Welcome, everyone. This is Chris Romeo with MedAxiom. We're going to give this just a minute for everybody to log on. We have a quite a large crowd today, so we're going to give it just a minute for everybody to have the opportunity to log on. Okay, again, welcome, everyone. This is Chris Romeo. I'm the Senior Vice President on the Ventures team here at MedAxiom. We've got an exciting webinar today that is sponsored by one of our industry partners, Octagos. Today's title is Overcoming the Challenges of Guideline-Directed Remote Monitoring. We've got a great variety of speakers today. Dr. Ben D'Souza, he's the Section Chief of Cardiac Electrophysiology at Penn Presbyterian Medical Center. We've got Dr. Neeraj Varma, who is the Professor of Medicine at the Cleveland Clinic, and Dr. Shanti Bansal. Dr. Bansal is the founder and CEO of Octagos Health and also of the Houston Heart Rhythm. Before we get started, let me go through just a couple of housekeeping items to get us started. Today's presentation is going to be submitted and available to anybody in the chat button at the bottom of your screen. If you click on that, the presentation will be there, made available for you to be able to click on that, download it, and actually be able to share that with your colleagues and staff. We're going to be going through the three speakers today, and at the end, we're going to be taking questions from the audience. If you have any questions, you can submit those via the Q&A button, also at the bottom of your screen. Submit those. We'll be monitoring those and submitting those to the panelists at the very end of the presentation. So again, today's title, Overcoming the Challenges of Guideline-Directed Remote Monitoring, and I'm going to turn this over to Dr. D'Souza. Dr. D'Souza, the floor is yours. All right. Thank you, guys. So looking forward to a lively discussion, and we're going to be talking about the future of cardiac monitoring, empowered by Alice AI, and I thank the folks from MedAxium and Octagos for starting this very interesting and exciting discussion in, honestly, what is a big struggle in our field of cardiac electrophysiology. So I think we're going to start with Dr. Neeraj Varma, and he's going to give us some more information on how remote monitoring is now in our HRS guidelines and consensus statements, and it has largely become what used to be considered optional to the standard of care for all of our patients. So I'll take it over to you, Neeraj, and looking forward to hearing your talk. Thank you. Thank you, Dr. D'Souza. Thank you, Dr. Bunsell, for the invitation. So next slide, please. So this shows the title page of the most recent guidelines. So we could pivot to the term guideline-directed remote monitoring. This really is the standard of care now. So a couple of points that I'd like to show is that this is an international consensus statement, HRS, Europe, Asia Pacific, Latin America, so it really is a global document. And what it states is, and the next panel will show this, is that remote monitoring is class 1A recommendation for follow-up care of patients with CIDs. So it's in preference to in-clinic evaluation. So this is a strong statement, 1A recommendation, and this is also for routine surveillance of lead function and battery status. This actually builds on the 2015 guideline, which also issued a class 1A recommendation. But adoption was modest following that, and that really signals that there were multiple pain points in adopting a class 1A recommendation, which is a very strong recommendation, and this is the preferred mechanism of follow-up. So what are those pain points? And this is what this document tried to identify and resolve, to provide a framework for effective remote management. Next slide, please. So just to reiterate, the reason why remote monitoring is preferable to in-clinic care, this was shown by the TRUST trial 15 years ago and multiple trials since then following the same lines, randomized trial of ICD patients, and the next panel will show that in preference to in-clinic evaluation, this was safe, there was no difference in the safety index, and it was more effective. The next panel will show that the number of missed free monthly follow-ups was halved by using home monitoring, remote monitoring. So this was more efficient, more effective. A very powerful statement from this trial, next panel, shows that early detection was enhanced. One could identify issues in device integrity or arrhythmias within 48 hours, and this is the basis for improved clinical outcomes, less inappropriate shocks, improved survival, early identification of atrial fibrillation, all of these things. They can be done early. And the next panel also shows that the number of in-clinic evaluations was reduced by almost 50%. So we have early detection, better clinical outcomes, and less clinic work. So why was adoption still modest following the results of this trial in the 2015 guidelines? Well, the answer is shown in the next few slides. So I'll show the next slide. The reason is all the invisible work that is undertaken during automatic remote monitoring, automatic, so you don't have to ask the patient to do anything, ask the clinic to do anything, automatic remote monitoring. But there's a lot of invisible work behind that. The next slide shows the elements of this. So this panel shows the slide that I showed earlier. In-clinic evaluations can be reduced by 50%, but is this an accurate measure of device clinic work? The answer is no, because the next panel will show that when you add in all the invisible work regarding three monthly remote evaluations and alert management, there's a large amount of work, which is not measured by simply in-clinic evaluations. Next slide, please. And the alerts have continued to increase in volume and complexity. Only a fraction of those come to in-clinic evaluation. So there's a lot of work that is done behind the scenes. Next slide. So the 2023 guidelines identified several points for intervention. One is to maintain connectivity. The second is to have patient education. And then the third is very, very important, data management. So only after those first three roles have been accomplished, then one can proceed to final sign-off, interpretation, calling the patient, documentation, and billing. Next slide, please. I'll begin with connectivity. We found that in 2015, connectivity was very poor. 50% of patients who received a remote monitoring-capable device never switched it on, 50% never switched it on. Without connectivity, there's no remote monitoring. The remaining 50% only intermittently connected. So we ascribe this to patient compliance, but also it's very difficult for the clinic to maintain connections with the patient. So this is an issue. Next slide. So the recommendations from the new guidelines are that for patients undergoing implantation, manufacturers should provide resources, and we should ensure enrollment and connectivity before discharge or within two weeks of implantation. So this is a significant step. It follows on with patients with CIDs with continuous connectivity. Connectivity should be maintained, so this is continuous surveillance. This is a lot of work for the clinic. Next slide. And for the patients who lose connectivity, clinics should have an established process to restore that. So these seem obvious, but they often break down, and we know this from clinical experience. But these are mission statements from the new guidelines. It does take a lot of clinic attention to deliver on this. Next slide. Patient education is vital. So I won't read all of these out, but these carry a class one recommendation, so very strong recommendation. Patient education should be delivered, the family should be educated, and this should start before implant, and then post-implant compliance should be monitored. Again, significant work for the device clinic. Next slide, please. Next, I go on to data management. I showed this slide earlier. A large amount of alerts are managed remotely. It's not reimbursed generally. Only a fraction of these yield in clinic evaluations. We know these alerts, and we know this from the next panel, are very important, and early intervention for lead fracture, early ERI, EMI can reduce patient morbidity and mortality. We know this from the randomized trials, but we need to be able to focus on the alerts that carry important information. Most of the time, we're flooded with non-actionable information, so this is a point of intervention that is necessary. So the guidelines in the next panel show that there are priority alerts, and these are obvious, ICD shocks, high thresholds, low battery, and ATP impedance changes. But also, and this is a recommendation, again, the next panel, that non-actionable alerts should be programmed off. So this requires continuous surveillance by the device clinic, class one recommendation. So if you're getting alert parameters that are unnecessary, then these should be switched off. Next slide, please. How can all this be accomplished? I've already shown a significant number of tasks. Staffing is vital. Staffing credentialing and qualifications are important. This is a class one recommendation. Quality improvement reviews need to be implemented. Next slide, please. So all members of the RM team should receive training, continuing education and certification specific to RM, and become knowledgeable about unique characteristics. Quality should be defined for each team member. So this is an organizational model. Next slide. So it is essential that adequate time to be dedicated to perform all RM tasks. The guidelines said an estimated three FTEs are required to support the care of 1,000 CID patients, managed with a combination of personnel, and this depends on individual clinic workflows. Now here, the guidelines also recognize that the staffing ratio will differ in practices using third party staffing resources. So third party is an important ingredient here, and I'll come back to that in a moment. Next slide, please. Neeraj, I'm sorry to interrupt, but I wanted to ask a question specifically about that. Was the guideline committee particularly concerned with the issues that we've all had with staffing, meaning staff leaving or turnover, that having three FTEs per 1,000 would be unobtainable? Because just here at the University of Pennsylvania, we have multiple hospitals. Each has at least between 5,000 and 10,000 patients with implanted devices. So I'm just hoping you could comment on that number, because most of us, when we saw these guidelines come out, thought there's no way that we would be able to justify the increased addition of staff. Yeah, a very important point. So thanks for bringing that up. And I'll come back to that in a couple of slides later, but let me address that. So this was a number that we thought we had to issue, rather than give a sort of generalization. It was calculated on the basis of published data. On the basis of published data regarding the amount of time that was required to manage a routine in-clinic appointment, a remote appointment, manage the alerts, and manage actionable data from patients. So this was calculated from available data. I will say that the available data are sparse. There are only two papers that actually address this. I will also say that following the publication of this, because this is a class one recommendation, but without a large body of data, there are publications that have come through addressing this. Some saying it's insufficient and some saying that it's more than sufficient. So I think it really depends on the organizational workflow of that particular clinic. So it's very dependent, but this is work in progress. I don't think this is set in stone. I think it's a very reasonable number. This came up for discussion within the committee several times, but this was calculated very carefully on the basis of available data and collective experience. Thank you for elaborating. So third party is introduced here. So what does the third party do? So in this sort of cooperative network, third party would take data from the manufacturer's server and then process it and provide it to the hospital team. So this cuts out a lot of tasks for the device clinic personnel. Next slide, please. So I've shown these panels before. Next slide. So what happens with the use of third party is that the first row and the third row there, the gray and the beige, are delegated to the third party. Patient education and enrollment is still the responsibility of the device clinic, but maintaining and monitoring connectivity, which is an onerous task, and data management, triage and review can be performed by a third party. And we see issues on the evolution, the right-sided column for the third row, data triage and review. Third party software can be very useful. Again, very few data for this. So this is where third parties can integrate very well with device clinic workflows. And then the responsibilities are for the bottom green panel for the final sign-off, interpretation, documentation and patient calls. So this is where a great deal of the work that is required by the device clinic according to the guidelines and according to our experience can be done effectively by another party. Next slide, please. This is a publication that was just published in HeartRhythm about two months ago, Impact of a Universal Monitoring System on Outcomes of ICD Patients, a Nationwide Study. So when facilitated by a third party platform, remote monitoring improved patient survival and reduced the time spent in hospital. So this is a very, very effective form of patient management, of management of patients with devices. Next slide, please. So in summary, remote management requires patient education, enrollment, scheduling, troubleshooting, connectivity, data triage and review, alert management, documentation, communication, billing, interfacing with electronic medical records. It's a lot. The tasks fall largely on allied health professionals, is usually unstructured and under-resourced, risking staff dissatisfaction and turnover and lost revenue. Exactly your point, Dr. Sousa, from earlier. The tasks are large, trained personnel are few, and device implantations, device volumes continue to increase. So the problem, if anything, begins to amplify. Next slide, please. So as a result, third parties have a significant role here. And the guidelines issued a Class 2A recommendation, which is a very strong endorsement of use of third parties for the care of patients with CIDs on remote monitoring. Class of level of evidence was Class C, expert opinion, because there were very few data, apart from the slide I just showed you earlier. But the committee recognized the importance of third party resources here. Thank you very much. Thank you, Dr. Parma. That was wonderful and really an excellent summary for something that is relatively recent that we've known about for a long time. And I think many of us know that sometimes guidelines lag behind what we do in terms of clinical practice, but it's very, very helpful. So I'm going to now speak a little bit about how we got to our remote monitoring current situation here at the University of Pennsylvania and how we got to the point of using a third party. I'll also comment that I think it's very interesting that HRS put that into the guidelines specifically that a third party utilization can be helpful in terms of managing this massive amount of data. So next slide, please. So this was me when we first started the remote monitoring program. It's an old picture. You can tell I had smiling and had more hair and less gray. And so I was essentially the most junior partner, and I had to kind of take over the remote monitoring program for any of you that do this. It's largely a thankless job that people are usually just unhappy when remote monitoring is not working or we miss something. But it's extremely important, just as Dr. Barmer had commented on, that it is now in our guidelines. It's our standard of care to be able to care for these patients. And so next slide. When I first started, this is our group here at HRS a few years ago publishing actually an abstract on same-day discharge for AFib. Well, prior to that, same-day discharge for devices pretty much also became our standard of care. We used to keep patients in the hospital, and obviously that became more difficult. Well, the problem with if you have a completely ingrown network of, as we had mentioned, APPs, techs, nurses, et cetera, to be able to manage this is that it's really hard. There's a lot to do with this. And unfortunately, it's hard work, it's time consuming, it's laborious, and people either don't like it or they get really good at it and they go to industry, or they decide to have families and you lose your staff that you spent years, you know, training. And, you know, unhappy staff is like, you know, happy wife, happy life. You gotta make sure that your whole team is enjoying this. And so, next slide. So we decided that we did want to utilize a third party. And for many that had to go through this process, we have to pay for anything, right? I'm constantly dealing with administration to ask for new things. I think I had to sell one of my children back to Penn to get pulse field ablation on the shelves. And so my point is that anytime you talk about something that costs money, you have to justify it. This actually turned out to be a fairly easy justification for many reasons. As Dr. Varma had mentioned, our compliance was less than probably 40% in terms of patients actually transmitting remotely when we started this. We started same day discharge and we felt it clinically appropriate that we monitor patients to make sure that the lead didn't dislodge or that there wasn't any issues. We needed to free up our staff to be able to do the appropriate things. Patients like to know that they're being monitored. The recalls is, you know, I'll show more about moving forward in a little bit have become an issue. We're just dealing with the most recent recall that we just found out about the last few weeks ago. And again, now compliance with national guidelines, right? It's in our guidelines that this is our standard of care. So we needed to do it. And ultimately it was not as difficult of a sell to our administration to move to a third party. And I also wanna be clear, this was prior to this being in the guidelines. So this is something that we felt was clinically necessary and appropriate. Next slide, please. And so we opted to do this right around 2020. And so as you all know, the COVID pandemic we lived through, this was an article in New York Times where patients weren't coming in when they were actually having myocardial infarctions at home because they were so terrified. We couldn't get patients in the hospital. And I had all of these referring clinics calling us from Philadelphia area, New Jersey saying, you know, I have this sweet little old lady who's not on remote monitoring. I have no idea how much battery she has on her pacemaker and I'm concerned about her, but we physically could not get people into the clinic. And so this became even more important. And so it's really revolutionized how we care for patients, not just for, you know, devices, but for afib ablations and pretty much everything, as I mentioned, same day discharge. Next slide, please. And so we continued to build our telemedicine and remote monitoring program, which did not exist prior to the pandemic. Now I do it routinely for many of my patients and sort of integrated into this as well. And so it is really our standard. Next slide, please. I did see that there was a question about the most recent recall, which was the Boston Scientific one in terms of early battery depletion and deaths associated with it. So here's our remote monitoring growth that continued. You can see, right, that was around 2020 and it just has continued to grow. So more and more patients, you know, pacemakers, defibrillators, and loop monitors, you know, just continue to gather more data. And so it was incumbent upon us to be able to manage this data. It's not so much putting the device in, it's managing it for the years and years after. Next slide, please. So here at the University of Pennsylvania, we use Epic, which many folks do, and whatever your EMR is, it was very much a requirement that whatever third party we were going to utilize needed to integrate into our EMR, that we didn't want patient data being left out there. There's lots of concerns for potentially stealing a patient data and the ability from a medical legal standpoint to make sure that it's appropriate. So, you know, really as a requirement for us using a third party would have to integrate into our EMR, in this case, Epic are rebranded as PenChart. And so next slide, please. So I mentioned medical legal concerns. You know, we tried to not practice medicine based on the possibility that you could get sued despite the fact that I work in one of the most litigious cities in America. And I can't tell you how many times I'm going around on a patient at noon and they're saying, are you on this drug? They're hearing commercials and they're looking at me, you know, literally while I'm talking to them. And so it is very important for patients and honestly for us too, to make sure we're doing the right thing. This is an actual message from a patient that had a loop monitor, is a snowbird who lives down in Florida, was in AFib and we didn't know about it. And there was concerns that they would have had a stroke because we were not monitoring this data as well as we can. Patients literally think I'm looking at the computers 24 seven to see if they're going into AFib. And so that's the expectation from patients. And if you put a monitor in someone and then they have an arrhythmia and you don't notify them of it, cause you don't know, you're on the hook for that. And look, we're all trying to do the best for our patients. And the last thing I want is my patient to have a stroke, was AFib who's not on any coagulation that I don't even know about. This is a huge deal. And it is obviously was a big part of when we spoke to our administration about utilizing a third party to help us take care of these patients. So next slide. AI and medicine. So AI and machine learning has really taken off over the last few years. And I think that the use of a third party that can potentially utilize this is very important. We'll hear more about this later. But I think that any way that we can use computers and machine learning and AI algorithms to help us do this better so that we're not doing a lot of manual work is very important. So these are all the little things that end up turning into a big thing when we decide to party with the third company. Next slide, please. So this is where we sort of stumbled upon Octagos. And again, I'll be introducing Dr. Bonsal in a little bit. But many years ago, we were on an advisory board and I was sitting in between another electrophysiologist and Dr. Bonsal and Shanti and him were talking about the struggles that they have with remote monitoring. And I'm sitting here in both ears listening and I'm like, that's my struggle right now. And that's our struggle here at Penn. And then I learned about Octagos and learned about how they pretty much put together all of the things that I just mentioned. And that's why we have been utilizing them for the last few years and are very happy with them. Next slide, which you'll hear more about in just a little bit. And this workflow allowed us to integrate all of these things that we talked about. We personally like the idea of not just a computer and an AI algorithm giving us information. We like humans looking at the data too. And so, Octagos has the ability to do both of those things. They formulate all this data, they give it back to us. So we use their full service, not just their software program. And then this allows us to really increase our amount of transmissions and we've gone to significant improvement in that data. Next slide, please. I mentioned Epic integration. This was very important to us and to many health systems that this data is housed also in our own EMR as well. And the ability to potentially read and look at data and also to gather what medications they're on. Do they have left atrial appendage closure? Do they have the things, not just looking at the rhythm issues, but tie it in to the actual patient themselves. Next slide, please. So money, I mentioned that this is important. And we've looked at our own pro forma. This is actually from a practice in Atlanta. And you can see that this actually makes a significant amount of money for your health system to the point where we actually used revenue from Octagos and the use of a third party to hire more staff. Many staff are actually worried they're going to get fired and lose their job if you use a third party. We actually, it's the opposite. You can actually hire more staff and staff that are actually doing more clinically relevant jobs and less sort of paper pushing and not doing what makes them happy. They're engaged more in patient care and they actually enjoy it significantly more. So I've not lost a single staff member. In fact, I've hired more staff to be able to help me do more practice-based projects and doing new, exciting things which I'll briefly talk about as well. Next slide, please. Yes, yes. What is your staffing ratio now that you have third party? Yeah, so it's a good question. And so we currently have, and again, we follow probably close to six to 7,000 patients. I have four dedicated FTEs in terms of techs slash MAs that helped me with this. And then we also have a dedicated APP that's assigned on a daily basis to take help with alerts in addition to our physicians as well. So that's not even close to what your guidelines have recommended that we need to have, but we're very capable of doing those things because we use a third party. Quite frankly, without that, we would drown in this data and honestly, it would be a ticking time bomb for us and for many programs that have the same issue. Yeah, and I completely endorse that. I mean, we're unable to hire enough staff to cover three FTEs per 1,000 patients. Yeah, and honestly, it's difficult. You have to train them. And if they decide to leave for whatever reason, you kind of start back to the drawing board, so to speak. And honestly, this became not just a business decision, but a very important. Yeah, so I think this is a universal challenge having the staff to maintain a device clinic. So we need all the help that we can. We have to adhere to the guidelines. It's very important. Yeah, agree, agree 100%. And that was the conclusion that we came to. We said either we're gonna triple down on efforts to hire staff and do this internally or partner with a third party company like Octagos to be able to utilize this as well. But you pivoted to a third party before the guidelines were issued. So how was that received by your administration? Yeah, it's a good question. It actually was better received than I thought it would be. And it's largely due to a combination of the medical demand, the possible medical legal ramifications of us not following it, looking at the financial improvements by more than doubling the compliance of these devices, not to mention that, and I'll show this in a couple of slides, we were not following heart failure metrics and following other things that are actually billable revenue that we weren't even utilizing as well. So, I mean, quite frankly, I'm embarrassed to say we had dead patients on the portal. We had patients that were following from another institution that we weren't correctly following. It was not what we considered to be what the University of Pennsylvania is. And that really what started with remote monitoring being kind of a, we're trying to do it, but not really doing it to honestly doing a really good job in terms of managing these patients was a combination of obviously our own internal team, but a big help from, you know, Octagos. And so, you know, this is showing just some of the analytics that comes from the platform. You know, when I think of analytics, I think for by my Philadelphia Eagles are gonna go for it on fourth and one instead of kicking the field goal. But it turns out that analytics are also very important in terms of our patients and how we can utilize this data. And so it's really not just the transmissions and the interpretation of information, but going really a deeper dive into how we can utilize the platform. And honestly, we're just scratching the surface of some of the stuff that I believe we can do with this. And so, next slide. And Dr. D'Souza, you've used a number of platforms even before using Octagos. Can you describe some of those challenges? Sure, yeah, we started, that's a good question. We've gone through more than a few to be honest. And so, you know, we started with something that was homegrown from a previous CRM rep who wanted to, you know, contribute. We, and truth be told now, it's sort of the writing's on the wall, tried to utilize PaceArt along with our own internal staff. And that really did not go well, even though despite a lot of effort internally to try to build that integration and that platform. And we trialed a few other companies and quite frankly, just weren't satisfied. And now, and I can say, because I get all the complaints from my colleagues on a regular basis, they're not happy. It's the happiest they've been in years in terms of being able to partner with, you know, with a third party and with Octagos. So, yes, we trialed all of them. And obviously my recommendation is always to do your homework and make sure that you're happy with what are the needs of your institution. But what I particularly liked in terms of that partnership was that Octagos worked with us. If there was something that I wanted that was different or my team wanted, you worked with us to be able to build it and continuing to build it. I'll go through the last two slides relatively quickly because I know I'm over time. But again, you can gather a fit burden from your patients. You can figure out whether they need an ablation or whether they need a watchman as well. And again, just barely scratching the surface of utilizing this in terms of our, you know, our practice. Next slide, please. So I mentioned recalls. These are very important. And this was one of the other things I brought to my administration. We were going through multiple recalls. Every company has them. These devices are man-made. They're gonna have issues, but it is incumbent upon us to be able to utilize those recalls. So the most recent one that I mentioned, we reached out to Octagos and said, can you guys utilize your platform to tell us how much battery longevity and stratify these patients that are on recall to figure out who are the highest risk to get them in? And you're able to do that. And so these are the important things that when we need to very quickly query our data, go back to the patients, send them letters, send them messages, getting them into clinic, make sure nothing bad happens to them is very important. So again, this is another piece of the puzzle that our administration agreed that we needed to be able to provide the best care for these patients. So next slide, please. So price negotiation, I mentioned money and we can utilize this to say, hey, we know that we have a whole bunch of Medtronic devices that are going to reach ERI in this timeframe. Let's go and do a bulk order purchase with them and save some money for the health system. And let's utilize that money to buy more equipment or to be able to hire more staff. These are the different kinds of QI programs we've done here at Penn by utilizing a third party because we didn't have this data. So my administration gets worried if they're going to buy a hundred pacemaker cans and have them sit on the shelf if they're not going to be utilized. But I can use this platform to say, we're definitely going to utilize them, go back and try to get a bulk deal so that we can save money. So these are all little things that add up to a big thing in terms of keeping the ship afloat and keeping us in the black when a lot of health systems are struggling, to be honest, with this as well. Next slide. So I mentioned some heart failure data. I'm not, I'm going to briefly cover again, we do Cardio MEMS and we do a lot of other devices. And my, I mentioned the open architecture as we get new devices and new toys and EP, which we love, we need our platform to be able to integrate that data. So Cardio MEMS, wearable monitors, Apple Watches, Cardio Mobile, whatever it is that I get data in, I need our platform to be able to utilize that and streamline it. And again, we built a Cardio MEMS platform with Octagos to be able to help our heart failure colleagues with this as well. Next slide. And so, again, this is just showing that. Next slide again. And so, you know, I can't take credit for this, to be honest, even though I want to. One of our wonderful nurse practitioners said, you know, Ben, we're not looking at any of these heart failure metrics. We're getting patients admitted to the hospital and their, you know, their scores on their heart logic are through the roof and we're ignoring that data. So she correctly built a collaboration between our heart failure colleagues and we utilized Octagos as a platform. And I went to Shanti and their team and I said, I want you to design a specific spread sheet that looks only at heart failure. My heart failure colleagues don't want to see impedance data or arrhythmia burden, or they don't even know what a threshold is. And I, honestly, I'm not capable of dealing with the heart failure metrics. I want my heart failure colleagues to do that. And so that's what we did. And we gathered all this data, we published it and ended up, you know, utilizing this to get even more revenue to hire more. We're actually in the process of hiring a combined EP heart failure nurse who can help triage our device data and our CardioMEMS data as well. So all of these things generate revenue and they're very exciting to me in terms of QI initiatives that, you know, we can utilize and replicate. And so these were all the things that were very important to us when we decided, you know, this is what we wanted in terms of a partnership. And it should be a partnership when you utilize a third-party company. So next slide. That might be it. So that's my last slide. And so I want to turn it over to Dr. Boncil. I will say that when I looked at many of these companies, I appreciate that an electrophysiologist is the one who started the company because he actually understands what is the struggle that I and we all have in terms of, you know, just a day-to-day struggle. And so I'm going to turn it over to Shanti so that he can speak a little bit more about how- Can I ask a question now? Yes, go ahead. Yeah, Dr. Susan. So very nice description of your experience. I mean, this is very sophisticated. So in generally, connectivity, which underpins remote monitoring, obviously, is very haphazard and we both recognize that. So do you have an idea of your connectivity levels on a day-to-day basis, the proportion of patients who maintain a high connectivity since you switched to a third party? Yeah, it's a good question. And so you were correct. And like, you can say that you do remote monitoring, but if your patients aren't connected, they're not sending the data. And again, I didn't cover this, but, you know, having a patient engagement team that can call my wonderful nine-year-old patient who lives down in Cape May, New Jersey to make sure that their device is plugged in. You know, not all devices are completely wireless. Not everyone wants something on their phone. It is, it's important. And so I will say that we went to probably less than 30 to 40% prior to Mal, close, more than 90% in terms of connectivity, which is really revolutionary in terms of being able to manage these patients. And, you know, on an almost daily basis, we get patients that reach out that they're having issues with the app on their phone or having this, and then I can, instead of me or my staff taking the time to call those patients and get them connected, we utilize Octagos to do that. And so they help us with getting the patients hooked up, or if they went down to Florida and they didn't bring their monitor, to help them get connected to the company to get them a new monitor and those kinds of things. And so these are all the things that I think are very important for anyone who's deciding to utilize a third party to help them, you know, do better at this. And so it has been significantly improved. Great, thank you. Of course. All right, I'll turn it over to Shanti. Yeah, well, thank you so much, Dr. Verma and Dr. D'Souza for those two talks, very enlightening. With Dr. Verma, he's really an expert when it comes to remote monitoring, wrote some very seminal papers on remote monitoring and now guideline-directed remote monitoring. He reminds us that remote monitor is a class 1A indication. It's like putting a pacemaker in for complete heart block. You just would not do it. And reaching that goal of three FTEs per 1,000 patients is a difficult challenge, right? Even in the big city like Houston, where we're based out of, to find the right level of employees that are educated sufficiently enough in this field is hard to do. And that's where I think it's critical to our third-party companies such as us come in and help. And Dr. Ben D'Souza brings that real-world experience of third parties and what it is like to be in the trenches with mid-levels and other doctors looking at this complex data. So thank you very much for those two talks. By the way, I don't have any slides. There's a QR code. Feel free to use that if you'd like to see the platform in more detail. I wanted to talk a little bit about my own personal experience. I'm an electrophysiologist out in the Northwest part of Houston, Texas. I started my practice several years ago and I was one doc, one doc starting a practice. And that came with the opportunities, but a lot of challenges as well. I would put pacemakers, defibrillators inside of patients and inevitably they would come back to me and say, hey doc, did you know I had an episode of atrial fibrillation? Hey doc, did you know I had a shock? And for a person who is responsible for knowing that was going on, I didn't know. That data was going to manufacturer's clouds, difficult for me to look at, analyze, aggregate. And so it's a very uncomfortable conversation for me. In addition, I knew our team was spending a lot of time aggregating this level of data. So the team was spending a ton of time and yet failing on top of that. And last of all, I knew I was leaving revenue on the table. And as a small practice, I knew this meant a lot. So I put together a technical solution for my own clinic, found that I was able to deliver better care. Two, I was able to save the team a lot of time. And then three, I was able to generate revenue that I didn't see before. And so I knew we had something special. We started commercializing Octagos Health back in 2020. And since then we've grown into 200 plus clinics and hospitals throughout America. We're in 30 plus states. We're the fastest growing company in remote monitoring. And part of the reason that we've been successful in this approach, one, we've always done a clinically based approach. We are here for electrophysiologists. We're here for mid-levels. We're here for nurse practitioners to try to deliver the right data at the right time and really try to make sure we have an impact on the healthcare system as a whole on all of those three things, saving time, generating revenue, and bringing the best clinical care. Our company is focused on a lot of different areas than most other companies are. We've employed AI to be able to understand this very complex data. Even for a normal transmission, it can take 10, 15 minutes to go through a hundred page report, even though it may be completely normal. And for complex report, yes, you may miss things if you don't utilize AI like we do. EMR connectivity, we're a big believer in EMR connectivity, being able to integrate into virtually any EMR system, Epic, Cerner, Athena, ECW, and many of them we can integrate almost overnight. We believe in the mantra of no data left behind, which means that every piece of data we're pushing, PDFs, billing, and pulling from the EMR system, things like medications, past medical history. This level of connectivity is unheard of at the extent that we can do it, how sophisticated we can do it, the level of quality we can do it, and certainly the price point as well. We know the physicians are complex. They're going to want to see lots of data, including implantable data, including wearable data, including RPM data. And our goal is to be able to aggregate all of these things into one platform. Probably the cardiologist is the one physician that sees more data than just about anybody else. And being able to find a centralized location to see this data, be able to synthesize this data, look across multiple data streams is absolutely critical for you to be able to tell the patient what to do next. Having the right data at the right time without unnecessary alerts, without alert fatigue is absolutely critical for you to be the best physician, the best mid-level out there. We strongly believe in data migration, bringing in PASART data into our platform, bringing in other legacy data such as Geneva. Even modern systems as well will bring in their data as well. So we have no problem bringing in legacy data, taking the whole SQL database, being able to import every field. And for us, we've never charged a dollar for that type of data migration or that EMR connectivity. And so really meeting you and the clinic where the needs are. For us, guideline-directed remote monitoring is the basis for everything we do. We want to make sure that we are delivering on the promises that we talked about. And these recommendations came out last year, but remote monitoring has been a Class 1A recommendation for a long time. And it is a critical piece of the care that we deliver as electrophysiologists and as cardiologists as well. And so those are some of the remarks I wanted to put out there. Happy to take questions and field questions from the audience or any of the panelists. Thank you, Dr. Brahma and Dr. Boncil. Go ahead, Dr. Brahma, you had a question? I was just going to say, I want to congratulate you on this enterprise. It's a terrific enterprise. How do you see it evolving? You mentioned wearable data. I mean, the guidelines so far have concentrated on the implantable devices, and that's taken a long time to shift the needle in that space to get connectivity, to be able to analyze the data. Where are you positioned with the wearable data? Because there's probably a lot more data than the implantables provide. Yeah. First, let me just comment a little bit about the implantable side. I think there's still a lot of green space out there. There's only maybe a million patients out there that are currently connected by a modern remote monitoring company out of 10 million possible devices. So there's 90 million patients who are addressable that really don't have that great connectivity, a system that they can really understand the complex data that's coming in and to make it actionable for physicians. And so I think there's a lot of runway here in being able to manage these complex devices, which arguably are the most complex that we implant into physicians. And being able to do multi-modality, I think, is where the field is going to be evolving, both on the wearable side and on the implantable side. We see it as much more of a spectrum than a hard shift when somebody goes from a wearable device such as an MCOT or Holter onto a loop recorder. There used to be a big divide between the implantables and the wearables, and now it's just a continuum of care from the patient having palpitations, suspected arrhythmia, to have confirmed AFib through an MCOT, now going onto a loop recorder, and then going onto ablation. And so being able to get those critical insights as they progress through this spectrum is going to be very, very important. And none of this is possible unless you can actually get it connected to your EMR system and be able to transmit that data to your colleagues. And so systems like this are absolutely important. We're really the last mile for the data after they're done with the manufacturers, who in many ways were symbiotic with them, because at the end of the day, they're interested in getting the pacemaker or the device into the patient, and then they want to leave the rest to someone else. And that's where companies like us come into play. So I will say that, you know, when I actually talk to patients about implanting a device, I tell them about remote monitoring, explain what it is. And I do tell them that we partner with a third-party company and explain, you know, what Octagos is, especially if they see their name in the, you see your name, you know, on the spreadsheets that they get on their, so the patients get either one monthly or three monthly through, you know, MyPenMedicine, which is our version of Epic. They can actually read the reports, everything that's there as well, and they appreciate that. And so, and I do tell them that, you know, it was started by, you know, Dr. Bonsall down in Houston, and I tell them that I wish I had that idea, because I'd be a lot more well-off financially if I had come up with it. So yes, I also applaud you in this effort. And, you know, there's a question for me, actually, in terms of did we migrate PACER data to Octagos? And the answer is, we did sort of. So when we decided, and I will say, we spent over a year of meetings, probably every week for at least an hour, talking about this integration. It was very time-consuming. That's time that I won't get back, you know, to spend with my children and my wife, but it is what it is. And so after all of that, I mean, we were manually entering in serial numbers and doing a lot of manual data entry on our end to be able to get this data in. And then when we started the process here at Penn, just utilizing it, it was a disaster. And we just could not use the system to the best of our abilities. It created more work for us. And so we ended up going with another third party that is no longer a company that basically built an agnostic kind of PACER, the Java-based platform, which we were also not happy with. And so we wanted something that was web-based that could be accessed from wherever and could integrate into Epic, which is our EMR. And so, yes, we pulled the PACER data and, you know, Shanti's team and the folks from Octagos pulled that data. I will say they have a really wonderful onboarding team because we're, you know, we're the University of Pennsylvania. We want it the best. And so when we beat them up pretty good, and I will say that, you know, Chris and Sybil and the team over at Octagos, they dealt with all of our nuances of what we wanted to be. You know, us and EP were very analytical. We like to really go down to the nitty-gritty and we wanted that ability. But it actually was about the most seamless transition that we've done. And we've done multiple with previous companies to be able to get to where we are now as well. So, yes, we did. And I did have a follow-up question for Shanti. With PACERT now no longer being, you know, even an option for people, what do you foresee in terms of the options for, you know, for many clinics that feel like they're probably going to be hung out to dry, so to speak? Yeah. So PACERT is no more. It is a forgotten child of Medtronic. And they, truthfully, even before they officially announced it, it was neglected for years. And the PACERT was built in 1985. That's when Back to the Future, the movie, came out. And so it's been around for 40 years. And in 40 years, technology has evolved quite a bit. And so the important point to make to those who are on PACERT is that you have options. And PACERT data is very easy for us to migrate. It's a SQL database that resides on your server. It's a copy function to bring that data over to us. We have built out special functions to be able to take every single data point that a patient has, whether it's previous PDFs, previous images, previous information about their hardware, and being able to import all of that data into the Octagos platform. And then we layer on the new incoming transmissions that the patient has as well. So you're looking at potentially terabytes worth of data, thousands of discrete data points we're able to bring on board. And so the really important point to these clinics is that you're not alone, you do have that support, and you don't have to settle. And I also had a follow-up question for Dr. Varma. The guideline, the consensus statement and guidelines you presented, what do you think are going to be the true implications for them for many of the practices across the United States, especially ones that maybe are not utilizing a third party? Yeah, I mean, the purpose of these guidelines, extending from the ones that were published over 10 years ago, was really to identify the pain points that had really sort of impeded adoption of remote monitoring. That's one recommendation. So it was identifying the pain points and trying to provide solutions and trying to think this through, often without information, without data. So you see a lot of recommendations, class one recommendations with only expert opinion, no data. So I think this is an important statement. I think the committee was brave in issuing these recommendations. And I think most of them hit the mark that these are pain points and they need to be resolved. And once you resolve, once you address these, then you'll have an effective service. But the underlying issue is staff, as we've discussed. To adhere to all of these, including patient education, ensuring connectivity, managing the data, is a huge amount of work. And none of us can recruit three FTEs per thousand patients. So that's where we are. So I think the problems have been identified. The solutions may not necessarily be complete at this point. Agree completely. And so just as a follow up to that, there's a question in the chat for Dr. Bonsall. So we've all identified this is in the guidelines. It's important. It's important for patient care. We've also identified that staffing is an issue for almost every place in America and across the world in terms of doing that. So using a third party makes sense. What separates Octagos from some of the other options out there? So I'll let Dr. Bonsall answer and I can certainly chime in as well. Yeah. Well, there's a couple of things and probably the last question we'll have to take. But one is our AI to be able to take this complex data, be able to synthesize it, makes our reports far more accurate than just a pure human approach. Two is EMR connectivity, the level and sophistication of EMR connectivity. Three, our cost structure. Oftentimes our cost structure is way less than most other companies are. And I did want to get back to a previous point that somebody had brought up around patient engagement. We're one of the few companies that do a lot of work with patient engagement. We make close to 70,000 phone calls every month trying to make sure patients are connected and transmitting and patients really understand the value of remote monitoring. We do letters, SMS messages to patients. We have a patient facing app that's going to be coming out very shortly. And thankfully, all of this great work that our engineers, our team are doing are supported through a Series B funding that we received more than $50 million last year. And so we're in it for the long haul. And at the end of the day, we're going to deliver for the clinics and the patients. Thank you, Dr. Bonsall. Yeah, I agree with many of the things that you refer to. In addition, as someone who's making the decision for our team as to whether to utilize a vendor, I mean, you mentioned costs, like we did not want any hidden costs, costs related to integration with the EMR. We have many patients that call in with palpitations and they're having a non-billable transmission and want to know what their monitor shows. We don't want to be billed for that because we can't bill the patient for that. So we're not making money, but we're providing patient care and you guys are able to do it. I will say that having a team in place to help with connectivity, having the patients have that as a resource is very important. I mean, when I'm on call, I'll get calls from you guys that says, hey, this patient had an ICD shock or based on our criteria to alert us to that. And so I think all of these things are very important. What I'm super excited about is heart failure. And I'm one of the few electrophysiologists that actually does enjoy partnering with our heart failure colleagues. Most of us are pretty siloed and I just want to go back to my EP lab and ablate stuff. But I think that this is going to be a huge unmet metric and very important to health systems as we know that we don't get paid for readmissions via Medicare for these patients. We need to keep people out of the hospital. The guidelines have clearly showed that minimizing hospitalizations for these patients is important. And so these devices, as more and more devices can read and interpret heart failure earlier in the disease course, us managing that data is even harder than it is for managing arrhythmia data. And so I think that I had an interest and our team had a project and we brought it to Octagos and they worked with us to be able to do it. And I think that for me, as I had mentioned earlier, it's all about partnership. And so we think anytime you're going to be working with any company, I would recommend that you utilize that partnership as much as possible. So I think we're up on time and I believe we've answered all of the questions. So I wanted to thank both Dr. Barman and Dr. Boncil for a wonderful conversation. And actually, it looks like one question just came in. Give me one second. So the question is, and I'll give this to you, Dr. Boncil. So what benefit could Octagos provide for a clinic with 10% loss to follow-up due to missed remotes? And does heart failure monitoring for CRTs and ICDs meet criteria for heart failure management? Yeah. So heart failure monitoring is indicated for CRTDs and ICDs, certainly. And these are patients with low EF. And so you can certainly make that decision on a case-by-case basis as well, but most of those patients will require it. And 11% is a good number of patients. And I suspect that number could even be higher than that. And so making sure your patients are connected, but having a platform to be able to aggregate this level of data is important to show also to the patients that you're looking at this data and for them to know that you care about their device. And this is the new level of expectation of these patients and in today's day and age, certainly post-COVID. Yeah, I agree with all of that, Chauntee. And Dr. Barman, any comments? And we are at the top of the hour. I do want to thank Octagos for sponsoring this terrific webinar. I also want to thank our panelists. As a reminder, you can download the presentation. The link is in the chat. We're going to be recording this and pushing this out to the membership via our daily news. So be able to look for that and access it in the academy. But once again, thank you very much. Everybody have a great day. Thank you. Thank you so much. Thanks, everybody.

remote monitoring

cardiac care

guideline-directed

cardiac implantable devices

AI integration

EMR systems

Octagos Health

data management

healthcare technology