In March 2020, the United States began to experience the reality of a pandemic. However, implementation of social distancing, cancellations of elective procedures, and a significantly decreased volume of in-office patients forced us to explore new and different ways to care for patients.(1) As with most medical practices in the country, telemedicine was an abstract concept prior to the COVID-19 crisis.
Getting Started with Telemedicine
When our practice initially began to consider telemedicine, the thought of developing a telemedicine program in a span of days or weeks was very daunting. The challenges of implementing telemedicine originated largely from the CMS regulations surrounding rules for telehealth. These included dictating where providers could be located, mandating that patients be in rural areas, requiring patients to have a prior relationship with the physician, and stipulating requirements for HIPAA-compliant technology.
On March 17th, 2020, in order to facilitate compliance with social distancing in healthcare while allowing providers to care for patients, CMS released a ruling stating that it would pay for telemedicine services in any healthcare facility, including a patient’s home, and that the established relationship rule would not be enforced.(2) In addition, CMS allowed for a variety of virtual methods of obtaining face-to-face contact with patients, waiving the prior HIPAA-compliant rules, and allowing much needed flexibility for practices not well versed in telemedicine to care for patients.
Relaxation of previously stated CMS rules around telemedicine opened the door for practices like ours to take advantage of technology to keep patients at home while still providing good cardiac care. Over the course of a few days, approval by most other insurance carriers followed.
Determining a Workflow
In order to get started, our team first explored options for technology. Our practice has used a variety of options in the last few weeks, including FaceTime, Google Duo, WebEx, Zoom, Doxy.me, and Doximity. More recently, our EPIC IT team has worked to make accessible MyChart Video Visits, in which a patient can join a video visit with their provider from their MyChart application on their smartphone or computer. This has proven to be very successful and has also encouraged patients to sign up through the patient portal, utilizing technology in which our system has already invested. We recognized early on that standardization of telemedicine across our healthcare system was necessary. Having multiple providers using different platforms was confusing for both patients and support staff. Additionally, there was a need to standardize documentation for our coding and compliance team.
After several iterations, our current workflow is to identify the type of technology that a patient has available at the time that the appointment is made. This allows both the provider and support staff to know which modality for telehealth visits works best for individual patients. Our experience is that the majority of patients have access to technology required for telehealth visits. Research suggests that 96% of Americans have a cell phone of some kind, with 81% of Americans owning a smartphone (increased from 35% in 2011).(3) In addition, the majority of Americans have desktop or laptop computers.
Several days before the appointment, an office staff member contacts the patient and verifies technology options as well as helps the patient through a “dry run” of the technology. This time is also used for medication reconciliation and reminding patients to send any available Apple Watch or KardiaMobile (AliveCor, Inc.) EKG strips through the patient portal for review at the time of the appointment.
Telemedicine has also been instrumental in our device clinic setting. We have been able to virtually perform wound check appointments and evaluate device data through a remote transmission, allowing patients to stay home and have the same level of care as coming into the office for in-person evaluation. By incorporating this technology, our electrophysiologists and entire device clinic staff have been able to work nearly exclusively from home since mid-March. Very rarely are office visits are required, primarily for device reprogramming.
While COVID-19 has dramatically changed our healthcare world, it is important to remember how this pandemic has also affected our patients. Not only are they being asked to socially isolate, they are also being asked to communicate with their providers in ways that can be intimidating for them.
An important first step when considering implementation of telemedicine, and a learning experience for us, has been to explore communication barriers within our patient population. An integral part of our discussions with patients is reassuring them that we are “right there with them” in the technology learning curve and being willing to talk through how to activate a camera or microphone on their desktop computer or smartphone. It has also been important to give all of our patients an opportunity to participate in this type of care. For example, we have had patients up to 97 years of age successfully complete telemedicine visits. This has been rewarding for both the patient and the provider.
Our team has found that patients are incredibly appreciative of this approach to healthcare. The anecdotal stories of being able to avoid a 2-hour road trip or not have to manipulate wheelchairs in and out of office buildings have strengthened our resolve to work through technology challenges to continue to provide this type of service going forward.
There was some hesitation in our ability to effectively move our Atrial Fibrillation Clinic and Advanced Heart Failure Clinic to a virtual model. With targeted patient education and strategic scheduling, we have been able to move both of these clinics to all virtual visits, with the exception of one day per week in the office for very rare in-office visits.
Another important initiative was being able to provide the same level of service to our patients with cardiac implanted electronic devices (CIEDs) undergoing MRI scanning and cardioversions during the COVID-19 crisis. Our EP team developed a hospital protocol that allows for remote interrogation of devices using each device companies’ remote interrogation system followed by reprogramming if necessary by local personnel, reducing patient and staff exposure while still providing appropriate oversight. With appropriate use of technology, we have been able to eliminate the need for industry representative checks in the majority of our clinical settings.
Utilization of Remote Monitoring in Telemedicine
One concern with seeing patients virtually as opposed to in person was our ability to access data from implantable devices (pacemakers, defibrillators, loop recorders) or obtain an EKG to assess rhythm. The information contained in these reports such as atrial fibrillation burden, percent CRT pacing, and heart failure diagnostics can be instrumental in developing a patient care plan.
We have found that utilizing our dedicated heart failure remote monitoring device clinic, we have been able to follow patients’ physiologic data (including thoracic impendence, respiratory rate, nighttime heart rate, activity level, and heart rate variability) on a monthly basis and identify those that are at high risk for heart failure hospitalization. The clinic follows patients on a weekly basis after a hospitalization for heart failure. Recently, we began weekly transmissions as well for patients at high risk for heart failure hospitalization. This information is available in EPIC for all providers to review at the time of telehealth appointments. A protocol for adjusting diuretics as well as appropriate patient education and guidance has been developed for this CHF device clinic.
Implantable loop recorder patients are also followed monthly, allowing for access to relatively real-time data such as arrhythmia burden and heart rate trends. For those patients who need information that is more up to date, our device team is able to pull data from the night before the appointment by downloading a report from their remote website and relaying it to the following practitioner.
In addition to implanted devices, we have a significant portion of our atrial fibrillation patient population utilizing Apple Watch and KardiaMobile for rhythm evaluation. These patients are encouraged during the pre-appointment phone call to upload any strips that they would like to be reviewed during their telehealth appointment.
Learning From Others
As we began to explore options for virtually caring for our patients, we reached out to Dr. Jose Osorio and Brigham Godfrey, BSN, RN for guidance. Dr. Osorio is the Medical Director and Brigham is the Director of Clinical Transformation at Grandview Medical Center in Birmingham, Alabama. Dr. Osorio and Brigham have developed a robust telemedicine program that has been in place for several years. Their input was instrumental in the development of our program in an expedited way.
Keys for Successful Implementation of Telehealth:
- Anticipate your patients’ needs (communication barriers, access to technology).
- Assess your staff’s resources (home internet access, home phone access, cell phone coverage, computer access).
- Determine best workflow for your team.
- Be flexible with technology.
- Celebrate successes.
Cone Health is a 1,254-bed hospital system located in Greensboro, North Carolina. Cone Health is an integrated not-for-profit health care network serving 6 counties in North Carolina. The community has a very active accountable care organization (ACO), Triad HealthCare Network. Triad HealthCare Network (THN) is a physician-led next-generation ACO encompassing Cone Health's employed physicians as well as the broader independent provider community.
- Lakkireddy DR, Chung MK, Gopinathannair R, et al. Guidance for Cardiac Electrophysiology During the Coronavirus (COVID-19) Pandemic from the Heart Rhythm Society COVID-19 Task Force; Electrophysiology Section of the American College of Cardiology; and the Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, American Heart Association. Heart Rhythm. 2020 Apr 1.
- Medicare telemedicine health care provider fact sheet. CMS.gov. Published March 17, 2020. Available at https://go.cms.gov/2VqTTHT. Accessed April 14, 2020.
- Demographics of Mobile Device Ownership and Adoption in the United States. Pew Research Center. Published June 12, 2019. Available at https://pewrsr.ch/2K4A4Rd. Accessed April 14, 2020.
- COVID-19 pivot to telemedicine: resources & video interview. Heart Rhythm Society. Published March 23, 2020. Available at https://bit.ly/34zLohT. Accessed April 14, 2020.
- Telehealth implementation playbook. AMA. Available at https://bit.ly/3bb4D3A. Accessed April 14, 2020.
- Rescheduling workflow triage for COVID-19. Arrhythmia Institute at Grandview. Available at https://bit.ly/2K3UWIn. Accessed April 14, 2020.