As countries around the globe enforce social distancing and self-isolation to fight the COVID-19 pandemic, telehealth is emerging as a critical tool to connect physicians and other healthcare professionals with patients dealing with chronic cardiovascular conditions.
“Before this pandemic, telehealth was sort of an ‘icing on the cake’ kind of a situation for the vast majority of healthcare facilities, at least in the cardiology space,” Andrew Freeman, MD (National Jewish Health, Denver, CO), a member of the American College of Cardiology’s Health Care Innovation Council, told TCTMD. “This has actually been a blessing in a very awful disguise in that we now have an enormous impetus to do this and do it well. But that being said, what that looks like is very rapidly changing.”
Telehealth is a broad term describing the provision of healthcare to patients virtually, whether that be over an institutional video conferencing program, a more commercial application like FaceTime or Skype, or even simply via telephone. With the current public health crisis, the Centers for Medicare and Medicaid Services and the Food and Drug Administration have each loosened prior telehealth restrictions on what physicians, nurse practitioners, and a variety of other providers can offer to their patients and receive reimbursement for. As reported by TCTMD, during the height of the COVID-19 outbreak in China, physicians relied heavily on the country’s 5G network to offer telehealth services to patients with nonemergent heart disease.
Some institutions have been offering telehealth services to patients for years now, mostly for rural and disabled patients unable to travel for in-person appointments, but many cardiologists have now been tasked with transforming their practice almost overnight.
This has actually been a blessing in a very awful disguise in that we now have an enormous impetus to do this and do it well. But that being said, what that looks like is very rapidly changing.ANDREW FREEMAN“”
“People need to go in expecting that it’s not going to be the same as a face-to-face visit,” advised Freeman, who recently co-authored a how-to article on telehealth. “But I would say that in general the technology is very easy to use and, provided you have an even borderline internet connection, it’s quite doable.”
In response to questions from TCTMD, the American Heart Association (AHA), which published a primer on telehealth back in 2016, recommended that providers who have never used telemedicine should “opt for basic technologies that allow for real-time video/audio communication and are easy to use for providers and patients alike. Many vendors provide live training sessions for new users. The key is to adopt technology that is affordable, covered by insurance (both public and private), and easy to use.”
Specifically, the AHA reply noted, the Office for Civil Rights (OCR) of the US Department of Health and Human Services last week lifted restrictions on the use of non-HIPAA-compliant software platforms to conduct telehealth visits.
“Covered healthcare providers may use popular applications that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype to provide telehealth without risk that OCR might seek to impose a penalty for noncompliance with the HIPAA rules related to the good faith provision of telehealth during the COVID-19 nationwide public health emergency. In general, however, the provider should work with the patient to determine what is the best way to communicate to ensure optimal care,” advised the AHA.
Society for Cardiovascular Angiography and Interventions (SCAI) President Ehtisham Mahmud, MD (University of California, San Diego), told TCTMD he made the decision for his department to begin conducting telehealth visits for as many patients as possible last Monday. His team uses FaceTime to assess patients, and he estimates that of the 200 patients or so their busiest clinic sees on a daily basis, fewer than 10% need to come for in-person visits.
“Our staff communicates with them beforehand, gets their list of medications and all of that stuff, and so when the physician sits down with them, they’re documenting on a desktop—we have an electronic medical record—and they are able to see the patient, talk to them, and review their medications,” he said. “Obviously you cannot do a true physical exam or [take] vital signs, but the patient can usually get their blood pressure and heart rate if they have the [proper tools] at home. And we have changed our formatting of the note for telehealth. . . . We can do the initial consult, order the relevant blood tests, [decide] if they need an echo or Holter or EKG, and then determine who needs to be seen in person.”
So far, Mahmud said patients have “embraced” this new method of delivering care, but he added that “we’re reassessing this obviously on a weekly or almost daily basis.” They are billing video visits the same as they would in-person appointments—here’s a helpful tip sheet on billing and coding for telehealth.
The biggest challenges, he said, are making sure the patients have the proper technology to be able to use FaceTime (for those who don’t receive telephone calls) and getting accustomed to the lack of physical exam. “There’s still that shortfall in heart failure patients or patients who are coming for a referral where you need to have that physical exam to add to where the patient is in their clinical symptomatology,” Mahmud said. “Overall, I would say for the follow-ups, the refills, and for straightforward consultations at this point it’s working quite well.”
Freeman added that “not everybody has a reliable internet connection that can support video” and many patients at home might be dealing with reduced bandwidth given the current strain on internet service providers. “Of course, it’s harder to squeeze a swollen leg or listen to somebody’s lungs,” he noted, and while technologies are emerging as solutions, “most of them are not ready for prime time yet.”
He also cautioned physicians to make sure they are only treating patients in states in which they are licensed. “You could imagine a situation where, for instance, if I practice in the tristate area and you live in Connecticut and I’m in Manhattan; there are some legal statutes to lift or blur those lines a little bit, but they change. And so I would encourage folks to investigate this thoroughly.”
According to the AHA, “One of the biggest misconceptions about telehealth is that it is a complex ‘disruptor’ of the practice of healthcare. It isn’t. It is not intended to supplant traditional modalities of healthcare delivery but augment them. It is simply a different way of providing healthcare. A second misconception is that it is something that older citizens (who have a disproportionate demand for healthcare) will not be willing to use. Studies have shown that the elderly are willing to use telehealth if they are assured that the protocol applies to their condition and the technology is usable and able to be personalized.”
Hope for a ‘Lasting Thing’
After all is said and done, Freeman said he is optimistic that the national experience with telehealth during COVID-19 times will have a permanent impact. “I’m hoping that this will be a lasting thing, meaning that virtual visits will actually markedly improve access to care, particularly for those who are older or disabled or unable to travel,” he said.
Mahmud agreed. “Any tragedy or any pandemic or issue of this magnitude accelerates things that we have been trying to do or want to do but just haven’t been able to do because change is always difficult for people,” he said. “This has required us to adapt very, very quickly, and I think we will have lessons from that adaptation. And when this hopefully settles, I think telehealth will come out in a better way. We’ll learn from it, and we’ll figure out how to better organize it and deliver it. I think it’s good for patients, especially for a lot of our elderly patients.”
This has required us to adapt very, very quickly, and I think we will have lessons from that adaptation. And when this hopefully settles, I think telehealth will come out in a better way.EHTISHAM MAHMUD“”
For now, it’s important not to lose sight of the fact that all of the patients with chronic disease who were being cared for prepandemic “haven’t gone away,” Freeman emphasized. “We need to be able to manage, maintain, check on, and adjust to keep people out of harm’s way for those conditions just as well as COVID.”
Mahmud encouraged any healthcare workers new to telehealth make sure that they have the support of their institution’s IT department to bolster any technological needs. Also, “like anything else, there’s sort of the initial learning and growing pains. But we as physicians can do this much more easily and help our patients transition, because whatever stress and anxiety we’re feeling, the patients are feeling it much greater,” he said. “We all need to embrace it, and we all need to guide our patients through this very difficult time. And if people can’t get to a full video virtual visit, then a telephonic visit certainly suffices, and I think most of these patients we should only bring into the clinic or for procedures if they absolutely need it because the exposure for them could be catastrophic.”