Good afternoon. I'm Michael Gold. I'm a cardiac electrophysiologist at the Medical University of South Carolina. On behalf of the Heart Rhythm Society, I'm very pleased to present and introduce this session of technology. I have with me Shani Kress from the Rhythm Management Group, and Shani's going to present her presentation now. Thank you, Dr. Gold. I'm excited today to talk to you about the five remote monitoring best practices. So let me talk to you a little bit about Rhythm Management Group and what we do and our history. We are a company that has been in the rhythm management space, remote monitoring, for the last 10 years. We have 70 team members and patients in 30 states across the United States. We have 50 plus years in remote monitoring across our team. A few areas we're going to discuss today are optimization, staffing, connecting patients and keeping them connected, monitoring and scheduling, and then, of course, auditing. So optimizing, what does that mean? It means a few different things to different people. For us in the remote monitoring space, it means that all patients who are eligible for remote monitoring are on the system, connected, and being monitored. However, what HRS has found in the past is not even 50% of patients who are eligible for remote monitoring are actually on the network being protected. What we find in our own company history is that the number may be closer to 60 or 70%, which is still far behind where we consider optimization of a practice, which is above 90% connected and scheduled and optimized. What you see here is some compliance numbers from a practice that we began partnering with a little over a year ago. That practice began with 60% of their patients scheduled and a little more than 70% of their patients connected to the network. In a nine-month period, we took that practice all the way up above 90% connected and 95% scheduled, and we've maintained that for the last nine months. It was a lot of work to work through all those patients, but we were able to manage all of that work with our high-touch model of reaching out to patients and using technology to work through the data. What goes into remote monitoring? A lot of people ask us that question. It truly is a team sport. It's not just about having a clinician to read and interpret the data. It's about keeping those patients connected and understanding their expectations for remote monitoring. For every 1,000 patients, it takes at least one clinician, sometimes more depending on the device mix, three administrative staff who are all highly specialized in different areas of the remote monitoring space, meaning we have one who communicates directly with patients to ensure they understand what to expect from the service. We have a person who ensures that everyone is scheduled and stays connected to the network. We ensure that as ongoing as we add patients, we get them onto the network and they are also connected. For every ILR patient, it's about one hour a month of time across our team. For every pacemaker and ICD patient, it's around half of that, about 35 minutes a month. The ideal is to get patients connected when they're implanted. We've discovered that that leads to long-term compliance with remote monitoring and success in the service. However, as I said at the beginning of the presentation, less than 50% of patients get connected at implant, so that leaves the other 50% out there waiting to be added to the network. What we've been able to do is perfect our script with the patients and ensure that they get onto the network and connected and they understand what to expect from the service and how to use it, but we also ensure that we keep them connected over time. Nowhere is that more evident than in the ILR patient population, some of the most vulnerable patients in the CRM device space. Here's a great example of how keeping a patient connected helps to change their plan of care and provide early intervention for significant arrhythmias. This particular patient presented to the website with no alerts on their transmission. Our clinician took a look at their transmission, obviously saw a significant pause in their rhythm, conferred with the clinical team, communicated back to the provider in the office, and within three hours of receipt of this transmission, the patient was scheduled for a pacemaker implant. But it isn't just about monitoring the alerts. We find that many practices out there just look at the service as an alert service. They get alerts quicker, which is great. It's a great benefit of remote monitoring. However, if you don't have a regularly scheduled transmission, you're really missing out on getting a full picture of the patient and what's going on with them. Not only that, but you're also not optimizing your billing practices. So what we've been able to do is get patients on a schedule and ensure that we get data from them at regular intervals. But it isn't just about keeping patients connected, getting them scheduled, getting them onto the network. We have to make sure that all of our processes are working and ensure that we can intervene and provide modifications when necessary. So auditing is the way that we do that. That's where technology has really come in and help us by providing data in a more efficient fashion, where we can review an action in a more timely manner. This has allowed us to achieve greater than 90% connected patients throughout our patient population and more than 95% scheduling compliance. So technology and service must coexist to provide stellar care to patients. You can't have one without the other. Our model of using technology has allowed us to become more efficient and provide more timely care to our patients and give more information, more relevant information to our providers. So obviously we can't talk about remote monitoring and not mention COVID as it's changed our lives in so many ways and many of us will never be the same because of the pandemic. So much has transitioned into the remote monitoring space because of COVID. And the great thing is we've been in this space for 10 years, so these best practices translate into other areas, not just the CRM device remote monitoring space. So nowhere has that been more evident than in the new service line we provided called remote patient monitoring. This particular case study came from a patient who doesn't have a CRM device implanted. We monitor her weight and some other metrics. We noticed that there had been a change significantly over a few days. We reached out. The patient had attributed her symptoms to pre-existing health conditions. However, we determined that she may have COVID. And so we sent her in to see her physician and thereby she was subsequently tested and we're still waiting for those results. This intervention could possibly have saved her from going into the hospital. So to bring it all together, we're able to look at a clinic and determine their optimization and bring them up into 90%. We also work very diligently to keep those patients connected and scheduled so that the data is received and actioned off in a timely manner. We increase compliance through collaboration between us and our clinics and, of course, by the use of technology, which has allowed us to scale whenever we speak with new practices. Thank you so much for your time today. So, Shani, thank you very much for that excellent presentation and very, very interesting technology. I think it's a very important area that almost all arrhythmia practices that have devices have been challenged by. So I'm wondering if you could give us a little more detail in terms of you're doing the actual overreads yourself internally? Yes. We have clinicians who do the readings. And are those clinicians experienced with devices and electrograms? Absolutely. So the least experienced clinician on our team has three years of experience, and the most experienced clinician has more than 40. 40 years is a long time to be doing devices. That's great. And then is there flexibility in terms of what's considered an urgent message? So can you tell Rhythm that we want to hear about new onset atrial fibrillation but not every day or we want to know about a defibrillator shock but not an episode of non-sustained VT and so on and so forth? Can that be sort of prescriptive? Absolutely. Whenever we partner with a new practice, we have an alert protocol template that we use. And then that's tailored to what's relevant for that practice and their general plan of care. And we can also tailor it to a patient if we're watching a particular metric or condition. And do you contact the patients or can you contact the patients or is that done through the physician's office? We do contact patients for monitor connectivity and to retrieve transmissions. However, we do not distribute any of the medical data to the patients. They would need to contact their provider for that. But for alerts, if an alert comes up, what's the workflow of new onset atrial fibrillation or a period of heart block or something like that? We have a couple of different protocols that we utilize with some of our collaborative clinics. There are some where we will call the patients for symptom data to gather some more robust report for the physician. And in some of our practices, we simply write the report and pass that along to the practice and then they reach out to the patient for symptom data. It varies, but we do have a tailorable protocol. Great. And a very important part of this is the workflow. So I'm wondering if you'd give us some details as to when a report is done, is that sent to the doctor's office? Do you have methods to be able to directly upload into the EMR for that patient or is there some sort of hybrid process that goes on? We get that question a lot when we start our partnerships with practices. Again, it's something that can be tailored. What most practices prefer us do is upload directly into the patient's chart and the EMR and we do that. We also have employed fax, secure email, secure cloud solution, lots of different methods for getting the data to the physician via whatever method they prefer. The physician can actually log into our system as well, into our platform, our software platform, and retrieve the data there. And it's accessible through both handheld devices and desktop devices. And when it's sent to an EMR, let's say, or however it's sent, how do we know about it? How do we know that Mrs. Jones or Mr. Smith has a report that's been in their system because we won't be tracking as you do if you're scheduling the appointments? Some physicians prefer different methods for their alert notifications. Many like text messaging because they're always on the go in between cases, in between the office and the hospital. There are some physicians that request we task within the EMR itself, either directly to them or to their MA or their nurse so that they're notified. So there's a couple of different methods that we use. Of course, we call as well if they need to discuss the findings in more detail. But yeah, just to back, not for alerts, but just for the routine. So if you're doing, let's say at my center, you're doing 30 remote monitors a day. How do I know which of those 1,000 patients, which 30 of those, how do we monitor that I have to address in our EMR? The typical protocol for the routine reports, whenever we have the ability to upload into the EMR, then that permission's granted us by the IT department. There's an appointment on the calendar in that EMR. And so that patient has been checked in and seen essentially virtually. And then we upload the report to the EMR that way. So the physician can look at that day, that remote schedule and know that they've been seen. We also have the ability to task even remote reports within the EMR and the routine ones with no alerts and let the physician or their care team know that there's a report waiting. And then the physician is able to oversee to sign off on that report? Yes. Yes. And how does the billing work for these reports? So does the physician who was ever doing it, do they drop their own bill in an EMR or do you facilitate that? We have a couple of different protocols in place depending on what they have asked us to do, how we've partnered with that practice. We do drop the encounter and a couple of the practices that we work with and others that billing is generated from a billing report by the billing department in the practice. So they work from a spreadsheet. What are the problems that we see? We're obviously not nearly as good as you are, which is why you're successful in what you do, but we get patients who think that everything's working okay, but it's not working okay. Or there's some problem with their specific monitor and other things. Do you go directly to industry and say to whatever company that there's a problem here or do you alert the practice to say, we're not getting the reports from this patient? Also a really good question. So we look at the device sites every day, obviously, and in each vendor website, there are lists of patients who are disconnected or otherwise not near their monitor. Now, sometimes that's normal. The patient travels, they don't take their monitor with them. They might be hospitalized for a few days. So a short period of disconnection is very typical for most patients. However, if they're disconnected for more than five or seven days, we reach out to the patient and we will attempt to get them reconnected. Occasionally, we do discover monitor issues. And because we have a large patient population, we often discover issues early, like before the device companies have released anything to the public. And so we're able to work with the device company and say, okay, we identified this issue with a monitor. Is this an overarching issue or maybe a subset of the monitors have a problem? Most often patients become disconnected just because they're away from their monitor for a few days. Well, great. Well, thank you. I mean, this has been a very informative, very interesting and innovative service you've set up. So I really appreciate you taking the time to share with us and everyone else as part of our HRS virtual meeting. Thank you.

remote monitoring

cardiac electrophysiology

patient connectivity

scheduled transmissions

COVID-19 impact