Cardiology monitoring solutions become smaller and more powerful

While visiting her daughter in Midland, an Ontario resident experienced a fainting spell. Her daughter brought her to Georgian Bay General Hospital where she was prescribed the m-CARDS PocketECG, a wearable cardiac monitor that provides real-time monitoring of heart rhythms and symptoms for up to 28 days.

The small, easy-to-use device was shipped to the daughter’s home the next day and the woman began to use it, attaching three electrodes as instructed and using the touchscreen to record her symptoms and activities.

A short while later, on her car ride home to St. Thomas, Ontario, and still wearing the device, she had a second spell. Her husband rushed her to St. Thomas Elgin General Hospital.

While she was being seen in the Emergency unit, the report from her mobile heart monitor was being read by a cardiologist on the m-CARDS system, who subsequently contacted the treating physician to alert him that she required a pacemaker. She was transferred to London Health Sciences Centre where she was fitted with a pacemaker the following day.

“They had been investigating her syncope for 15 years and nobody had been able to capture it,” said Sandy Schwenger, CEO and founder of m-Health Solutions, the Burlington, Ontario-based company providing the integrated m-CARDS system for remote patient monitoring and cardiac diagnostics. Recently, m-Health Solutions adopted the PocketECG, manufactured by Medicalgorithmics, as its go-to technology. Schwenger calls it “a Holter on steroids” and says that it is indicative of the “smaller, cleaner, faster and better” trend in the digital cardiac monitoring space.

The PocketECG is about the size of a cellphone. In addition to capturing and classifying every heartbeat, and detecting all ventricular and supraventricular arrhythmias, it applies proprietary algorithms to run full statistical analysis on the data collected. Reports are in-depth and aid in determining a precise diagnosis for even the toughest of cases.

Whereas in many cases a Holter monitor needs to be returned and data downloaded before a report can be generated, data from the PocketECG streams in real-time. When an alert occurs, the information is uploaded to one of 300 Ontario cardiologists currently on the m-CARDS system, who make diagnoses or recommendations and notify the patient and/or treating physician.

“Our service standard is that the cardiologist has to look at it within 60 minutes of it arriving in the queue,” explained Schwenger, noting that patients are matched to the cardiologist nearest to their geographic region. “In the event they can’t get to it, we have somebody who is on call who can take a look and do the assessment.”

The service is available province-wide and prescribed by more than 3,500 general practitioners. Data is stored securely on servers in Canada and patients are supported by a call centre that supports 12 different languages. The units themselves ship from a central warehouse. To date, more than 85,000 patients in Ontario have been diagnosed on the system and the company is now working on a similar project in Alberta.

“We looked at building it ourselves, but the answer was no, there is something out there that meets our needs,” explained Schwenger, who says the company’s innovation is on the process side, implementing the mobile technology in a way that makes sense for the Canadian market. “We’re a virtual cardiac healthcare facility,” she said.

A two-year study under way at Hamilton Health Sciences is using the m-CARDS system to monitor patients at home as they recover from minimally invasive transcatheter aortic valve implantation (TAVI). Funded by the Ministry of Health and Long-Term Care Health Technologies Fund, the project aims to show that remote monitoring can reduce complications after TAVI and shorten the time patients spend in hospital post-implant.

“We call it expanding the walls of the hospital into the home,” said Katie Porter, Director of Research Administration at Hamilton Health Sciences.

Typically, patients recovering from TAVI remain in a special telemetry unit where they are closely monitored for five to eight days. Now that open heart procedures are being replaced with minimally invasive surgery, however, they feel normal soon afterwards and are eager to return home.

Funding for the study is being used to build out a closed-loop notification between the m-CARDS system and HHS’s Meditech electronic health record so patients can receive the same high-quality monitoring for adverse or unusual events at home as they do in telemetry.

The real-time reports generated by the wearable monitors are securely stored by m-Health Solutions and forwarded to electrophysiologists at HHS for review. The TAVI team is brought in for consultation as required to provide direction as to whether a symptom is perfectly normal or a patient should return to hospital.

Ultimately, the streamlined process reduces unexpected visits to the ER and catches symptoms that may be ignored otherwise.

“The goal is to see if we have better outcomes using remote monitoring,” said Porter. A comprehensive economic analysis will be completed as part of the study to show the return on investment and compare the cost of remote monitoring versus a hospital stay. Results are expected to be available by spring 2020.

The University Health Network, in Toronto, is another Ontario healthcare and medical research organization investing in remote cardiac monitoring as a means to shift care to the home and reduce the burden on acute care services.

A telemonitoring program called Medly, developed at UHN and now used by the Peter Munk Cardiac Centre (PMCC) to remotely monitor and manage heart failure patients, is the new standard of care.

The program includes both a technology and a service component and is embedded into the day-to-day practice of the clinic. Patients are referred to Medly on a case by case basis.

The first step is onboarding which includes training on the smartphone app and remote monitoring process, and on any Bluetooth-enabled peripherals required to measure weight, blood pressure and heart rate.

Kits range from a full model that includes all required devices to a bring-your-own model that allows patients to use their own phone, weight scale and blood pressure cuff. Once home, they record their readings and complete a brief symptom questionnaire each day.

The proprietary Medly algorithm, a rule-based expert system refined by PMCC heart failure clinicians, automatically analyzes the information that is entered and generates feedback tailored to personalized thresholds and treatment plans set out by prescribing cardiologists. If a patient’s physiological parameters are normal, no action is required. If something falls outside of the normal range, the app may tell them to take a prescribed medication or to contact the clinic, for example.

Registered nurse Mary O’Sullivan serves as the full-time Medly clinical coordinator, helping to onboard patients and monitor alerts remotely using dashboard software that is part of the program. One of her primary roles is to monitor alerts, triaging and escalating clinical concerns to cardiologists as required.

“When a physician identifies that somebody might be Medly appropriate, I teach them about the technology, what we expect from them and what they can expect from us,” said O’Sullivan. Not only does the dashboard enable her to “evaluate quickly who’s getting into trouble” but it also provides a holistic view by summarizing a current medication list, heart failure-related lab data, and historical trends for each patient.