Sunday, January 24, 2010

Remote ICD monitoring: where is my pony?

Have you ever seen the TV spot where two little girls are offered ponies by a shady banker? The first girl is given a toy pony while the second one gets a living animal. When the first girl protests, the banker dismissively replies, “You didn’t ask.”

The voice over concludes: “Even kids know it’s wrong to hold out on somebody.”

While the ad cracks me up, it also reminds me that when it comes to remote follow-up and monitoring of ICDs and pacemakers: patients are getting toy ponies while doctors and industry are getting the real ones.

Patients are asked to adopt this new technology and are pitched the conveniences of fewer office visits, lesser travel expenses, and the ability to send transmissions anytime from (almost) anywhere.

Medtronic’s web site, for example, promises patients “a new sense of freedom through remote monitoring.” It claims that “nearly 300,000 people around the world benefit from Medtronic’s home monitoring,” gaining more freedom, convenience and peace of mind. While I agree that these are definite benefits, they’re not significant enough to persuade me to adopt remote monitoring.

They also do not compare to indisputable financial benefits both doctors and manufacturers enjoy from our adoption of the technology. “By enabling routine device follow-ups remotely, doctors can quickly and thoroughly review the status of a patient’s heart condition, and schedule follow-up appointments only when necessary,” says Medtronic in this press release.

The key word here is “quickly”. In a world of declining reimbursements, efficiency means profitability. Remote monitoring allows for doctors to “see” more patients without really seeing them. Sadly, most of us are only too happy to jump on the bandwagon without giving it a second thought.

Should we want fewer office visits?
So, are fewer visits to the doctor a real benefit to us? Not necessarily. During my visits, I always ask for and bring home copies of my interrogation reports. I enjoy reviewing the report with my electrophysiologist and appreciate our interaction and access to his knowledge and expertise. I would not trade this valuable time for the convenience of remote monitoring alone. Sure, remote monitoring has its conveniences, but it also means having less access to information. And, to me, that’s a serious inconvenience.

The plastic toy pony. Here’s the breakdown of what you’re giving up when you agree to the “plastic toy pony”:
  • You are passing up the opportunity for valuable face time with your doctor. It’s your chance to ask questions and get educated about your condition. It’s about access. If you think you can call the clinic and get your EP on the line to answer your questions after transmitting your data, good luck and God bless your credulous heart.
  • It’s much harder to get a copy of your interrogation report if you don’t go into the clinic. Ironically, with remote monitoring, your data is even less available to you. You must ask the clinic to mail you a copy of the report or use 20th century technology and have it faxed to you. If you’re already at the clinic, all it takes is to ask them to print you an extra copy.
  • You must have a landline to use remote monitoring. If you’re like me and others who only use mobile phones and digital/VoIP phones, you’re out of luck. Most remote monitoring systems only work over traditional landlines. The only exception (as I write this) is Biotronik’s system. Biotronik is the pioneer in the field of remote follow-up and monitoring of pacemakers and ICDs. The data retrieved from their devices is transmitted to a center in Germany using the GSM (Global System for Mobile Communications) network. This is the main advantage of their system.
Moreover, as doctors Mark Schoenfeld and Dwight Reynolds ask in their article Sophisticated Remote Implantable Cardioverter-Defibrillator Follow-Up: A Status Report, (Pacing and Clinical Electrophysiology, April 2009), “If a patient spontaneously transmits data through the Internet that is not accessed nor responded to in a timely fashion, who is responsible, particularly if a poor outcome arises from delayed interrogation? This situation is not likely to arise during a scheduled clinic visit when the physician knows that a specific device interrogation is being made.” As we look for ways to reduce heath care costs, remote monitoring and follow-ups for patients with pacemakers and ICDs is likely to become the standard of care.

However, I believe patients must be made a part of the equation and be empowered to review all our data via the Internet.

After all, it is data about our bodies. And as our own best advocates, we’re entitled to having full access to it.

One thing is for sure. Until I can get a “real pony,” I'm holding off on remote monitoring.


Dom said...

I'm not sure I completely agree with your posting. First, typically the ICD monitoring visits are performed by the nursing staff, so my "face time" with my EP is not affected. Second, the downloads are not meant to be for an emergency situation, for those situations patients really should be calling 911 or equivalent. Lastly, I do believe this is indeed a way to cut healthcare costs all around.

That being said, I do agree that I loose the accessibility to my medical information, and I do ask for a copy each visit. However, if needed a copy could be made and emailed or kept until my next visit if I truly desired that information. Your argument about "timely" review is valid. I've often wondered that myself and the snail-mail letter I receive that everything was "OK" is a bit crude. But as with any technological advancement, we have to start somewhere. I have three young children who are active. Our weeks are crazy and my work schedule equally so. Reducing my visits helps me tremendously...and it's nice to save my co-pays for those "at-home" interrogations. Another nice feature that I have taken advantage of is being able to "download" a report when I didn't feel that great, or had a concern but wasn't at the level of an emergency situation. In those situations I called my EP's office...transmitted a report and received a call that everything was fine. That transmission was done at night, after office hours and didn't require me going to the emergency room...all around savings!

So, while the toy pony argument is valid, I think that we as patients have the opportunity and responsibility to utilize this new technology but also assist the manufacturers and medical staff on how best to utilize it!

Illinois said...

I think you're absolutely right, Hugo, and I too decline to go remote.

Dom, I understand how in your case the remote is convenient -- for me, luckily, I work near the device clinic, and don't have young kids. However, you won't be saving on those co-pays for long; most docs are already (and the rest will be soon) charging every 90 days for the remote interrogations, and you'll owe a co-pay on that.

Remote monitoring is "lucrative" for EP practices (the term for it in a recent article in EP Lab Digest). Since they benefit by it, patients should too, by better, rather than less, access to their own medical data. Once they give me access to the secure online site for my own interrogations, I'll be aboard.

Thanks for interesting opinions!

Anonymous said...

As a Certified Cardiac Device Specialist and device engineer who runs a large academic center clinic, I'd disagree with any patient declining the service. First, the monitor itself is included in the cost of the ICD! Use it, you paid for it! Secondly, it automatically transmits any anomolous data that it retrieves during it's self test (done daily). For instance, a lead wire is generally very stable for many years, however, moving and bending almost 100 thousand times per DAY, there is the off chance that the actual coil inside can fatigue and break or the insulation that coats these coils can wear. In either case, you wouldn't know it until you received a shock... or two... or more. The daily reading would indicate that failure is imminent and it could be dealt with before it becomes an emergency. Also, episodes of arrhythmia that are treated with painless therapy (ATP) will be sent for review. So will short, non-sustained episodes. All of these things can be going on and you won't know it until your next 3 month appointment or ER visit.
As for being a cash cow, remote monitoring, when performed CORRECTLY, is NOT a time saver for any office. Investigating all anomolies or alerts and all of the data is time consuming. Our clinic dedicates two full time clinicians to this service. It takes time to compare todays data with that of last check or to see whether that new atrial arrhythmia requires treatment, etc. If you're not getting a phone call or letter with a DETAILED explanation of your data, then perhaps you should ask your clinic WHY?? Proper monitoring of patient data is neither simple or "quick".
BTW-I advocated remote follow up, "just in case" for both my father and my grandmother. For my father, it meant finding and treating asymptomatic atrial arrhythmias that could have resulted in stroke or worsened heart failure....

basilrene said...

I have a medtronic defibrillator and it is monitored by Mount Sinai hospital in New York City. It's too inconvenient for me to go into the city every three months for ten minutes for the nurse, not the doctor, to interrogate the ICD. I have seen the doctor that implanted the ICD only once since the implant in 2007. I've only seen nurses.

When I transmit my info, I get an email from medtronic that it went through, then sometime during the day, I get a call from Mount Sinai giving me the details of my transmission. They then send a copy via email or fax to my regular cardiologist and one to me.

I also had an incident where it almost went off and I did not know, and my unit transmitted and I was called by Mount Sinai to let me know. If I had not had the device to call in, I would not have known until the next visit in three months.

I'm happy with the remote interrogation and all you have to do is ask for your info and they have to give it. If your clinic is not providing you copies of your transmissions, then change clinics.

Anonymous said...

I am only in my second month of having a pacemaker/defibrillator implanted into my body. I have fought it every step of the way. Although I am very grateful that my life was probably saved, I resent the fact that more information was not given to me prior to the implant (I was in the hospital a full three days prior) and that I am just in the last few weeks being given the information that I asked for prior to heart cath/ep study/implant. My monitor just arrived by FEDEX rush yesterday (six weeks after implant - so what was the rush and extra expense all about?) It included a blood pressure monitor and scale. I was not consulted about the inclusion of the last two items. I am yet to install any of it. 1) I have a medical grade scale in my home and I am quite capable of weighing myself and knowing when I have gained too much weight too quickly. I do not see the need in remotely transmitting that information. 2) I have a blood pressure cuff already.
I am not really crazy about my ICD being monitored remotely especially with the changes coming in healthcare and the government's involvement. My blood is still boiling over this. I need someone besides a ICD salesman/rep to sell me on the idea that I am in any kind of imminent danger if I do not comply with this monitoring.