The Impact of Direct to Consumer Wearables in Pediatric Electrophysiology Telehealth Clinics: A Real-World Case Series

The Impact of Direct to Consumer Wearables in Pediatric Electrophysiology Telehealth Clinics: A Real-World Case Series. Roelle L, Dalal AS, Miller N, Orr WB, Van Hare G, Avari Silva JN. Cardiovasc Digit Health J. 2020 Oct 7. doi: 10.1016/j.cvdhj.2020.09.005. Online ahead of print. PMID: 33043315 Free PMC article.   Take Home Points: Direct to consumer wearables have played a pivotal adjunctive role in the remote diagnosis of arrhythmias, especially during the current pandemic. These tools will impact the implementation of telehealth, particularly in pediatric electrophysiology telehealth clinics. Two prominent D2C devices that provide real-time electrocardiogram (ECG) data include the KardiaMobile (AliveCor, Mountain View, CA) and the Apple Watch Series 5 (Apple, Cupertino, CA). Developing simple workflows to securely transmit and integrate these electrocardiographic tracings into the electronic medical record (in these cases, use of the MyChart application and the EPIC electronic medical record) have been described. There are important economic, reimbursement, workflow, and data integrity considerations that should be more thoroughly explored in future studies. Patient and physician workflow for obtaining and transmitting electrocardiogram (ECG) tracings from direct-to-consumer (D2C) wearable devices. The gray workflow, or “Patient Workflow,” clarifies the stepwise approach the patient takes to obtain the ECG tracing, review the tracing, and upload the tracing via the EPIC MyChart application. The screen shot images associated with each step demonstrate what the patient sees at each step. The orange workflow, or “Health Care Team Workflow,” delineates how the message appears in the EPIC inbox (Patient Advice Request>>Non-Urgent Medical Question), where the attachment hyperlink is shown, and how to reply to the patient. AF = atrial fibrillation; VT = ventricular tachycardia. Commentary by Khyati Pandya (Augusta, GA), section editor of Congenital Electrophysiology Journal Watch: The current study describes two pediatric cases using the D2C cardiac devices and discusses how they have positively impacted the telemedicine and patient experience. The authors describe two individual patients each of whom benefitted from a different D2C cardiac device. The first patient was a 20-year-old African-American man who was diagnosed at age 15 with paroxysmal atrial fibrillation. An extensive workup revealed a normal echocardiogram and a diagnostic electrophysiology study demonstrated no inducible arrhythmias. Over the next several yearly office visits, he reported having clinical episodes of AF approximately once a year, lasting seconds to minutes, that always spontaneously converted back to normal sinus rhythm. There had been no documentation of these episodes. The patient had a telehealth visit with his pediatric cardiac electrophysiology team, during which, he reported having episodes of “skipped beats” that lasted for only a few seconds, but no concerns for AF. ECG application was setup by the team and he was encouraged to obtain a real-time, “on-demand” ECG tracing using his Apple Watch (figure above). This tracing was then e-mailed to the team, by whom a real-time assessment of his heart rate and rhythm could be performed, confirming that he was in normal sinus rhythm with a rate of 89 beats per minute (bpm). In addition, the team worked with the patient to establish a workflow for submission and evaluation of future tracings using the electronic medical record, in this case using the EPIC MyChart functionality, whereby he could securely send tracings and questions to his health care team and the team could reply using a HIPAA-compliant mode of communication when the patient had symptoms concerning for AF. The Apple Watch Series 5 has the ability to provide continuous heart rate trends in addition to obtaining a single-lead ECG, or “on-demand” recording. The second patient was a14-year-old female patient with a past medical history of hypothyroidism who presented to the emergency department with an irregular heartbeat, after having tracked her heart rate by pulse assessment and pulse oximeter, between 80 and 140 bpm and associated intermittent chest pain with palpitations. She was diagnosed to have ventricular tachycardia (VT) arising from the right ventricular outflow tract (RVOT). An EPS and transcatheter ablation was acutely successful for radiofrequency ablation of her RVOT-VT with recurrence of her clinical VT several hours post procedure. The patient was started on oral verapamil and titrated to a therapeutic dose of 120 mg every 8 hours, with significant decreased premature ventricular contraction (PVC) burden and VT. An AliveCor KardiaMobile for assessment of her heart rate and rhythm at home during symptomatic events. Teaching was provided prior to discharge for family to understand the differences between sinus rhythm tracings and VT on the KardiaMobile, as well as workflow teaching for transmission of tracings using MyChart to allow for a secure, HIPAA-compliant transmission. After hospital discharge, the patient/parent transmitted multiple ECG tracings from the KardiaMobile demonstrating normal sinus rhythm, PVCs, and nonsustained VT (Figure 1), which has helped guide her outpatient medical management and drug titration. After consecutive tracings demonstrated nonsustained VT, the decision was made to pursue repeat EPS. Following repeat ablation of her RVOT-VT, follow-up KardiaMobile tracings demonstrated normal sinus rhythm with sinus arrhythmia with no PVCs at rates of 62 to 74 bpm. Symptomatic tracings recorded for concerns of chest pain or skipped beats confirmed sinus rhythm with no PVC recurrence. The authors rightly point out that integrating new, commercially available technologies into electrophysiology telemedicine clinics will be an important value-add to deriving the most benefit from these types of visits by improving physician-patient communication, diagnosis, and treatment of cardiac arrhythmias. Pediatric patients may be ideally suited to these visits and technologies, as they are often technologically savvy. Additionally, pediatric patients may have access to their parent’s D2C wearable device for obtaining ECG tracings. However, two important hurdles, as identified by the authors, are the accessibility of these devices to the vast majority of patients and economic barriers that may represent a financial hurdle to widespread adoption and implementation of these devices. More importantly, although the KardiaMobile is cheaper, the Apple device offers a significant number of additional functions by not just being a fitness partner, but also providing the ability to make calls and providing a plethora of useful apps that can help an individual attain a heart healthy lifestyle. The two patients described in this paper were older adolescents who are typically capable of seeking attention from health care providers on their own. Exceptional situations such as arrhythmic syncope, a younger child who is likely to panic during an arrhythmic episode or a specially abled adolescent, would not be able to use the KardiaMobile as the device does require coordination in the form of placing fingers on a sensor enabled pad in order to record and transmit the rhythm during symptoms. An Apple watch maybe more useful in these situations, as the automated detections would be stored as long as the watch is worn. Other questions that remain to be answered are the ability to detect these rhythms in individuals with conditions such as dysautonomia, Raynaud’s phenomenon, hyperhidrosis etc. that may interfere with the ability of the device to sense the pulse and therefore the heart rhythm. These individuals may benefit from the conventionally used event monitors with direct application of patches on the chest. KardiaMobile may represent a more economical option for patients that depend on insurance or FSA reimbursement to cover medical costs. Both systems require a paired smartphone for full functionality, which impacts the total cost. Patients and families with more disposable income may be more likely to invest in a product that will provide insight into their symptoms, diagnosis, and treatment regardless of insurance reimbursement. Additionally, for some patients, there may be personal stylistic preferences that may drive decision-making about cardiac wearables. Teenagers are often embarrassed to used devices that may draw attention from other students in a classroom setting and may end up ignoring their symptoms or waiting to transmit after class by which time the arrhythmia may have terminated. An Apple watch maybe better suited in these instances to retrieve the rate and rhythm recorded during symptoms. Thus the diagnostic abilities of any wearable device, is significantly dependent on patient compliance. The authors mention encouraging patients to obtain an ECG tracing on the day of and prior to their telehealth visit, and to utilize the MyChart application, embedded within electronic medical record, EPIC, to upload the data for review prior to/during their telehealth visit. However, institutions or facilities that have EMRs other than EPIC, may not be able to talk to wearable monitors, further limiting user friendliness. Comparative studies assessing diagnostic quality of the Apple Watch Series 5 ECG compared to standard 12-lead ECGs would provide important data to support its use in an electrophysiology telehealth clinic. In addition, various other wearable devices should also be compared with each other across different population subsets to understand the benefits and possibly enlarge the scope of usage.  


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