Clinic Time Required for Remote and In-Person Management of Patients With Cardiac Devices: Time and Motion Workflow Evaluation.

Amber Seiler,Marco Di Bacco,Mirko De Melis,David Lanctin,Emmanuelle Nicolle,Eliana Biundo,Juliette Hennion,Sarah Rosemas,Laura Van Heel

doi:10.2196/27720

Abstract

BackgroundThe number of patients with cardiac implantable electronic device (CIED) is increasing, creating a substantial workload for device clinics. ObjectiveThis study aims to characterize the workflow and quantify clinic staff time requirements for managing patients with CIEDs. MethodsA time and motion workflow evaluation was performed in 11 US and European CIEDs clinics. Workflow tasks were repeatedly timed during 1 business week of observation at each clinic; these observations included all device models and manufacturers. The mean cumulative staff time required to review a remote device transmission and an in-person clinic visit were calculated, including all necessary clinical and administrative tasks. The annual staff time to manage a patient with a CIED was modeled using CIED transmission volumes, clinical guidelines, and the published literature. ResultsA total of 276 in-person clinic visits and 2173 remote monitoring activities were observed. Mean staff time required per remote transmission ranged from 9.4 to 13.5 minutes for therapeutic devices (pacemaker, implantable cardioverter-defibrillator, and cardiac resynchronization therapy) and from 11.3 to 12.9 minutes for diagnostic devices such as insertable cardiac monitors (ICMs). Mean staff time per in-person visit ranged from 37.8 to 51.0 and from 39.9 to 45.8 minutes for therapeutic devices and ICMs, respectively. Including all remote and in-person follow-ups, the estimated annual time to manage a patient with a CIED ranged from 1.6 to 2.4 hours for therapeutic devices and from 7.7 to 9.3 hours for ICMs. ConclusionsThe CIED patient management workflow is complex and requires significant staff time. Understanding process steps and time requirements informs the implementation of efficiency improvements, including remote solutions. Future research should examine heterogeneity in patient management processes to identify the most efficient workflow.

Highlights

remote monitoring (RM) capabilities are a standard feature of modern cardiac implantable electronic device (CIED), and data are continuously transmitted through landlines or mobile networks, which supplies health care providers with critical clinical and device-related information that allows them to adjust and optimize patient treatment
During 11 total business weeks of data collection, observations included 276 in-person clinic visits (124/276, 44.9% the United States and 152/276, 55.1%, Europe), 1948 (1269/1948, 65.14% the United States and 679/1948, 34.86% Europe) individual remote transmission review tasks, and 440 other patient management tasks
Considering all individual time recordings, approximately 50.21% (2424/4828) of the observations were in patients using pacemakers, 17.13% (827/4828) were in patients using implantable cardioverter-defibrillators (ICD), 20.89% (1009/4828) were in patients using cardiac resynchronization therapy (CRT), and 11.76% (568/4828) were in patients using insertable cardiac monitor RM (ICM)

Summary

Introduction

Mean staff time required per remote transmission ranged from 9.4 to 13.5 minutes for therapeutic devices (pacemaker, implantable cardioverter-defibrillator, and cardiac resynchronization therapy) and from 11.3 to 12.9 minutes for diagnostic devices such as insertable cardiac monitors (ICMs). In the 2015 Heart Rhythm Society (HRS) Consensus Statement on remote interrogation and monitoring for CIEDs, endorsed by European Heart Rhythm Association and other international societies, RM combined with an annual in-person visit is recommended rather than in-person evaluation alone, with the strongest (class I) recommendation and the highest level of evidence (A) [5] This recommendation is primarily because of earlier detection of clinical events, including atrial fibrillation, ventricular arrhythmias, and pause arrhythmias, to which RM enables faster clinical response and appropriate medical action [7,8,9]. Several studies have confirmed the clinical and economic benefits of RM, including improved patient outcomes and reduced health care use [5,9,10,11,12,13]

Results

Discussion

Conclusion