Case Study: What They Don't Teach You in EP Fellowship

These days, pacemakers and defibrillators are often interrogated via a home-monitoring system that uploads information contained in the implanted cardiac devices automatically to a central server so it can be accessed by physicians remotely.  This feature was added to most defibrillators after the rash of recalls struck the industry in 2005-6.  Not only can the information be uploaded electively by the patient, it can also be automatically uploaded if a nightly self-check detects a parameter out of range.  In this case, the patient was being monitored by Medtronic's Carelink remote monitoring system.

"Dr. Fisher, I think we have a problem with Mr. Smith's RV lead (not his real name)," my device nurse said as she handed me the Carelink transmission that triggered an superior vena cava (SVC) high voltage coil impedance warning:

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"What did the last interrogation look like?" I asked.

"Here's the old one was sent just three days before and looked fine," she said. "It's so weird.  We've not had a problem with this patient's device since it was implanted in 2012."

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Real-time intracardiac electrograms seen on the earlier transmission - Click to enlarge

"Strange.  I'm not sure what to make of this.  Give him a call - we might have to change that RV lead," I said.

"Okay," she said, then returned to the device clinic and I went back to seeing patients.

Some time later, my nurse returned.

"Um, Dr. Fisher, could I speak with you a moment?" she asked.  "I got some more information.  I think you better look at this" and she handed me his most recently transmitted real-time intracardiac electrogram recording that was sent with the latest transmission.

What did it show and why were the RV lead parameters abnormal?

-Wes

Telemedicine: Cardiology's New Frontier?

EKG at home?   Check.

Blood pressure at home?  Check.

INR check at home?  Check.

Cholesterol blood level at home?  Check.

Maybe an echocardiogram at home, too? Check.

Hey, maybe there's something to this!

A cardiologist with an MBA has launched a telemedicine business starting with international retailer Walmart (NYSE: WMT) with the goal of providing affordable healthcare in areas underserved by providers.


Dr.Raj Shah, who runs a 37 year-old, 10-physician cardiology and internal medicine practice in Langhorne, Pennsylvania, is the founder of Telemed Ventures and CEO of Smart Care Doc. Having formed the company nearly three years ago, he opened its first telemedicine unit in Bensalem in suburban Philadelphia and another is scheduled to open in Willow Grove, Pennsylvania later this month.


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The unit includes a flat screen TV and a dentist-style chair and has a set of bluetooth-enabled medical devices administered by an on site nurse including a digital stethoscope, a handheld EKG device, a finger pulse reader and a digital thermometer. A light pen camera is used to look into ears, at the throat or skin lesions. All of the readings from these devices can be transmitted to the attending physician or entered into a computer and sent to the physician in real time. Nurses also provide immunizations, minor wound care, and other services.

Patients also get a personal health record referred to by the practice as a “patient passport.” It includes continuity of care records and documents, medical problems diagnosed from their encounters with Smart Care Doc physicians, prescribed medications, allergies and appointments. In the years before he started his telemedicine business, Shah had launched a patient passport business to help patients keep track of their records


Despite Shah’s presence at Walmart, his relationship with the big box retailer is only as a tenant, so he is not tied to a partnership agreement. But he hopes to expand the practice if enough people use the service to rural areas across the country where Walmarts are located. Walmart declined to comment.

While this $59 model might work pretty well for preventative cardiology and parts of diagnostic cardiology, I'm not sure interventional cardiologists will be too happy with their door-to-balloon times.

Just sayin'.

-Wes