In this feature interview, EP Lab Digest speaks with Dr. Colin Movsowitz about his experience with the MoMe® Kardia cardiac monitor (InfoBionic). Dr. Movsowitz is an electrophysiologist with Cardiology Consultants of Philadelphia in Philadelphia, Pennsylvania.
Tell us about your practice.
Cardiology Consultants of Philadelphia is the largest private cardiology practice in the U.S. We have 97 cardiologists, including 10 electrophysiologists, and practice at a number of different hospitals in the greater Philadelphia area. Our practice provides an in-house external ambulatory monitoring service line for our patients that includes Holters, event recorders and mobile telemetry monitoring (MCT). We have partnered with a number of different companies over the years and have participated in the development of ‘true’ MCT monitoring.
What does it mean to have ‘true’ MCT (Mobile Cardiac Telemetry) monitoring?
The original promise of MCT monitoring was to replicate inpatient telemetry. MCT monitoring was to overcome the limitations of Holter, event, and loop recorder monitoring. (Table 1)
Our expectation was that ‘true’ MCT monitoring would provide continuous long-term ambulatory monitoring — meaning that patients could be monitored for up to a month, all of the data [symptomatic and asymptomatic events] would be captured, we would have easy access to this data and be able to determine whether the patient was compliant in wearing the device, we’d be able to see all the reporting and verify whether it was accurate, and we could look at the onset and offset of any arrhythmia. We expected to have timely access to transmissions of clinically important events and the full dataset available on any computer with Internet access. That would be akin to telemetry in the hospital.
Like most other cardiology groups, we initially outsourced this service line to third-party independent diagnostic testing facilities (IDTFs) that provide MCT monitoring. We signed off on the alerts and the End of Service Summary Reports generated by the IDTF technicians. We assumed that we were providing our patients with continuous monitoring, and that if needed, we could easily access the full disclosure dataset. Unfortunately, our clinical experiences with these services did not live up to our expectations.
We found that MCT monitoring solutions frequently provided by IDTFs are complex multicomponent devices that are mailed to patients with a 15-minute instructional video on how to use the device. However, many patients are older and struggled with the technology. There are two ways that events are triggered — either the patient activates the device when they have symptoms, or the device algorithm automatically detects an arrhythmia and transmits it to an IDTF — at that time, technicians read the recordings and, at the discretion of the technician, forward these on to physicians. However, we found that technicians do not take the time to locate the onset and offset of the arrhythmias that are missed by the detection algorithms. The remaining data — meaning, all the other data that is not triggered — does not appear to be looked at by the majority of companies, and many times that data is lost or cannot be accessed in a timely fashion when requested by physicians. Monitoring companies also do not do a great job ensuring that patients are actually wearing the monitors — frequently waiting 24-48 hours before calling a patient if the monitor is not transmitting data. In addition, the reports on arrhythmia burden for atrial fibrillation (AFib) are frequently inaccurate, and there is no way to verify accuracy without access to all the data. We were also disappointed to find that automatic device algorithms were frequently employed to detect the maximum and minimum heart rates, resulting in transmission of spurious data to us as there was no visual oversight of the data by the IDTF.
It dawned on us that with outsourced MCT monitoring, we really don’t know what we don’t know.
Fortunately, ‘true’ MCT monitoring does exist and is embodied in the MoMe Kardia cardiac monitor. The MoMe solution provides full disclosure and a unique service model. The MoMe device provides easy access to all the data, and data acquisition is near real time. The accompanying service plan requires purchase of the device by the practice. The practice owns the service line, checks the patients’ insurance, enrolls the patient in the portal, and chooses the appropriate alerts and duration of monitoring. The practice then provides in-person instruction to the patient receiving the device. The practice also bills the global fee.
What are the benefits of full disclosure?
Full disclosure implies easy access to all the recorded data. That may sound like a headache, since who would want to look at all of the electrograms? However, similar to inpatient telemetry, MoMe displays the 24-hour heart rate trend. Examining abrupt changes in the heart rate allows one to focus in on a timeframe that is of interest — one can click on the time and evaluate the associated electrograms. (Figure 1)
One can also look at every trigger and verify the accuracy of why it triggered, including if the arrhythmia was AFib or not. The other value of full disclosure is that one can see how an arrhythmia started; when you view the heart rate trend and see that it suddenly changes, you can then view the electrogram to see how that arrhythmia was initiated, how long it lasted, and when it terminated. Initiation and termination of arrhythmias are very important, because they can be helpful in determining the mechanism of the arrhythmia (Figure 2). Full disclosure allows one to scroll backwards and see how that arrhythmia started as well as the context in which that event occurred (Figure 3). Finally, a device doesn’t always trigger with an asymptomatic event. If a trigger is set at a heart rate of 150 bpm, that means it’s not going to pick up any asymptomatic tachyarrhythmias slower than the cutoff rate. For instance, a patient could be in slow atrial flutter, and if both the patient and device do not trigger it, and if no one looked at the heart rate trend in the full disclosure data, then no one will know that the patient had a sustained arrhythmia, which is clinically significant. (Figure 1)
How has use of the MoMe service impacted the experience for your patients? Do you see a higher rate of patient compliance?
In the MoMe service model, the practice owns the devices and provides the entire service. This is particularly valuable, because the practice’s allied health professional hooks up the device to the patient and provides them with personal guidance on how to work the device. This model drives compliance.
Furthermore, MoMe is small, lightweight, and simple to use with only one button. It comes with a charger and two battery packs. One is in use attached to the monitoring and transmitting device, while the other is being charged in the charging station. The device has 3 leads that allow for 2 different high-fidelity electrograms. There are no other components.
Many of the other companies have multiple components, such as a separate transmission device, recording device, and charging device. Patents have commented favorably on the simplicity of the device.
Tell us about the difference of getting an alert from MoMe and getting an alert from another company.
Alerts typically come in either during office hours or after hours. Alert criteria and notification are individually programmable with the MoMe device. A major advantage with MoMe is that when an alert transmission occurs at night, it goes straight to your cell phone, so you’re able to immediately access the electrogram as well as the patient’s phone number. It’s very easy to then verify the arrhythmia and contact the patient. Most other companies contact the physician via the practice’s answering service, requiring a call back to a technician for their interpretation of the arrhythmia. MoMe allows immediate visual oversight of the alert and access to the patient if necessary. (Figure 4)
Did you have concerns with the prospect of owning the MCT service line?
A practice faces two concerns when owning the MCT service line. First, can the practice deliver a quality service that is as good or exceeds what is provided by IDTFs? In order to provide in-house MCT monitoring, the practice does need to put in time and effort into developing a workflow to effectively deliver the service. Physicians need to be educated on appropriate use criteria. Staff are also required to oversee the inventory, check insurance coverage, enroll patients in the portal, choose appropriate alerts and duration of monitoring, instruct patients on device use, and troubleshoot. Once these steps have been taken, in-house MCT monitoring can be more efficient and hassle free than sending it out to a third-party vendor. The MoMe model is uniquely suited to this workflow. It is incredibly user friendly and can be accessed from any computer anywhere. It’s a hassle-free interaction with the data — an IDTF does not have to be contacted in order to download the data. For example, if you’re with a patient and want to show them an electrogram, you can just pull it up on your screen and show them, and if they’re still wearing their device, the data will be populating right there on the screen in front of you and your patient.
Second, can this be a financially viable proposition for a private practice? In my experience, the efficiencies of the MoMe solution have obviated the need to hire any additional staff. The current reimbursement for MCT monitoring is financially viable for a private practice employing the software as a service model provided by MoMe, while the practice bills globally for the service.
What would you say are the most important things about this service that other potential users should consider when thinking about MoMe?
In summary, the value proposition includes:
- The ability of the practice to provide a complete external ambulatory monitoring service line in which the practice can ensure delivery of a quality product;
- Improved compliance driven by employing the practice’s allied health professionals to hook up the small and user-friendly MoMe devices;
- Setting individual alerts at the time of hook up;
- Easy access to full disclosure, allowing visualization of onset and offset of arrhythmias;
- Verification of arrhythmia and arrhythmia burden, allowing identificaiton of arrhythmias that would otherwise go undetected by the notification criteria;
- Hassle-free, after-hour smartphone notifications;
- Clinical decisions based on data rather than on what an IDTF technician chooses to send;
- A Virtual Telemetry Station on any computer with Internet connectivity (Figure 5).
Disclosure: Dr. Movsowitz discloses that he has served as a consultant for InfoBionic.
This article is published with support from InfoBionic.