Well, welcome, everyone. Thank you for those who have held out the last session of the last day of HRX 2024. It's been a great meeting so far. And today our discussion is going to be on the new horizon of remote monitoring. My name is Aileen Farrick. I'm a nurse practitioner from White Plains, New York, White Plains Hospital. I am here with a distinguished group of panelists. I was privileged to co-chair the writing committee for the 2023 document on the practical management of remote device clinic, which was published last September. And some of our panelists were part of my writing committee. So I'm just going to go down the line, if you wouldn't mind just introducing yourself and where you're from. Good afternoon. I'm Dheeraj Verma. I'm a cardiac electrophysiologist at the Cleveland Clinic. Good afternoon. My name is Arati Dalal. I'm a pediatric electrophysiologist at Vanderbilt University in Nashville, Tennessee. Good afternoon. I'm Camille Frazier-Mills. I'm one of the electrophysiologists, adult, sorry, at Duke University Medical Center. And I'm Amy Tucker. I am the nurse manager of the Cardiac Device Clinic at Sanger Heart and Vascular Institute in Charlotte, North Carolina. Hi. I'm Janet Han. I'm a cardiac electrophysiologist by trade. And I'm at the VA Greater Los Angeles Healthcare System. And I run the CIED clinics and digital devices for the Arrhythmia Center. Okay. So I just want to remind the audience that they can go to, you know, our session here and the question and answer section. We'd like this to be an interactive discussion. I want to start by saying, yes, we wrote the 2023 documents that sort of re-established that remote monitoring is standard of care. It was an international document. It included the Latin American, the Asian Pacific, and the European Heart Rhythm Societies. And it covered a number of topics, but it also raised a lot of questions. And so I'm hoping to have some of those discussions today. I think I'll direct the first question to Janet. Thanks, Aileen. To get the discussion going. So connectivity was hallmark, is hallmark to remote monitoring. If people are not connected, you're not going to have an effective remote monitoring clinic. So my question is, what new measures or new techniques do you see on the horizon that may help our clinics maintain adherence to connectivity? And what do you think the role of industry should be in that? That's two questions. Oh, sorry. I have a backup. Three questions. So yeah, that's a hard one, right? Because I think connectivity has been sort of the bane of our existence. Outside of obviously like data overload, that's like the big other mountain that we have had to surmount. But connectivity, I always think of it as like, look, if you're not connected, the data never gets there, and then the patient never benefits. So that's like your first hurdle. You've got to overcome that hurdle first. So you asked me what's kind of out on the horizon. I think in my own wish list, first, I know that already there are multiple patient apps that are out there with each company that will tell the patient whether or not they are connected. So I think that's the first step. If you can get your patients on some kind of smartphone or something like that, that's helpful. Obviously, the little light on the monitor will help if they notice it, right? And if they understand what it means. So there's a lot of education that's behind that. But I think on the wish list on the horizon, what I would love to see is you ask if industry should take a stand in that or take some kind of onus in that. I think so. I think they have made the devices. They should take some onus in that and the owner should lay some, you know, somewhat on them in as far as to create some kind of ability to be able to let their patients know quickly that they're disconnected, but also let us know that they're disconnected in some way that's universal, right? And maybe agnostic to whatever system that we're using, whether I'm in the VA and I'm using the VA system or whether you're in private practice or in an academic institution, it has to be able to be easily seen and universal so that we can get that data from our patients so that they benefit. Just to add. I mean, so I agree with Janet completely. And I also think part of that is when you do realize you're disconnected, making it easy to sort of troubleshoot that, right? Absolutely. Being able to call a single number and make it easy, whether it's my 16 year old patient or an 80 year old patient, right? Who is trying to, who does not like staying on hold or can't sort of, you know, can't hear, so is unsure what to do. So making that part of it also really easy. Yeah, I think it's repeated patient education, right? And so that patients know where to look and how to stay engaged with the remote monitoring and then having a system in place when you see patients on your disconnected list, that you have a protocol in your system in order to address that. And so you have people to allocate it, but then going to reach out to the patients and tell them how they need to get connected. Whether you're sending them MyChart messages or you're calling them directly or somehow engaging the patient, the family member, whoever's the responsible party for that patient in order to try to really improve that connectivity. I think there's a lot to be said too for giving positive reinforcement. Every time you touch a patient, it's an opportunity to educate. And when I talk to a patient on the phone, it's, hey, your monitor is perfect. Leave it right where it is. Keep it connected like it is. A hundred percent. I think there's a lot to be said to that too. Like every time we see a patient, the first words that come out of my technician when they are hooking up the patient is, your remote monitor is a hundred percent connected. Congratulations. Such a great job. Right. And that's positive reinforcement for sure is helpful. So backtracking though. So when you are having a discussion with patients about what device that you are going to implant, is that part of the shared decision making process? Do you talk about remote monitoring and the options and what they're most comfortable with? I think it's important to think about what options they have and what their connection is. And so whether or not you need to use something that's more land-based versus someone who's going to use the app system. And then making sure that when we're talking about implanting device, it's not just implanting the device and how it's functioning, but how we're receiving the information. And so I think that definitely should be a part of the pre-conversation that you're having before implant. I think that sets expectations a little bit, right? I use the sort of saying that once I put a device for you, we are married, right? Like you're kind of married. So you have me forever, I have you forever for at least a lifetime of your device. And that part of that marriage is using remote monitoring so that can keep you safe, right? And keep you healthy and keep that relationship going. I also sort of tell them to, I take an assessment of what their sort of digital literacy is right off the bat to show them a monitor. And then perhaps even say, do you have a smartphone and pull it out? And what can you do on your smartphone? So that I can sort of understand, do I even approach them with like a smartphone-based remote monitoring option? I was just going to add when I, prior to implant, I sort of will offer them their two choices. And then right after it's put in, I make sure that we either have, we were ready to mail out the home-based device or if they're already connected via their phone before they get to charge that next day. So it's, before I put it in, I know what kind of monitoring they're going to be establishing. Great points. Yeah, no, I completely agree with those comments. I think it's very important to identify what kind of remote monitoring system and therefore device is best suited for that patient before the implant. And often for elderly people or people with difficulty with eyesight, hearing, it's very important to have a completely automatic system. The less they have to operate, the better. So that is very important. It may not be so portable, but nevertheless, if it's very, very secure in its connectivity and only one on-off button, it's most likely to work very, very well. I also say to patients that remote monitoring is forever, and I also explain to them why we need it because often they don't understand that. And it gives us continuous connection and we can identify problems as soon as they occur. So once we give them some explanation, then the patients are more invested in maintaining their remote monitoring connection and they will watch it. Otherwise, they'll think of it as a curiosity, as a toy, and they won't pay attention to it. So talking about connectivity and, you know, the importance of that, my next question is directed towards you, Neeraj, as far as alert-based follow-up. That was part of the documents as a recommendation, but sort of generated a lot of questions. And I know you've published a lot on this, and this is something that is close to your heart. No pun intended. So I'm wondering if you can explain to our participants here today what your vision is of alert-based, you know, follow-up and how you see it working. Yes, thank you for that. So to endorse Janet's point earlier, once we've implanted a device, we've initiated a contract with a patient, and it's forever. And we have to follow that patient and their device. And historically, we have brought in patients every three months with an ICD for face-to-face interrogation, and that's been the model. And the way we practice remote monitoring now is to replace some of those three-monthly calendar-based checks with remote interrogations, which gives us the same data. So this has worked out very well, and it is equivalent to or superior to conventional in-person follow-up. And of course, with remote monitoring, we add continuous connectivity, so problems are identified as and when they occur. Now, historically, the basis for three-monthly checks of an ICD were related to manual capacitor reforms. Now, we're talking about 34 years ago. So that's the basis of the three-monthly check. Now, of course, we don't need to do that with ICDs. They manage themselves very, very well. And if a problem should occur, it's not going to occur on that calendar-specified date when they come to your clinic or have their remote interrogation. It's going to happen in between. And that's what we need to find out about it, and hence the importance of continuous monitoring and alerts that are transmitted by the device within 24 hours of that critical event happening, even if the patient is asymptomatic, for instance, lead fracture. So the value of the follow-up interaction after the device implant really relates to the identification of a problem, which is best transmitted by an alert. So why not simply go to alert-based care? This does not mean that we abandon our patients. We're managing the entire cohort of patients in whom we've implanted devices. They're under continuous surveillance. But we will bring in immediately sometimes the patients who flag a critical event on the basis of their alert. And when we've measured it, the three-monthly routine interrogation, whether remote or in person, has an actionability of less than 10 percent, about 5 percent. So 95 percent of those interrogations are non-actionable, whereas alerts generate actionable work. And they're unscheduled. And as we know, unscheduled care consumes a lot of resources, a lot of time. It becomes very difficult to manage in a busy clinic. They're all understaffed. But that is where the important work is done. So what we have suggested is why not shift from work that is predominantly routine, calendar-based follow-up, which is non-actionable, to alert-based care, where we deliver more meaningful therapy. And that way, we can deploy our limited resources to the work that needs to be done. So I think we have shown, not only in trials in the U.S., but also in Europe and in Japan, that this works. It is safe. It is effective. And it consumes far fewer device clinic resources. Any of the other panelists want to comment? I think we have to remember that this is predicate upon patients being connected. Absolutely. Absolutely. Without connectivity, the system will become dangerous. And that's fantastic to think about, alert-based monitoring. I do just want to mention that I've been in remote monitoring a long time. We started our clinic at Sanger in 2005. And my concern with alert-based monitoring is that I have prevented quite a few catastrophic events just by watching trends with routine scheduled remotes and getting to the patients before their RV lead impedance hit an alert state in a dependent patient. And I'm interested in the panel's thoughts about that. And no, it doesn't happen very often, but it has happened in the past where we have prevented those events with routine schedule. Or how about slower rate ventricular arrhythmias that are below the alert? Below the monitor zone. Yeah, I think to Neeraj's point, it's that you're still surveilling your patients. It's not like you're not watching them. It's just you're not bringing them in, right? That's how I kind of understand it as well, is that we're watching our patients, we're watching those trends as we are allowed to watch, that we have enough workforce to be able to do that. But we don't bring the patient in queue three months face-to-face to sort of, I don't want to say waste resource, but to take up resources from someone who may need it more, right? So I would say, I'm still watching trends. I watch them like a hawk, right? But we may not bring a pacemaker patient in, but every two years now, because now I have a two-way indication to do that, right? But the trends is very important. I mean, I gave the example of a lead fracture, which is obviously a critical event. It'll send a red alert in any system, and we'll see the patient immediately. But many changes occur in a much more nuanced fashion, and they will shift trends. But we can create alerts to pick up on those trends that are going in the wrong direction. So you can create an alert for that scenario, yeah? It's not a sort of black and white lead fracture. Those trends can be captured. And if we think about it, after Fidelis, one of the lead integrity alerts captured three different trends. And in fact, it was probably one of the first AI kind of solutions, multi-parametric trending, multi-parametric analysis. And this is 10 years ago. It picked up on lead impedance trends. It picked up on non-sustained arrhythmias. It picked up on short detections. And when you flag two out of three, then it sent an alert, yeah? So these are all silent. They're all trends, but you can capture trends. And I think some of the new heart failure algorithms, too, capture trends. They're all changes in trends. No critical event has occurred, but a critical event might be predicted by those trends. So I think we're in a position now, particularly in this meeting with so much AI, yeah, that we can actually create alerts that will be flagged by AI analysis. I think the benefit of also moving to alert-based care is if you think about the cost that you save to the patient, right? If we're talking about bringing patients in every three months, as we're discussing equity and I have patients that are across the state of Tennessee. And if I can convince them that, listen, I only need to bring you in for care when it's necessary, we're saving them time, we're saving them money. And I think they also, they value that. And again, it reinforces the importance. If you stay connected, I don't need to bring you in for these appointments that I won't, I'm literally just saying, good job. Your device looks great. I also just want to say that this, so for an old curmudgeon like me, Nurse Ratched, who's been doing this a long time, we are talking about the horizon, what's in the future. So for some of us, it's really hard to let go of what we've done, how we've done things and what worked in the past. So for people like me, that's hard. Well, it's the same thing as the old, right? You check thresholds, now the device does it itself. Can you trust that? It was voodoo. That was my era. I think it's important for us to adopt the changes. I think it's like, it's going to be a balance, right? We're not going to all say, I'm going to stop scheduled remotes, right? What you're going to do is say, if someone has shown stability and they're good with connectivity, this person, I'm going to change more to alert-based, right? And so I'm going to stop utilizing resources on this, still monitor my patient appropriately, but it gives me the comfort in saying that I'm going to not be so hyper-vigilant with that patient, okay? And then those are the patients that move to the, every two years. But you might, exactly, right. You get to pick and choose who are your higher risk patients. But there's also another opportunity for you to redefine what your thresholds are. So before, you may have said my alerts for, you know, something and you said, but now I'm saying, because I'm spreading your interval for assessments, then my alerts may become a little more robust for that patient so that I can make sure that I'm not missing any changes. So I think it's the balance, right? It's not a complete change of armor. It's a transition in that we all will feel comfortable with. So I think we have to select our patients. It's very important for alert-based care. We don't want patients on alert-based care seen every two years if they have unstable conditions like heart failure. And I might sometimes bring in my patients, CRTD patients, who've had a heart failure event and I'm changing their programming very frequently, every two weeks, every three weeks, for a period of time until they're stable. And that brings me to another point. When we go to alert-based care, we're not abandoning the clinical connection with the patient. They are still seeing their doctors. They might see me in the capacity of an electrophysiologist for arrhythmias, not necessarily for the device interrogation unless I'm reprogramming, but I might see them for arrhythmias. My heart failure colleagues might see them for heart failure. On the other hand, a pacemaker patient with hypertension whose device is stable can be seen every two years. That doesn't mean they stop seeing their primary care doctor for hypertension. So we preserve that clinical connection, and that is essential. It is very, very important. We're not suggesting that we abandon the patients to clinical care. It merely regards device follow-up. And I think if we can do exception-based care for that and allocate resources for the patients who really need that care, sometimes very frequently, they might have to come in every two or three weeks for a period of months, then we have the capacity in our clinics to do that if we go to alert-based care. At the moment, we are overloaded with a lot of non-actionable work. Only because we're supposed to be interactive and it's hard because we don't have the app. For those in the audience, since the guidelines have come out, how many of you have gone to alert-based care or are starting to shift towards alert-based care? How many of you are still doing the standard three to six-month, bringing them into the office? I think to your point, they're all curmudgeons. It takes time for there to be a paradigm shift, right? And that's the important thing. We can talk about it because we sort of rewrote the guidelines, but how is it being implemented? Also, I think it is true with everything at this conference, which is there has got to be a little bit of discomfort to adopt new things. It's just like riding your bike. You're going to be scared, you're going to fall off, and you're going to fall off. But then you get right back on and you're going to be fine. I think you have to have trust a little bit in the system. There are those of us that have done this for many years and the patients have done quite well. Trust the system a little bit and just try. Try with your patients that you pick properly first. Absolutely. Which brings me to my next question, which I'm going to direct towards Camille, because we're talking about overburden of work and an option of alert-based or I like exceptional-based follow-up better. So, utilization of third-party resources. We have a lot of representation here in this venue. Camille, there's plenty of programs that do not have third-party resources. What are your thoughts on how you decide whether that's an option for your clinic? And to take it a step further, because this has been my experience, is administration doesn't always get it. They don't understand the deluge of and burden of the alerts and follow-up. So, what is your thinking on how who should use third-party resources and how can you convince administration that this may be an efficient solution for us? Yeah, I think that's a wonderful question. So, I think that there's, as you've seen around here, there's tons of companies, right? And I think there's a lot of opportunity. And depending on what your staffing mode is for your clinic, it may be something that would be really useful for you. In the end, you want high-quality care for your patients and you want that data that's in your device to be sent to you in a package that's easily interpretable, right? And then to apply it into their medical record. And so, I think utilizing the various services can be beneficial if you don't have the number of staff in order to accommodate the needs of your patients. And then there's other ways to utilize the systems is that maybe they have software that's better than what you have. And so you can utilize them for their software as well and that can be a great option in order to have it then filter into your system. And if it combines the data in your EMR with their system, it makes it even easier for you as the person who's caring for the patient to be able to interpret or apply that data in the overall care of the patient. So, I think that these services or softwares really have a high yield and can be very exceptionally and helpful in managing the patients that you have. For us personally, we just switched over to one of the systems and we use it for its software. I have the people in-house, right? I have high-skilled people in-house. But the software system that we had before wasn't meeting our needs, right? And so we transitioned. And since I'm over all of that, we went through a whole assessment of a bunch of different companies and then we ended up selecting one, which is working fine, but we're in the early phases of adoption. And so I tell people that you have to look at what do you need and then find what works for you. For getting the hospital system to take on that financial risk, it takes some negotiating, right? And so that took us, it's like a two-year process to go through it for us, right? Because I had to meet with so many different boards, finally getting up to the executive board for the health system before I could get it approved. And so it takes a lot of time and effort and commitment, but once you present the data from a patient management, the importance of properly managing our patients, the integration within systems, the ease of getting my colleagues in order to sign the reports, right, and doing the work that we need to get it back into the chart. And then the financial fund flow that can happen afterwards, it became an easy sell. And so you just have to know to be persistent and to keep working within your system in order to get whatever it is that you need for your patients approved. We know that remote monitoring gives us better quality care for our patients. We keep them out of the hospital, we get earlier treatment for their atrial fibrillation, we do strokes, hospitalizations for heart failure, all these things that has benefit to it. And so by having those numbers in front of you and presenting it in a way that the health system sees safety, which is obviously their highest priority, right, overall in our patient care, and then financially that it's advantageous, and then it became an easy sell. So happy to talk to anybody about what we did, but I think that it's really important to find the right system for you that's going to work for your system. But then if you don't have the resources, if you don't have the staff, then utilizing one of these systems that has staff for you is like the best way to go, because you have to take care of your patients, and that's the bottom line. Since we're being interactive, how many people here in the audience use a third-party resource? So not a significant number, so great information. Anybody want to add anything? I think that it's interesting to ask the audience who uses a third-party resource. Of those people that use a third-party resource, are you actually using personnel as well or just software as a service? Software? Both. Using both. So is that the majority, I guess, is maybe using both. I have to second what Camille says. I think that people sometimes are not aware that you can just use software as a service. And I think, again, if you have the personnel, that's the right way to go. But for me, that I don't have personnel, I think the better way would be to go with someone who has personnel for you as well. And in remote communities is the other thing. And so when you have a doctor out in the middle of wherever in North Carolina who's implanting devices but the patients aren't being followed, yet then somebody, they're coming in and a rep is doing a check every whatever for that patient, getting that patient and then remote monitoring and having that clinic followed in a remote monitoring system with a partnership with one of these third-party systems would be really probably better care for that patient and then having that information dumped into it. So through, you know, I'm at Duke, and so we have LifePoint hospital systems. And so one of the big things is now that I have a program established at us that we're happy with and whatnot, now how do we bring our LifePoints into my bigger system? Now that's going to stretch my manpower. And so if we do, then at least for LifePoint systems, I may utilize kind of the service component of the program that we have in order to accommodate LifePoint until I build up the number of people in order to handle the influx of data if I take all of these various systems, which is, you know, this is a system-wide thing as opposed to my three hospitals right now that I manage. And I was just going to say that sometimes having to fight for staffing goes hand-in-hand with not getting approval to get a very, very expensive software solution. You know, we're fortunate at Sanger that we do have a software solution, but we've also had really amazing administrative support to get a robust staff. But I think that that's a struggle, staffing and a software solution at the same time. I do want to underscore that I think for all of these challenges, I think at the end of the day for any of our systems, it comes down to money, right? So if you can demonstrate that by capturing a device check, whether a remote check, getting into the system in a timely manner that allows other care providers and the patient to sort of see what's going on with their device, that is a sell, right? So part of it is, you know, you should talk to Camille about it, but how do you sort of structure that argument that says, yes, it's going to take an investment if you want to sort of upgrade the software or whatever platform, but the benefits that come out of it, not just from a workflow and a time save from a provider standpoint, but also allowing other team members to sort of see if you see that person in clinic and they're in the ER a week later, it's really helpful for that team to know what's going on with that patient. So I think it just comes from transparency of data and, you know, just allowing everyone who's involved in that patient to take care of them well and also for that patient to have access to that information. Yeah, and I think that's why you can push it for safety, right? You say that by having the information get into the system quickly, it's safer. And that's what health system buzzwords, right? Safety and then money. Those are your two buzzwords. Yeah, I was going to say that same thing, actually, because I'm the only panelist that wasn't on the committee to write that HRS consensus statement. So I say patient safety and the HRS consensus statement when I go to administrate. Yeah, for us in the VA, it is not about dollars and cents, right? Because we don't bill per patient, but it's about patient safety. Anytime you say patient safety, like all the ears perk up, right? So bottom line is always patient safety first. I think one of the challenges when we present to administration is quantifying the invisible work that is associated with remote monitoring. By definition, it's invisible. There are no patients in the waiting room. So how do you demonstrate this? How do you measure this and present it to administrators? Yeah, I think that's a great question. I'll start it and then others can obviously add in. But I think from at least as just going through all of this again, more recently, it is looking at how many FTEs of various people's time, nurses, admins, you know, front desk people, all of those. And we had to quantify it. So we did like a little time study and going through and seeing how much time. And then, you know, for someone to click a vibrant order, for the order then to get pushed up to this part, for this to then make it to the next, you know, it took time. And so when you have a system that we've converted over to that is more automated and that it cuts out some of those in between clicks, you know, that everybody gets very frustrated with, then you have better satisfaction overall. And so I think that taking and doing a time study is really important for your own center and to see where people are spending it and their satisfaction. So it's not just what are they doing, but are they happy that they're doing it? And what you'll find is that people are very frustrated as they're clicking. OK, what they really enjoy. My nurses love talking to patients. They love educating patients. My admins, they much rather call a patient and make sure they're staying connected than to sit at a computer and hit and click 10 times to get it to the next step. So then I can arrive and do the next step in my process. And so you can improve their overall satisfaction. And then you have kind of what you're doing with that FTE of a person and making it more satisfying for the person overall. So I think that's how you can you get the data by making people quantitative. And then after that saying, how do I want to improve what the patient person is actually doing, the person is actually doing. So those are the things that I did. Which sort of brings me to another question that I get a lot when we're talking about the consensus document. Janet, you may be able to answer this because, you know, in my last position, I tried to get increased staffing and was told, oh, are there any guidelines, you know, to direct us on what the ratio should be? And we came to the three FTEs per a thousand patients. But so many people have asked me, how do you distinguish or how do you in that three FTEs, how many should be non-clinical versus clinical? And I know every clinic is different. But one of the major questions is if you're using a third party resource, how do you incorporate that into that calculation when you're dealing with administrators? And I think that's what's hard, right, is you hit it on the head when you said every system is different. When we made that calculation, obviously, I think I saw Prash out there for a second earlier, but we used his paper. We used, you know, Amber Siller's paper. And we did a lot of mathematical computations, taking into ratios of how many pacemakers you have, how many ICDs you have, how many ILRs you have, right, because we know that ILRs take a lot of time. Now, the AI that has been put into many of these ILR systems has, you know, deburdened some of that. And then we took into account, like, when you look at that, how many hours per year does that take per device type? And so in the initial calculations, you know, with pacemaker, compared to Europe, between Europe and the United States, it was somewhere in the 1.6 to 2.3 arena just to look at the data, right? This is not taking into account any of that other workload that we just talked about, calling patients, scheduling patients, you know, doing the unscheduled things. And then we worked into that, tried to take into account some like time off and vacation and truly what in that year of work. Is it actual work, right? So that's how we kind of came up with a calculator. So if you go onto the HRS website, you can pop in your numbers of how many pacemakers or device types you have. And then what is your FTE that you have? And then what sort of FTE work do you do in a year? And then you come up with a number. I don't know that it takes into account third party, right? And we let that sort of be so that you could take into account your system's issues, right? And for me, my system's very different from Camille's, right? Like I have a third party, but that's like a VA third party. And none of the, you know, the device interrogation remote gets into our EHR, but the notes don't get in, like the actual notes and clinical action don't get in there, right? So that's not accounted for. So everyone's going to be a little bit different. So we let that alone so that you could say, yeah, you need probably three FTE per thousand, but there is flex depending on your system. So that's the best that I can say is you have to say that that's the base, right? That it's minimum three, but you can flex up, you can flex down depending on what your system needs. Anybody else want to comment on that? Only that she put a lot of thought into it when coming up with that calculation for the, for the guidelines. Oh yeah. And it has, I have to tell you the feedback I've gotten is that it has really helped a lot of people improve their staffing, but you did hit on a point of how the ILRs have really overburdened us you know, as compared to the old days RTL throw this question at you. So I look at it as two different types of devices we're following, right? There are the therapeutic and there's the diagnostic and sort of the pathways for managing them in clinical decision-making is similar in some regards, but different in others, because the whole nature of having, for example, an ILR is you're going to possibly find something because it's diagnostic. So do you think there should be a separation in clinics and training? And should there be a separate remote monitoring for therapeutic versus diagnostic? It's a great question. I mean, I think at the end of the day, it comes back to the amount of data, right? And almost to what Neeraj was saying earlier, which is actual items that come out of that data. I mean, I think all of us, when I think about ILRs, it sort of also gets expanded to all of the consumer wearables that are also coming through, right? So all of these sort of diagnostic platforms that we have to collect patient data, it is overwhelming. The way I, I don't know if I would separate it so much as to sort of completely separate the clinics because there is fluidity in the data that's coming through. And you, a lot of these patients or some of these patients are going to graduate from the diagnostics to the therapeutics. But where I do see sort of a difference is that when we, at this conference, we're talking a lot about AI and sort of using these platforms to, to really make the workflow more efficient. And so this is where I sort of see using those algorithms really to, to help us before we even see it. Is this something that's a red alert? Is this something that's just, you know, sinus tack? And then you wait, you should hopefully not need as many people to sort of go through that data if you're, if you're using machine learning to help go through that. And then, and then the difference is because with therapeutics, again, by definition, right? We are putting them in patients that are needing active care. And so in my mind, still, we're going to have that process of having machine learning and AI and all of those things. But there's going to be a little bit higher level of interaction because you're also going to be looking at all the other things that are involved in that patient. And so I wouldn't separate it completely, but I do think it allows us to use the technology that is currently being developed and probably implemented in certain centers more efficiently. Other comments on that, in that regard? I agree. I think it's important. And I, the other thing is there's not a huge pool of staff who's trained in devices. And so if we separate them out, we're going to lessen our pool, right? And so it, I think people need to be cross-trained and it needs to be probably one. It's, it's a lot and it's hard to figure out how to handle them best. But, you know, I think it's best to keep them as one. Because it is also interesting, right, Amy, that I don't know in Sanger, if this is the case, but there are a lot of remote monitoring clinics now being asked to follow the wearables in addition to doing all the other devices. How has that impact? And how do you see that in the future? Because more and more utilization of those devices are coming into play. How do you see us managing that data? Well, that's a great question. And it's really timely because at Sanger, this is what we're considering right now. And so at Sanger, we are not providers. The 40 of my teammates are the bridge between the patients and the providers who are looking at this information. And in the ideal world, for me, it is we have a documentation database. That information feeds into our documentation database. My teammates filter that information so that only the actionable information gets sent to the provider. We filter the rest out. We call the patient similar to a symptom event with an ILR. We got it. There is no cardiac association with your symptom. We'll continue to monitor that sort of thing. That never goes to the provider because it doesn't need to. I see in the ideal world that all of that feeds in to our documentation database. But we just talked about not everybody has a documentation database. You have to maintain patient safety for all of that wearable data to come in. Because if all of this lives in the device clinic, then CID management personnel is being pulled to do the wearable data. And you have to make sure that everybody is safe. And we just heard Camille and Janet talk about staffing. If you don't have the resources and you don't have 40 teammates for your 13,000 patients, then you have to consider that also. And some organizations have that. Some don't. And not all wearables companies have the ability to send that data. That's a big deal. We have to partner with industry. They have to develop ways to make the patient's lives easier. They need to be able to push a button. That data needs to send wherever it goes to. If you don't have a documentation database, it goes to what one of my EPs calls the trash can, the media tab. Wherever that goes in your EMR and gets managed by whoever that gets managed by, it needs to be easy for the patient and easy for the people who are managing that data. But in my ideal situation, all of that gets managed in the device clinic, if you have a device clinic. We are the arrhythmia specialists. I have two teams. Like, I feel like the implantable devices should stay with the implantable people. And looking at those remote monitored things. We've been doing that for two, three decades now. We're very good at that. The issue with patient-generated health data is a whole other beast. And Neeraj, please, jump in. Because we wrote a paper recently on the promises and perils of the whole digital consumer wearable space. But I got to say, the Office of Information Technology in the U.S. had this really lovely white paper they wrote in 2018 about patient-generated health data adoption curve. Starting in 2018, it was lovely. It had a nice red arrow. And it said that we should be at our utopian state by 2024. And we are not. There we are. We are not there. Clearly. And you think, well, why is that? Because when you think about all the wearables, there is no one common language. One. And then two, the other issue is we just heard on the PPG talk this morning is that all devices are not created equally. And all people are not created equally. Some people can use them well. Some people can't. Some devices are good with dry electrodes. And some aren't. Right? So I think for now, I think they should be separate. Because that takes a whole other sort of piece of training to be able to understand how to parse that data appropriately for the patients. And then, again, you're taking away personnel that I don't have. You may have it. I don't have it. I got to have some other team that does that. It's hard to believe that we only have a few more minutes left. I could go on with about 10 other questions. But one I do want to touch base with, because it is on the horizon, is the whole idea of remote reprogramming of patients' devices. And I know patients are always freaked out when they read Robin Cook books and know that their device can get hacked and be reprogrammed and presidents can die because their pacemakers are shut off. And this is a reality of what patients do bring to you. So how do you see that working? You know, do you think that we can make patients accept the whole idea of being able to reprogram their devices remotely? I'm just picking on you. So we have the ability for remote control. Actually, I didn't realize that we had it until COVID. And then there was an FDA-approved system for remote control. This is not really remote programming in the patient's house. We don't do that. It is possible with ILRs, but not with CIDs otherwise. But the remote control facility allows staff, personnel who are not EP-trained or CID-trained or device-clinic experienced to be able to apply a programmer to a patient with a device in a clinical setting. In our case, it was probably a satellite hospital, a satellite facility. But the actual reprogramming could take place from anywhere in the world, typically from our main campus or from industry's headquarters, wherever that may be. It doesn't really matter because it's internet enabled. So remote control can be done. Remote reprogramming can be done. It's certainly possible. So is that on the horizon? Is that something that you see as a realistic thing in the next five years? I think it'll come through in various shapes and forms. And I think it'll get in. Again, people have to become comfortable with it. Patients have to be comfortable with it. And we have to become comfortable with it. But I see this playing some part in our remote device clinic work in the future. I agree. I mean, I think it's where it's going, right? I mean, I think to Neeraj's point, we can reprogram ILRs, right? From our office. But I think as we, as our technology continues to get better and we feel more comfortable, right? I mean, we just, we did a raise of hands and people are not comfortable sort of doing alert based care yet. We'll get there, right? And it's once that becomes the standard and accepted, I do think patient, I mean, telemed was not like a huge thing until we were forced to do it because of the pandemic. And I think patients are going to start demanding the ability to sort of not travel for all of their necessary care. And, but I think to maybe Neeraj's point, maybe we are the ones, right? That are actually the most nervous about it. Because I know I have a lot of fear of being, you know, I have control issues as most electrophysiologists do. But so I think it's coming. I think we have to catch up. So I think a newer generation of patients who receive implants will actually want this. They want continuous monitoring. They want access to their data. They want the ability for remote programming. They want AI enabled algorithms to predict events before they occur. And that's particularly true for heart failure. And arrhythmias, right? Arrhythmias, heart failure, lead trends. I think that's very important as well. So everything that we are monitoring for in a device clinic can potentially be predicted by AI algorithms enabled in the software. Now, devices themselves don't have the computing power to do all this. So this has to be done outside the device on the basis of remotely transmitted data. And that can be done by third party platforms which have the advantage of being agnostic to manufacturers. And you can set the parameters that you want. But I think the future generation of patients will be demanding this. This will be the new environment for remote device clinics. I totally agree. With that, I think we need to conclude. We're a little over. Thank you so much. It was a great panel. As I said, I have about 10 more questions I can ask, but maybe next year. Thank you.

remote monitoring

HRX 2024

Aileen Farrick

patient connectivity

alert-based care

wearable devices

AI-enabled solutions

remote reprogramming