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The latest updates and insights in cardiac electrophysiology
Remote Monitoring: Getting It Here From There
T
he evolution of cardiac implantable electronic devices (CIEDs) has been rapid
over the past few decades in a variety of
ways. Indications for use have expanded, access
has increased, technologies have improved, and
the ability to monitor CIED patients remotely has
grown. In the early days of remote monitoring, portions of a traditional device interrogation visit, such
as remaining battery life, could be accomplished
through transtelephonic monitoring (TTM). Since
then, technical capabilities have evolved to allow for
true remote monitoring in some cases, a paradigm
that allows for 24/7
automatic monitoring.
Each major device
manufacturer has its
own remote monitoring system, and while
these systems are
all FDA cleared for
remote monitoring
and are evolving to
become more similar,
there are important
differences that may
Emily P. Zeitler, MD, MHS
make one a better
fit for a particular
patient. Therefore, thoughtful hardware selection
at the time of implant includes consideration of
the associated remote monitoring systems.
As the new era of remote monitoring has commenced, data demonstrating its many benefits has
accumulated.1 It is no coincidence that this data
accumulation has occurred in parallel with the
era of “Big Data;” widespread remote monitoring
results in an amassing of data by device manufacturers. The “Big Data” revolution has resulted
in advances in computing power and statistical
techniques that have made these massive data
sources incredibly revealing. Indeed, some of the
most compelling evidence for the clinical benefits
of remote monitoring—including mortality—originate from these enormous data sets.2
Evidence of advantages of remote monitoring
over the traditional model of device management
continues to mount, including patient satisfaction
and quality of life, healthcare utilization, disease
management for heart failure and atrial fibrillation, reductions in inappropriate shocks from
implantable defibrillators, cost effectiveness, and
the special role of remote monitoring in the case
of at-risk devices under advisory or recall. It is no
wonder, then, that the Heart Rhythm Society has
unequivocally recommended that all patients with
14
CardioSource WorldNews: Interventions
a CIED be offered remote monitoring in a set of
2015 guidelines.3
Unlike most other interventions in medicine,
remote monitoring of CIEDs requires a paradigm
shift in the way health care is delivered. There is
precedent for this “remote” model (e.g., heart failure management), but the growing pains for such
a shift persist, and this is reflected in the suboptimal uptake of remote monitoring: less than half
of eligible patients are enrolled, and only a subset
of enrolled patients actually participate fully.2,4
This is particularly disappointing since it appears
that earlier and more frequent remote monitoring
is better than later and less frequent.2,5 No single
group is to blame for the relatively poor uptake of
remote monitoring. Barriers, both real and perceived, exist for all stakeholders. Some physicians
fear the medicolegal consequences of transitioning
to remote monitoring. Moreover, they may have
insufficient support from office or health system
Unlike most other
interventions in medicine,
remote monitoring of
CIEDs requires a paradigm
shift in the way health
care is delivered.
be uncomfortable with the technical expertise
required to set up and maintain a remote monitoring connection, or they may not have access to the
necessary telecommunications infrastructure to
facilitate such a connection. For example, while
this is changing, voice over internet protocols
(VoIP) and cable connections in place of traditional analog phone lines are incompatible with
some remote monitoring systems. In light of the
critical role that patients play in the success of a
remote monitoring program, patient engagement
is paramount and may be helped by interventions
borrowed from colleagues with expertise in interventions to change health behaviors. For example,
there may be benefit in the use of patient contracts
to improve patient compliance with a remote
monitoring program.
There is good news, though. The direct-toconsumer market for medical devices is booming,
which may increase patients’ appetite for and
tolerance of remote interaction with doctors. If,
in parallel, barriers related to patient privacy
and safety can be overcome, we may be able to
more fully engage our patients in their healthcare
through sharing of CIED data. Moreover, it may
be possible to someday use remote monitoring
platforms to facilitate a randomized controlled
trial that tests truly disruptive interventions like
remote programming.
Thus, while the realities of remote monitoring
have not caught up to its promise, one need only
follow the data to get there from here. ■
REFERENCES
1. Zeitler EP, Piccini JP. Trends Cardiovasc Med.
2016;26(6):568-77.
2. Varma N, Piccini JP, Snell J, Fischer A, Dalal N, Mittal S.
J Am Coll Cardiol. 2015;65(24):2601-10.
3. Slotwiner D, Varma N, Akar JG, Annas G, Beardsall M,
Fogel RI, et al. Heart Rhythm. 2015;12(7):e69-100.
4. Piccini JP, Mittal S, Snell J, Prillinger JB, Dalal N, Varma N.
Heart Rhythm. 2016.
5. Mittal S, Piccini JP, Snell J, Prillinger JB, Dalal N, Varma N.
J Interv Card Electrophysiol. 2016;46(2):129-36.
Emily P. Zeitler, MD, MHS, is a Clinical Cardiac
Electrophysiology Fellow at Duke University Hospital.
personnel (vis-à-vis reimbursement, for example)
to sustain a robust remote monitoring program.
Health care systems and reimbursement structures
are, at best, inconsistent with their support and
facilitation of true remote monitoring systems;
security issues—whether real or imagined—may
prevent the full commitment of some physicians
and health care systems.
Patients may be reluctant to give up face-toface interaction with their physicians, they may
Emily P. Zeitler, MD, MHS is a fellow in clinical cardiac
electrophysiology at Duke University.
September/October 2016