It certainly is an understatement to say that running an effective and efficient cardiac device remote monitoring clinic is a challenge. Any clinic manager who is evaluating an existing remote monitoring program for improvements or who is launching a new remote monitoring program must dedicate time to analyze their clinic’s current staff, workflow, and capabilities against what is needed. This will help anticipate and stave off many of the most common challenges faced by device clinics – problems such as staff burn-out, unscheduled patients and incorrect billing.
Every clinic has a unique workflow, complications, and issues when it comes to running a cardiac device remote monitoring program. Clinics receive tremendously large amounts of device transmission clinical data coming in daily. Many clinics do not realize the value of remote monitoring and operate without a dedicated remote monitoring staff. Clinic managers may underestimate the amount of hidden workflow involved in remote monitoring which causes many pain points for staff struggling through the heavy workflow. Many clinics struggle with the standardization of an alert protocol and alert criteria. There is certainly a prevalence and frequent misunderstanding of the value and requirements of remote monitoring which commonly leads to ineffectively managed remote monitoring programs.
“Unfortunately, there is a lack of a unified approach to remote monitoring across the entire cardiac device remote monitoring space. This leads to confusion of what is needed to run a device remote monitoring program. There is an unfortunate tendency where this type of remote care can lead to a devaluing of the work being performed, simply because there is not a face-to-face patient interaction taking place, the value of the clinical care should not be minimized.” Jess Rizzo, CCDS, PrepMD Clinical Operations Director
Without an established Remote Monitoring Process in place, How are these questions answered each day?
“it’s important to remember that all of these device clinic remote monitoring tasks are essential, including the variable and hidden tasks that are difficult to quantify. In fact, not recognizing them can certainly lead to a loss of revenue, missed clinical needs, and that overburdening burnout feeling that many clinicians feel.”
Clinical Workflow: Who, What and How?
In order for a remote monitoring program to run effectively and efficiently the following must be clearly delineated: the tasks (what), the who (which clinic staff is doing each task) and how (training needed, communication, and timeline/processes for all tasks) must be clearly delineated to ensure quality.
Big Picture Questions to Analyze a Cardiac Device Remote Monitoring Program
- What: What are the required tasks for a best-in-class remote monitoring program?
- Who: Who on the clinic’s staff is best suited to handle each of these required tasks? What training is required?
- How: How will these individuals accomplish the required tasks? What is the overall process and what are each individual contributor’s roles and expectations? What quality measures need to be in place?
Beyond the big picture questions, there are many more questions and details that go into implementing and improving a device remote monitoring program. Each clinic handles things differently, so who is responsible for all the tasks of remote monitoring is extremely variable for each clinic. Efficient handling of remote monitoring is possible, but only with the proper staff and workflow. It is infinitely difficult to quantify all of the tasks of remote monitoring because the same task might take 30 minutes one day and three hours the next. A relevant time and workflow study published in JMIR Cardio 1, “Clinic Time Required for Remote and In-Person Management of Patients With Cardiac Devices: Time and Motion Workflow Evaluation” is a persuasive argument for the efficiencies of remote monitoring. However, this study certainly does NOT take into account all the intricacies and requirements regarding remote monitoring workflow, tasks, training and more.
- Staffing: Who is/are the right individual(s) on the staff for each of the required tasks? Is it feasible for one or two individuals or is a dedicated team required for certain tasks?
- Monitoring of the device company websites: adding, deleting, or transferring patients clinic to clinic. It takes time to go through each of the manufacturer’s websites plus clinic sites.
- Report Triage: So here is where you’re deciding basically the seriousness of each report. You’re checking to see if the alerts are actionable. You’re checking to see if that patient initiated is actionable. It can include alerts or concerns within the scheduled reports. This also includes making sure those actionable reports or alerts are brought to the proper clinical staff, whether that be to a PA or a physician.
- Report Construction: What are the tasks and process needed to complete even just one remote report? This includes everything from data download, clinical write-up, report sign-off, and billing. This also consists of which includes alerts and patient-initiated transmissions. This task will look very different depending on the clinic’s software. It is also important to remember that there is an element of triage here with many alerts found within scheduled transmissions. In these situations, the clinic staff needs to determine if they’re actionable or not actionable, brought to the proper staff, in addition the writing that scheduled report. The person writing the remote report must take patient history into consideration and make appropriate recommendations for clinical care.
- Charting/Documentation: The documentation includes moving that report in an organized and accurate manner into the electronic health record, ensuring proper documentation of the report and any follow-up actions needed.
- Patient Communication: Each clinic is unique regarding the type of communication done with the patient to inform them of the remote report and this can be done by mail, phone or through a patient portal. If there was something on the remote that is serious enough the patient may need to be seen in clinic. This requires a phone call to the patient to ask about any symptoms they’re having and make a determination to have the patient seen in clinic.
- Billing: Attention to detail for accurate billing is a challenge. Is the coding/billing accurate, based on the type of report? Is it a scheduled transmission or is it an alert transmission?
- Scheduling Patient Follow Up: Is the next visit an in-office or a remote follow-up? This may be as simple as confirming that the schedule is correct on the websites or within the EHR.
- Final Documentation and Sign-Off: The next step is about documentation which includes ensuring the report is kept in the proper place in patient records, as well as getting the final sign off with clinic staff.
- Patient Education: This includes initial and ongoing communication to ensure that the patient understands the value and functionality of remote monitoring. This includes instructions that clearly communicate the need for the patient to plug in and keep the monitor connected and explain how it transmits important clinical data as part of their overall care program.
- Transmission Connectivity and Troubleshooting: This is the task of identifying who is not transmitting data and troubleshooting with those patients in order to help get them transmitting again. It is important to focus on not only getting patients reconnected, but ensuring they are properly connected and transmitting moving forward.
- Quality: Who is responsible for checking up on quality metrics on report writing, patient communication, connectivity, billing, and how often are these quality checks performed?
Is a Dedicated Remote Monitoring Clinical Staff Required?
Some clinics are set up to have remote monitoring responsibilities assigned as fill-in-work when the clinic staff have availability during their downtime. This can lead to inefficiencies and cause a tremendous amount of confusion about billing practices, and a valuable loss in revenue.
“We see some clinics with two different mindsets when it comes to remote monitoring: Full-time and dedicated staff versus staff handling on as time-allows basis. Having Clinic staff dedicated to remotes results in a far more efficient and effective remote monitoring program. The clinics without a dedicated staff for remotes are truly at a disadvantage – far more likely to experience an overburdened staff, missed billing opportunities and quality issues.”
Who should be tasked with taking on these important roles and responsibilities to run an effective cardiac device remote monitoring program? Each clinic is unique and must determine who should fill these roles and what roles are even needed.
- Administrative Staff: An administrative role can take on so many non-clinical tasks and provide tremendous help and structure to a remote monitoring program. Our team here at PrepMD finds this role to be absolutely indispensable. The administrative staff can help with so many steps to include scheduling, billing, patient communication and connectivity issues, adding, deleting, and transferring of patients on the websites. This frees up the clinical staff for patient care requirements and can certainly help with overburdening and burnout of all staff.
- Report Writer: The Report Writer is the clinically trained person who is the primary writer of the device patients’ remote report. This person is carrying out the monitoring of all of the websites. This person should be triaging the downloads, constructing the reports, and communicating with other clinical (secondary reviewer) and administrative staff on next steps. Most often this role is filled by an allied professional (Cardiac Device Specialist) who often holds an IBHRE® certification (CCDS and CDRMS). Some clinics choose to outsource this triaging and/or report-writing to a 3rd party vendor remote monitoring service provider.
- Secondary Report Reviewer: Typically, the secondary report reviewer oversees and supervisors the primary report writer. Depending on the clinic, this role may be filled by an experienced cardiac device technician, a nurse, a mid-level, even a physician. This person is responsible for carrying out the recommendations for patient management, while considering the patient history, patient medications, previous indications on the remote reports, and the review of the current data and report. This individual reviews, assesses and makes recommendations for further care management.
- Final Report Reviewer: Depending on the clinic, sometimes the final report reviewer is a physician or physician’s assistant who review the final interpretations and signs off on the report.
There are many complexities to running a quality cardiac device remote monitoring program, resulting in frequent burnout, and overburdening of clinic staff. This can and should be avoided if a clinic takes the time to have a clearly defined process, trained staff and reasonable expectations and allowances to ensure each person responsible is capable of completing tasks with quality, competence, and efficiency.
1 Boriani, Giuseppe and von Wagner, Boriani, “Clinic Time Required for Remote and In-Person Management of Patients With Cardiac Devices: Time and Motion Workflow Evaluation, ” NIH, JMIR Cardio, 2021 Jul-Dec; 5(2): e27720, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8556635/