Telehealth Shaping Up for COVID-19

Cardiology illustrates what specialties can do to be ready

As COVID-19 coronavirus encroaches into communities across the U.S., cardiology’s use of telemedicine could set a precedent for what specialties can do with the technology to both protect coronavirus-vulnerable patients and manage comorbidity that arises.

“Self-quarantine and social distancing are important tools in managing disease transmission, especially among patients who are acutely vulnerable to the risk of infection,” noted an American College of Cardiology (ACC) and American College of Physicians statement urging greater use of telehealth tools to combat community spread.

Cardiovascular disease, along with older age, appears to be emerging as a key factor in vulnerability, according to the sparse data available so far, noted ACC President Richard Kovacs, MD. Fully 40% of coronavirus cases from Wuhan, China,had chronic cardiovascular or cerebrovascular disease in a report in The Lancet.

In the case of heart failure, for instance, contracting a respiratory virus like the flu is known to contribute to exacerbation of their cardiac condition, noted Partho Sengupta, MD, of West Virginia University Heart and Vascular Institute in Morgantown.

Reducing Exposure, Speeding Tx

For heart failure patients who get COVID-19, virtual visits by a care team who knows them could speed these patients to emergency care, Sengupta noted.

“We need to see them earlier,” he toldMedPage Today. “People with heart failure are really at risk for getting decompensated. Screening; making sure people are doing well certainly makes sense. We need to be on the watch for clinical signs [of COVID-19].”

But telemedicine could also help keep uninfected chronic cardiovascular disease patients out of the emergency department, Kovacs told MedPage Today.

In heart failure, for instance, “symptoms may be indistinguishable, if they are short of breath, from infection with a respiratory virus,” he said. “Being able to tell the difference and not having a patient who is having a heart failure exacerbation mixed in with patients in an emergency department being in close proximity to patients who are infected we think may be very important.”

With virtual visits and/or remotely collected data, he said, the care team could assess symptoms and help guide patients in deciding whether to “seek care in a place where they might be at higher risk or maybe there are some simple interventions, some simple medication adjustments that might be made over the telehealth conduit to fix the problem.”

Ambulatory hemodynamic monitoringhas been shown to reduce hospitalizations by 24% to 30% in chronic heart failure patients. A wearable patch with multisensor telemetry was also shown capable of predicting exacerbations about a week ahead of hospitalization in a recent study.

Legislative Help

An $8.3 billion emergency supplemental spending bill for the COVID-19 outbreak passed by Congress on March 5 included provisions for Medicare telehealth spending. President Trump signed the emergency funding into law on Friday.

“It’s a positive thing,” Kovacs said. “I don’t know if it’s going to be enough or not. We don’t know how big this is going to get.”

Notably, the legislation lifted restrictions on telehealth as had been requested by a number of professional organizations to allow use and Medicare reimbursement regardless of originating site or geographic location.

The wording of the emergency legislation wasn’t clear as to whether Medicare reimbursement would extend to virtual visits for any condition or just COVID-19-related illness specifically, cautioned Mei Kwong, JD, of the nonprofit Center for Connected Health Policy’s National Telehealth Policy Resource Center.

It’s up to Centers for Medicare & Medicaid Services (CMS) how to interpret, and there are large swaths of the population for whom this policy change won’t impact access, such as the privately insured and those with Medicaid, she told MedPage Today.

CMS did not respond to a request for clarification in time for publication.

At least some organizations interpreted the law broadly. The American Psychological Association, for example, said in a statement that the legislation would allow “more older adults to continue to receive essential health and mental health treatment, including at their home, during this public health emergency period — potentially helping to minimize exposing others to the virus.”

In England, National Health Service plans released Friday call for practices to replace as many face-to-face visits with phone, text, or other telehealth contact as possible.

Cardiology ‘Out Front’

Cardiology has a long history with remote monitoring of vitals, from pacemaker telemetry to home blood pressure and wearable ECG data, although these have been carved out as distinct from telehealth (with fewer restrictions) by CMS for the purposes of reimbursement.

At West Virginia University’s clinics, most of which fall under the rural health exception to Medicare’s prior restriction on telehealth, a mid-level provider or nurse takes vitals and starts the virtual visit connection in the remote office and manages the digital stethoscope for the cardiologist, explained Sengupta, who helped start the program.

Starting next month, though, his group will start testing a new smartphone app for survivors of myocardial infarction that keeps up a continuous conversation with the patient about medication adherence, weight checks, and such and that warns the care team navigator of problems.

Artificial intelligence-based monitoring systems, even if not widely used in clinics, are available and could be adopted quickly by cardiology care teams within days or weeks if the coronavirus outbreak requires it, Sengupta said.

The technology is there for remote monitoring of other chronic conditions too, Kwong noted.

Cardiology has been out in front on specialty use, though, Kovacs said. “I suspect that other specialties will get interested in this, and I hope it stimulates a bigger conversation.”

“Specialty societies and the clinicians and the cardiac care team, we want to sort of get ahead of this. Hopefully, we won’t have to do a great deal of this [virtual visits], but we want to offer something concrete that will be a solution in a time when people are searching for solutions,” Kovacs said.