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Source: Department of Health and Human Services. Telehealth: Delivering Care Safely During COVID-19. Available at: www.hhs.gov/coronavirus/telehealth/index.html. Accessed July 24, 2020.
Disclosures: Benziger, Julien, Khera, Klonoff, Kodali, Manney and Okwuosa report no relevant financial disclosures. Singh reports he consults for Abbott, Biotronik, Boston Scientific, Cardiologs, EBR, Impulse Dynamics, Medtronic, Microport and Toray.
September 22, 2020
13 min read
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Telehealth shift during COVID-19 pandemic shows capacity to safely deliver cardiology care

Source: Department of Health and Human Services. Telehealth: Delivering Care Safely During COVID-19. Available at: www.hhs.gov/coronavirus/telehealth/index.html. Accessed July 24, 2020.
Disclosures: Benziger, Julien, Khera, Klonoff, Kodali, Manney and Okwuosa report no relevant financial disclosures. Singh reports he consults for Abbott, Biotronik, Boston Scientific, Cardiologs, EBR, Impulse Dynamics, Medtronic, Microport and Toray.
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As clinicians around the world rapidly transitioned from in-person to telehealth visits during the COVID-19 pandemic, it required managing many changes at once.

Cardiologists in particular have worked to find new ways to support patients with CV disorders who rely on data-driven care and multiple in-person visits, as well as patients with other chronic conditions that require close follow-up. Available technologies have helped to keep patients and physicians connected, without increasing risk for exposure to COVID-19.

Howard M. Julien, MD, MPH, from the University of Pennsylvania, and other cardiologists weigh in on the pros and cons of telehealth.

Source: Penn Medicine. Printed with permission.

The rapid shift to virtual visits in recent months has left many wondering what will come next, now that certain telehealth regulations have been temporarily loosened.

“Necessity is the mother of invention,” Howard M. Julien, MD, MPH, assistant professor of clinical medicine at University of Pennsylvania Perelman School of Medicine, told Cardiology Today. “As a result, the requirement and the need for social distancing [during the COVID-19 pandemic] forced us to use all of the tools in our toolbox, and telehealth, being one of them, has been accelerated in its adoption across the country.”

Telehealth “has totally changed the way we practice outpatient cardiology,” Cardiology Today Editorial Board Member Jagmeet P. Singh, MD, ScM, DPhil, professor of medicine at Massachusetts General Hospital and Harvard Medical School, said in an interview. “The move from 0 to 60 was almost instantaneous. The adoption was universal and fairly uniform.”

Still, a rapid shift to widespread virtual visits is unlikely to be seamless. Recent changes at the federal level — adopted to allow maximum patient access to telehealth during a public health emergency — could also compromise patient safety and privacy, according to experts. Additionally, any broad adoption of telehealth after the pandemic will not be possible unless temporary changes in reimbursement become permanent.

“CMS needs to put some permanency in place,” Singh said. “There are several subgroups of patients that telehealth serves as a very useful, complementary strategy to in-person visits. Community hospitals and areas with limited resources need to be supported in this endeavor. Telehealth should actually be promoted to enhance access and deliver care to the disenfranchised. We need to make a conscious effort to prevent any possibility of the digital divide worsening, and the federal and state government need to take that responsibility to ensure this.”

Another concern is how HIPAA flexibility implemented during the pandemic for easier telemedicine utilization will be updated once in-person visits become more common again. At the beginning of the pandemic, guidance from the HHS Office for Civil Rights allowed cardiologists and other health care providers to provide telehealth services using remote communication technologies such as Zoom, FaceTime and Doximity.

Questions also remain about whether its use will exacerbate disparities in care. And, the lack of a physical exam and other critical tests present additional challenges for physicians.

Providers, meanwhile, are navigating these issues, all while delivering care via technology.

“What has been wonderful about it is during this pandemic when our patients are generally considered higher risk for having more severe COVID-19 illness and when they’ve been asked to stay at home, we are still able to maintain their care through video visits and telephone visits to refill medications, check in with them about symptoms, continue to advance their care and their evaluation and work up for symptoms even though we’re not bringing them into clinic,” Catherine Benziger, MD, MPH, director of heart and vascular research and noninvasive cardiologist at Essentia Health in Duluth, Minnesota, told Cardiology Today.

‘A new norm’

Increasing opportunities for telehealth has long been a goal for many in health care, who have cited advantages of doing away with a commute to a clinician’s office and time spent sitting in a waiting room. Until recently, however, the shift to virtual visits had been a slow one. In 2019, only 8% of U.S. residents used telemedicine for care, according to a study published in the Journal of the American Medical Informatics Association.

During the COVID-19 pandemic, that percentage grew exponentially. In the same study, researchers observed that between March 2 and April 14, virtual urgent care visits at NYU Langone Health grew by 683% and nonurgent virtual care visits grew by 4,345%, in daily averages. During the 6-week study period, 144,940 video visits were conducted involving 115,789 unique patients and 2,656 unique providers. Of all virtual visits, 56.2% of urgent care and 17.6% of nonurgent visits were COVID-19-related.

Amit Khera

“In all, results reflect what may become a new norm of future health care, and in particular during periods of contagious disease outbreaks,” the researchers wrote. “With a mass mobilization of health care providers onto diverse telemedicine platforms, an aspiration of the industry for years has materialized in a matter of days.”

Similar shifts have taken place among cardiology practices across the country. At Essentia Health, one of many health care systems that accelerated the switch to telehealth during the pandemic, health care professionals “were well positioned to launch our virtual visit, including video visit care, right when COVID-19 hit because we had a primary care project that was aimed at chronic diseases,” Sarah Manney, DO, chief medical information officer for Essentia Health, told Cardiology Today. “We were going to do a nice pilot. We had the technology pretty close to ready to launch in April, but we recognized that COVID-19 was a significant issue and we needed to keep both our patients and our staff safe. By deploying this technology rapidly, we would be able to do so.”

For some physicians, the shift meant navigating virtual care for the first time.

“I didn’t know how well-developed video visits were before COVID-19,” Tochi M. Okwuosa, DO, associate professor of medicine and cardiology and director of the cardio- oncology program at Rush University Medical Center, said in an interview. “With COVID-19, I realized just how fast things can change in medicine because it affected every aspect of our lives.”

As rates of COVID-19 start to decrease in some areas of the country, regular patient visits are starting to be offered to patients again.

“Proportionally, the number of telehealth visits are decreasing,” Singh said. “I see all new patients in-person and use telehealth for most, but not all, follow-up visits as appropriate. Overall, [I see approximately] 70% via telehealth and 30% in person.”

The ratio of telehealth to in-person visits may adjust accordingly as rates of COVID-19 fluctuate.

“Patient visits are certainly opening up again in terms of face-to-face visits,” Amit Khera, MD, MSc, FACC, FAHA, professor of internal medicine at UT Southwestern Medical Center, director of the UT Southwestern Preventive Cardiology Program and immediate past president of the American Society for Preventive Cardiology (ASPC), said in an interview. “However, the COVID-19 pandemic is in flux with numbers and outbreaks varying every few weeks, meaning face-to-face visit numbers are also oscillating. Thus, we are now learning how to blend telehealth and face-to-face visits, keeping flexibility to accommodate both.”

Jagmeet P. Singh

Advantages of telehealth visits include safety and convenience, though in- person visits offer a more personal interaction between cardiologist and patient.

“With some kids staying home to do virtual learning, our faculty have commented on the convenience of having that ability to work from home maybe once per week,” Okwuosa said. “However, we are finding that most patients prefer the personal touch of in-person visits so that the volume of telehealth visits are decreasing. Clinicians are therefore conducting more in-person visits with patients.”

New opportunities, challenges

COVID-19 was a catalyst for increased use of telehealth in cardiology and medicine overall.

“In the early stages of the pandemic, there was a transition to reliance on telehealth for patients who were deemed high risk or had anxiety about coming into a health care setting,” Julien said. “As the prevalence of COVID-19 rises again [in different areas], it will be interesting to see how the use of telehealth shifts if the incidence of [COVID-19] cases continues to rise.” Societies such as the American College of Cardiology, American Heart Association, Heart Rhythm Society and the ASPC provided updates and have prepared guidance documents on the use of telehealth.

“We really felt like it was time to focus on the acute issue and the acute emergency, but we really wanted to spotlight these emerging issues that will and are going to happen and have now happened,” Khera told Cardiology Today about the ASPC statement. “We wanted to not just talk about the potential problems, but lay out a series of solutions that we could implement to avoid these things from happening down the road.”

Singh said that there have been some guidelines for improving “web-side” manners during telehealth visits.

“ACC recently had a roundtable putting these together,” Singh said. “It is tough for many to use virtual care, as much of medicine is also about nonverbal cues in making assessments. I know that some clinicians have missed incident heart failure and critical limb ischemia in a tele-visit, which they would have picked up in person.”

Catherine Benziger

The American Medical Association released a playbook of telehealth implementation, which details how to set this up in clinical practice, the team needed to support it and how to partner with the patient. Other organizations that have prepared guidance and recommendations in this area include CMS, American College of Physicians, American Academy of Family Physicians, among others.

Although societies have released toolkits and other guidance in this area, more will be required, especially as the pandemic evolves.

“What is really needed now is best practice guidance on how to have the most effective visit,” Khera said. “These articles and guidance documents are likely in development but are really what is needed for the next phase.”

CMS made several changes to adapt to this increased use of telehealth. There was a temporary expansion for the scope of Medicare telehealth that allowed patients to receive this virtual care from any location. In addition, CMS added 135 allowable services that can be obtained through telehealth, including home visits, ED visits and therapy services. These changes also addressed payment, as physicians would get paid for telehealth services at the same rate as for in-person services.

Sarah Manney

It is critical that patients maintain access to care, whether a new patient visit or a follow-up visit via telehealth, although this technology should not replace in-person visits in the long term.

“It’s important to recognize that telehealth should not be used as a substitute for an in-person visit; it’s an adjunct,” Julien said.

Although telehealth does not allow cardiologists to perform a physical exam, important information can be obtained from a video visit.

For example, “you can get some clues by looking at their neck when they’re talking, you see their neck veins bulging,” Susheel K. Kodali, MD, director of the Structural Heart and Valve Center at New York-Presbyterian/Columbia University Medical Center, said in an interview. “You can have them point the phone at their feet to see if there is swelling, edema or poor blood flow, but the exam is limited. For what I do, the limitation is I can’t get the ancillary testing I want to get to answer the question of whether we can do the procedure safely or not. With that testing, they have to come back in anyway.”

Telehealth can also allow more timely care for patients.

“I had an urgent call on Wednesday from a primary care provider who was worried about a patient’s symptoms,” Benziger said. “I saw the patient virtually on Thursday. I ordered a cardiac catheterization on Friday and they went for bypass on Monday. In the old system, there’s no way that would have happened that quickly without virtual visits.”

Issues during, after COVID-19

Still, disadvantages and challenges remain. For example, some patients lack the technical skills or resources necessary to join a video visit. Although these patients may still participate in phone visits, it may not be as productive as a video visit. In addition, telehealth may exacerbate the digital divide and inequities in health care.

“It’s important for us not just to think about the patients in front of us, but the underlying landscape and environment in which they are situated,” Julien said. “The underlying digital divide is real and affects far more patients than we have an appreciation of. This may only get bigger as financial strains and stress affects patients and their ability to pay for and afford access to high-speed internet.”

In a study published in Circulation in June, Julien and colleagues reported that, of 2,940 patients who were scheduled for a telehealth visit at the Hospital of the University of Pennsylvania, only 46% completed the telehealth encounter. Compared with patients who had a no-show or canceled visit, those who completed a telehealth visit were slightly older and more likely to be male.

For some, telehealth may allow physicians to “see” their patients, but it can lack the empathy and connection often felt during in-person visits, Julien said.

“There are some patients who miss the handshake and the hugs, as do the clinicians too, but in the COVID-19 era, handshakes and hugs are historical at least for the moment. That personal connection for some means a lot,” Singh said.

Tochi M. Okwuosa

As providers adjust practices to move to telehealth, they also must work with patients across different ages and socioeconomic backgrounds to find the best communication platforms for a successful virtual visit — and that can raise privacy concerns.

The federal Office for Civil Rights at HHS, which is responsible for enforcing certain regulations issued under HIPAA, acknowledged that some technologies used to communicate with patients during the COVID-19 public health emergency, and the manner in which they are used by HIPAA-covered health care providers, may not fully comply with the requirements of HIPAA rules. In March, the federal agency announced that it will exercise its enforcement discretion and will not impose penalties for noncompliance with the regulatory requirements under the HIPAA rules against covered health care providers in connection with the “good faith provision of telehealth” during the COVID-19 nationwide public health emergency.

“When the COVID-19 emergency is declared to be over, I expect that there will be tremendous pressure on the Office for Civil Rights to continue to facilitate use of telehealth platforms to allow better access to health care,” David C. Klonoff, MD, FACP, FRCPE, medical director of the Diabetes Research Institute at Mills-Peninsula Medical Center in San Mateo, California, and clinical professor of medicine at the University of California, San Francisco, told Cardiology Today. “I expect that after the pandemic, many patient information privacy laws, such as HIPAA, which were written before the internet revolution, will be rewritten to streamline telehealth.”

Prevention, management for telehealth

In cardiology, a shift to remote visits could allow broader improvements in CV care in the long term. It may also prevent deferring or delaying care. In a study published in the Journal of the American College of Cardiology in June, researchers found that the total number of CV hospitalizations declined by 43.4% from March 2019 to March 2020.

“There are now tons of papers showing that delays in care for people who are not presenting for heart attacks, strokes and aneurysms,” Khera said. “It’s not that those aren’t happening. ... People are staying home and not getting that care.”

“There is a lot in cardiology that you can do through telehealth because you don’t necessarily need to always put your stethoscope on the chest of every patient, especially those that you have been following for a long time” Singh said.

Susheel K. Kodali

Prevention can continue for patients who require routine follow-up for stable issues like CAD, for example. Patients with hypertension can take measurements at home and report to their cardiologist via telehealth visit.

Telehealth can also be used in interventional cardiology, particularly in patients who do not have a straightforward condition and who require a discussion to determine the best approach.

“Rather than bringing them back, that consultation when you’re giving them your opinion is really well suited for telehealth because we’re not examining or looking at studies, but we can interact with them,” Kodali said. “That aspect of it allows us that second consultation that’s facilitated by telehealth because then we don’t have to wait 2 weeks for their next appointment to bring them in to have that conversation.”

Interventional cardiologists have also used telehealth for postprocedural follow-ups, particularly if patients had no complications.

In electrophysiology, many patients have implanted devices that provide objective information.

Management of HF is one challenge in cardiology. For example, some physicians said congestive HF can be challenging in a telehealth setting because these patients benefit more from a physical exam, whereas others said the need for frequent interactions make the HF population suitable for telehealth visits, and video visits still allow visual assessment. In addition, many patients with HF with reduced ejection fraction have implanted devices, including implantable cardioverter defibrillators and pacemakers, that feature HF diagnostic capabilities.

What the future holds

As clinicians and other providers adapt to telehealth and the shift in overall health care seen in the past 6 months, one big question remains: Once the public health emergency is deemed over, will things return to the way they were?

David C. Klonoff

“We’ve been exposed to the convenience of telemedicine and we know that it works in certain situations. It’s [going to be] hard to go back and say no, we can’t do this now,” Okwuosa said. “Most of us feel that it’s here to stay. There’s still fine-tuning to be done to make it as efficient as possible.”

For example, one area of focus is how to perform certain tests such as ECGs, echocardiograms and bloodwork when patients are not in the office.

“There also need to be more concerted efforts from the perspective of local and federal government on ensuring that broadband access is available and affordable for all Americans, not just in highly dense metropolitan areas, and also affordable so that patients can have access to it so they can take advantage of things like video telehealth,” Julien said.

Payers will play an important role in the continued use of telehealth after the pandemic.

“We’ll see in the next couple months what the reimbursement has been like, but if the reimbursement is much worse, then that’s going to kill it in many practices,” Kodali said. “Every practice is already struggling from COVID-19, the shutdown and the financial hit they took. [Reimbursement] is going to be a big impediment for telehealth to be implemented broadly.”

As behaviors start to return to how they were before the pandemic, regulatory bodies will also determine whether telehealth visits can be performed by cardiologists who have patients in other states. As of now, it is unknown whether cardiologists will have to be licensed in the states their patients live, even if they do not have a physical practice location in that state.

Regardless of the unknowns and challenges that remain, the COVID-19 pandemic has provided an opportunity for cardiologists to explore to use of telehealth on a larger scale.

“Having that capability is a good thing,” Okwuosa said. “Right now, for our stable patients, it works very well; for the not-so-stable patients, maybe not as well. Once we’re able to establish testing in such a way that some of them can be done remotely, telemedicine would become one of the major ways that patients can visit their physicians in the future.”