Sep 14, 2020
By Lucy Reyes

How expansion of remote monitoring was a win-win for patients and care providers

istockphoto.com/andsusRM exemplifies the capabilities and benefits that technological innovation brings to health care. It is patient-centred in that the patient is able to stay in their home setting while maintaining access to specialized care.

Takeaway messages

  • Remote monitoring (RM) fills an important care gap: a patient can be adequately evaluated in their home rather than visiting a specialty follow-up clinic.
  • Patients have peace of mind, knowing they are being closely and continuously monitored by experts, ultimately reducing anxiety and eliminating unnecessary hospital visits.
  • Provincial implementation of RM has greatly facilitated continuing care of patients during the current pandemic, without subjecting patients to excessive infectious risks.

“We heard, we listened, and we acted upon what we heard to benefit our patients and their families.”
— Lucy Reyes, 2018

Background

Cardiac implantable electronic devices (CIEDs) are heart therapy devices that include pacemakers, defibrillators, and long-term heart rhythm monitors. CIEDs treat serious heart rhythm disorders, collect data used to diagnose patients, and provide continuous (24/7) monitoring.

CIEDs improve survival, reduce hospitalizations, and enhance quality of life; they require careful and expert follow-up. This care has traditionally been provided face to face in specialized clinics. This can be inconvenient, resulting in delays in care for patients in rural or remote areas who may find travel impractical. In-person visits are further complicated in the context of the current COVID-19 pandemic.

Remote monitoring (RM) fills an important care gap: a patient can be adequately evaluated in their home rather than visiting a specialty follow-up clinic. RM uses a patient-centred approach to care. With RM, CIEDs can be evaluated at any time as long as a cellular or Wi-Fi network exists.

Patients enrolled in RM programs require fewer face-to-face visits and can have their serious heart rhythm problems identified immediately. Patients also have peace of mind, knowing their CIED is being closely and continuously monitored by experts, ultimately reducing anxiety and eliminating unnecessary hospital visits.

Patients are integral care partners in CIED management. Teaching is done on a one-on-one basis at the time of CIED enrolment to RM. Following initial teaching, patients are asked to send a sample transmission from their home monitor. Subsequently, the clinicians set the programing of their monitors for scheduled transmissions. Unscheduled or unplanned transmissions are received by the clinics if there are any concerns regarding heart rhythm problems or concerns regarding the function of their CIED.

Until recently, RM technology in Alberta was limited to only two urban CIED clinics. This meant that most patients in Alberta could not access this system. Alberta Health Services (AHS) initiated the PERFORM (Performance Evaluation and Rhythm Follow Up Optimization through Remote Monitoring) program, funded by Alberta Innovates, to address this inequality.

Our work was led by frontline clinicians and was informed by formal patient engagement using surveys and qualitative studies.

Our team included broad representation of health-care providers and operations stakeholders within AHS. Our goal was to transform the patient journey of a potential CIED recipient, from the time of initial referral up through their long-term follow-up, aligning it to AHS’s information and technology strategic plan.

PERFORM formally ended in 2018, but its legacy achievements live on. In particular, provincial implementation of RM has greatly facilitated continuing care of CIED patients during the current pandemic, without subjecting patients to excessive infectious risks.

Critical factors for success

Patient and clinician engagement

Our work was led by frontline clinicians and was informed by formal patient engagement using surveys and qualitative studies. This was key to our success. Early work found that CIED recipients valued the RM model of care, and this informed development of best practices guidelines and policy practices of AHS.

Alignment with operational priorities

The team looked at AHS’s procurement practices for these RM applications and worked with privacy leaders in transforming site-based privacy impact assessments (PIAs) into one standard PIA. The team reviewed the clinical processes across the different sites and standardized practices, such as having one patient consent versus numerous vendor-owned, site-based consents, and aligned it to current guidelines.

Clinical practice alignment

The team looked at the criteria for RM enrolment as well as standardized patient teaching tools. A review of the organizations’ clinical documentation guidelines and policies was done to align with Canadian Cardiovascular Society (CCS) standards.

We created standardized patient consent documents and teaching tools and we tracked frequency of RM monitoring and in-patient visit follow-ups. A common referral pathway was implemented for all CIED clinics. The success of this alignment can be attributed to the clinicians leading and doing the work.

Information management and information technology assessment

Prior to the project the RM databases and RM capabilities were available only at the two urban centres, so patients living in rural areas were underserved. The continuity of patient flow is hampered by duplication of data entry and repeated patient interviews, resulting in more time expended by the clinicians in information access and retrieval.

Since PERFORM, over 70 per cent of patients in Alberta with implantable defibrillators use RM.

The team worked with information technology and management personnel for the technology assessment component, explored the different technology platforms, and ensured alignment with the AHS electronic health record strategic plan. The RM databases were integrated with the main AHS repository to be able to extract the RM clinical data automatically. This facilitated the integration of RM into the province-wide AHS Connect Care electronic medical records initiative.

Key patient benefits

Since PERFORM, over 70 per cent of patients in Alberta with implantable defibrillators use RM. This represents a doubling of RM prevalence among rural patients. The following are some of the benefits from the perspective of patients living with a CIED and their families.

  1. Ability to be served in their homes, or closer to their homes, with the expansion of RM in urban and rural areas.
  2. Reduced travel times and expenses, as well as other costs (e.g., parking, caregivers), since clinicians can use RM virtual visits to assess the key CIED parameters that would otherwise be assessed in a face-to-face appointment.
  3. Fewer missed or cancelled appointments due to extreme weather.
  4. Faster review of CIED issues, since the patient’s device sends scheduled and unscheduled transmissions of cardiac events.

The PERFORM initiative set the foundation for the transformation of the care of this population.

What do our patients and families say?

"I am the primary caregiver for my grandchildren and live in rural Alberta. RM allows me to get my ICD [implantable cardioverter defibrillator] checked without having to spend 3 hours driving. It is a huge benefit to me."
— 68-year-old woman

"Winter roads can be very scary to drive on. I used to cancel my clinic visits when the roads were bad. Now with RM I don't need to do that."
— 65-year-old man

"RM gives me the peace of mind that my son's device is being monitored for any problems."
— 28-year-old mother of a 3-year-old CIED recipient

"When I was travelling and my husband had a shock from his device, I was able to call the clinic right away. The nurses were amazing and reviewed things immediately. I am so happy to have this service available to my husband and me."
— 58-year-old woman, spouse of CIED recipient

"My pacemaker gets checked using Carelink Express at a nearby hospital. Before this, I would have to travel 2 hours one way for my visit. This is much easier to coordinate, as I don't drive anymore."
— 95-year-old woman

RM exemplifies the capabilities and benefits that technological innovation brings to health care.

Key clinician benefits

  1. Clinical CIED experts can proactively deal with both planned/scheduled transmissions and unplanned transmissions when something might be wrong with the device.
  2. Care of patients is now standardized across Alberta with the implementation of provincial CIED guidelines.
  3. The expansion of RM throughout Alberta has enhanced the efficiency of follow-up and provided patient-centred care.
  4. The device can be programmed to send transmissions when some parameters go into an “abnormal” category.

Research and knowledge translation

RM exemplifies the capabilities and benefits that technological innovation brings to health care. It is patient-centred in that the patient is able to stay in their home setting while maintaining access to specialized care.

The following studies were completed with the program.

  1. We published a paper, “Assessing Physician Knowledge Regarding Indications for a Primary Prevention Implantable Defibrillator and Potential Barriers for Referral,” which is now cited internationally (Bernier et al., 2017).
  2. The team completed a population-based study that looked at how clients were adhering to criteria and guidelines for implantable cardioverter defibrillators. The study consisted of a review of all ICD procedures performed from January 1, 2015, to December 31, 2016, in Alberta. The purpose of this study was to evaluate the proportion of patients receiving appropriate ICD therapy and to identify reasons for non-adherence. The results of this study have been published in peer-reviewed journals.
  3. A patient quality-of-life survey was completed provincewide; 625 surveys were returned. We heard about several patient-related issues such as missed appointments due to bad weather, travel times, and the need for caregivers to take time off for appointments. The study found that pacemaker patients reported greater overall device acceptance and better return to life compared with ICD patients. ICD patients with RM, meanwhile, reported better quality of life compared with patients without RM.

Conclusion

PERFORM has resulted in broader and more equitable implementation of clinically proven RM technology. This was achieved using a strategy that standardizes the whole process, connects different clinicians, integrates data from different clinical applications into a central hub, and makes data extraction easier as the organization advances with implementation of electronic health records. This has improved the care of Albertans with CIEDs. Our group continues further expansion of this program and will be studying a fully remote-care paradigm for CIED patients in an upcoming pan-Canadian clinical trial.

References

Bernier, R., Raj, S. R., Tran, D., Reyes, L., Sauve, M., … Sandhu, R. K.  (2017). Assessing physician knowledge regarding indications for a primary prevention implantable defibrillator and potential barriers for referral. Journal of Cardiovascular Electrophysiology, 28(11), 1334–1341.

Lucy Reyes, RN, MN, is a research coordinator at the Cardiac Sciences Cumming School of Medicine, and is the clinical lead for the remote monitoring project mentioned in this article as well as overall project manager for the PERFORM program. She has extensive experience as a frontline leader/manager in acute and ambulatory care.

Co-authors
Derek V. Exner, MD, MPH, FRCPC, FACC, FHRS
Satish R. Raj, MD, MSCI, FHRS, FRCPC

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