Abstract: An improved device and method for performing automatic capture/threshold determination that is particularly useful in an implantable cardiac stimulation device. While conventional devices use a fixed shortening of the AV/PV delays during automatic capture/threshold determinations, any shortening can unnecessarily cause discomfort to patients with heart blocks and unnecessarily diminish the atrial kick for other patients. Accordingly, embodiments of the present invention periodically measure the AR/PR conduction times and tabulate and/or otherwise process this data. Preferably, these measured conduction times are also correlated with the current heart rate. Finally, when an automatic capture/threshold determination occurs, this measured conduction data, which corresponds to this patient, is used to adjust the AV/PV delays while minimizing patient discomfort and adverse hemodynamic effects. Alternatively, the AV/PV delays may be manually programmable by a medical practitioner.

Abstract: A heart stimulator has an atrial and ventricular pulse generator for producing atrial and ventricular stimulation pulses, an atrial sensor for sensing atrial signals and an evoked response detector for detecting the occurrence of incipient fusion beats from measured ventricular signals. A determination unit determines an incipient fusion AV-interval from the sensed atrial signals and the detected fusion beats, and a controller controls the pulse generator to deliver stimulation pulses at a controlled AV-interval which is shorter than the incipient fusion AV-interval.

Abstract: Detection of a discontinuity, a disconnection or loss of conductivity, of cables connected to a physiological signal recorder, in particular a Holter recorder of ECG signals by measuring an impedance of the line(s). To measure the impedance of the line comprising the connecting cable connecting an external electrode placed on a patient to a signal terminal (12) of the recorder (10), one generates a current impulse, applies this impulse to the line, measures the variation of voltage resulting on the terminal from the signal during the application duration of the current impulse, and determines the impedance of the line based upon the voltage variations thus measured. The current impulse is a biphasic impulse including two successive cycles of opposite polarities, the durations and the amplitudes of these two cycles being selected so as to define approximately equal respective loads and of contrary signs.

Abstract: Various embodiments can permit electrode configurations that are used in implantable devices to be automatically changed. In some embodiments, configurations that are used to ascertain capture (ventricular and/or atrial) can be automatically changed by a stimulation device and then automatically configured for use. Various parameters associated with the electrical configurations can be automatically calibrated so that a stimulation device's automatic capture feature can continue to function notwithstanding the fact that an electrode configuration change has taken place.

Abstract: A cardiac rhythm management device capable of delivering multiple uni-chamber stimulation pulses to a patient's heart and suitable for verifying capture independently for each uni-chamber stimulation pulse. The uni-chamber capture verification mode of the cardiac rhythm management device may be activated via telemetry or by applying a magnetic field proximate the device. During the capture verification mode, bi-chamber pacing, for example, may precede or follow uni-chamber pacing to allow for pacing support. Also, the energy levels of the pacing stimulus over several beats may be varied, thereby verifying the programmed safety margins.

Abstract: Triggers and noise should be available as information in recorded electrograms in memories of implantable medical devices. Particularly where the recording of electrogram data is done in the far field, there will be considerable noise and the interpretation of ECG's reproduced from such recorded data will benefit from the storing of information regarding contemporaneous noise. By storing contemporaneous trigger data and noise data directly in the ECG data, recordings of the ECG data become more useful for physician use when played back through an external display system with minimal loss of ECG data, since out of range values are employed for the noise and trigger information and this non-ECG data is limited in size to no longer than individual point values of the ECG signal.

Abstract: Sensing artifacts in cardiac signals picked up by electrical leads are reduced by placing an electrical shunting switch across the conductors of the ECG sensing leads and the stimulation leads that deliver a subthreshold electrical stimulation. In addition, impedance switches are placed in series with the sensing leads. The shunting switches and impedance switches are then manipulated to present cardiac signals that can be analyzed for diagnostic purposes within less than 100 ms from delivery of a subthreshold electrical stimulation.

Abstract: A programmer for an implantable medical device includes a display which displays a graphical representation of an area of interaction of the medical device within a patient. The graphical representation includes at least one independently selectable graphical object. The programmer includes a unit for associating parameters or functions used in controlling the medical device with the object, so that when an operator, via the programmer, selects an object, the associated parameters or functions are displayed for consultation, modification or execution. By directly linking the programmable parameter or function with an image of the device and the surrounding parts of the patient's body, the clinician is immediately presented with a clear and understandable link between the parameters and a physical entity.

Abstract: Disclosed is a method and apparatus for configuring an external device so that may communicate with and an implantable medical device in accordance with a desired telemetry protocols. The external device utilizes a telemetry module can be loaded with a protocol driver necessary for communicating with the implantable medical device. Once the desired protocol driver has been installed, the telemetry module and its associated external device, e.g., a physician programmer, are enabled to communicate with the implantable medical device.

Abstract: An electrical medical lead is provided having two or more electrodes, electrically insulated from each other and electrically coupled to individually insulated filars in a multi-filar coiled conductor. When the lead is used with a medical device equipped with a switch matrix, electrodes are selected individually or simultaneously to serve as an anode or cathode in any unipolar, bipolar or multi-polar configuration for delivering stimulation and/or sensing signals in excitable tissue. In one embodiment, a tip electrode array is expandable for improving electrode contact with targeted tissue and stabilizing lead position.

Abstract: Exemplary methods and devices for determining whether atrial fusion, atrial pseudofusion and/or atrial native activity have occurred. Various methods and/or devices are suitable for use with atrial autocapture. Other methods, devices and/or systems are also disclosed.

Abstract: A system and method for use in an implantable cardiac stimulation device permits automatic induction of a tachyarrhythmia of a heart to permit the performance of an electrophysiological test of the heart. A pulse generator repeatedly delivers a group of first and second sets of pacing pulses to a chamber of the heart. The pacing pulses are separated in time by interpulse intervals to overdrive pace a chamber of the heart. A processor, coupled to the pulse generator, varies the second set of interpulse intervals according to a predetermined protocol after each group of pacing pulses is delivered to the chamber of the heart. The successive groups of pacing pulses are delivered to the heart until the tachyarrhythmia is induced.

Abstract: A method and apparatus for performing self-tests on defibrillation and pacing circuits including a patient isolation switch is disclosed. Following a test of the defibrillation and pacing circuitry, the isolation switch is tested by closing certain switches within the defibrillation circuitry so as to create a circuit path, and then opening and closing the isolation switch. Alternative tests may be performed depending on whether the impedance at the output of the defibrillator is determined to be an open circuit or a short circuit. If the output is determined to be an open circuit, then the test monitors the voltage across the output of the defibrillator as indicated by the voltage of a DC offset of a preamplifier coupled to the output of the defibrillator. For the short circuit test, the voltage on the energy storage capacitor is monitored.

Abstract: A method of optimizing cardiac resynchronization therapy delay over a patient's full range of activity for use in operating an implantable cardiac pacing device and such a device are disclosed. The method includes measuring selected conduction time between selected sites in the heart for a plurality of beats and logging the values on a periodic repeating programmable basis to produce cumulative data and constructing a current template of conduction time in relation to one or more other sensed parameters of interest over a desired range of patient activity levels. The current template is used to derive suggested optimum pacing timing.

Abstract: A technique for acquiring and accessing information from a medical implantable device is provided. Analog waveforms of interest are sensed and processed by signal acquisition circuitry. Analog parameters of interest are applied to selector switches which are controlled by a logic circuit. The logic circuit is also coupled an A/D converter for converting the analog signals to digital values. The digital values are stored in dedicated registers and are available for telemetry to an external device upon receipt of a request or prompt signal. When a digitized value is accessed and telemetered, the control logic circuit changes the conductive state of the selector switches to apply the corresponding analog signal to the A/D converter. The resulting digital value is applied to the corresponding register to refresh the accessed and telemetered value. The technique permits the external device to request and configure the implanted device to send only digitized values of interest.

Abstract: Byte-based and page-based techniques for performing error detection and correction in an implantable medical device with minimal overhead are provided. With the byte-based technique, single bit upset errors are detected by hardware during a read cycle. A software-based error correction system corrects single bit errors and detects multi-bit errors. By providing error detection in hardware and error correction in software, single bit errors can be immediately detected during read cycles such that a microcontroller of the implantable device is not at risk of receiving erroneous data. Yet the total error detection and correction overhead is kept low so that the size, cost, and longevity of the implantable device are not significantly and adversely affected. With the page-based technique, single bit upset errors are detected and corrected by software between therapy delivery cycles, such as between successive pacing cycles.

Abstract: In a method and circuit for monitoring an oscillator in a medical implant, a physiological parameter is obtained from a subject in whom the medical implant is implanted and an electric signal containing a time component, is generated based on the physiological parameter. The functioning of the oscillator is monitored using this electric signal to identify if the functioning of the oscillator deviates from a specified functioning of the oscillator.

Abstract: Systems and methods are provided for displaying statistical distributions of cardiac events. According to one aspect, a programmer device is provided that generally comprises circuitry for communicating with a medical device, and a display. The medical device collects data regarding cardiac events occurring at two or more sites, and the display provides a histogram of the data as two or more statistical distributions for the two or more sites. In one embodiment, the data includes both sensed intrinsic cardiac events and paced cardiac events. And in another embodiment, the histogram generally comprises a plurality of histogram bins that provide statistical distributions for the cardiac events. Each of the histogram bins generally includes a portion of a first cardiac event distribution and a portion of a second cardiac event distribution.

Abstract: A cardiac pacemaker has a pulse generator for delivering stimulation pulses to a patient's heart and a control unit for controlling the delivery of the stimulation pulses from the pulse generator. The control unit includes an altering unit for altering the AV-delay value from a predetermined first AV-delay value to a predetermined second AV-delay value, and back to the first AV-delay value. A sensor measures a parameter related to cardiac output of the patient, the sensor measuring this parameter in a time window within a time of operation with the first AV-delay value, and in a time window within the time of operation with said second AV-delay value, and in a time window within the time of operation after the return back to the first AV-delay value. A calculation unit calculates respective average values of the parameter during each of the time windows, and a determining unit determines from these average values which of the AV-delay values results in a higher cardiac output.

Abstract: A system and method for automatically selecting among a plurality of pacing modes based upon capture detection. Patients suffering from heart failure may be optimally treated with different resynchronization pacing modes or configurations. By detecting whether capture is being achieved by a particular configuration or mode, a device is able to automatically switch to one that is both optimal in treating the patient and is successful in capturing the heart with pacing pulses.

Abstract: Methods for failure recovery in a cardiac rhythm management system and apparatus capable of carrying out the methods. The methods include applying a first pacing therapy using one or more leads. The methods further include detecting a failure condition on one or more of the leads, wherein the failure condition prohibits or frustrates application of the first pacing therapy. The methods still further include applying a second pacing therapy using one or more of the leads subsequent to detecting the failure condition. The second pacing therapy is preferably chosen such that the detected failure does not interfere with the second pacing therapy. The second pacing therapy may be applied for only one cardiac cycle. The second pacing therapy may further be applied continuously until the failure condition is resolved, or it may be latched such that physician intervention is required to resume the first pacing therapy.

Abstract: A connector assembly of an electrophysiologial device. The connector assembly includes a substrate forming a tube extending from a proximal end to a distal end an electrical circuit formed on the substrate, such as etching or printing, where the substrate is optionally non-conductive. In another option, the connector assembly includes clad wires and/or flexible circuits within an insulated terminal structure.

Abstract: A method for operating a cardiac rhythm management device used for cardiac resynchronization therapy in which the storage of diagnostic data is triggered by detection of a condition indicating that the effectiveness of the therapy has been compromised. Such diagnostic data may be electrograms or marker/interval data acquired from the sensing channels of the device.

Abstract: A multi-chamber stimulation device and associated method reliably and automatically distinguish fusion from loss of capture during ventricular stimulation. The stimulation device provides immediate and accurate fusion detection when a loss of capture is suspected in the ventricles without delivering back-up stimulation pulses. To achieve this objective, the far-field signal present in the atrial channel is examined for evidence of a far-field R-wave whenever the ventricular channel detects a loss of capture. If a far-field R-wave is present, fusion is confirmed, and a far-field R-wave is absent, loss of capture is confirmed. Additionally, the stimulation device inhibits unnecessary back-up stimulation and threshold tests when fusion occurs, and provides appropriate adjustment of stimulation parameters based on confirmed fusion detection such that fusion re-occurrence is minimized.

Abstract: The date and time of death of a patient may be recorded in a memory of a microprocessor used in an implantable cardiac rhythm management device by detecting the failure of the heart to produce an evoked response upon the application of a pace pulse to the heart. To confirm death, other physiologic sensors used in the cardiac rhythm management device may also be sensed to determine the absence of an expected output signal.

Abstract: The present invention takes the form of a current limiting apparatus and method for limiting current flow, induced when the level of an external signal is greater than an external signal threshold signal level, in a conductive loop formed by a medical device implanted within a living organism having electrically excitable tissue. The system includes an implantable pulse generator (IPG) system having a housing, a signal generator disposed in the housing that generates an electrical signal, and at least one lead extending from the housing to convey electrical signal to the patient. To limit the induced current flow, the IPG includes current limiting componentry, an impedance increasing element, and/or alternating current blocking elements. These components provide an alternating current impedance path to the electrical ground from a lead coupled to the capacitive element. Also disclosed are techniques for reducing the effective surface area of the current inducing loop caused by the IPG system.

Abstract: Systems and methods for distinguishing a valid sensed cardiac signal from an invalid signal, such as a myopotential. In one embodiment, sensing an electrical signal with one electrode causes a timing window to commence. When the electrical signal is sensed by another electrode in the timing window, the sense is deemed valid. When the electrical signal is not sensed by the other electrode in the timing window, the sense is deemed invalid. Therapy may be adjusted when an inordinate number of senses are invalid.

Abstract: A method and an apparatus for performing a device component failure analysis in an implantable medical device using current consumption data. A current consumption signal relating to current consumption in an implantable medical device is generated. The current consumption signal is then processed. A defect of a component in the implantable medical device is assessed in response to the processing of the current consumption signal and appropriate action is taken, such as selecting alternate therapies, generating an alert signal, and turning off circuits corresponding to the assessed defect.

Abstract: An automatic rate response sensor mode switch is implemented in an implantable medical device to monitor and isolate any sensor in an integrated sensor scheme. The isolated sensor is based on identification of problems associated with the sensor. The implantable medical device will switch to operate with the remainder sensor(s). Specifically, an algorithm tests and determines sensor status to initiate and operate the sensor mode switch. The software continuously monitors, isolates or qualifies a sensor to come back on-line automatically.

Abstract: An implantable cardiac stimulating device has a control circuit which varies the rate of stimulation pulses up to a maximum pacing rate. A sensor senses at least one evoked response parameter to a delivered stimulation pulse, and the control circuit compares a time gap between the stimulation pulse and its associated evoked response parameter. The control circuit lowers the maximum pacing rate if the time gap does not increase as the pulse rate is increased.

Abstract: An implantable pulse generator and a method of operation, where the pulse generator is adapted to sense at least a first cardiac signal. Cardiac events are identified in the first cardiac signal, in response to which a blanking interval is started. The blanking interval includes a repeatable noise window blanking interval. When noise is detected during the repeatable noise window blanking interval, the noise window blanking interval is repeated. Depending upon the type of sensed cardiac event (paced or intrinsic) the blanking interval is adjusted to either to a first overall duration or a second overall duration. The second overall duration includes a first timed interval that has a programmable value. The repeatable noise window blanking interval starts after the first timed interval of the second overall duration. The duration of repeated repeatable noise window blanking intervals is summed and compared to a pacing escape interval.

Abstract: A cardiac stimulation device and method automatically confirm capture by detecting the polarity of a post-stimulation signal. A capture detection circuit is subjected to recharge and block overlap signals applied such than an evoked response signal is characterized by a primarily positive polarity and a polarization signal is characterized by a primarily negative polarity. An amplitude detection feature, such as peak amplitude or signal integral, and its polarity are determined from a post-stimulation signal sensed by the capture detection circuit during a capture detection window. Capture is confirmed when the amplitude detection feature has a positive polarity.

Abstract: An implantable cardiac stimulation device and method provides reliable sensing of cardiac events to support cardiac pacing or fibrillation detection. The device comprises a sensing circuit that senses the cardiac events in accordance with a plurality of threshold characterizing parameters. A parameter control adjusts the threshold parameters responsive to the rate of the sensed cardiac events in a manner which precludes positive feedback to prevent continued oversensing, undersensing, or noise sensing.

Abstract: An implantable cardiac stimulation device, such as a pacemaker, defibrillator and/or cardioverter, and an associated method that provide cardiac stimulation to at least two ventricular stimulation sites, within a single ventricle or across two ventricles. A high intrinsic atrial rate triggers a retrograde conduction detection routine when a high ventricular stimulation rate is sustained for a predetermined number of cycles during an atrial sensing mode. This routine interrupts concurrent stimulation, and alternates the stimulation output to the different ventricular sites.

Abstract: An implantable cardiac stimulating device has a control circuit connected to first and second electrodes respectively for stimulating first and second ventricles of a heart. Evoked response sensors respectively sense evoked response parameters to stimulation of the two ventricles. Delivery of stimulating pulses via the respective electrodes to the respective ventricles in the same cycle of the heart is controlled so that there is a time interval between the pulses respectively delivered to the two ventricles. The control circuit controls delivery of the stimulating pulses so that the respective evoked response parameters of the two ventricles occur substantially simultaneously.

Abstract: A heart stimulator has a pulse generator which emits stimulation pulses for delivery to the heart of a patient through a lead connected to the pulse generator and introduced into the heart. The heart stimulator has an evoked response detector which includes a measuring unit for measuring electrode signals picked up by the lead. An averaging unit is supplied with the electrode signals and forms an average value of the amplitude of the respective electrode signals for each heartbeat. A comparator in the evoked response detector compares the average value for each heartbeat with two predetermined limit values and emits a signal indicating that the electrode signal results from a fusion beat if the average values are between the two limit values.

Abstract: An implantable cardiac stimulation device and associated method capable of delivering non-invasive programmed stimulation for electrophysiological testing in which the onset of the non-invasive programmed stimulation is triggered by a cardiac event, either a detected intrinsic event or a stimulated event, occurring in the heart chamber to be tested. When a non-invasive programmed stimulation command is received by the implanted device, it switches to a routine that allows transition to a non-invasive programmed stimulation from a standard operating mode, during a refractory period. The stimulation device also provides a recovery delay following the last pulse of a non-invasive programmed stimulation sequence. If no intrinsic activity is detected during the recovery delay, a refractory period is started following the expiration of the recovery delay.

Abstract: A system and method for passively testing a cardiac pacemaker in which sensing signal amplitudes and lead impedance values are measured and stored while the pacemaker is functioning in its programmed mode. The amplitude and impedance data may be gotten and stored periodically at regular intervals to generate a historical record for diagnostic purposes. Sensing signal amplitudes may also be measured and stored from a sensing channel which is currently not programmed to be active as long as the pacemaker is physically configured to support the sensing channel. Such data can be useful in evaluating whether a switch in the pacemaker's operating mode is desirable.

Abstract: An implantable heart stimulating device with atrial overdrive capability has an atrial stimulation unit for stimulating the atrium via stimulation electrode(s), an atrial evoked response detector adapted to determine an atrial evoked response amplitude, and an atrial control unit to control an atrial timing unit to set an atrial stimulation time interval length between consecutively applied atrial stimulation pulses. The atrial stimulation time interval length is set in dependent on the determined atrial evoked response amplitude such that the next time interval length is a predetermined percentage of the present time interval length. If the ER signal amplitude decreases, the stimulating interval has to be decreased. The pacemaker can also try to increase the stimulating interval back to back until a decrease in ER signal amplitude is seen in order to avoid too high stimulating rate.

Abstract: The present invention relates to an implantable cardioverter-defibrillator or pacemaker whose standard circuitry is used to trend a physiological cardiac parameter using intra-cardiac impedance measurements. The trend information may be used to predict the onset of a sudden cardiac death (SCD) event. By being able to predict the onset of an SCD event, patients and their physicians may be forewarned of a life-threatening event allowing them to respond accordingly. The trend information may also be used to predict the efficacy of cardiac-related medications, monitor progress of congestive heart failure, detect the occurrence of myocardial infarction, or simply track changes in sympathetic tone.

Abstract: An evoked response detector for a biventricular pacing system has a measuring arrangement for measuring a cardiac parameter signal indicative of mechanical contraction of the heart after a biventricular stimulation. A comparator compares the parameter signal, in a time window of predetermined length after the stimulation, with a number of predetermined stored parameter signal templates representing different capture situations to determine most similar template and thus the existing capture situation.

Abstract: An implantable pulse generator senses a cardiac signal, identifies cardiac events in the cardiac signal, and starts a blanking interval including a repeatable noise window blanking interval in response to each cardiac event. When noise is detected during the repeatable noise window blanking interval, the noise window blanking interval is repeated. In one embodiment, the duration of repeated repeatable noise window blanking intervals is summed and compared to a pacing escape interval. When the sum is greater than the pacing escape interval, asynchronous pacing pulses are delivered until the noise ceases. Alternatively, when the sum is greater than the pacing escape interval, the pace escape interval is repeated.

Abstract: An apparatus and method are disclosed including an implantable medical device electrically coupled to a patient, having a sensor for sensing physiologic conditions and circuitry coupled to the sensor for emitting therapy in response to sensed physiologic conditions. A detector is coupled to the cardiac device for detecting the presence of electromagnetic interference and the intensity thereof and an alarm is coupled to the detector to signal the patient of the implantable medical device of the presence of electromagnetic interference.

Abstract: An implantable heart stimulator has a control and detection circuit which operates a pulse generator which emits stimulation pulses which are delivered to cardiac tissue via at least one electrode lead adapted for insertion in the heart of a patient. The electrode lead has an electrode surface which is intended to be in contact with heart tissue. The control and detection circuit performs a microinstability test by causing the pulse generator to emit a predetermined number of stimulation pulses, each having the same stimulation energy. The control and detection circuit determines a microinstability test value, representing a measure of the contact between the electrode surface and the heart tissue, as a ratio of a number of stimulation pulses, within said predetermined number of stimulation pulses, for which capture is detected, and the predetermined number of stimulation pulses.

Abstract: Implementing a subcutaneous medical electrode system involves positioning a number of electrode subsystems in relation to a heart so that noise cancellation provides an improved signal to noise ratio of the cardiac signal and/or to provide one electrode arrangement preferential for cardiac signals and another arrangement preferential for noise signals. One of the electrode subsystems so positioned may include one or more can electrodes located on a housing enclosing a medical device. The medical device may be configured to provide therapeutic, diagnostic, or monitoring functions, including, for example, cardiac arrhythmia therapy.

Abstract: Polarization signals, which represent voltages measured at a pacemaker electrode, are not constant and may drift. Polarization signal drift, which often precedes undesirable pace polarization artifacts, is more significant when the pacemaker is inhibited from providing an electrical stimulation to the patient's heart. The present invention provides an implantable system and methods for stabilization of a polarization signal. Electrical pulses may be applied to stabilize a polarization signal. In one implementation of the invention, polarization signal stabilization may be used as part of process to terminate tachycardia.

Abstract: An electromagnetic immune tissue invasive system includes a primary device housing. The primary device housing having a control circuit therein. A shielding is formed around the primary device housing to shield the primary device housing and any circuits therein from electromagnetic interference. A lead system transmits and receives signals between the primary device housing. The lead system is either a fiber optic system or an electrically shielded electrical lead system.

Abstract: An implantable cardiac stimulation device and associated method perform a true or blanking period ventricular undersensing detection algorithm in response to ventricular loss of capture not associated with fusion or a change in capture threshold. The test identifies an originating cause of loss of capture, which may be ventricular undersensing of intrinsic R-waves or premature ventricular contractions occurring during a ventricular blanking period or atrial undersensing of P-waves resulting in blanking period ventricular undersensing. A corrective action is taken to reduce the likelihood of blanking period ventricular undersensing by automatically adjusting device operating parameters. The corrective action may include automatic adjustment of atrial sensitivity, shortening of the ventricular blanking period, or adjustment of the base stimulation rate.

Abstract: A system includes a housing with energy delivery circuitry and detection circuitry. One or more electrodes are coupled to the circuitry and used to sense cardiac and muscle activity. A processor is coupled to the energy delivery and detection circuitry. The processor may detect a ventricular arrhythmia using a cardiac signal developed from the sensed cardiac activity and may also detect an activity state of the patient using an activity signal developed from the sensed muscle activity. The processor modifies delivery of a therapy to treat the arrhythmia in response to the activity signal. A method involves detecting signals using subcutaneous electrodes, and discerning a cardiac signal and a patient activity signal from the detected signals. Arrhythmia therapy may be modified to treat the arrhythmia in response to the activity signal.

Abstract: An implantable medical device (IMD) provides an alert to a patient that has the IMD implanted in their body. The alert is used to remind the patient to schedule and/or proceed to a follow-up physician visit. The reminder is also used to remind the patient to initiate a remote communication so that stored data or other information may be transmitted to a remote computer network or other communication node.