Facilitators and Barriers to Uptake of Remote Cardiac Monitoring in a Rural Setting: A Qualitative Analysis

Abstract

Background

When part of a comprehensive cardiac implantable electronic device care program, remote monitoring (RM) is an effective strategy for maximizing clinical and patient satisfaction outcomes. In rural settings, however, there are multilevel influences that could simultaneously make RM care less attainable. We sought to identify facilitators and barriers to effective RM as part of a cardiac implantable electronic device care program in rural areas.

Methods

Using a qualitative study design, semistructured interviews were conducted of patients with a cardiac implantable electronic device and physicians who treat these patients in rural New England inclusive of primary care doctors, cardiologists, and cardiac electrophysiologists. Data were analyzed using a mixed deductive and inductive approach to identify themes related to barriers and facilitators to RM.

Results

The final group of patient interviewees (n=23) included a combination of those who do and do not participate in RM (n=14 and n=9, respectively). There was a total of 15 physician interviewees. Analysis resulted in 5 patient themes and 4 physician themes. Overall, there was general satisfaction with RM. Facilitators included ease of integration, adequate initial education, and clear communication. Barriers included resource constraints, incomplete communication, and inadequate ongoing education.

Conclusions

This qualitative study of patients and physicians in rural New England identified facilitators and barriers to effective RM. Optimizing RM education, infrastructure, and staffing at local and national levels, including through policy changes, may have important and relevant applications beyond cardiac implantable electronic device care, including other emerging areas of digital health.

Nonstandard Abbreviations and Acronyms

EMR

electronic medical record

RM

remote monitoring

Clinical Perspective.

What Is New?

• Despite challenges to connectivity in rural New England and opportunities to further reduce barriers, patients with implantable cardiac devices and the physicians who care for them generally report satisfaction with systems of care.

What Are the Clinical Implications?

• Cardiac remote monitoring programs in rural areas that prioritize ongoing, dynamic education; easy integration into patients' lives and clinicians' practices; and adequate resource allocation are most likely to result in successful systems of care.

• Aspects of remote monitoring care for implantable cardiac devices in rural New England that facilitate care and reduce barriers likely apply to other forms of digital health in rural areas.

Digital health technologies hold promise for patients in rural areas by reducing the burden of travel and expanding access to medical subspecialty expertise. Remote monitoring (RM) of cardiac implantable electronic devices (CIEDs) is an example of this paradigm. Irrespective of geographic location, RM is considered part of the standard of CIED care based on demonstrated benefits with regard to quality of life and patient satisfaction, reduction in health care resource use, reduced hospitalization risk, and lower mortality. ¹ Moreover, when evaluated qualitatively in an urban setting, patients and physicians generally report a high level of satisfaction with few barriers to adoption. ² RM can serve as a substitute for most routine in‐person CIED evaluations, and this is of particular relevance in rural communities where limited resources and greater distance from facilities make in‐person visits more difficult.

Despite these benefits, RM uptake is variable across patient demographics, regions, and health systems factors. ³ , ⁴ Although the impact of living in a rural area has not been examined specifically for RM uptake, important disparities in RM uptake have been demonstrated for older patients and those without health insurance, ⁵ both of which are characteristics overrepresented in rural areas. In addition, limited patient resources (eg, high‐speed internet) and facility resources (eg, staffing and technical capabilities) in rural areas create unique challenges to establish and run an RM program ⁶ and may impact delivery of efficient and timely RM, even to willing and capable patients.

Patients in rural areas of the United States have significant potential benefits from RM, but little is known about their experiences, including multilevel facilitators and barriers to RM. Likewise, physicians practicing in rural areas face unique challenges to bring CIED expertise and management to their patients. Rural areas differ substantially from one to the next, and northern New England is no exception; it exhibits a unique combination of population characteristics and health care challenges. Thus, as a starting point, the aim of this study from the Center for Rural Healthcare Delivery Science at Dartmouth Health was to elicit facilitators and barriers to CIED RM from patients and physicians in rural New England to identify best practices that can potentially inform resource allocation and workflows for the administration of RM in rural areas.

METHODS

Data Availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Study Design and Research Team

We used a qualitative study design and followed the Consolidated Criteria for Reporting Qualitative Research guidelines. The study was collaboratively designed by an interdisciplinary team representing cardiology and cardiac electrophysiology (E.P.Z., M.A.C.), medical anthropology (K.E.S.), health services research (E.P.Z., K.E.S.), and qualitative research (J.W., L.B., K.E.S.). The study was approved by the Dartmouth‐Hitchcock institutional review board. A separate institutional review board review and approval were acquired from the University of Vermont Medical Center; the recruitment processes at Maine Medical Center did not require a separate institutional review board review. All participants gave verbal, informed consent for participation.

Study Participants

Study participants included patients with a CIED and physicians who treat patients with a CIED from different relevant specialties (primary care, cardiology, and cardiac electrophysiology). All participants lived or practiced, respectively, in northern New England (Maine, New Hampshire, or Vermont).

Patients

Patients were eligible if they had an implanted CIED, which includes a pacemaker, defibrillator, cardiac resynchronization therapy device, or implantable cardiac monitor. We recruited patients through the device clinics at 3 separate facilities: Dartmouth Health, University of Vermont Medical Center, and Maine Medical Center. Device clinics at each site separately generated a list of patients monitored in their clinics, including patients who did and did not participate in RM. Letters were sent to eligible patients directly from each device clinic, inviting patients to contact the study team by phone, email, or online survey if they were interested in participating. Screening for potential participants was performed via online or telephone survey by the research team and consisted of questions about the location at which they receive care, distance to the clinic, years with their device, participation in RM, age, sex, household income, race, and educational attainment. Information about the type of implanted device was not solicited. We used stratified purposive sampling to ensure balance related to care location and distance to care, sex, age, and RM versus non‐RM participants. If eligible, we scheduled virtual interviews with the patients. Patient interviews were conducted from February 2024 through August 2024 by 2 investigators (J.W., L.B.) and lasted ≈1 hour. Patients were offered compensation for their time.

Physicians

We targeted physicians practicing primary care, cardiology, and cardiac electrophysiology in Maine, New Hampshire, and Vermont. We identified physicians primarily through personal networks of the study team and invited them via email. Some physicians were identified and interviewed based on recommendations of other interviewed physicians. Virtual physician interviews were conducted from December 2023 through June 2024 by 1 investigator (E.P.Z.) and lasted ≈1 hour.

Interview Guide Development

We developed 2 interview guides focused on eliciting opinions and perceptions of RM facilitators and barriers from the perspective of patients and physicians. See Appendix A for the final interview guides.

Statistical Analysis

We deidentified and uploaded unedited interview transcripts into Dedoose version 9.2.007 (2024), a cloud application for managing and analyzing qualitative data (SocioCultural Research Consultants, Los Angeles, CA; www.dedoose.com). We used a mixed deductive and inductive approach to code and analyze the data consistent with standards to promote rigor and dependability in qualitative analysis. ⁷ , ⁸ In this approach, we developed 30 initial codes based on the a priori research questions and generated new codes directly from the data through an iterative process of constant comparison and thematic analysis methods ⁹ for a final code count of 71. The codebook was developed jointly by E.P.Z., J.W., and L.B. and was iteratively finalized after coding 10 transcripts. Intercoder dependability was established and maintained using several processes. First, clear code definitions were created and refined throughout the coding process, which included tracking decisions and reasoning for changes. Second, agreement was reached on codes, code applications, and code definitions through a consensus process in which J.W. and L.B. independently coded 10 transcripts. They then met regularly to compare, discuss, and refine codes and their definitions, periodically seeking input from E.P.Z. to ensure accurate data interpretation, until consensus for code application was reached. Finally, once consensus was reached, 1 researcher (L.B.) did the majority of the coding, with assistance from another team member (J.W.), including coding checks on approximately 20% of the coded data with continued discussion and refinement for any remaining coding discrepancies. For analysis, structural variables were used to categorize transcripts by participant characteristics, including demographics (eg, age) and care/work characteristics (eg, RM participation, physician role). Our analyses were conducted in Dedoose using code applications, code co‐occurrences, and code by structural variables, to explore patterns and arrive at the preliminary themes, which were then reviewed by the full study team to consolidate the findings and finalize the themes.

RESULTS

Participant Characteristics

Patients

Potential patient interviewees were contacted directly by their device clinic team. A total of 375 invitation letters were sent to patients. From the University of Vermont Medical Center clinic, 60 letters were mailed, with even distribution between those who did and did not participate in RM. From the Maine Medical Center clinic, 120 letters were mailed, with even distribution between those who did and did not participate in RM. From the Dartmouth‐Hitchcock device clinic, 195 letters were mailed including 100 to patients who did participate in RM and 95 who did not (Figure 1). Ultimately, a total of 23 patients participated from the 3 device clinics (Figure 1 and Table 1), with 14 patients engaged in RM and 9 who were not. Time having a device ranged from <1 year to >20 years, and the time to travel the distance to the patients' sites of device care ranged from <15 minutes to >90 minutes. Most patients (n=15, 65%) were ≥65 years old, and more than half (n=13, 57%) had a college degree or higher.

Figure 1. Diagram of patient interviewee recruitment.

Initial solicitations for participation were sent via letter directly from the patient's device clinic. Initial letter solicitations were nearly evenly split between patients who did and did not participate in remote monitoring. UVM indicates University of Vermont Medical Center.

Table 1.

Characteristics of Patient Participants With a CIED

Characteristic		Total	RM, yes	RM, no
		N=23	N=14	N=9
Care location	Dartmouth	10	5	5
	MMC	7	4	3
	UVM	6	5	1
Time with device, y	<1	2	2	0
	6–10	9	7	2
	11–15	2	0	2
	16–20	4	1	3
	>20	3	2	1
Distance to care, min	<15	5	3	2
	15–29	4	3	1
	30–44	4	3	1
	45–59	3	2	1
	60–90	6	2	4
	>90	1	1	0
Age group, y	35–44	1	1	0
	45–54	2	2	0
	55–64	5	2	3
	65–74	4	3	1
	75+	11	6	5
Sex	Women	11	7	4
	Men	12	7	5
Race	Black	1	1	0
	White	22	13	9
Educational attainment	<High school	1	0	1
	High school/GED	3	2	1
	Some college	6	4	2
	4‐y college	4	2	2
	>4‐y college	9	6	3
Income per year	<$30 000	4	2	2
	$30 000–$49 999	3	1	2
	$50 000–$74 999	6	4	2
	$75 000–$99 999	3	3	0
	>$99 999	7	4	3

CIED indicates cardiac implantable electronic device; GED, General Educational Development; MMC, Maine Medical Center; RM, remote monitoring; and UVM, University of Vermont Medical Center.

Physicians

A total of 36 physicians were contacted for participation, among whom 15 responded to solicitations and were interviewed (Table 2). In this group of 15 physicians, about half were cardiologists (7, 46%), with the remaining representing primary care (4, 27%) and electrophysiology (4, 27%). Physician participants were equally distributed across the 3 states and represented both community and academic‐based practices. Among the 15 participating physicians, 13 practiced in a rural practice setting at least some of the time.

Table 2.

Physician Participant Characteristics

Characteristic		Count	Percent
Specialty	Cardiology	6	40
	Electrophysiology	4	27
	Primary care	5	27
Practicing state	Maine	5	33
	New Hampshire	5	33
	Vermont	5	33
Practice setting	Clinic‐based	8	53
	Hospital‐based	7	47
Total		15	100

Themes

Overall, there were 9 themes related to CIED and RM, 2 of which were identified by both patients and physicians (Figure 2). Table 3 lists the themes including relevant subthemes for each participant group. There were 5 major themes from patients and 4 from physicians.

• Theme 1. Patients want to be informed about their device and the RM process to be more confident in RM and their device care more broadly.

Figure 2. Summary of themes.

Patients with a cardiac implantable electronic device and physicians who provide care for these patients identified barriers and facilitators to remote monitoring care in rural New England based on semistructured interviews. Summarized themes are depicted. Some themes were overlapping between physicians and patients, and some themes represented both facilitators and barriers, depending on the extent of optimization.

Table 3.

Themes

Patient themes	Exemplar codes
Patients need to feel they are properly informed about their device and the RM process to feel confident in RM and their device care more broadly.	Changes to care: More accessible information about device activity. Patient expresses they wish they had more or better information about the data their device collects/transmits. This might include RM reports.
Patients highlighted the importance of not only their initial but also ongoing education about both RM and their devices more broadly.	Patient education context: Details about the context of the device education patient received; for example: who provided education, when it took place, patient's satisfaction/dissatisfaction with education.
bIn addition to education about their device and RM, patients want 2‐way, transparent communication with their physicians.	Changes to care: More accessible information about device activity. Patient expresses they wish they had more or better information about the data their device collects/transmits. This might include remote monitoring reports. Barriers–communication difficulties between patient and providers: Patients describe instances where the communication from their provider has been insufficient or unclear.
2Disorganization and dysfunctional workflows within health care systems are barriers to patient device care and their access to RM.	Barriers–scheduling and follow‐up: Patients experience difficulty getting scheduled to see their providers, or providers are not following up with them to schedule their appointments. Barriers–communication difficulties–EHR issues: EHR (eg, Epic) systems might create a barrier to communication and thus a barrier to patient care (eg, separate EHR systems between different specialties, difficulty communicating through EHR).
3Overall, cardiac devices are easily integrated into patients' lives. The reported ease of RM facilitates this integration.	Patient impact of device–minimal impact: Patient expresses that their device does not impact their activities or lifestyle. Facilitators–low/no responsibility: The patient feels they have little to no burden/responsibility when it comes to the remote monitoring of their device.
4A lack of access to the resources and materials necessary for RM is an additional barrier to patient engagement.	Barriers–lack of access to necessary tools: Patients lack access to tools or resources necessary to engage in RM or get adequate device care. Tools/resources include: Wi‐Fi/internet, cell phone reception, device compatible with RM. Barriers–cost/insurance coverage: The cost of remote monitoring or device care more generally is a barrier to patient access or engagement. This might include lack of insurance coverage.
5There are individual patient characteristics or preferences that may act as facilitators or barriers to RM or device care.	Patient takes initiative in their device care: A patient takes personal responsibility and initiative for their device care. This might take the form of advocating for themselves or asking a lot of questions, for example. Barriers–prefers in‐person care: A patient's barrier to RM is that they prefer to be seen in person for device care.
Physician themes
Access to support, primarily the ability to contact and collaborate with other physicians and industry professionals, is a key facilitator to providing successful RM support.	Facilitators–access to support: A patient or physician expressing that they were able to receive support (get their questions answered, had someone who could provide knowledge). For patients, this would come from their clinical team, and for physicians, this would come from colleagues.
2Inadequate staffing and lack of clear role expectations and necessary clinic time and capacity are barriers to RM and CIED care more broadly.	Barriers–lack of clinic resources: This might include lack of time/clinician workload, staffing issues, and lack of financial resources.
3Physicians require an integrated system in which they can access patient information and easily communicate with other physicians across systems about patients and patient needs.	Barriers–communication difficulties–between clinicians for patient care purposes: This might be because of different EHR systems and workflows.
4Physicians' ability to provide direct support for RM is often hindered by their lack of understanding or lack of training about RM.	Physician education–insufficient physician education: Anything related to a physician's education around CIEDs or RM falling short.

CIED indicates cardiac implantable electronic device; EHR, electronic health record; and RM, remote monitoring.

Patients generally reported a desire to have more education about their CIED, inclusive of the monitoring process. This theme was broad and encompassed 2 subthemes. For the first subtheme, patients highlighted the importance of initial and ongoing RM and device education. Initial education on RM was generally reported as sufficient, and this was a facilitator of RM, as described by 1 patient.

“When [my pacemaker] first was put in, I'd say the thing that made me the most comfortable was them showing me how to connect it to my phone and be able to look and see what was going on. You don't really have any control over this. I'm not afraid it's going to stop working.” Patient

However, the timing of this education tended to be immediately before or after device implantation, when details were more difficult to remember. Some patients expressed appreciation for the participation of a support person (eg, spouse) in the education process as a facilitator to RM. Conversely, patients generally had limited ongoing education about RM or their CIED despite a sense that the technology was evolving over time and ongoing education was desired.

“[Education] wasn't part of my regular care. And I think these people who just do these 1‐shot things where they see you once and then you never see them again, I think that's a problem.” Patient

In the second subtheme, patients expressed a desire for 2‐way transparent communication with their treating physicians. They reported wanting to be in the loop about their CIED and RM process, including notifications of RM transmissions and acknowledgement of a received transmission.

“I feel good that somebody's remotely monitoring. Yes. Do I wish I had more information about it? Yes…I don't know if somebody's looking. They tell me somebody's looking at it, but what do I know? Because I hear nothing.”

Patients participating in RM were more confident that their physicians were getting necessary device‐based information than patients who did not participate in RM. In the latter case, device‐based information would only be accessible at the time of periodic in‐person evaluation.

Many patients expressed a desire to receive acknowledgement of RM transmission receipt and routine RM status updates. A smaller group expressed a desire to have an explicit review of the information in RM transmissions as a means of empowerment and engagement in their own care.

“Just knowing…that there is a human being…that's looking at this and talking to me, describing to me what they're seeing from the downloads every 6 months or 8 months or something. …the remote monitoring and the placement of the pacemaker is great. But you need a human, or at least I need a human connection somewhere in the year to reassure me and support me in having this thing inside me.” Patient

• Theme 2. Disorganized and dysfunctional workflows within health care systems are barriers to CIED care and RM.

Patients generally described the health care system as dysfunctional across a wide range of issues (eg, for scheduling visits), and this included a sense of disjointedness between various clinicians about their implanted device. For example, patients expressed frustration that some members of their care team did not seem to have the information or training to answer questions about their implanted device or RM.

“My cardiologist really seems to have no connection to it at all. He didn't know how it worked… I was surprised that my cardiologist really doesn't seem to know anything about the thing plugged into my heart.” Patient

For some patients, this discontinuity resulted in confusion about how to contact the right team when questions arose.

“…There was no place to call if I was going to have a problem or something…There was an emergency room number that I could call because that's how I was admitted in… But there was no place to connect back to that practice…” Patient

• Theme 3. Overall, CIEDs are easily integrated into patients' lives. The ease of RM facilitates this integration.

Patients engaged in RM reported that setting up RM was easy, and they feel good about having little to no responsibility in device monitoring. Some patients reported that they forget about their CIED. Patients engaged in RM acknowledged that the reduced need for in‐person evaluation facilitated by RM made their care simpler. Those patients not engaged in RM generally reported that they would like to do RM if they were eligible and had appropriate resources.

“I basically don't have to do anything except go to bed. So yeah, I don't have to…download anything. I don't have to push any buttons. Every once in a while, if the power goes out, I have to reset the [monitor].” Patient

“To be honest, half the time, I don't even remember I have [my pacemaker]. It hasn't disrupted my life whatsoever… Even when I went in to have…the battery replaced…it was light sedation, so it didn't even really disrupt the day other than I couldn't drive.” Patient

• Theme 4. Lack of access to resources and materials necessary for RM is a barrier to engagement.

Both physicians and patients described limited resources as the most common barrier to effective RM. The limited resources most commonly cited included poor connectivity, typically resulting from limited cell phone reception or wireless internet, as well as insufficient physician availability. Some patients reported difficulty obtaining replacement parts for monitoring when items were lost, malfunctioning, or obsolete. Additionally, some patients reported hardship with the fees associated with RM.

“I've requested not to have to do [RM] as much. Unfortunately, it does cost every time you do it. So probably the biggest part was the money. At the time, I was under an insurance that had a high deductible as most are nowadays.” Patient

For patients who did not engage in RM, frequent in‐person evaluations are necessary, and this is limited by clinical availability.

“I don't think there are enough slots available for the electrophysiologists….We're booking out [a few months] for new patients. A lot of the patients recur every 3 months due to…connectivity problems, we don't have universal remote monitoring. [This state] has tremendous lack of cell phone coverage.” Physician

“I would welcome remote testing….I've got my personal care doctor. I have to go in every 3 months. I have to go to a podiatrist every 3 months. I have to go to endocrinology every 3 months and pacemaker clinic every 3 months. So unless we can bundle the appointments on 1 day, it's very difficult for my daughter. She has to take time off from work.” Patient

• Theme 5. Individual patient characteristics or preferences can act as facilitators or barriers to RM.

There appear to be some aspects of RM care that consistently facilitate or obstruct care, but in addition, there are individual patient characteristics that influence RM including level of trust with technology, for example. Many patients reported a desire to participate more fully in their CIED care, but this was both a facilitator and barrier to RM; some patients appreciated the ability to initiate, access, and review RM transmissions, whereas others insisted on in‐person device care as a means of expressing their empowerment as a patient.

“So I said, ‘Just let me come in, and we'll talk.’ I like personal connections. I don't like over the phone or Zoom or whatever they call that.” Patient

Physicians

The 4 themes identified from physician interviews centered more around the health care system writ large and how physicians operate within that system.

• Theme 1. Ability to contact and collaborate with other physicians and CIED experts facilitates successful RM support.

Regardless of clinical specialty, physicians nearly universally reported that the ability to communicate with other physicians and industry representatives about RM and to accurately direct their patients to sources of RM information was a facilitator to RM.

“We have good industry support… and we have a network where if we need troubleshooting, we can bring people in not just [locally], but to places around the state. So I think having that infrastructure makes it very easy.” Physician

“I'm really lucky to have trained nearby. So I know a lot of the cardiologists at [the hospital]. And so they know when I'm calling that I'm not just barking up a tree. So that's really helpful. I think that the thing that I've had a harder time with is when I'm reaching out to some of the health systems that I'm not as familiar with.” Physician

• Theme 2. Inadequate staffing and lack of clear role expectations and necessary clinic time and capacity are barriers to RM and CIED care more broadly.

Nearly all physicians discussed inadequate clinic resources including staffing and time to process the enormous data associated with RM. In addition, inadequate staffing prevents clinic staff from achieving specialization in RM knowledge and tasks that furthers gaps in capacity to maximize RM and CIED care.

“I think we do a pretty good job of keeping everybody safe and alive, but I don't think we really monitor or leverage monitoring as thoroughly as we could to benefit our patients… And it's a matter of staffing. I think that's sort of our biggest barrier is just having enough people to do the work.” Physician

“Somehow [patients] fell through the cracks in the device clinic. Either [patients] couldn't reach people or stopped trying to reach people just ‘cause [clinics] are so overwhelmed with patients.” Physician

• Theme 3. Physicians require an integrated system to access patient information and easily communicate with other physicians across systems about patients and patient needs.

Physicians emphasized the need for integrated records to streamline communications. Integration was noted as both a facilitator and a barrier to RM based on whether physicians did (facilitator) or did not (barrier) perceive their clinical system as integrated. For example, physicians cited differences in health record systems used even within the same health care network, which led to problems in communication and discontinuities in care.

“The electronic medical record can be a problem there… Our electronic medical record is not the same as [the hospital] electronic medical record. So if it's a [hospital]‐generated report, there may be a lag… and it's just a matter of me finding the report.” Physician

“It's just an annoying thing on the provider side, as you can imagine, ‘cause you're, like, communicating with 2 different sets of nurses, and you know, sorta hunting things down and communicating from one to the other… I would say that the challenge is on the backside, that it adds time and work.” Physician

• Theme 4. Physicians' ability to provide direct support for RM was hindered by lack of training or understanding about RM.

Physicians who received training or education in RM reported that their knowledge became obsolete quickly, hindering their ability to answer patient questions and provide adequate care.

“Staff training would be really useful because a lot of the devices… it seems like they're changing all the time. And I really haven't learned much about them since medical school.” Physician

“I don't know how much training [cardiology fellows] are getting in device monitoring and management or whether it's all being captured by the electrophysiologist, which is fine and dandy, but [electrophysiologists] don't have the time to follow all these patients… it's gonna be interesting going forward. I think that the challenge is that as—so much of cardiology is becoming increasingly specialized and increasingly stovepiped. And that's fine for large medical centers and congregations of large numbers of cardiologists, but it doesn't compute in our [rural] area.” Physician

DISCUSSION

Rurality creates unique challenges for the care of patients with a CIED, including greater geographic distance to care, fewer specialists, and an older and sicker population that predisposes them to a greater need for CIED care. Lessons learned from remote monitoring of CIEDs may inform other rapidly growing digital health platforms that are emerging to treat various chronic illnesses, such as chronic obstructive pulmonary disease, diabetes, and sleep apnea.

Our findings, based on semistructured interviews of patients and physicians, provide several important insights. First, patients and physicians in these rural areas were generally satisfied with RM. For patients, this appeared to be driven largely by ease of integration into their lives and limited ongoing responsibility to share their data with their physicians. This finding of easy integration is consistent with prior work, ¹⁰ , ¹¹ including 1 clinic‐based assessment where 95% of respondents to a survey were content or very content with RM compared with in‐person. ¹² Although our findings are mostly consistent with those studies, a recent study that focused on patients with an implantable cardioverter‐defibrillator did not demonstrate as clear a preference for RM, suggesting more room for investigation. ¹³ , ¹⁴ Findings from the present study also support and add to these findings in that RM met physicians' needs, and that they had clarity about how to seek more information or support as needed.

Second, albeit in different ways, physicians and patients reported resource limitations as a barrier to RM, including insufficient staffing to reap the maximum benefit from RM data. Challenges related to inadequate staffing reported in RM clinics are likely intensified in rural areas given overall health care personnel shortages. Acknowledging local resource constraints could empower device clinics to innovate how RM care is delivered, such as using remote clinic staff or monitoring via an alert‐only paradigm, where review of routine RM transmissions is deferred to prioritize alert‐based transmissions (eg, detection of new atrial fibrillation, lead integrity issue). Further research and policy solutions for this model in resource‐constrained settings such as rural settings deserve increased attention to increase capacity for RM.

Third, both physicians and patients indicated that more education would be a facilitator for better RM systems. This is consistent with prior work irrespective of geography. ² , ¹⁵ , ¹⁶ , ¹⁷ For patients, ongoing education is desired beyond that provided at the time of implant to meet evolving needs. For some patients, as seen in prior work, this includes acknowledgement of RM transmissions to close the communication loop. ⁶ The 2023 Expert Consensus Statement on Management of the Remote Device Clinic recommends 3 phases of patient education to optimize patient adherence and satisfaction: before implant, shortly after implant, and ongoing. ¹

Barriers to physician education in RM are likely increasing as the diversity and complexity of device care increases in parallel with rapidly evolving systems for remote monitoring at the manufacturer and health‐system level. Experiential education in remote monitoring that accompanies medical training and day‐to‐day practice is most likely insufficient to establish expertise, especially if CIED care is a small part of a physician's practice. Patients appeared to view lack of knowledge on the part of the physician as a reflection of disorganized workflows. On the other hand, to physicians, it reflects the increasingly specialized nature of CIED care and their high level of trust in RM systems, including experts in RM. Thus, although ongoing CIED education may be lacking, physicians identified specific contacts within their health system or local representatives from device manufacturers as the main source for information related to RM and felt that their educational and informational needs were adequately met.

Finally, we learned that some expected barriers to RM, such as discomfort with technology, were not often present. Also, some potential facilitators to RM, such as reliance on caregivers, partners, and family members, did not appear as frequently, presumably because it was not needed. Moreover, although cost has been raised in other qualitative studies of RM, ² it was infrequently mentioned by patient participants in this study.

Strengths and Limitations

This study applied rigorous qualitative techniques and achieved thematic saturation making the findings reliable and robustly derived. Nonetheless, there are important limitations. First, in the process of performing these interviews, important additional stakeholders in the RM ecosystem were identified including the device clinic nurses and other staff. Based on comments by physicians and patients, it is likely that this group would identify unique facilitators and barriers to RM in rural areas and could be the subject of a future qualitative study. Second, rural geographies are remarkable for their heterogeneity, such that the specific racial and ethnic constituency of rural New England varies substantially from other rural geographies, and these differences may affect the findings. However, commonalities likely exist between rural New England and other rural areas in the United States and those outside the United States, in which systems of care are substantially different.

Conclusions

We found general satisfaction with RM care in rural areas facilitated through ease of care integration and ready access to experts to provide clinically meaningful information in a timely way. Inadequate physician and patient education, disjointed and unpredictable communication between and within teams, and inability to retain adequate staff were identified as barriers to RM. Beyond the immediate benefits to rural CIED programs, optimizing RM through enhanced education, infrastructure, staffing, and strategic process and policy changes may have important and relevant applications beyond CIED, including other emerging areas of digital health.

Sources of Funding

This work was supported by the National Institutes of Health/National Institute of General Medical Sciences (grant number P20GM148278). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Disclosures

Dr Zeitler reports the following disclosures: Member of Boards of Trustees for Dartmouth‐Hitchcock, research support (nonfinancial) from Sanofi, Biosense Webster (Johnson & Johnson), Boston Scientific; consulting support from Element Science, Medtronic, Boston Scientific, Biosense Webster (Johnson & Johnson), V‐Wave; Travel support from Boston Scientific, Medtronic, Philips. All other authors report no relevant disclosures.

Supporting information

Data S1: Supplemental Methods