In Depth: A Conversation with Heart and Vascular Center of Arizona
Arizona Physician sat down with Nathan Laufer, MD, CM, FACC, FCCP, FACP, FRCP(C), founder and Chief Medical Officer at Heart and Vascular Center of Arizona to discuss big data and its impact on cardiology and his practice.
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ARIZONA PHYSICIAN: Does your practice leverage any data from outside sources?
DR. LAUFER: We do. We’re involved in the Merit- Based Incentive Payment System (MIPS), and we do quality metrics using the American College of Cardiology Pinnacle Registry. We can pick the criteria that we'd like to submit. We have had a 95 to 100% success rate. If we don't measure up, then we would take a cut in Medicare fees. We have always gotten an increase by doing these submissions.
ARIZONA PHYSICIAN: Which wearables do your patients use and would you say that they work well?
DR. LAUFER: Wearable devices have a wide range of potential clinical applications, including screening for atrial fibrillation, hypertension, obstructive sleep apnea, heart failure, and cardiovascular fitness. As the use of wearable devices grows, we need a multifaceted approach to integrate these technologies effectively and safely into routine clinical practice. We also have implantable defibrillators and pacemakers. We have loop recorders that measure arrhythmias. Each company has its own website, and it becomes very time-consuming for us to do this on our own. We did that for many years but now have a company that collates all the data from implantable devices and sends us alerts.
Heart & Vascular Center of Arizona by the Numbers:
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Founded in 1998
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74 Employees
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Includes medical assistants, technicians, billers, schedulers, authorization specialists, and front office staff.​
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8 Physicians
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10 Nurse Practitioners
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4 Locations
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Central Phoenix, West Phoenix, Globe, and Show Low​
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Services include:
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Non-invasive, invasive, and interventional cardiology, electrophysiology, nuclear cardiology, cardiac PET scans, echocardiology, and peripheral vascular imaging.​
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Visit Heart & Vascular Center of Arizona at www.heartcenteraz.com​
ARIZONA PHYSICIAN: Does the evidence show that tracking data would help to prevent serious episodes like cardiac arrest?
DR. LAUFER: It depends on which implantable device we get data from. Heart monitors or loop recorders are designed to find rhythm disturbances that occur so infrequently that we cannot find them on routine 24 hour or 2-week wearable monitors. In patients with a history of atrial fibrillation we may want to know if our medication is working. If they have had an ablation procedure, patients may not feel their recurrent atrial fibrillation. This is an excellent way of monitoring the patients. We do pick up quite a bit of atrial fibrillation in patients who may have had a previous warning stroke, or TIA, where their rhythms in the hospital are completely normal. We may find atrial fibrillation a month or two later using these implantable devices. We can also pick up other rhythm disturbances that can cause passing out spells and treat them appropriately.
ARIZONA PHYSICIAN: Are the devices paid out of pocket?
DR. LAUFER: The implantable loop recorders and wearable monitors are covered by insurance. We sometimes have to fight to get authorizations and are usually successful. Other patients may need a pacemaker. Today, all implantable devices come with a transmitter at the side of the bed that transmits data through a third party to our computers. We’ll know if patients have fast rhythms, slow rhythms, or ventricular tachycardia. We also have defibrillators that we implant for patients who have weak heart muscles or have had a cardiac arrest.
ARIZONA PHYSICIAN: Does the data just tend to grow and grow? Is it too much?
DR. LAUFER: It depends on what we do with it. For each individual patient, it is fine. They're subcategorized in their electronic records, and we know how to find the data we need. We need bigger servers all the time, and we're paying a fortune in IT support to keep it all functional in the cloud. Once you start paying for IT support, it never stops!
ARIZONA PHYSICIAN: Does it help to have the patient more involved in monitoring their own care?
DR. LAUFER: It’s very helpful to have patients monitor their weights and blood pressures. However, they don't have access to the transmitted data that we have access to. In the future, more patients will be able to track more data.
ARIZONA PHYSICIAN: Has cardiology improved or declined with greater use of data?
DR. LAUFER: I think cardiac care has improved greatly with all the monitoring data we now have available. However, managing our data is very cumbersome, and there are only so many hours in the day. The company that monitors our implantable devices was offering to send all kinds of alerts to the cell phones of all our physicians. We said that there is a point in time where we don't need all this data immediately. We need to sleep at night. For something urgent, we will get alerts. We have an infrastructure in our practice with triage nurses and nurse practitioners. They field phone calls. They look at transmissions. We also have a full-time device nurse who does in office device monitoring and imports the data to the patients’ charts. So, we have a huge costly infrastructure to be able to take care of our patients. However, insurance companies keep beating us up on reimbursement. When the overhead is higher than the revenue, we're going to have a major problem.
ARIZONA PHYSICIAN: What do you think about security and privacy of data?
DR. LAUFER: Security has become much tighter than it was in the early days. However, there is always a concern that hackers may be able to get in and turn off a defibrillator just like they can start a car remotely. We routinely assess our cybersecurity with our IT firm looking for gaps. We also have cybersecurity insurance to protect our network and electronic medical records. Ransomware has happened to hospitals. Very few want to publicize that they've actually paid a ransom because it's bad for their image. Hospitals are bigger targets than cardiology practices. One of the things that was supposed to be a promise of electronic medical records is that all these different systems would be integrated at some level. That has never really come to fruition. There is no interoperability. All these computer systems are potential gaps where security could be compromised.
ARIZONA PHYSICIAN: Are we heading in the right direction?
DR. LAUFER: It’s all very complex and big data means ‘Big Brother’ is watching, which is probably why all these electronic records were mandated in the first place. In the old days, I would sit with a Dictaphone in front of a patient. They would hear everything I was saying, and I'd be looking them in the eye and we'd have a conversation. The dictation would then be transcribed. I would then sign off on the record a day or two later and it would get mailed to the referring physician. Now, instead of a 2-page note, it's a 10 to 15-page note, most of which is junk. This has nothing to do with patient care. When I receive records from other physicians, or send notes to them, everybody knows to cut to the chase, which is really in the few lines at the beginning or at the end of the note. Everything else is data for quality metrics for insurance companies and for Medicare and AHCCCS.
ARIZONA PHYSICIAN: What do you see as the largest obstacles in running a practice today?
DR. LAUFER: Prior authorizations are very cumbersome. I see no reason for this. We spend too much time with peer-to-peer discussions or appeals to take care of our patients. Our authorization success rate is close to 95%. The truth is physicians’ costs are less than 5% of the dollars spent on healthcare. And yet we're the low hanging fruit that everybody beats up on. Many physicians are getting fed up or burned out by the bureaucracy when they just want to take care of patients.
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ARIZONA PHYSICIAN: A very high percentage of cardiologists are hospital employed. What are some of the biggest opportunities of running your private practice?
DR. LAUFER: Independence. I'm seeing a swing nationally by employed physicians who are not happy and want to go back to private practice. They don't want to have to deal with hospital administrators. They don't trust them and mostly for good reasons. We have one physician in our practice who was in a group for 17 years. His practice was sold to a hospital, and they cut his salary by a third a year later and so he left that group. Whenever we have physicians interviewing with a hospital, we have them meet this gentleman who usually talks them out of it.
ARIZONA PHYSICIAN: What are the impacts of growth for EMRs and quality metrics?
DR. LAUFER: That's what's leading to burnout. Most physicians want to spend time looking at patients and not looking at computer screens. There are physicians who spend most the evenings or weekends catching up on their charting. Plus, in our field, we are also on call at night for cardiac emergencies. Healthcare today is very complex and cumbersome for physicians and patients.
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