through the noise, an innovative approach to cardiac remote monitoring. Oh, and welcome to my group here, the participants in HRX. It's so great to have everybody, a live audience in front of us. My name is Aileen Farrick. I'm a nurse practitioner. I am at White Plains Hospital in New York. I'm also the assistant research coordinator at White Plains. I have been doing cardiac devices for probably 40 years. And I had the distinct privilege of co-chairing, I'm sure you guys are familiar with the consensus, expert consensus document that was published last September in Heart Rhythm. I'd like to have a warm welcome to Teresa McElrath. McElrath. Oh, sorry. It's OK. McElrath. I'm going to have you introduce yourself, Teresa. And maybe as part of that, give us a little background on Piedmont Health Care System, which is where Teresa is coordinating a very large center. Absolutely. I'm Teresa McElrath. I'm a graduate level engineer. Been working with implanted devices for 35 years. And have landed in the last decade at Piedmont Health Care. I'd been there previously, left for a while, but went back because the team there is amazing. Their program is amazing. We have many hospitals under the Piedmont umbrella. I coordinate the clinics for four of those hospitals. We follow 14,000 patients in our clinics with a team of what should be nine. We're down two people if anybody's looking for a place to land. And one person on our remote monitoring desk that handles all of those patients because we partner and outsource with Pacemate. OK. So I think we're going to start by talking a little bit about the old remote monitoring workflow. We all remember the old days when remote monitoring was initiated. Maybe you could work us through a little bit the workflow that you experienced then. So the old model for remote monitoring was complicated. We had a team of three individuals. Most of them had extensive experience with remote monitoring. They came up with remote monitoring because it was implemented 20 years ago-ish. So they kind of grew with it. More and more people became enrolled. More and more people were followed. And as a consequence, the data that rolled in every single day became overwhelming and untenable. Our people logged into four to five different sites every morning. They had to review real alerts versus repetitive alerts. They had to integrate, move things manually to our electronic medical record. They had to make phone calls for people who were late. They had to ensure that all of the true alerts were addressed in a timely fashion. There was a lot on their plate. With that being said, we were unable to keep people because of the overwhelming workload and ended up with a problem staffing. Every institution, I think, ran through the same process that Piedmont did in that as those alerts and as that data overload came to the clinic, it was too much. They looked for work elsewhere. So we had to retrain. So we kept going through this process of retraining and losing people. Well, and if I can say, connectivity was the key. And in those days, connectivity was the patient had to make a manual transmission. Absolutely. And then there was also the whole scheduling of that. There was a lot to staffing problems. And that was all of those things. The phone calls had to be made to patients who didn't bother to send for that scheduled transmission. They might not reach the patient. We end up in this phone call doom loop where it's missed call and phone tag. Then they had to bill and make sure that the 67 transmissions they'd received over the past 30 or 40 or 50 days for that patient, which one was billable. Where's my billing interval? It was difficult for them. And they couldn't manage it anymore. They basically said, there has to be a different way. We don't know what that way is. And we eventually looked to make changes. Right, it was quite an onerous endeavor, right? And now, since 2015, remote monitoring has been standard of care. Absolutely. The 2023 guidelines only reinforce that, that it is standard of care. Absolutely. In addition to that, we had the whole COVID epidemic, right? And now we pushed a lot of our patients onto remote monitoring because they couldn't come into the office. And ironically, we're in the old days, right? People were pushing back on remote monitoring because they thought there was a disconnect in relationships with their clinic. Now that they're comfortable with it, they don't want to go back to being in office. Correct. COVID was a huge push for us because we weren't seeing patients in the clinic unless it was urgent in the early months of COVID. We made a huge push to reach out to all of our patient population that wasn't connected remotely. We enrolled them. We explained to them that you can't just come into the clinic for a check. That's not something we're doing at this time. So begrudgingly, a lot of patients connected. And then they found out after a few months, maybe a year, that this is a great thing. I don't have to come in. I might have some palpitations. I could just call somebody. They'll tell me to push a button. We can review that data and save them a drive that might be an hour and a half round trip. So for those people that were uninterested previously, they came around and were connected. And even more data flowed into our clinic. I think the other huge surge in data is the implementation of implantable loop recorders. Absolutely. And for the past, we started implanting them. COVID happened. People didn't come into the office to have them implanted. And then now there's a whole backlash and a huge increase in volume of implantation. We did play catch up for about a year after COVID. So there were all these recorders out there that needed monitoring. And as we started monitoring all these additional loops, of course, there are transmissions for over-sensing, under-sensing that come over as pauses, and tachycardia, and they're not real. And that became one of the reasons we really started to look to outsource, along with other factors. But that was pretty much the straw that broke the camel's back. We couldn't effectively manage all of them. The remote team was getting burned out. We had an instance where our clinic missed a large pause that was true in a patient that had had a history of under-sensing in his loop monitor, despite efforts to correct it. 15 seconds, and it was archived. So it wasn't addressed until the patient came in for a clinic visit. And that's pretty much when we said something has to give. We've got to have better eyes, more eyes, more effective implementation of systems to follow patients effectively and not let them down. They're trusting us to follow them and do the things that need to be done for their issues. There's a reason they were implanted. This gentleman had had recurrent syncope previously, and that was pretty much, yeah, it was missed. So that was the straw that broke the camel's back, and we needed to start looking for something else. So yeah, so on-premise, right solution, helping data overload, overburdened staff is what led you to your search for. And we looked at several different vendors over about a six-month time period where we reviewed what their data looks like, what their team looks like, how they integrate with our systems, and we ended up with Pacemate. And I think it was primarily because they have a team of certified individuals who are reviewing our data. And we needed to make sure that the people we choose are gonna love and follow our patients just like we would. So tell us a little bit about their, in your selection, the criteria. Obviously, you say in credentialing, so tell us a little bit about what you were looking for. So it had to be easy integration with our EHR system. We needed 24-hour coverage. And that was important because we felt that some of those three-day and four-day weekends where patients weren't having a review of their data, we were missing things or delaying treatment that was needed. And Pacemate was the only company that offered us all the things that we were looking for. And they did it in a way that was very, very accommodating, telling us upfront, we can change this if you don't like it, we can do this if you want it. And that was very appealing to us. We had a big meeting with everybody. We looked at everybody's criteria, and Pacemate stood out. Did you utilize resources like other institutions that had possibly used Pacemate to see how relevant it would be for your solution? We did not with Pacemate. We did with some other vendors. We looked at different hospitals, and we looked at their, some of them we went to their main hub where they were set up. And most of them were great, but they weren't stellar, and we needed stellar. We have a big system. So describe to me some of the process, right? So why is it stellar? What is it that now has changed, right? So obviously it's incorporated into, unlike the past where we could incorporate like the four websites into one, obviously this offers a much greater service. Absolutely. My team comes in in the morning, my team of one comes in in the morning, she logs in, and she can see every alert that's billable or not billable that's meaningful, meaning there are some people that have AFib alerts on for permanent AFib patients. We would normally look at those all day, every day. Pacemate filters out that noise, sends us the ones that are meaningful and actionable. The old process was looking at all of that and trying to decide. So the new process is you come in, you look at what's important, you send that information to nurses or to the device clinic, and you move on with your day. And it gets built in the background like magic. So it's a much more streamlined approach than the workflow that we were previously describing as your new workflow with Pacemate. So it's just sign on to one. Correct. And I think the whole having at your fingertips the patient's entire history and medication record and all that without having to go toggle back and forth from one electronic healthcare record to your third party resource for remote monitoring is a huge difference. I'm not gonna tell you that the implementation went smooth. When you bring in a new system, we as an institution had 10 electrophysiologists that needed to come to consensus on what our alert criteria looked like. And we were a little loose with our criteria. I think the first month or so, we got almost as many alerts in our box as we would have addressed without another outsource. We made a quick correction. I think we knee jerked and we tightened up too much. We missed a couple things. We learned, we changed. Part of that change was every quarter we have a sit down face-to-face meeting with the Pacemate team and they go over what's working, what's not working, the changes that we can make to make things smoother, better, faster. Efficient. Exactly. So that growing process in the first six months or so, little bit painful, but in the end, it worked out to be delightful. So the learning curve was steep. It was steep. But in the ultimate, it was worth the effort in the end. So one of the recommendations in the 2023 consensus document is that patients be notified or that they understand that there's a third party vendor who is looking at their data. There's concerns of privacy, there's concerns of hacking their device. So how did you handle that when you initiated this new system? Prior to making this change, we posted literature and we posted signage in all of our device clinics indicating that we were gonna partner with an outside vendor and that the patients may get calls and these calls are gonna come from people who will identify themselves as pacemake calling on behalf of Piedmont. So they knew that if they got a phone call like that, it wasn't spam, it wasn't scam, it wasn't a data breach. And all of our new, newly implanted patients are given that pep talk as well so that they know the expectations that there may be somebody calling to help them if their monitor becomes unplugged or if they miss a transmission for those few manual senders we have out there. And they know that they're getting that call to improve service and to help them stay on track with the care we're trying to provide. So another recommendation was for patients to receive an agreement form. Our patients who were part of the writing committee group, we did have patients that participated in preparing the document, did not like the idea of contract, but they did like the idea of having some brochure so that they would understand sort of what their responsibility is. But actually it's the reverse. They wanted to know what we were going to provide them, but it's also an opportunity for you to teach them what responsibility we expect you, like keeping connected, making sure you keep your data updated, that if we need to contact you, we have a current number, those sort of things. Is that something that you might have implemented in your? So Pacemate provided some brochures for our patients and it explained what they do, when it'll happen if they get a communication, and how they're partnering with us. So patients didn't go out of the office without some kind of information available and a phone number. We gave them both our contact information and Pacemate's contact information for any questions they might have. So we tried to make sure that they were all informed to the best of our ability. Well, tell us more about how you have coverage as well. So many clinics work business week, so they may be Monday through Friday, eight to five. They don't necessarily have coverage on the weekend. Clearly a contract is important for a patient to understand that. It's not an emergency system. If something happens, don't wait to hear from your remote monitoring clinic. So how does your clinic differ? So Pacemate offers us 24-7, 365 coverage. Patients that have issues relating to safety, issues relating to safety, like V-fib events, multiple shocks, loss of capture, lead problems, those issues, if they're found after hours or on the weekend, Pacemate calls our hospital and notifies our on-call EP service so that those patients can get directed care immediately. They're not waiting until Monday when we come in. That's been a game changer. We had so many patients previously that that was always their question. What happens if I have a problem on Saturday? You're not gonna see it until Monday? And the answer was yes. So I think by using Pacemate, we've eliminated a lot of those fears that patients had about being neglected, about not being told what to do in the event of a problem. And they're all very happy to know that there's somebody watching over them all the time, not just business hours. So they've got a lot of comfort. Let's talk a little bit about your alert notifications because, again, the consensus document did have recommendations for what you should program, you know, for alerts and including the high-priority alerts, like what's a red alert, what's a yellow alert. Did the consensus document at all guide your customization, if you will, because that is also part of the document is the whole idea of customizing your programming for individual patients. Right. So we began this process prior to that document with, like I said, many EPs giving their input about what we should monitor and how we should monitor it. A lot of them implemented some of their own personal preferences into our alert criteria, which became, like I said, problematic and led to so many additional alerts. And when we relooked and made changes, we missed a couple alerts. But now that we've spoken with Pacemate, we've discussed the issues, we're looking at all the analytic data, and we've come to, I think, a very happy medium where we're getting the things that are appropriate. We're not seeing things that we don't need to see. And for those patients that we are getting alerts for changes, they might have had paroxysmal AFib and then persistent AFib, and now it's permanent. We do a review process before patients come into the office, and we're making sure that those alerts are disabled so we're not dealing with alerts that are unnecessary or no longer appropriate. And it's not us looking at it, it's Pacemate. So as our team, we want them to have a manageable workload as well. We try to the best of our ability to make sure during our wound checks and whatnot that patients, maybe they were implanted for a second-degree heart block, they're pacing 50% of the time. Some of the vendors will leave the nominal settings on where we're getting alerts because they're pacing, or those AFib alerts and those permanent AFibers that aren't turned off. So we try to the best of our ability to get in there and manage those alerts in the device rather than in the manufacturer settings or in the remote vendor settings. And so that brings another question, is your communication between, and I don't know how you operate, I guess every clinic operates a little differently, some follow remote monitoring data as well as checking patients in office, others sort of have a separation. Here's the remote monitoring team and here is the in-office team. So how do you interact? So obviously the ILRs you can reprogram remotely, but you can't necessarily on for all things and for the other devices. So how do you interact with your people that are going to see the patient in the office to make sure that what you need to have adjusted or customized? How do we communicate that between the two clinics? So Pacemate has built a clinical notes section for us so that that's where we park all of that intraclinic communication. We get alerts for their undersensing, we're not going to bring the patient in for that at their next visit. The cardiac device specialist that's going to see that patient in their review is going to see the clinical notes sitting in there that say the remote desk saw this and it needs to be done at the next visit. After it's finished, it's wiped away and the patient is taken care of appropriately. But because we have that available to us, there's always good communication. Previously there was intermittent communication, it wasn't great. So this this is a huge step up. So it sounds like it's almost immediate. It is. As soon as you identify, you can send a message to your in-office. They're in the patient chart on the remote desk. So if they're in the Pacemate chart, they're just adding it right there. And when we see the patient, it's right there. If it's something that needs to be done prior to the next scheduled visit, then they're just going to tell us bring this patient in. Right, right. Yeah, that's a great communication piece that we didn't have previously. Uh-huh. Yeah, that sounds like it's quite effective. It is. So tell me a little bit about how you manage heart failure diagnostics then, right? So you know, we talked about that a little bit in our conversations about the difference between a therapeutic device like a pacemaker defibrillator, a diagnostic device like an ILR, and the devices also have the ability to give us information on heart failure. Yes. So you have that built-in communication within your device clinic, but how about heart failure? Like if you notice somebody's octavol is increased or whatever, you know, their heart logic, whatever, has changed, do you have a way of communicating to another clinic? We're working on integrating our heart failure teams with Pacemate. I know that they've been approached by Medtronic for their triage system, but that's setting them up for the piecemeal login, get the data, log out that we used to do. Right. What we want to do and we're discussing with our heart failure program is integrating with us. We don't want to put every patient into heart failure monitoring, especially if they're a primary prevention device for maybe brugada or long QT. But those patients who may have had an admission and maybe a second admission, those are patients that really should begin monitoring and we should be reviewing their information regularly and we need to send that to a specialist. Currently, if the patient is connected to our heart failure clinics, we'll send that information as a courtesy, but they don't get alerted to it through our system yet, but we're going to work on that. Stay tuned on that one, right, which is a great interdisciplinary approach to managing our patients and it works so hand in hand, right? New onset heart failure, new arrhythmias, AFib, VT, whatever, so it works definitely to obviously improve patient outcomes. Absolutely does. Maybe you can give us a little bit of an insight on how your alert burden was reduced, how it impacted your office, your clinic workflow. So after the first six months and having these meetings, face-to-face meetings with Pacemate, we were given helpful hints on how we can program, how we can make things better, a list of people who are deemed frequent flyers and these are the people that they may have AFib, we're going to do an ablation, we're going to start a medicine, but we haven't turned off those alerts yet, so they're coming every day. Pacemate's reviewing those every day. They're only sending us what we ask for, but they're looking at it every day. So we take this list of the frequent flyers, some of these are people that just push the button every day, twice a day. And how do you get that list? So Pacemate, is that part of your... We have it built into our analytics where we can look to see how many of those patients are there, how many they've sent in the last 30 days, and ironically a lot of them are 30 for 30 overachievers. Well there's always those patients that have the total misunderstanding no matter how many times you tell them you do not have to push that button to make transmission. But they don't miss a day. They don't miss a day. So we reach out to those patients if it's somebody that's a button pusher and explain to them we don't need to do that and the education piece usually eliminates that. And then we have the other group of people who may have VT or waiting for a spot for them to have an ablation when that gets taken care of the issues rectified. And for some of those people it's we have to change settings in the device. So we'll look to see their next visit, we'll make that note through the the clinical note section reminding the next cardiac device specialist please turn off this, turn on that to eliminate all those extra alerts. And the frequent flyer list we look at pretty regularly and try to get people involved in even if it's not your desk day to work on that. If you have extra time just log in, make a phone call, get them off the list. Do you find that there's one type of device? You know so we're dealing with ILRs again the therapeutic versus the diagnostic that is more work intensive, higher alert burden than another in your analytics. Without question it's the ILRs. It's either the symptom people or unfortunately undersensing or oversensing. So with those we'll bring them in to filter out noise to make it more or less sensitive based on the issue at hand. And for some of them they may be you know just those people that every palpitation they have they're pushing that button two and three times a day. And we explain to them that if you're feeling the same thing today that you felt yesterday and you sent it, don't send it again. We've looked at it and most of them will stop. There are those few holdouts but we try. Yeah that is very very labor intensive. So how about the true actionable events or alerts that you get? So how does the the clinical decision making pathways, how are they initiated? How are they? So we have one person that's still managing all of those remotes. First thing in the morning she comes in at 6 30 and she looks at all the red alerts and sends anything that's RVR, additional VT episodes, new AFib. Sends those to our nurse pool for the nurses to get with the patient, get with the physician and come up with a plan. So that's one set of one direction that those alerts move to. And the other direction is if it's somebody that needs reprogramming, we're undersensing, we're oversensing and it's leading to therapy or lack of therapy. Then she'll send it to the cardiac device specialist team and we'll just have admin reach out, get that patient in as quickly as we can to resolve the problem. And do you have like, I'm sorry, clinical pathways? So do you utilize, for example, an advanced practice provider who has, oh if it's nuanced at AFib, I'm going to do you know X, Y and Z, initiate anticoagulation, whatever? We do. We have several EP, APPs that are at all of our locations. So we can find a spot for some of those patients as early as today to get them managed appropriately. Great. You want to go through a little bit about how your... Alert burden reduction. So with all of those tools at our disposal, correcting our overall alert burden sheet or alert criteria sheet and programming pathways for patients, we've reduced our alert burden by 9%. That's an increase. But we've had an increase overall of 11% in our total devices. So we're adding more devices and having fewer transmissions and that is always the goal if you're managing patients remotely. You don't want to see noise, you don't want to see things that aren't going to help you. If it's not actionable, we don't want to see it. Unfortunately, Pacemate sees a lot of that and tell us, help us manage that patient appropriately so that we can fix that issue. So that the only things that are coming over to us are things that we have to act on. And that's what remote monitoring should look like. It's either good or it's not. It's binary. It shouldn't be the gray area in the middle or the noise in the middle. So tell me another question that I receive from a lot of people that are running remote monitoring is, how did you get administration to buy in? What is the process that you use? I hear so many of my colleagues saying, I put a plan together. I said, you know, if we followed our scheduling appropriately and have all of our patients appropriately on remote monitoring, that we could increase our revenue because we would be regularly billing and appropriately billing. And administration doesn't always seem to get it, even if you try to put the numbers down. Tell us how you were able to convince Piedmont administrators that this would be a great option for you all. Well, first of all, billing for remote monitoring was sporadic because the turnover and because we were so short-staffed on that remote desk because of all the noise in the background. Things weren't getting billed appropriately and we knew it and our physicians knew it. So that was part of the request. We also had a physician champion, Tom Dearing, to come in and say, yeah, these are things that need to be fixed and if we're going to run a real program, we have to have these things addressed. So a lot of it was, we weren't billing appropriately and missing a few things like that loop recorder with a 15-second pause. If you can't see it and you can't fix it, what are we doing? Right. So we had to make sure that all of it got shored up. So I don't think it was a tough sell for administration simply because they could see we were floundering in what needed to be done. We weren't billing appropriately. In fact, after we implemented Pacemate, we had a few patients come to us and say, I've never gotten a bill before when they'd had advice for two years. That in itself was an issue. So we had to tell them, great, you had two years of free service. I see a lot of people in the audience here shaking their heads. Yes. Right. Have had the same experience. Absolutely. And it's not different from any other clinic I worked or for people that come to us from other clinics where their clinics were running essentially a free service because they couldn't get everything together on time or they got frequent denials because of lack of appropriate intervals. So no, and I'm sure that's no fault to the clinic, the clinics that are, but I am sure that is happening now. And staffing has always been a big issue, right? A major component we know is an increased burden, but administration's not always willing to give you the numbers. And that was one of the motivating reasons why I was able to co-chair that document because I felt very strongly that we needed to have guidelines for staffing because whenever I went to administration, they would say, well, are there guidelines that tell you what the ratio should be staff to patient? So our writing committee worked very diligently to use the evidence that was available, which was limited, but there was evidence there to say that there should be three full-time equivalents for every 1,000 patients. So how does that impact you now that you are using a third party to? So having that third party monitor for us, we can effectively manage 14,000 patients with nine cardiac device specialists and two admin. So that need for three people for every 1,000, that math speaks for itself. And I will say that we made it clear in the document that you needed to incorporate the use of third party resources as part of that three to 1,000. So help us out here because I also have a lot of people saying, well, how do you incorporate that? You know, we also made it clear that you shouldn't use non-clinical as well as clinical staff to do some of the things that are not necessary for a clinical person to intervene on, like scheduling, calling patients for troubleshooting, which now PaceHeart has totally done for you. So how would you recommend if someone is looking to talk to their administrator about utilizing a third party resource, how it would impact them in staffing and, you know, the whole balance of revenue in reducing your staff, even though you're paying for a third party resource? I think there are three big points I would make if you're trying to sell your administration on outsourcing your remote monitoring. Number one, those patients can be monitored 24 hours a day. We can find things on those long weekends that we wouldn't catch until much later. Number two, the billing piece is entirely outsourced and you don't have to add admin people to oversee that piece. And number three, they're going to make those phone calls to patients for you so that we don't have to add more personnel to take care of that. And if we do hire personnel to talk to those patients, they have to understand what they're talking about. So finding the right people is crucial to a good program. They do that for us. Pacemate takes care of all of those things for us and we don't have to think about it ever. That is your sales pitch to your admin right there. Less people, they do a better job, and they do it all day and all night. You're just managing those patients that need to be addressed with an actionable, a true actionable alert because they filter out all the rest. So we found that they had made, I think we have numbers in here, they made over 25,000 patient calls on our behalf for patients who were disconnected, for patients who were late in sending, and for patients who needed troubleshooting to send a transmission that wasn't a scheduled transmission. They didn't know how to do a manual transmission with a machine. If those phone calls averaged only five minutes a piece, and I think most of them are probably more than five minutes if you speak to a patient on the phone, it's not a five minute phone call, they would have saved us over 2,100 hours over the last two years. That's half of an FTE. Wow. So they're doing that work that we would have done. And that's just the phone call work. Right, right. Yeah, that's, hey, you haven't sent today, or I, you know, get a text you need to send or whatever they, however they choose to be contacted. But as you and I think everybody else knows, when you're calling that patient and they don't answer and you're in that phone tag, it isn't a five minute phone call, it's five minutes here, it's five minutes there, it's another five minutes here. So it becomes something that's a distraction from your everyday work and if you get in touch with them today or tomorrow or next week, they're already late in sending and they might need additional help. So they've taken all that off the plate and that's, again, huge for us and huge for anybody that's trying to get a system in there that works. Tell me about your reporting as well. So we also have the document, our consensus document. What we suggest should be a comprehensive report. How do you communicate, you know, to your referring physician who's always asking, how come we didn't get a report for Mr. So and So from his last device check? And more importantly, right, how do patients get communicated about their device checks? I'm so glad you asked. Because we use Epic, we have MyChart, and it's a huge push for all of our patients to use MyChart. Every signed physician report shows up in their result. So they can see exactly what the report says and that way they're not guessing. I know I had a scheduled transmission today. I know I had sent something. How come I didn't hear anything? It's right there in MyChart. You can look at it. It's also helped us with that piece where, you know, you see those people that have paroxysmal AFib. Patients don't know what paroxysmal AFib is. They see it in their chart. They call us and they say, how come nobody called me about this? So we've incorporated into our post-op teaching. When you go in to get your results, you may see that there are arrhythmias or numbers or things that you don't quite... How do my impedance go from 800 to 550? Exactly. So for all of those patients, we explain to them that before that report gets there, your physician had to review it and had to sign it. So if he signed it and didn't think it was important enough to call you, then it's not something you should worry about. And we also tell them that if you do get a phone call, it's going to be before that issue results in your chart. We're not going to let you be surprised by something. There's a broken lead. They're not going to see that before they get a phone call. They're going to hear right away from a live person about any issues that are actionable. So they're very happy with that. So that's how they get their reporting. If they're not interested, we do have a declination in Epic where it shows they didn't want to be informed via my chart. And the referring physicians, how do you deal with the same thing? Do they... Most systems in Atlanta are on something that uses Care Everywhere. So all those... So they have access to looking at everything as well. So one of the other things that it was sort of a little controversial with the consensus document was the concept of alert based follow up. How do you think that would impact your current system? I don't know if people are familiar with what alert based follow up is. So it doesn't mean people are not taken off of remote monitoring. It means everybody is continuously on remote monitoring, but you don't do those very low yield quarterly follow ups that you're really just billing for, right? So you're doing the look and doing a bill so that you can get reimbursed. But the patient is still being watched and the document had suggested based on some of the evidence that patients really don't have to come into the office every 24 months for a pacemaker or even a defibrillator under certain circumstances, right? That they're very stable, that they're cooperative, they're very well connected. But it still means that you're continuously watching a patient or waiting for an alert for a patient is really what you're doing. And then you're having them come into the office for a routine check maybe once or twice or every one or two years. What are your thoughts on that? If it's a primary prevention device, ICD, and the patient's stable, we're just waiting and watching their device. It might be med management. And we do have some physicians that have elected to go 12 months between follow ups if the patient is connected, but only if the patient's connected. If patients have no remote monitoring, they're on a three month follow up. So what do you think are some of the other things that we would miss if we followed the alert base? I know some people feel that there are certain trends that are missed or if a patient had, in the course of not seeing them for a year, maybe undetected ventricular arrhythmias because it's below the detection rate, or they may not have had left ventricular capture in those patients with resynchronization devices. We get a lot of reports from Pacemate where, because they're reviewing so much, so often, where that presenting rhythm does show intermittent loss of LV capture. And a patient with heart failure, that could throw them right in. They also send us, you know, not that an impedance might be out of range, but that it's trending upwards. So that's important information. That needs to be seen regularly. The only weak link in the whole system is that moving part, and that's the lead. So if we're not watching it all the time, it can be normal at 500, also normal at 700. It can be normal at 900, but that trend is moving upward and it needs review. So those are the things that I think we really should stick with quarterly monitoring. Right. And a lot of people too are, you know, the whole reimbursement concept. If you don't create a bill and generate a report, then you won't get reimbursed. So under current circumstances, that's something that I think it's an interesting concept. And the reason why we put it in the document is first, is, you know, something to think about in the future. Now that we have AI as well, there may be built in mechanisms for seeing if a patient is, you know, on his way to getting a ventricular tachycardia or a new onset AFib just based on machine learning and AI. But that's to be continued is what I say, but an interesting concept. Okay. We have about 10 minutes left, so I'm going to go through. The audience has sent us up some questions. The first one is who covers the 24-7 remote issues? What is that workflow? I think you might've answered that by saying. Yeah. So when Pacemate reports that, it's a phone call to the on-call service. And the on-call service is an EPAPP or an EP where they can reach out to the patient and direct, we need you at the ER. We need you in the office tomorrow. We need, you know, they direct the care from there. So it has to be something that's very urgent. Maybe the patient got three shocks in a row, two failed and one final. We want to see that patient now. We don't want to wait until their next visit. Lead issues and patients who are dependent, they're going to make that phone call. Those patients need to come in right now. So we've been notified in our hospital system and they're very succinct about what the issue is and how it can affect the patient if it's not taken care of. So the person on the other end of the phone in our institution understands what the problem is and what needs to be done. And that's the benefit of having somebody watching that 24-7. Another question is, did you encounter any challenges integrating Pacemate into your electronic health records? So you use Epic. Do you have any understanding of other electronic health record systems and the ease of integration of Pacemate into that? Depending on your institution, your IT team may make things more difficult than it needs to be and that is our system. It was easier than at previous systems where we had integration of platforms. It didn't take as long as I thought it would and it seemed on Pacemate side that it was not too much trouble. So another question, I think this is now we've also come to the challenges of the newer personal digital wearing devices, right, for following AFib, Apple Watches, Cardea, Fitbit, whatever. And I'm hearing from a lot of remote monitoring clinics that that has now been incorporated into their management of data following. Does Pacemate have an option for including those patients that are using Apple Watches or Cardea for following their data as well? I don't know that, to be honest with you. So you don't have it in your system? We do have some patients that will send their information in if a physician says send it to me. But to my knowledge, no. Okay. One of the other questions here is, can you give us an average of how many hours you saved? I think we did say that. I think we and you actually translated the number of hours saved. That was just the phone calls. Okay. That was just the phone calls. So if it's actual personnel, we needed probably five people to effectively monitor on a daily basis during business hours. So we use one person now. So we've saved probably four and a half FTEs. Wow, that's a lot. Total. Right. Ongoing. Wow. So incorporating that into the calculation of three FTEs per 1,000, I mean, that is a significant contribution to that staff-to-patient ratio. And probably even more so than the three, obviously, three to 1,000. So that is a major impact. Let's see. This is an interesting one that says, when remote programming is available, for some, actually, ILRs, you can do that now. But I think that's another question that comes up with regular devices, therapeutic devices, as I call them. So will you allow PaceMate to do the reprogramming? So how would that work? I know it's not something that... But have you started to think about, if you could reprogram remotely, what would your workflow or your path for doing that, do you think, would be? I think, to be determined. If it were something as simple as we're seeing loss of capture, yeah, I think we would probably have a protocol where they can bump output up a little bit. If it were sensing, based on the measurements, yeah, I think we would probably have a protocol where they can bump output up a little bit. If it were sensing, based on the measurements, yeah, I think those are things that, in the future, might be something to look at. It saves the patient a visit, and they have an incredibly competent team that identifies issues for us now where we have to bring the patient in to make those reprogramming. So it's not out of the realm of possibility. Which brings me to another question, because we're talking about the whole credentialing and how good PaceMate has been as far as professionalism and being competent. The question is, do you audit them on a regular basis? I know you said that you do meet... Quarterly. It's quarterly, okay. Do you also look at just who it is that is doing your reading and what their individual credentials are as far as being maybe EB certified? So they have an all-certified staff. So that's pretty much blanket. We do have, from time to time, something that may be read a little differently than we would have read it. If we bring it to their attention, they'll usually say, okay, I can see it from that perspective. We'll change the report. And it's just a very quick, simple submission of an email. Another question is, is there a mobile app? So now electronic health records, right? I can here in Atlanta look at my patients up in White Plains, New York on my app. Is there an option for that with PaceMate for you now here at the meeting? Can you go back to your hotel room and open up your phone or your tablet and review the alerts? PaceMateLive.com. It's live. Amazing. So how does that work? I can log in from anything. Oh, because it's on the cloud and so that is the beauty. You can work anytime. And I know we're coming to the end. We only have a few more minutes remaining. I guess one of the big things, right, is that we know that PaceArt was acquired by PaceMate. Yes. So how do you think that's going to impact your practice and your relationship with PaceMate? Well, I think it's only going to make them better. They have more information. PaceArt had an incredibly long history. When I bought our first system, it was from Dr. Bergelson, their creator, out of the back of his station wagon at a meeting. And we went through all the changes. I moved from DOS to Windows with PaceArt and saw all the changes that they went through. They had some great things integrated into their platform. And I think PaceMate will probably utilize some of that long history and maybe pick and choose some of the things that their customers really appreciate from that system and hopefully they'll incorporate those into their current system. There are a lot of things that I think PaceArt stopped growing and changing a long time ago and PaceMate is leading the charge in growing and changing with your practice and with your needs. So that's why we've partnered with them and that's why we left PaceArt behind. We needed somebody that would make meaningful changes for us, that help us run our practice, that help us take care of our patients and do the things that need to be done. So I think it's going to be a win-win. They're going to get a lot of great information from that acquisition. Which is another question I have. We're always talking about allied professionals putting the data out there, evidence-based practice and publishing. So data in, can you get data out and use that data to then publish? Because I think here we're talking about how third-party resources... Absolutely. We have some analytics platforms built for our VT clinic. So for those patients that we're looking to ablate, we can just pick and choose that data, pull it out. It offers us a lot going into research. So we can identify those patients that have need for a specific therapy or might be right for a specific trial or a procedure or something. But with it available, we have a lot of information. And with the information, the sky's the limit. Yeah, and it would be great for, as we're saying here, so many questions that we've raised today that other clinics have talked about. So we would love for you to write an article that you could publish about the benefits of third-party resource. Specifically ones that can offer full help with your workflow in your clinic. I think that would be very beneficial. With that said, I think we've had a very wonderful, robust discussion today. Absolutely. Teresa, thank you so much for sharing your experience at Piedmont, a very large clinic. And I'd like to say thank you very much and signing off. Thank you all.

cardiac remote monitoring

Aileen Farrick

Teresa McElrath

Pacemate

Piedmont Healthcare

White Plains Hospital

data filtering

patient care

alert prioritization

remote cardiac monitoring

Piedmont Health Care System

electronic health records

heart failure

evidence-based staffing

real-time data review

clinical research