Remote monitoring (RM) of patients with cardiac implantable electronic devices (CIEDs) is safe, efficient, and effective in the early detection and management of device-related and clinical issues. Several randomized trials, large registries, observational studies, and big data analysis in the last 15 years have consistently demonstrated the usefulness and cost-effectiveness of RM.¹,² Accordingly, the 2015 Heart
Rhythm Society (HRS) consensus document³ established that RM is currently the new standard of care for patients with CIEDs and therefore it should be offered to all patients over a calendar-based schedule of in-person CIED evaluation alone, when technically feasible.

In spite of evidence and guideline recommendation, implementing RM in daily clinical practice is still challenging and is not routinely offered to all candidates in several centers.⁴ The reasons include reluctance to accept new technology, concern for legal issues, reimbursement issues in some European countries, and concern for increased work burden in the transition phase.⁵ In fact, the greatest challenge in implementing RM in standard practice is the need to develop new organizational models. Use of telemedicine still constitutes a medical action, but differently to face-to-face visits, several actors actually play a major role in this new scenario. Importantly, the patient has an active role that is critical for successful monitoring. There are major changes in the relationship between the patients and the hospital staff, and the patients have to become used to applying new technology. Patient cooperation and awareness of technology, of the organizational model and of the overall process are mandatory for a successful RM.

Patient enrolment represents the key time when the medical team needs to establish a clear and open communication strategy with patients and their caregivers in order to provide detailed information on both the benefits and the limitations of RM. The main limitation is the inability of RM to act as an emergency response system. Although RM systems have alerts available, the patient and their caregiver must be made aware that there is a delay between an episode or alert and the transmission of that alert to the CIED clinic. These delays may be due to alert programming, patient distance from the monitor, cellular transmission unavailability, and website inaccessibility. The CIED clinic organization may also not be constructed to interpret and act on alerts immediately, but rather within an acceptable timeframe (such as the next day).⁶ Clear information on expected reaction times must be carefully explained to the patient and also how the patient or caregiver should react in an emergency. Such information is essential in patient teaching and may be formalized in a signed patient agreement form. Showing the monitor to the patient and encouraging transmission tests during enrolment may improve patient reassurance and compliance. For elderly patients or for patients with mind impairment, the cooperation of relatives or caregivers who will play an important role in the overall patient clinical management may be needed. The key to improving patient compliance is making them aware that without their active cooperation the monitoring system just does not work. For this purpose, details on how the overall monitoring chain actually works and well-defined scheduling of remote transmission may help. Following patient contacts during the follow-up may reinforce patient and caregiver cooperation. Poor patient compliance may impair workflow efficiency, mainly because of missed scheduled remote transmissions or duplicate transmissions. Phone call burden because of patient noncompliance may negatively impact on personnel workload. The patient has to understand that it is their responsibility to cooperate with the hospital and that in case of inappropriate behavior, the RM service could be prevented by the clinic. Among patient duties, updating phone and mail contacts as well as promptly informing the clinic about new clinical events, hospitalizations, and changes in drug therapy play a role in improving benefits of RM. Timing of starting RM is a matter of debate. Theoretically, the systems should be delivered as early as possible after implant. However, it should be considered that the implantation of the device represents a major change for the patient (a change for life), which may deeply impact on their psychological status.
The patient may need some time to accept the implanted device and in the meantime he/she may not be ready to also accept the monitoring system. He/she could think of being abandoned by the hospital staff. For this reason, enrolment time should be adapted to every individual patient and for many of them probably delayed to the 1-week or 1-month visit.³

Automatic RM enables routine follow-up evaluations without face-to-face encounters and also permits in-person assessment when required, and sooner. This shift to exception-based assessment has key advantages for patients who, to maintain in-person follow-up, have to take time off work, or need an accompanying person, or for whom access is limited (eg, nursing home residents, geographically remote patients). Patients who travel extensively (including internationally) may benefit from the versatility of cellular service. Social and economic costs for standard face-to-face follow-ups have been demonstrated to be onerous.⁷ Published studies usually show high patient satisfaction rate, ease of use, and compliance with the use of RM systems, even when inductive technology was the standard.⁸,⁹,¹⁰ In spite of some initial concern, RM has been demonstrated to be easy to use and well accepted even for elderly people and for patients with a low level of schooling.¹¹ Only few patients do not accept RM, mainly for concerns about technology and about the risks of losing the human contact with nurses and physicians. Automaticity and reliability of remote technology used is important. In the TRUST trial,¹ no patient assigned to RM crossed over during the study and 98% elected to retain this follow-up mode on trial conclusion, indicating patient acceptance and confidence in follow-up with this technology. Patient-clinic linking improved because RM patients were more compliant with scheduled in-person evaluations when required. In contrast, conventional care was characterized by follow-up attrition, indicating how onerous patients find scheduled clinic visits.¹²