So, my name is Martha Ferrara, I am the Assistant Director of VP Services at White Plains Hospital and my, and I know this sounds trite, but my passion really is remote monitoring. So, I wanted to have you each introduce yourselves so that we know, you know, where we're starting the conversation. Hi, I'm Carissa Pastilli, I am the Nurse Practitioner at the Valley Health System in New Jersey and I work in the whole EP office, but I'm also the Device Clinic Supervisor for the last four years. Hi, I'm Rebecca Epasion, I am an EP Nurse Practitioner as well, formerly worked at Duke and Lifespan Health Systems, but now currently work at Cardiac RMS as Associate Manager of CID Operations. So, I also have a passion for remote monitoring. Hey, good morning, my name is Andy Winburn, I am a Product Manager at Merge right now. I've been with Merge for about four years, started out as a Customer Success Manager and before that worked for Medtronic for about 13 years as a Clinical Specialist and I'm also a Registered Nurse, so that's kind of how I got into doing this, but I too have a passion for remote monitoring and workflows. Hi, my name is Anne Croman, I am a Cardiac Electrophysiology attending at MUSC, Medical University of South Carolina in Charleston, South Carolina and I am in charge of our Cardiac Device Clinic, not just in Charleston, the mothership, but as we expand across the regional health network. I'm also the Physician Lead and Medical Director of our HERT Station, which is all of our ambulatory monitoring, all of our EKGs across our regional health network as well and I will second or fifth the opinion of everybody that devices and remote monitoring is also one of my big passions. Oh, that's fantastic, so this should be a pretty wonderful discussion on, you know, what we all just love to do and by all means, anyone who wants to ask a question, just send it on the Q&A question or step up to the mic, you know, this is a just pretty relaxed conversation. So, I wanted to just concentrate on several questions from the 2023 HRS Expert Consensus on the practical and I underline practical management of the remote monitoring clinic. So, we all know that the benefits of remote monitoring of cardiovascular implanted devices, including an impact on morbidity and mortality, so it's standard of care. We all know at this point, this is standard of care. We now need to write in our notes why we are not providing remote monitoring for patients. That's a shift because it's now a legal issue, right? It's standard of care. So, I wanted you each one to describe your clinic's current workflow and how you enroll patients in remote monitoring when they have an implanted device and for companies, for Merge and RMS, I wanted to know how do your companies assist us clinicians in this process? Carissa, if you can describe your clinic. Sure. So, we have, gosh, 7 or 8,000 remote monitoring patients and right now, we offer them the remote monitoring first at the hospital and, you know, of course, that conversation can get pretty lengthy, so that really just continues when we bring them in for the first wound check and at that point, I mean, we have really a lot of buy-in from our patients for remote monitoring and, like you said, it is the standard of care. It's not, you know, sometimes the conversation can be, this is an option for you and that's, you know, really shifted. Now it's not necessarily an option that we're offering you. It's really something that you should be doing, not only for your safety but the communication and we found it pretty successful just having that conversation several times from different modalities. So, like I said, at the hospital and then you get it, again, from the device techs and you get it from the providers and, you know, like I said, we've had a lot of buy-in from our patients. So, I can speak from a clinical perspective and then also from the industry side too. So, when I was at Duke, in particular, we started really pushing for remote monitoring back in 2017 and to get buy-in, we actually eliminated the device clinic and made device checks only with APPs and that limited the number of appointments. And so, you had to get remote monitoring, you had to get on board with remote monitoring because otherwise we wouldn't be able to check your device or you'd have to come into clinic every time for a check. And so, that actually became very effective and then it was extremely helpful because we already had it established when COVID really shut everything down. So, now at Cardiac RMS, the way we help is we try to filter out the noise, right? We filter out all the alerts that are not really alerts and we read those transmissions, we filter out the ones that you don't need to see, the ones that are false positives. And try to get only the patients you really need to see their transmissions in front of the clinicians that we serve. So, I think that's one of the biggest advantages for clinicians to use remote monitoring services or to have a department that really specializes in remote monitoring is to have people filter out the stuff that providers don't have time to look at. There's just not enough time to look at oversensing, there's not enough time to look at noise on an ILR. So, we help with that and we also help identify alerts management that needs to be changed. So, if we know somebody has AFib and they're anti-coagulated, do you really want an ILR transmission every single time or do you want one once a month? So, let me just focus the question. So, when Carissa has a patient with a device, whether implanted at the hospital or whether the patient wants to join the clinic, how do you know that this patient is now onboarded onto Carissa's clinic? How is that communication going on between your company and the clinicians? So, we actually use Merge software and so when a patient is enrolled, when a patient is enrolled, it comes through the vendor site and Merge picks those up and it directly enrolls them into Merge. So, they show up and there they are and that's how we start managing them. We don't have to have a team to call and get patients set up. We do have a whole team that does call and helps get disconnected monitors. We help, especially when we onboard new clinics, we help call and make sure we go through their vendor sites to help weed out deceased patients, inactive patients, patients that are no longer being followed. But thanks to the modern day remote monitoring companies and software platforms, a lot of that is automatic for us and so it helps so that we don't have to get a notification of a new patient. From a Merge perspective, yes, it is pretty easy to opt that patient into remote monitoring when they start sending their transmissions or if they're seen in the office. What we do a lot in onboarding to varying degrees with any clinic that we work with, there is that patient engagement piece. So, we're asking in workflows, like, what happens in the new implant process? How are you getting the patient engaged and opted in from the patient side? Not just clicking a button to say, hey, you're opted into remote monitoring in Merge. Just kind of getting that engagement, whether that's a consent, whether that's that multiple or iterations of engaging with the patient to say, this is how we monitor your device, to a signed agreement. This is how we do it. I work a lot on the heart failure side of things, heart failure remote monitoring, and patient engagement is huge because you're conceivably checking the patient's device more frequently. Patients have to be definitely engaged in that process, there's a collaboration there. So, we've seen it done in varying ways across the country with how clinics engage their patients. From a heart failure perspective, just specifically, giving the patient the option, we're going to do this, is that okay with you? They methodically opt that patient in. For others, it's more like, hey, this is how we do it. You have the indication, say, systolic heart failure, you have the device, this is how we do it at the clinic. And certainly, the patient can opt out, but it's more the exception rather than the rule that you're opting somebody out. And so, they're engaged that way. But it all starts with that patient contact, that dialogue with the patient to say, this is how we do it. I think this is a great discussion and a great question, and I'm going to kind of split it into two parts. When I took over at MUSC for the device clinic, I helped to transition us a large, you know, about 9,000 to 10,000 patients from a PACE-ART system to, we started to partner with PACE-MATE. And I think partnering with MERGE, PACE-MATE, different vendors like that is really crucial. That helped us organize and get a handle around, especially in these big referral centers. Some of our patients had, you know, been lost to us, but had transitioned back to whatever their primary practice was prior to them getting referred in for specialty kind of EP procedures. And that helped us start the conversation with patients to kind of, you know, say, okay, we're changing the way we do things. This is new. You know, this is now, even back then, you know, we knew that was heading towards being the standard of care overall for EP and getting patients on board with that. And now we partner with them every time, you know, our hospital system acquires a new clinic or a new hospital. We do the same whenever we start to onboard that clinic is to really start the foundation of communicating with the patient, patient engagement. They like communicating with both our clinical device team, as well as the PACE-MATE team. And that's been key for us. I think another important side certainly that we see in the Southeast and in South Carolina, that's also come up in a few other roundtables that I've been at and in a few conversations this meeting that I think is very important, is that we also have to be very cognizant and aware of some sort of disparities that we see in our population. And that's also an important point of conversation to have with patients is not everybody in our community has anywhere near the same access to technology. And we're talking about even mobile phones that are in flip phones, reliable landlines. And we, you know, as we move forward, you know, this fascinating and blistering pace in the technology and digital space, we can't leave our patients behind that don't have those economic technological resources. And that's going to be a very important point that we, you know, and we certainly are very aware of that, respectful of that, and do everything we can to go out of our way to try to still make that work for them. That's just an incredibly important point. Techquity, right? Techquity for all. That's a great word. I love that word. You know, what I was thinking as well, as you had brought up the term automatic, and you know, it's interesting because I think a lot of our patients have to understand that the remote monitoring really does make that automatic ring of communication there for them. But, you know, those patients who are not able to enroll in remote monitoring for whatever reason, you're right, we can't let that trip us up. We can't let that trip up their care as well. It is automatic for a lot of people, but we can't always be automatic. So Martha, this came up actually on a panel you were on yesterday, this concept of not everybody has access. Somebody mentioned a story about not having, they were unhoused and in a shelter and had a box that they needed to plug in, but they were worried about it being stolen. I actually had a patient when I was in practice who got an ILR because that was what you do when somebody had his particular condition, and the monitor that he had was one of the more cell phone type monitors, and he had his monitor stolen at his shelter. He was unhoused, had it stolen because it looked like a cell phone. And so he had to come into clinic on a regular basis to have his ILR checked while we looked for things. He was having unexplained syncope. So I think the one thing that has to be taken into consideration for the health tech equity is making sure that we're selecting the right solution for the right patient population. So had he been maybe better screened and they realized he was unhoused and that having a cell phone type device wasn't really feasible for him, maybe that particular type of ILR or an ILR at all was not necessarily the best choice. So I think choosing the right patients who have the access to make sure that remote monitoring is the best solution for them, that is something that still does need to be taken into consideration. I agree 100% with that, and I'm going to change the format a little bit because questions are coming in that are important to the question we're discussing. So how do you, and I'm going to address this question to the Merge and RMS, how do you protect your remote monitoring data either from cyber attacks or general misuse? How big a concern is cybersecurity? Oh, that is a fantastic question. I can take a stab at that real quick. SOC 2 certification is one of the big things that we pride ourselves on and basically as a standard of security. Any clinic that we, or healthcare system that we sign on or that signs on with Merge, there is a security vetting process that is undertaken, very intense security documentation, proof that we are secure and all that, so I'd say that's kind of the main step that we go through if we're signing on a clinic, and then we have those security standards in place indefinitely. And so at Cardiac RMS, we use Merge, so we automatically have that guarantee, and then we also, SOC 2 certification, we actually just did our SOC 2 recertification, just finished it, but then beyond that, we only allow employees to use our laptops that we issue that are monitored by a security service, they're encrypted, they do regular audits on them to make sure that every software update is there, any sort of security updates is installed, they can push updates to our laptops, and they do audits to make sure that we are in fact using our work laptops regularly. So if somebody is clocking in and doing work every day, but their laptop is inactive, then we know they're not using, and so we have those measures in place to make sure that we're doing that, that we're using secure, encrypted, monitored devices to read remote transmissions and protect our patient privacy. Super important, what I hear here, for me anyway, is very, it's crucial, the communication between clinicians and whatever agency, whatever platform we're using. So the next question I have is actually one of my passions, and I get demanding on answers from companies, because I also use a third-party platform, and they are my off-site remote monitoring team, they definitely know that they're my remote monitoring team. So we all know that connectivity is the Achilles heel of remote monitoring. So the question that I have, Carissa, so what is, what is your, the size of your clinic, but more importantly, what is the connectivity rate of your clinic population, and for Merge and RMS, I want to know, how are these companies reporting to you, the clinician, what their connectivity rate is, and for me, anything under, below 95% connectivity, they're not doing a good job. So I hold my remote monitoring team that's off-site absolutely on point for that. So I'm not sure about the exact number of our connectivity rate, but we do have a lot of systems in place to make sure that our patients are connected. So we use our remote monitoring platform to, you know, to make reports of those patients, and then they are called by our third-party remote monitoring services, and then our in-house device techs, they're, you know, getting those lists, we're getting patients into the clinic to make sure that they are reconnected. I know that we have a pretty high number for connectivity. That's also something that we've recently added to our reports to make sure that everybody knows what the connectivity is, and to sort of identify those patients who are having a more difficult time for whatever reason, and, you know, I think the conversation really is just it needs to be had at every level of the visit, at every visit, to make sure even if you have 100% connectivity, that person might not understand that they do, that we're very happy that they do, but it needs to continue, or, of course, those people who are not connected and need help getting reconnected. Yeah, that's another one of my big points as well. So yes, we run, I believe, especially for, you know, our Charleston kind of main central campus that we've got up and running around 98%, and we are very also very diligent with Pacemate and as well as our device team in keeping track of those people, making sure that they don't just drop off after several, you know, issues, and we know, and we always talk about with patients at clinic, you know, we say, hey, look, you know, we want you to go spend, you know, two months in Europe, you know, either take your thing or just let us know. If you're going away, just let us know. We make it very easy for them. We constantly have that conversation, and again, that goes back to patient communication, just really keeping those lines open, and we've seen that having, you know, the third party vendors involved has really made a huge difference whenever we take over clinics and start to do that. You know, we'll see connectivity rates that are pretty kind of abysmal and scary once we actually start looking at the data, and then find that before that, too, a lot of people don't realize what the connectivity percentages are. Until you really have a way and a dashboard to follow it, it can get frightening of how many people have just been lost, dropped off, or what the actual connectivity is, yeah. I really like your point about kind of encouragement and letting the patients know. I think that's a big thing. From our perspective at Merge, it can kind of take some different angles. We do have reporting of patients missing transmission reports, things like that, and we're actually iterating on that to actually with the manufacturers to hopefully get ways that we get more of a direct feed of that status of connectivity. That's kind of hopefully in the future, but if you take it from our services line who can help clinics like Cardiac RNS does for short periods of time, they can help with that connectivity status using those same tools that are in Merge through analytics. But it is interesting that it varies from clinic to clinic. I think of one specific clinic out in Oklahoma that I launched, 10,000 patient clinic, and they had their own specific logistics team only responsible for scheduling monitor connectivity. They're constantly calling the patients. Their compliance rate on their analytics was I think like 95, 98% for what that clinic wanted to monitor the standard of care. Really awesome to see. But then you go to other clinics and you look at their disconnected monitor status and you're like, oh wow, you got a lot. You got patients who haven't transmitted since 2016, 2017. I mean, that's eye-opening too. One thing that we do if a clinic isn't using our services, we do have our optimization team that will go in periodically, like once every six months, maybe 12 months. It's our account management team that kind of makes contact with the clinic. Hey, here's how you're doing. This is what we're seeing. How can we help you to make this better? And one of that is going to be the disconnected status. Okay, who do you have, and I know it's a heavy lift, but who do you have calling the patients? How are you handling this? These patients here that we see in the websites haven't transmitted since 2017. What can we do with those to kind of clean up everything and overall help your clinic kind of get back on the right track in that regard? And you call the clinic every six months on the connectivity rates? Not connectivity specifically, but we call it, it's our account management team that we go in and basically it's one of our teams that touches base with the clinic and kind of a check-in. Say, hey, here's how you're doing. Here's what we see from your eMERGE account. How can we help you make it to improve? Whether that's compliance score, whether that's not helping directly with disconnected monitors, but providing support, ideas, things like that, things that we've seen in other clinics that have had success with managing disconnected monitors, things like that. So that's kind of the angle we take without being directly involved with picking up the phone and calling the patients. So at Cardiac RMS, we actually have an entire team called the patient engagement specialists. And so whenever we bring on a new clinic, they are responsible for disconnected monitors. They call patients and they will make sure that those monitors are connected. I think we have a policy of calling at least three times to try to get them connected. When we onboard, we also set up regular check-ins with the clinic to show how the progress is going with, this is how many you started with, this is where you are now. We do a six-month optimization and then we go to yearly optimization meetings with the clinics to report. These were your stats last year. These are your stats this year. I would say with our connectivity rate on average between all of the clinics that we manage, which I think is over 50,000 patients now, is a 97% connectivity rate. And so we agree 95% is our worst-case scenario in our minds. But we have seen clinics that come on board with less than 50% connectivity rate and we can get them up to a 97% connectivity rate. So what I hear, which is what we've talked about for, you know, years. I mean, I'm in this space for almost 20 years. It's a team effort, right? Remote monitoring is a team effort. And it falls on us and not the patients to remain connected. The education that they need, it stems from us. I think that one of the nuggets that came out of the 2023 expert consensus and the practical, see, I love the fact that they included that word in that title, the practical management of device clinic was staff ratios. You know, in my mind, remote monitoring is not a cash register. It's a science and it's patient care. And we just happen to be in that technological space. So with staff ratios, I'm happy to report that my remote monitoring team follows very closely the ratios that were provided in the 2023 guidelines. And we can stand on that number now, at least, for administration to look at what we're doing. So could you share, Carissa, could you share your staff ratios in your remote monitoring clinic? And what are some of the aids that your companies provide to, you know, meet that standard? So right now we have four device techs and are a device RN and a dedicated device nurse practitioner, which is me. And but the whole team, you know, obviously remote monitoring is done by the whole team. The response to the remote monitoring is done by the whole team. And and then we have our third party remote monitoring team who's doing, you know, the alerts and whatnot. So, you know, trying to really just get ourselves up to those ratios and making sure that everybody has the right protocols in place so that we can even if we're not at that ratio, we have the tools that we need to, you know, provide the best patient care. It can be very difficult, obviously, when we have that deluge of information all the time to even use those ratios correctly. But I mean, right now it's it's really about putting everybody in their silos and making sure that we're all still working together appropriately. Yeah. So for, you know, our main Charleston campus, we have I think six device RNs. We're hiring additional people. We have some support staff who work kind of at the administration side of the device clinic. And then we have our pacemate remote monitoring team, which we I also in particular, but we really consider them are part of our team as well and are constantly talking with them throughout the day, too. So they're they're really part of us as well. We know them all well. And that really helps that that's really kind of changed our workflow, changed everything, changed the culture of our device clinic, you know, because before we found out it took 32 clicks to get a remote into Epic for our device nurses. And, you know, some of you would have to spend just just the majority of all day doing that. And now, you know, it's changed to where we our pacemate team does that. And then they're talking with us through the day. We're always logged in on dashboards. And then our device nurses, which is what they love to do, which is take care of patients, see patients, talk to patients. You know, we've sort of shifted and repurpose people to that. So it's it's it's a group it's a group effort. And I think it's been really helpful to have that 24 seven remote monitoring team that we have in place. And then our kind of our boots on the ground clinic team, which is is, you know, we all do what they get to do, what they love and see patients every day. I love the fact that you you know, you talk about things that are just natural to me now, like. Culture, that remote monitoring clinic culture, it really, truly is a culture. Nobody understands what we do when we say, you know, it took me 32 clicks to do that. So that is like you look at the person that says that to you and you're like aghast 32. So that is absolutely a culture that we do. So how do how do RMS how does merge help with with, you know, bringing up that third party vendor that's off site to be participant in that culture? Yeah, great, great question. And it is one of my favorite things, too, especially like the common theme of having a team one, the the chat within the merge platform where you're going to get someone to not necessarily help you clinically, but help you operationally using the platform, things like that, that is real time and you're going to get a real person, part of the customer success team. That's one of the front lines. But the platform itself, when we're minimizing those clicks and we when we implement merge and you have staffing ratios at a certain point at that time and over the course of, we'll say, two, three, six months as the as the clinic gets used to the merge workflow and sees the efficiencies there, that they're focusing more on the clinical rather than the administrative and the clicks and the automation that comes with that, like the billing automation and not having a schedule, not having to create appointments, all that stuff. You really get an idea of where your staffing ratios really are, and maybe you can still use the same staffing ratios that you have. And maybe you don't need as much. Maybe you need more. But you really get a good baseline of what you're truly there to do. You're not there to do administrative work. You're there to be a nurse and to be helpful to the patient. And that's been very satisfying for me as a nurse, being able to see that change happening in clinics. As time goes on, and say, I'll bring up our account management team again, when they come in and they're looking at things like staffing ratios and talking to the clinic about that. Where might we go from here? What do you think we might need? That sort of thing. They're having those kind of conversations, but I would also bring it back to the analytics that comes with, we'll say merge or any of these systems, that you could see the volume of transmissions you're handling, who's handling them, how long it's taking to do, all that breakdown. And we actually have tools now in dashboards that can give insight to what those forecasted transmission volumes and things like that, how that might affect your staffing ratio. And what we're looking at in terms of the amount of staff you have now, what they're handling, what your forecast is to potentially see in the future, what you might need, and it helps those clinics to have that conversation with administration, say, hey, I need these people and here's why. I'm handling a thousand transmissions a week and I have two people doing it, or whatever that ratio might be and whatever's gonna be the best for the clinic. But having those analytics has been very, very helpful. So a lot of my job at Cardiac RMS is people management. I have, I think, about 30 direct reports that all read remotes. And so I'm in a lot of meetings, weekly meetings, that we evaluate upcoming potential implementations and onboarding and how many patients that clinic has. And based on that information, we try to staff in advance, right? So we don't wait until the clinic is on board and then realize, oh, we just bogged down my staff, that we just added 5,000 more patients to their workload. So, and patients does not equal transmissions. We all know that, right? One patient might account for 100 transmissions a month. So we look at that. So we also have monthly audits of staff to see how many transmissions are they processing every month. We use the analytic tools within the software platform to see how many transmissions are they processing a month, not only to help them improve, but also to then we have a whole spreadsheet built out to determine based on the clinics we have, how many transmissions we're receiving, are we staffed appropriately? So we do that on a monthly basis as well to make sure that we haven't overburdened our staff because, oh, this clinic wasn't doing heart failure. Now they are, oh, that's different than just getting transmissions 91 days. Now that's 31 days. And so we look at that stuff on a very regular basis but like I said, we meet with the implementation and onboarding teams weekly just to make sure that we know what's coming down the, you know, what's in the pipeline and the anticipated onboarding date. And we know that, oh, that's gonna require X many more employees. And so we then start that hiring process right then. So it's a long, long way from where I started, you know, sitting at this table talking about so many things that were on the wishlist, you know, 15 years ago. So from the audience, I know that there's some nurses here. Do you all use a third-party vendor doing your remote monitoring work or? Okay, so my question, so my question to be seen is I love the fact that you ladies are here because you wanna know. Because you want to do better for your patients. So we have been in this space, you know, I'm, golly, 20 years. And so what would we say to these allied professionals that are here to get the knowledge that we have, you know, gathered for the past, at least me, for 20 years? I keep saying the same joke, but you know, I used to be taller, prettier, and skinnier before remote monitoring. It's just really intensive work. So what would we say to these allied professionals that want to know how they do this work better, but they don't have access to a platform, a third-party vendor? Carissa. Well, that's a tough question, Martha. It is a tough question. I mean, if you don't have a third-party vendor, it's gonna be just a lot of education and making sure that your staff is not being bogged down. And I know that you know that firsthand. It's a lot of education for the patients to make sure that they're not over-sending things. And, you know, you don't want people to be sending those hundred transmissions when, you know, that it's really not necessary. And I think a lot of it really is just based on education and making sure that we all know what the most important things are, that from a staff perspective, you're trying to tell the patients, and then vice versa, you know, what are we learning from our patients that's important from them that you can look for that is maybe not being handled by a third party? Yeah, and so I would encourage everybody to keep being interested, engaging in this conversation if you don't have that, and engage with your physician lead and your medical director. And, you know, when I took over the medical director for the clinic, that was also something I was passionate about. And it was a fight. So it was an extensive, you know, probably a year and a half battle with administration for me to get this changed and get it. And that's how I know how many clicks, because I did it and counted the clicks. And then I counted how many people per clicks per day. I did a whole PowerPoint presentation on the clicks. I did a whole, and the way I finally, you know, we started that tactic first, and then I added in the patient safety and quality aspect too to our administration. And, you know, I have some horrifying but fabulous ILR tracings of just, you know, huge pauses overnight. You know, a farmer who was out early in the morning, it wasn't overnight for him, but it was about 4.30 in the morning on the roof of his barn. Unfortunately, he's fine. He's a great pacemaker now. He's doing fabulous. But, you know, that wasn't seen until, yep, you know, it was early Saturday morning on a holiday weekend, and that's what happens. And that, it's not only the cost, the efficiency, standard of care, but it's that patient quality and safety. And that's what really forced the hospital system to start to say, okay, well, yes, this is gonna, they're gonna have to write the check for this. Ultimately, you know, by increasing the connectivity rate, the billing ratio, it's a win for them, but it was, you know, it's expensive for the hospital system to do at first and to change that. But that's the way, it's a fight, but you have to just not give up. And that's probably 20 years. That one sentence is 20 years for whatever that's worth to you. It really just comes down to patient safety because it is going to be more expensive for that healthcare organization to write that million dollar check when a patient has a terrible event outcome. And there's only one person doing that remote monitoring. There's just so much you ladies can do. So I would like to know from you ladies, I would like to know, what would you want to hear from us that takes some of those pain points away now? And I wanna hear from like RMS and Merge, like are you publishing agnostic workflows as to how to improve remote monitoring for clinics that don't have a third-party vendor? I think that would be so fantastic for clinicians that don't have platforms like yours. We are not, but that is a great suggestion. I love that suggestion. To get back to that question, and I definitely would like to hear from you guys. A couple of things that pop in my head for someone who doesn't have Merge or a third-party aggregator, alert management, making sure the alerts are dialed in in the websites, making sure that you have that patient engagement first and foremost, as much as you possibly can, using your reps, obviously, and I'm probably just preaching the choir here, but just kind of things that are popping in my head along those lines. One thing that kind of flipped the switch for me in terms of some of the administrative work, and I don't know how this translates outside of a third-party system, but looking at remote monitoring as a service you're providing to your patient. And when you translate that into billing, it's not as we've all kind of been brought up in the remote monitoring world, at least to some point, getting that transmission in on the 90th day and just moving heaven and earth to try and get that transmission on the 90th day. That's not what it's about. It's about providing that 91 or 31-day period of service to the patient, and if there's a way that you can monitor that outside of a third-party system, I think that at least takes a little bit of that burden off of being able to say, hey, I've gotten that transmission here. It didn't come in on the exact 90th day, but I've gotten the transmission maybe a couple of days ago. I can use that to support my billing, and I don't have to call the patients, hey, don't forget to push your button. It's the 90th day or 91st day. Things like that, I think, were really helpful to me when I started to understand that this is a serviceable period, not just that one transmission on the last day. So let me speak to the clinical question first, because at Duke, they do not use a third party. They have a platform, but they still perform their own remote monitoring. They've actually changed. I was talking with them last night. So they're part of PaceMate. No, they're part of PaceMate, but they don't utilize a third-party company to do the reading for them. They have their own team that they employ that does the reading. But what I'd like our, especially our allied professionals to know is that an unhappy nurse, an unhappy APP makes for an unhappy electrophysiologist. I think Dr. Croman would agree with me on that, is if you have unhappy staff, it makes for unhappy attendings. And so instead of there only being one squeaky wheel, everyone needs to be that squeaky wheel. We need more. This is about our patients. We need more. And what I found, at least the culture again at Duke, was if nurses, if allied professionals are complaining, we need to do something because they are on the very frontline of all of this. And they're the ones doing all those clicks. And they're the ones that are, they're doing, so as many clicks as it takes a physician, it takes our device techs and our device nurses who are reading even more clicks just to get that report into a legible format for a provider to read and then do 32 more clicks to do it, right? So- No, the 32 clicks was for my device nurses to get it in the center. I'm surprised it was only 32. I've used platforms that are many more than 32. But advocating for your patients, and that's what allies are best at doing, I think, is advocating for patients. So being that constant advocate, again, you can call it a squeaky wheel. I call it a patient advocate. But making nurses, making allies happy makes happy electrophysiologists and makes her happy EP department. So I think that to me would be my biggest advice as far as how do you make change happen? Because nurses administration, we all know, they don't listen to allies, but they will listen to EPs and they will listen to physicians. And so having the physician advocate, letting them know the pain points, I think is really important. So what I hear here is that you have to have a physician champion. You have to have an ally professional champion. So I understand about the squeaky wheel and I understand about that and I understand about patient care, but I'm gonna tell you ladies, from 20 years I'm a nurse, 41 years, longer than I'm married. So what I can tell you from all those years in this space is stand up and speak up and speak up with data. Don't just speak up because it doesn't work from personal experience. Have your data ready because patients do matter. And I can tell you that this is the line I walk into any organizations I go into. If you have a device, you wanna be in my clinic. It's incredibly powerful because it means you care. So we only have a minute. Who does the alert management and reprogramming in your clinic? So as far as like changing alert settings, so yeah, again, it's a team effort between our device nurses, pacemate. Sometimes the pacemate will say, hey, we've noticed that, for example, so post-ablation period, AF ablation, we'll change the alert, say we want to now know of every single episode in there. They'll say, hey, oh, because they two-way interface with Epic. They'll be like, oh, okay, so now we're past that period. Can we descale these things? And we say, oh, yeah, yeah. So I think it's that constant communication and it's sort of just that two-way conversation where they say, oh, hey, we noticed that this came in Epic that the patient now had a watchman and they're far up from that. Can we change this setting? Yeah, so it's just that constant knowing the patient, being the team. I think that the two-way integration with Epic helps them and then helps us and it's just that constant talk between everything, yeah. So we also, obviously, there's a big team effort in the alert criteria and making sure that we have the correct criteria for each one of our different groups of patients, but we were having a conversation about this just yesterday and just attending these types of events and getting input from different teams, knowing sort of what's working for you and at your different numbers than what we have is really important. So no matter what the team, it's always important to look outside of your team and make sure that you're getting all those best guidelines and all that knowledge that's really just up and coming. We have about 30 seconds. We do the same thing. We, when we recognize that someone is alerting frequently, we offer recommendations, consider doing this, consider changing these settings or we ask permission to change settings, especially if with the newer devices that can be reprogrammed remotely, we ask permission if we can do that. We try to be advocates just as much, again, because our ultimate goal is stop putting the patients that you don't need to see in front of you and only put the patients you do need to see in front of you. I would say from our perspective with workflows and clinics we work with, I would say alert protocols that clinics will do in their onboarding process and how they're gonna manage the alerts, but then using a tool like Merge to help filter out that noise, whether you're changing the triage color from a yellow to a red based on the protocol and that arrives on the provider's desk and they're able to filter that out right away, say, here are all my red alerts, I'm looking at those first and then kind of go down the line from red, yellow and green Thank you so, so very much for being part of this panel, much appreciate your attendance and if you have any questions, these are the experts.

remote monitoring

cardiovascular devices

connectivity rate

patient engagement

cybersecurity

clinic workflows

third-party vendors

continuous patient care