Remote monitoring of cardiac implantable electronic devices in Hong Kong: The healthcare provider perspective
Remote monitoring of cardiac implantable electronic devices (CIEDs), such as Abbott’s Merlin.net™ Patient Care Network, which were initiated in Hong Kong 10 years ago, can reduce the number of hospitalizations and clinic visits and prevent serious complications by enabling early detection of signs of worsening heart failure (HF). In an interview with MIMS Doctor, Dr Katherine Fan of the Cardiac Medical Unit, Grantham Hospital, Hong Kong, explains the workflow of her remote monitoring team and how healthcare providers and patients can benefit by participating in this programme.
Remote monitoring services in Hong Kong
In Hong Kong, remote monitoring services for CIEDs were first introduced in 2010 at the Grantham Hospital. At present, the team is led by Fan, and supported by other HF specialists and three nurses.
“The nurses at the hospital manage all received transmissions, liaise between patients and clinicians, and coordinate follow-up actions as required,” explained Fan.
Patients implanted with newer devices with embedded remote monitoring technology can participate in this programme. During remote monitoring, patient data are recorded and subsequently relayed from the device to the vendor’s secure web server for later access by healthcare providers.
The nurses retrieve and review the data from the server on a daily basis during regular office hours. If there are any aberrations or emergency alerts that need to be addressed, these will be forwarded to the clinicians for evaluation and appropriate intervention.
“Typically, patients are not contacted following routine scheduled transmissions, unless there is a need to intervene or an issue that requires clarification,” pointed out Fan. “Furthermore, currently, it is not possible to operate CIEDs remotely so as to alter patients’ cardiac devices disposition.”
In the recently launched ‘hub and spoke’ model for remote monitoring across Hong Kong, Grantham Hospital acts as the central hub, in providing support to other hospitals in the territory. “So far, we have received about 40 patient referrals from other hospitals. When a CIED transmission/alert is received from one of these patients, our nurses will relay that information directly to the patient’s primary cardiologist,” explained Fan.
“Currently, our nurses manage between 360 and 380 patients who are followed up within our hospital. As the programme expands to include other hospitals, we anticipate this number will grow to about 600 to 800 patients per nurse by the middle of 2021,” said Fan.
Patient education is an integral part of remote cardiac monitoring. Fan stressed that patients and caregivers should be advised on their responsibilities and expectations in addition to the potential benefits and limitations of the programme.
“Patient education is mandatory and remote monitoring patient briefing should be documented in medical records. Patients should be aware that the monitoring programme does not offer emergency medical treatment,” advised Fan.
Given the large amount of personal medical data being circulated via the interconnected technological systems, there are growing concerns regarding data privacy and cybersecurity. Fan reassured that in Hong Kong, the Personal Data (Privacy) Ordinance, which came into effect in 1996, ensures that patient data are kept confidential and are securely stored by the device manufacturer.
Unique features of remote monitoring
The transmitter automatically sends out patient data downloaded from the CIEDs via a telephone landline, cellular adaptor or broadband service, to a password-protected secure website for further review.
The transmissions can be scheduled, unscheduled or patient-initiated. Scheduled transmissions occur once every 3 months as routine remote follow-up before clinic visits. Unscheduled transmissions are triggered by predefined alerts, which concern either device integrity (eg, battery status, lead impedance) or medical data (eg, heart rate, arrhythmias, fluid retention in lungs).
“Changes in physiological parameters can help predict the likelihood of an acute HF hospital admission. This allows clinicians to intervene in a timely manner and take necessary steps, such as increase the patient’s diuretic dose, thus averting hospitalization,” remarked Fan.
“In addition to detecting anomalies in heart rhythm and pulmonary oedema, some CIEDs can also capture parameters related to patient activities, including breathing rate, minute ventilation, and heart rate variability,” she added.
Remote monitoring improves patient care and outcomes
Remote monitoring is associated with improved survival, irrespective of device type. A higher degree of adherence to remote monitoring correlates with greater survival gain. [J Am Coll Cardiol 2015;65:2601-2610]
Studies show that compared with conventional (in-office) follow-up, remote monitoring:
· Reduces in-clinic evaluations and improves patients’ follow-up compliance [Circulation 2010;122:325-332];
· Allows earlier detection of clinically actionable events [J Am Coll Cardiol 2011;57:1181-1189];
· Reduces accident and emergency (A&E) visits, total healthcare use and improves quality of care. [Circulation 2012;125:2985-2992] (Figure)
Remote monitoring of CIEDs allows the delivery of efficient and comprehensive patient care. Early detection of technical or clinical issues can facilitate prompt intervention, resulting in improved patient prognosis.