1 © Springer Nature Switzerland AG 2021 A. B. Bhatt (ed.), Healthcare Information Technology for Cardiovascular Medicine, Health Informatics, https://doi.org/10.1007/978-3-030-81030-6_1 Chapter 1 Telemedicine for Cardiovascular Disease Care Ami B. Bhatt and Sandra Nagale Telemedicine has become an essential mechanism for healthcare provision. We undertook this book prior to the COVID pandemic, which significantly changed the potential and future outlook for the implementation of virtual care worldwide. Telemedicine is broadly defined as the “use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, and public health and health administration” [5]. It is important to recognize that telehealth is not a disruptor of the practice of healthcare but rather it augments the traditional delivery of healthcare and enables a more agile and continuous mechanism of care provision, which engages the patient more strongly as an equal partner in their care. Telemedicine adoption has increased among clinicians and patients and we are now focused on promoting safe, effective, patient-centered, and equitable care. Telehealth promotes self-management, reduces medical errors, improves resource utilization and transitions cost savings to patients and their families. Each individual cardiology practice will find they have a range of provider adoption and use cases for blended virtual and in-person care. Across all practices however, establishing telemedicine workflows to ensure appropriateness of services, engagement in shared-decision making and promoting patient education and self-advocacy will be consistent themes. A. B. Bhatt (*) Harvard Medical School, Boston, MA, USA Massachusetts General Hospital, Boston, MA, USA e-mail: abhatt@mgh.harvard.edu S. Nagale Digital Health & Data Services, Boston Scientific, Marlborough, MA, USA e-mail: sandra.nagale@bsci.com
2 1.1 Cardiovascular Healthcare Technology Cardiology is the ideal discipline for the practice of telemedicine. As the infrastructure is built, it is essential to recognize that virtual and in-person care have a synergistic role, complementing one another to improve access and create safe, high quality care. Clinicians and patients must not expect a virtual visit to mirror a face to face visit, as it will have its own workflow as well as experience. Cardiologists need to be actively involved in the evaluation of digital medical technologies and administrators need to establish clear workflows to ease the transition to blended care by removing administrative barriers (Table 1.1). Lastly, reimbursement must be tied to patient satisfaction, provider reduction in burnout, quality of outcomes of care and adoption of new mechanisms of care delivery to truly establish a sustainable model of blended cardiac care delivery. The consumer-electronics market is also driving patients towards more sophisticated telemedicine capable technology at home. Smartphones are capable of gathering bio-parameters and sensor data, with patients using smartphones for video visits, healthcare data collection, medical prompts and education. The familiarity of using one’s phone to leverage a telemedicine monitoring platform to track their cardiovascular status carries value for the patients, doctors, hospitals and payers. Algorithms can then be taught to improve chronic care, and have already demonstrated improvements in medication adherence and blood pressure control [3]. Consumer purchased peripherals will continue to grow in number and purpose and produce aggregate data and the individual and community level (Fig. 1.1). A unique advantage of these peripherals is their ability to monitor health discreetly, thereby addressing health data collection with cultural sensitivity. As patients engage with providers remotely, they are increasingly engaged in, and can bring added benefit Table 1.1 Technological capabilities a. Audio b. Text messaging, email c. Chatbots d. Patient portals for virtual check-ins (eg. MyChart) e. Video 2-way: Apple FaceTime, Facebook Messenger Video Chat, Google Hangouts Video, Zoom, Skype f. HIPAA compliant video technologies: Skype/MS Teams, Updox, VSee, Zoom for Healthcare, Doxy.me, Updox, Google G Suite Hangouts Meet, Cisco Webex Meetings, Amazon Chime, GoTo Meeting, Spruce Health Care Messenger, American Well, MD Live, BlueJeans for Healthcare, Doximity g. Wearable devices and implantable devices (patient) h. Surgery telementoring systems – InTouch, Avail, Proximie, ExplORer i. Wearables/ Augmented reality: Video glasses (Google glass), MS Hololens j. Automatic data upload (no need for patient to do anything before e-visit) k. Adjacent integrated solutions eg. integrated scheduling and data collection/analytics, payment, insurance claims, etc. around telemedicine event A. B. Bhatt and S. Nagale
3 to, their local communities. Optimization of long term management in the community decreases chronic disease patient utilization of urgent care, and instead enables central institutions to focus on episodic emergent care, further improving resource utilization (Table 1.2). As sensors increase in number and with more disease specific value and via measurable RPM platforms, their financial value should soon be realized. Asynchronous Synchronous Remote Patient Monitoring Imaging E-Consults Live Video/Audio Remote Consult Telemedicine Fig. 1.1 Asynchronous vs. synchronous telemedicine Table 1.2 Telemedicine needs by type of user Non-surgical Clinical to patient • Remote visits (follow-ups, refills & consultations • Remote patient monitoring (non-invasive devices, implanted devices) • Remote decision support, tele-triage • Remote pre-visit prep • Inpatient Physician to caregiver/ patient • Virtual rounding • Remote video consult with family and clinician Physician to physician • Remote consult • Education/telemonitoring • Remote learning (clinician training) • Multidisciplinary team assessment Surgical Physician to physician • Surgical telementoring • Teleproctoring Physician to patient • Pre-operative screening • Post-operative follow-up • Post-discharge nursing follow up • Virtual cardiac rehab Live cases/physician groups • Remote live case education • Surgery broadcasting • Remote conferences 1 Telemedicine for Cardiovascular Disease Care
4 1.2 Impact of the COVID-19 Pandemic Pre-COVID, telemedicine was available (through large provider networks and employers) but not widely adopted. It often did not cover small practices/local physicians but instead centered on programs implemented at large hospitals. Consumers were often unaware that their physicians offered telehealth services. [2] Other major reasons for not using telehealth were preference for in-person interaction, privacy concerns, perceived challenges with technology, or lack of access to broadband. Provider level barriers included uncertainty about reimbursement, provider-patient workflow, incorporation of technology and ability to provide high quality care. Fortunately, a recent Cochran review revealed similar outcomes between in-person and telephone visits for patients with chronic conditions (diabetes, CHF) [9]. Similarly, in a pilot of heart failure virtual visits, 108 patients transitioning from hospital to home revealed a lower no-show rate for virtual vs in-person visits and no significant difference in hospital readmissions, ER visits, and death [4]. During the COVID Pandemic, telemedicine evolved rapidly as an instrumental enabler of remote hospital practices during the COVID-19 digital revolution. The use of telemedicine and virtual visits were used to address essential needs for both COVID and non-COVID patients. In addition to remotely connecting with and treating those patients infected with COVID-19, it also provided the opportunity to see healthy patients virtually to limit exposure to and spread of the disease and enabled remote (quarantined) physicians to work. In the spring of 2020, there was a significant surge in telemedicine adoption from 8% to 90% virtual visits across all specialities in the United States [8] with a 135% increase in virtual urgent care and 4345% increase in non-urgent care delivery [6]. There was considerable flexibility offered to HIPAA-enabled healthcare institutions, offering HCPs permission to use remote communication technologies (Facetime, Facebook Messenger, Google Hangouts, Zoom, Skype) even if not yet HIPAA compliant. Simultaneously, many Medicare restrictions were lifted allowing providers to provide patient care remotely, across state lines, deliver care to new patients, and bill telehealth at a comparable level as for in-person services. Unfortunately, the fear during COVID-19 of presenting for in-person care did drive patients to remain silent with symptoms or delay seeking care, resulting in late, more severe cardiovascular disease progression with delayed urgent and emergent cardiovascular care. Post-Covid, telemedicine is here to stay and will aid in the fast evolution of the “new healthcare practice”. Telemedicine enables physicians and nurses to work remotely, delivering high quality care, and augmenting in-person traditional care [10]. With patients and providers now appreciating the ease of use and convenience of virtual care, regulatory changes implemented during pandemic enabling rapid telemedicine) might be difficult to reverse post-COVID [7]. A. B. Bhatt and S. Nagale
5 1.3 Ensuring Equitable Care As blended virtual and in-person encounters continue to be rapidly adopted for the longitudinal provision of outpatient cardiac care, ensuring the delivery of high quality, equitable care is essential. Phone visits during times like the COVID-19 pandemic are a useful mechanism to ensure communication between patient and clinician. However, for optimal, long term care, video visits offer clinicians the ability to see the patient in their environment, respond to facial cues (i.e. pain, emotion, and comprehension), use image sharing for education and data review, and perform a virtual physical exam. It also gives physicians the unique opportunity to simultaneously connect with the patient’s family and caregivers. Cardiovascular management is also improved with vital sign monitoring and with integration into the EMR when possible. Navigating the use of new remote patient monitoring devices can also be taught during video visits. Therefore, it is essential to understand the barriers to video-based virtual care as well as the predictors of successful adoption (Table 1.3). Telecardiology can promote timely intervention, access for those living in medically underserved areas, and increased access to specialists by increasing provider Table 1.3 Telemedicine issues and risks 1. Learning curve for new technology Need for training 2. Implementation of new hospital/clinic guidelines Need for new reimbursement, payment policies and credentialing across hospitals 3. Need to quickly enable smaller hospitals with telehealth They are at a disadvantage vs teaching hospitals w established programs but essential to provide care to patients remote from big cities/hospitals 4. Implementation of new security guidelines Privacy, cybersecurity, interoperability, hospital reuse of technology 5. Legal, regulatory issues Obtaining Class I/II FDA approval for telehealth solutions like eICU, telementoring, etc. 6. Technology hurdles for seniors May not be using as much as younger or population. • 11–24% seniors have used telehealth in COVID period but ~68% have access to technology. • Opportunity to access patients through their caregivers • Prolonged stay-at-home order may lead to an increased use by seniors • Studies show that seniors will use telehealth if protocol applies to their condition, technology is easy to use and care is personalized (ref. 7) 7. Clinician preparedness Physicians need to be ready for “virtual rapport building, empathy, “facilitated” physical exams, diagnosis, and counseling” (ref. 10) 8. Patient Satisfaction and Accessibility to Provider Patient preference to see their own provider vs someone else 1 Telemedicine for Cardiovascular Disease Care
6 capacity. It is important that we pre-plan to address disparities in care ensuring that we do not worsen the digital divide and target increased access to specifically overcome barriers to care in at-risk populations. Wide scale implementation of telemedicine requires an infrastructure which addresses vulnerable populations including the elderly, those with limited digital or health literacy, individuals with decreased access, including rural or impoverished urban areas, limited English proficiency, racial/ethnic minorities, and those with low income or inadequate insurance. In older adults, visual and hearing impairment, cognitive decline and challenges with dexterity are just some of the deterrents to the utilization of video and digital technology. Future iterations of telemedicine workflows will need to include technical accommodations for sight and hearing limitations as well as hospital-based technology support. The close involvement of caregivers, family members and community advocates in preparation for and during these televisits will negate a worsening digital divide for access to care in the elderly. Digital and health literacy need to be addressed concomitantly with telemedicine implementation. Health literacy is a ubiquitous challenge throughout any healthcare system. Patients with chronic cardiovascular disease and social barriers to access are also those who feel digitally disengaged. They will benefit from digital skill assessment and ongoing support as the field of telemedicine evolves. Importantly, digital literacy is dependent not only upon skills but also the individual’s confidence with technology and can be further complicated by low health literacy. To proactively engage in healthcare, patients need to be facile with accessing services and comprehending basic health information for healthcare delivery to positively affect outcomes. Telemedicine offers an opportunity to address structural racism. Meeting the patient in their home provides a window into their environment and a chance to demonstrate respect and build trust with the individual and their family. Video visits enable us to tailor the patient’s care based not only on medical diagnoses but also on their social determinants of health. While telemedicine eliminates physical barriers to the delivery of care, we must actively avoid infrastructures which create digital isolation as a new barrier to accessing healthcare. Nearly half of the US population has slow or unreliable internet connection which contributes to isolation and decreased health literacy. While national legislation is underway to improve digital access, local efforts can include free Wi-Fi in rural and urban at-risk settings as well as the use of text messaging to minimize the impact of video streaming on limited data plans. At the clinician level, in addition to implicit bias and cultural competency training, equity dashboards can aid in awareness of existing inequities to allow practices to directly address unmet needs. Trust in the healthcare system becomes increasingly important as we increase the virtual and digital footprint of chronic disease management. Research confirms that Black patients are more likely to seek preventive care from Black physicians: racial concordance could reduce the cardiovascular mortality gap between black and white patients by nearly 20% [1]. It is our responsibility to seek out and train a diverse and culturally competent workforce as we educate the next generation and create digital health leaders. Our current systems must also be reviewed to ensure A. B. Bhatt and S. Nagale
7 equitable distribution of virtual care and implement tools and programs to aid patients in advocating for themselves and their communities. However, it is certain that multifaceted interventions will be necessary to achieve equity and address the dynamic SDOH that affect access to care including insurance, education, housing, wealth, racism. 1.4 Quality Measures and Cost-Effectiveness in Telecardiology In this book we will address the stakeholders essential to creating financially viable models for virtual care as well as the quality metrics needed to ensure safe and appropriate care delivery. While patients and providers are central to these processes, we will discuss the role of payers as essential stakeholders who impact the financial landscape of telemedicine through payment policies, benefit design, sales channels, government bid process, and, influence management of governmental insurance and medical coverage. There is a pivotal role for managing risk and cost in chronic disease populations by having care management teams help guide virtual vs. in-person care. Adopting the use of telemedicine will create cost savings where ordinarily unplanned utilization of care and ancillary authorization have created a financial burden. Improving access by expanding the geographic area of coverage and addressing social determinants of health can avert emergency utilization and brick and mortar overhead, thereby decreasing costs (16). In healthcare reimbursement models like those in the United States, payer quality is dependent on subjective feedback and the member’s convenient access to care using telemedicine may favorably impact quality metrics. Although telemedicine initially replaced non-emergent medical care in response to the COVID-19 pandemic, as pandemic wanes, cardiologists the world over must demonstrate the continued advantage of blended in-person and virtual care for patients and payers alike. 1.5 Conclusion Telemedicine rapid evolution post-COVID is driving fast adoption and imposing the demand for support of the new tools and support for larger scale. The choice of the right telemedicine technologies can help physicians, healthcare practitioners and patients recreate the future in-person experience; thereby creating an opportunity to reduce healthcare risks and create savings. In the future and for telemedicine to address the needs, it will be important to incorporate it within the rest of digital health solutions (devices, patient and physician software and applications, data analytics), maintain appropriate regulatory, privacy and security compliance within the application, and integrate telemedicine into existing clinical workflows (Fig. 1.2). 1 Telemedicine for Cardiovascular Disease Care
8 In this book we will explore the many facets of telecardiology including evaluating digital medical technologies, integrating wearables and remote patient monitoring and understanding the delegation of responsibility for data. We will also address the key mechanisms to build a digital heart center and explore the role of telemedicine as a growth strategy for improving patient experience, provider satisfaction and access to care.An emphasis of this book will be to alert readers to the risk of worsening the digital divide, and practical mechanisms to create structurally equitable virtual care paradigms. In an era of physician burn-out, improved engagement with telemedicine leads to opportunities for clinician creativity, productivity and higher quality care. Relationships are essential to the human connection and in a touching chapter on urgent care delivery, we will examine the positive effect of telemedicine on patient and provider engagement. Looking ahead, there is a need to consider our role in working with payers, developing curricula for virtual care delivery education and incorporating artificial intelligence to optimize care. Deliberate attention to these facets of telemedicine as we redesign cardiac care will create clinician-patient partnerships for longer, healthier lives. Access Education Experience Successful Implementation and Adoption -Affordability/cost -Insurance coverage (public/private) -Reimbursement -Awareness of telemedicine offerings and benefits -Ease of use -Ease of setup (e.g. between visits/cases) -Reliability -Transmission quality -Equipment portability -Seamless functionality within hospital network -Integration into physician’s and hospital established clinical workflow -Privacy ensured -Preserve quality of care -Demonstrate equal or improved outcomes Fig. 1.2 Successful implementation and adoption A. B. Bhatt and S. Nagale
9 1.6 Telemedicine Advantages 1. Keep patients out of hospital/ reduce ER visits 2. Bypassing ER visit, bypass prep, PCP exam, direct route for patient to hospital bed 3. Help enable social distancing compliance (non-urgent visits) 4. Enable combination of in-person and remote (quarantined) staff 5. Help physician with better-informed scheduling decisions for elective visits and surgeries 6. Better care for patients in rural areas 7. Enables better care for the elderly, disabled, unable to travel 8. Social determinants of health: telehealth an important vehicle for healthcare delivery for patients without housing and public transit 9. Physicians benefit from seeing patient in their home environment 10. Ability to ‘bring along’ caregiver for the visit 11. Opportunity for better harmonization and integration of patient data and clinical workflows through software solutions 12. Telemedicine may generate more meaningful data, leading to more insights, more future healthcare solutions 13. Faster decision making by care providers 14. Reduce number of visitors in hospitals 15. Enable remote visits to quarantined areas using telemedicine equipment 16. Easier for patients to discuss difficult topics and can have family presence during visit 17. Hospitals continue to generate revenue and able to reallocate resources 18. Ensure continuation of clinical/research studies 19. Reduce need for in-person physician interactions (procedure mentoring, proctoring, education, etc) via remote telemedicine equipment 20. Immediate access to specialized surgical expertise through telementoring, could have high impact to future patient care 1.7 Data and Analytics Enable Telemedicine 1. Data and algorithms for triaging (during COVID: travel history, exposure, vitals, other data) 2. Data obtained during tele-visit represent an opportunity to obtain more data and structured data when compared to an office visit 3. Opportunity for immediate data integration during digital visit 4. More data will be obtained due to video streaming, video capture during OR procedures - lead to more opportunity to educate others but also more privacy risk and need to ensure robust compliance 1 Telemedicine for Cardiovascular Disease Care
10 References 1. Alsan M, Stantcheva S, Yang D, Cutler D. Disparities in coronavirus 2019 reported incidence, knowledge, and behavior among US adults. JAMA Netw Open. 2020;3(6):e2012403. 2. CMS.Medicaretelemedicinehealthcareproviderfactsheet.2020.Retrieved2020Oct9fromhttps:// www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet 3. Fisher ND, Fera LE, Dunning JR, Desai S, Matta L, Liquori V, et al. Development of an entirely remote, non-physician led hypertension management program. Clin Cardiol. 2019;42(2):285–91. 4. Gorodeski E (2019. Virtual visits reduce no-show rates in heart failure patients. Retrieved from https://www.hcplive.com/view/virtual-visits-reduce-noshow-rates-in-heart-failure-patients 5. HHS. Telehealth: delivering care safely during COVID-19. 2020. https://www.hhs.gov/coronavirus/telehealth/index.html 6. Mann DM, Chen J, Chunara R, Testa PA, Nov O. COVID-19 transforms health care through telemedicine: evidence from the field. J Am Med Inform Assoc. 2020;27(7):1132–5. https:// doi.org/10.1093/jamia/ocaa072. PMID: 32324855; PMCID: PMC7188161 7. Mann DM, Chen J, Chunara R, Testa PA, Nov O. COVID-19 transforms health care through telemedicine: evidence from the field. J Am Med Inform Assoc. 2020; 8. Mehrotra A, Chernew M, Linetsky D, Hatch H, & Cutler D. What impact has COVID-19 had on outpatient visits?. 2020. Retrieved from https://www.commonwealthfund.org/ publications/2020/apr/impact-covid-19-outpatient-visits 9. Orozco-Beltran D, Sánchez-Molla M, Sanchez JJ, Mira JJ, ValCrònic Research Group. Telemedicine in primary care for patients with chronic conditions: the ValCrònic Quasi- Experimental Study. J Med Internet Res. 2017;19(12):e400. 10. TCTMD (2020). Telehealth offers a lifeline for cardiology patients during the COVID-19 pandemic. (https://www.tctmd.com/news/telehealth-offers-lifeline-cardiology-patients-during -covid-19-pandemic). Further Reading AMA quick guide to telemedicine in practice. https://www.ama-assn.org/practice-management/ digital/ama-quick-guide-telemedicine-practice?gclid=CjwKCAjw5cL2BRASEiwAENqAP rIMl_VaG90-r36DJd5k1NQdM3MpX9I7vFahJPbzZCxT6ewaEMFg7xoCTxQQAvD_BwE and https://www.ama-assn.org/system/files/2020-04/ama-telehealth-playbook.pdf COVID-19: the rise and rise of telemedicine. https://www.mobihealthnews.com/news/europe/ covid-19-rise-and-rise-telemedicine COVID-19 shifts Telehealth to the Center of Cardiology. https://www.medscape.com/ viewarticle/927465 FAQs on Telehealth and HIPAA during the COVID-19 nationwide public health emergency. https://www.hhs.gov/sites/default/files/telehealth-faqs-508.pdf https://pubmed.ncbi.nlm.nih.gov/32220575/ Surg Endosc. 2016;30:3665–72. Surg Endosc. 2019;33:684–90. Surveys suggest seniors aren’t using telehealth during COVID-19 crisis. https://mhealthintelligence.com/news/surveys-suggest-seniors-arent-using-telehealth-during-covid-19-crisis Telehealth coding and billing during COVID-19. https://www.acponline.org/practice-resources/ covid-19-practice-management-resources/telehealth-coding-and-billing-during-covid-19 Telehealth: delivering care safely during COVID-19. https://www.hhs.gov/coronavirus/telehealth/ index.html A. B. Bhatt and S. Nagale
11 Telehealth: rapid implementation for your Cardiology Clinic. https://www.acc.org/latest-in- cardiology/articles/2020/03/01/08/42/feature-telehealth-rapid-implementation-for-your- cardiology-clinic-coronavirus-disease-2019-covid-19 Telemedicine in the Era of COVID-19. Editorial. J Allergy Clin Immunol Pract. 2020 May. https://reader.elsevier.com/reader/sd/pii/S221321982030249X?token=E02C3738158B2FF2D 4AE434B1421339B22D3EB0B1AA16F6FF1A2EBECCB68E67DBDCF7697D05FCFEF 5E61644778360EC7 The evolution of surgical telementoring: current applications and future directions. Ann Transl Med. 2016;4(20):391. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5107399/pdf/atm-04-20-391.pdf The role of telehealth in combating the social determinants of health. https://www.healthrecoverysolutions.com/blog/telehealth_sdoh Virtual visits for care of patients with heart failure in the era of COVID-19: a statement from the Heart Failure Society of America. J Card Fail. 2020 Apr 18. https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC7166039/ Virtually perfect? Telemedicine for COVID-19. N Engl J Med. 2020;382:1679–81. https://www. nejm.org/doi/full/10.1056/NEJMp2003539 1 Telemedicine for Cardiovascular Disease Care
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