Telecardiology during the COVID-19 pandemic showed cardiologists another way to treat patients
Telecardiology saw major boost with during the COVID-19 pandemic and many health systems, having seen the benefits of virtual health, are now looking to permanently incorporate this type of care moving forward.
Cardiovascular Business spoke with Ami Bhatt, MD, the American College of Cardiology (ACC) Chief Innovation Officer, and an adult congenital heart disease cardiologist at Mass General Hospital (MGH). She is viewed one of the national experts on telecardiology, having been the former director of telecardiology at Mass General during the pandemic between 2020-2021.
Ty Gluckman, MD, MHA, medical director, Center for Cardiovascular Analytics, Research, and Data Science (CARDS) at Providence St. Joseph Health in Portland, Oregon, also added context as a first time user of telecardiology during the pandemic.
Telecardiology saw a major boost thanks to COVID-19
Telemedicine saw massive expansion overnight at the beginning of the pandemic as a way to continue patient care while at the same time limiting contact between people. The utility of virtual care was experienced over the past two years by clinicians to perform quick visits or check ins on patients. The time savings and reduced hassle for patients who were not required to drive to an office visit and possibly take off work was also viewed as an improvement on the patient satisfaction side of things.
While telemedicine has been around for more than a decade, it has never seen widespread adoption, mainly due to insurance companies preferring that patients have an in-person office visit. However, that quickly changed in the spring of 2020 as healthcare systems and government health officials looked for ways to reduce contact between people while still delivering care. The Centers for Medicare and Medicaid Services (CMS) authorized payment waivers for telemedicine during the COVID emergency, and this helped open the floodgates for its use.
Bhatt said many patients prefer telemedicine as a convenience.
"With hourly wage workers, it's a very expensive thing to come in. It's actually expensive to come in and park in Boston. There's time, there may be childcare or elder care. They need to find transportation, which might not be easy," Bhatt explained. "And there's a bit of an anxiety that comes to all of us when we have to go through that whole process to get into a hospital or a clinic."
"There are relatively few silver linings with the pandemic, but one of the silver linings was that it accelerated adoption of telehealth," Gluckman added.
His health system rapidly adopted a telecardiology program just after the pandemic began. He said most cardiologists, including himself, had never been involved in telemedicine prior to March 2020. But, he said it gave them a new tool and a new way of delivering patient care that has advantages in some situations.
"I hope that it's here to stay, but we still need to figured out how much as a percentage of encounters it actually fits in with. This is also going be shaped by whether the encounters are actually reimbursed," Gluckman said.
The telecardiology program at Mass General Hospital
Bhatt started her telecardiology practice in 2013 with congenital heart patients. She said it made a lot of sense to facilitate virtual visits because it was much easier for quick check in visits or updates with these young patients and their families. She said most of these families were in their thirties and busy with kids and jobs, so carving out time to drive to downtown Boston was a big time saver for them.
MGH initially started using telemedicine with its telestroke program about 20 years ago to provide remote acute stroke care and consultations throughout the New England area.
“There was a benefit to patients and there was a cost benefit. Once we saw that happen, myself and others in a variety of departments started to use telemedicine, recognizing its importance,” Bhatt explained.
This prior experience made things much easier once the pandemic started.
“So the fortunate thing for the Mass General system, and for our cardiology division in particular, was that we already had a telemedicine system in place and really just needed to activate it for the rest of the practitioners,” Bhatt said.
She said MGH was fortunate, because many large hospital systems did not have anything to start with. Those systems had to quickly figure out what telemedicine tools are available, who are the telemedicine companies that could quickly deploy a system, and how to enable HIPAA secure systems.
Ami Bhatt, MD, is the chief innovation officer of the American College of Cardiology (ACC) and an adult congenital heart disease cardiologist at Mass General Hospital.
Virtual care visits are declining, are now part of a blended approach
While the volume of telemedicine visits skyrocketed during the first year or so of the pandemic, Bhatt said she is seeing a regression in the number of virtual visits with phone calls or video as hospitals and clinics go back to in-person visits. But at MGH, they went to a mix of virtual and in-person visits, depending on what was needed.
“Blended care is the phrase that I like to use, where sometimes virtual care is appropriate, and sometimes in-person care is necessary,” Bhatt said, noting it is important keep in mind that different patients are going to feel comfortable with different strategies.
"As long as we are flexible and agile in allowing a mix of blended care, we're probably going to be more successful in using virtual care," she said.
Gluckman said the vast majority of his patient visits are not back to being in-person, but he wants to keep the option for telecardiology visits.
Simple things that cardiologists can do with telemedicine
Bhatt offered what she called “quick wins” for the basic use of telecardiology visits.
“So if you just need to do blood pressure checks and and you trust that your patients have a good blood pressure cuff at home, do they need to come in for a nursing visit?” Bhatt asked.
Because many hospitals and clinics have a nursing shortage, this is a good place to use virtual visits. Virtual check-in visits might also might be appropriate and can really help if there is something you are trying to quickly solve. She said showing a patient’s care team how telehealth can be used and when for simple things that avoid an in-office visit can be very helpful in showing how telemedicine can be leveraged to ease workflow and patient satisfaction.
How to start a telecardiology program
Bhatt said is there needs to be a clear plan for, and integration of, the clinical workflow when using a telemedicine platform. The key IT component of the program is a HIPAA-complient video conferencing system to meet with patients using a computer, tablet or smartphone. Often, email and texting are also incorporated into telemedicine programs.
Workflows: Bhatt thinks she and her colleagues were so successful because they had a workflow infrastructure in place for using telemedicine.
“I think what brings success to this is having infrastructure, and that doesn't just mean having hardware, software or technology, that actually means having workflows," she said. "So one of the hardest parts we talk about out a lot is provider adoption or patient adoption of new technologies. And I would say one of the greatest barriers for us to be effective in getting a new technology into healthcare is when we don't have a workflow as to how and when to use it."
It also took time to figure out each workflow and teaching them to staff, Bhatt said. And this is not just limited to clinicians or the patients, but anybody who interacts with a patient or clinician, such as the administrative staff. She said they might carry the largest burden of teaching digital literacy to individuals on both sides, whether it is a practitioner or a patient.
Video platform: You need a secure, HIPAA compliant video system, Bhatt said. The MGH started its telemedicine program using SBR Health, which provides video-based solutions that enable the creation of virtual healthcare delivery networks (VHDNs). They also used InTouch Health (now part of Teladoc). Recognizing the rapid increase in volume in virtual visits, she said MGH moved to Zoom for Healthcare. She said there are also many other companies out there for this type of service.
Reimbursement for telemedicine services
Bhatt started worked with the Massachusetts governmental affairs office a few years ago, helping officials understand how they can help support telemedicine. Massachusetts, as well as many other states, moved forward early on in the pandemic with paying for telemedicine visits. CMS also granted waivers that allow healthcare providers to use virtual platforms for visits. One issue that often comes up is that providers are licensed by state, but some states have worked to address this challenge with updated licensing policies.
"Other institutions are working very hard to help their physicians to get licensed in the states where they're providing care to patients," Bhatt said.
She said there is a big push right now to create legislation that will make telemedicine reimbursements permanent after the pandemic emergency has passed. "There are so many different pieces of legislation that are in Congress now and moving forward. And many of these are emphasizing the fact that there is a need for virtual care,"
Several professional medical groups, including the American Telemedicine Association (ATA) are actively involved in lobbying efforts on both the state and national level to support reimbursement for telemedicine programs.
"I think there are many of our government representatives who recognize the importance," Bhatt said. "I think there are many states where in-person care was really just not happening, or where getting to care was so hard. And now we're able to deliver care in those areas. Granted, there are some still some challenges in terms of access in how you reach those people. But I think a lot of our government representatives now understand the importance of blended care, the importance of allowing some virtual care and letting clinicians and patients use their own acumen and personal experience. I think that's why, why you see many of the societies coming forward, supporting this."
Telemedicine can help manage heart failure and hypertension patients
Telecardiology might be the ideal platform for patient engagement in monitoring hypertension and heart failure. Bhatt said having patients come in for check ups twice a year to get blood pressure readings is not the best way to keep them under control. Telemedicine allows for more frequent monitoring touch points. She said this approach in heart failure could help reduce hospital admissions or readmissions.
"Moving from episodic to continuous care naturally requires not just supporting in-person interval visits, but supporting continuous monitoring of patients with more continuous and easy to use communication in order to help patients engage with their own healthcare and really become the strongest self advocates that they can," Bhatt explained.
Making care management more convenient for patients will greatly increase compliance, Bhatt said.
"There are many studies that talk about the fact that the gold standard of in-person visits may not be the best way to communicate with your patient," she added. She cited a hypertension study of black mother's study by the Association of Black Cardiologists. It showed text messaging blood pressure readings in this population was much more effective with improved patient compliance than using in-office visits.
Telemedicine gets high marks for patient satisfaction
"Patient experience metrics with virtual care have been through the roof since the initial studies were done, and that's been years now. So it's certain that that patients understand that value," Bhatt said.
She said patients also know how to advocate for themselves when they want an in-person visit for a reason, or when they just want to talk on the phone or a video chat. Bhatt said doctors often want to have a face to face meeting to break bad news or have a serious discussion, but she found some of her patients just wanted to know what was going on without having to drive into the city or longer distances for a face-to-face meeting.
"I was certain that one of my patients needed me to hold his hand to tell him he needed a third surgery. I wanted to sit down and I was insistent with my administrative staff that he come in, and he was insistent back with them that he had done a virtual visit with me before," Bhatt shared. "He just wanted that. And when we finally had the visit, he said, 'thank you for accommodating this, because I need to be at home with my three kids to remind myself of why I'm going have that third surgery. This is where I need to be.'"
Communication with patients also can be enhanced through virtual visits.
"A few things that I've found very helpful is the ability to share imaging with a patient, to look at their X-ray and to let me circle what I'm looking at. There also is the ability to show what the four food groups are and what a healthy plate looks like and to immediately answer questions. I think that ability to draw for them and show imaging helps as visual learning aids. Adult learning happens in a variety of ways and many people are visual," Bhatt added.
"There's no question that an overwhelming number of patients love the luxury of being able to flip open their smartphone, turn on their tablet, or open up their laptop and be able to connect with their clinician as needed. And I think it there are unbelievable advantages to it," Gluckman added.
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Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: dfornell@innovatehealthcare.com