 2013.
- Dubner S, Auricchio A, Steinberg JS, et al. ISHNE/EHRA expert consensus on remote monitoring of cardiovascular implantable electronic devices (CIEDs). Ann Noninvasive Electrocardiol. 2012;17(1):36-56.
- Varma N, Piccini JP, Snell J, Fischer A, Dalal N, Mittal S. The Relationship Between Level of Adherence to Automatic Wireless Remote Monitoring and Survival in Pacemaker and Defibrillator Patients. J Am Coll Cardiol. 2015;65(24):2601-2610.
- Parthiban N, Esterman A, Mahajan R, et al. Remote Monitoring of Implantable Cardioverter-Defibrillators: A Systematic Review and Meta-Analysis of Clinical Outcomes. J Am Coll Cardiol. 2015;65(24):2591-2600.