Rapid Transition of a Traditional Cardiology/Electrophysiology Clinic to Telehealth in the Setting of an Emergent Pandemic

Introduction

The world is facing an unprecedented modern pandemic that has posed many new challenges to healthcare providers. The high infection rate of COVID-19 has presented an emergent need to continue providing patient care and follow-up while adhering to social distancing and isolation guidelines. Telehealth offers physicians and patients the opportunity to remotely communicate through phone or video. The rapid transition to a telehealth clinic allows practitioners and patients to continue healthcare encounters and provide continuity of care, especially to high-risk patients. In this article, we describe an easy, cost-efficient, HIPAA-compliant telehealth solution being used at the Long Island Heart Rhythm Center (LIHRC) that allows for the immediate provision of care to new and established cardiology patients that display an increased COVID-19 case fatality rate compared to those with no comorbidities.¹ 

Previous Use of Cloud-Based HIPAA-Compliant EHR

The feasibility and benefits of a cloud-based virtual medical office (VMO) were previously documented in the March 2019 issue of EP Lab Digest.² The article used the LIHRC as a model and explained the necessary resources to establish the VMO, including a cloud-based HIPAA-compliant electronic health record (EHR). The advantages of this model include low overhead costs, a decreased need for ancillary office staff, and a decreased carbon footprint resulting from these economies. For the past 18 months, the LIHRC has used this system to allow flexibility in accessing records and offering care in multiple locations, including home health settings.²

COVID-19

In late December 2019 and early January 2020, a series of pneumonias of unknown origins in Wuhan City, Hubei Province, China were reported to their local World Health Organization (WHO) office, prompting further investigations by WHO. Soon after, a novel coronavirus (2019-nCoV) was identified as the culprit.³ The large family of coronaviruses include those responsible for past outbreaks such as severe acute respiratory syndrome (SARS) and Middle East Respiratory Syndrome (MERS).⁴ Scientists suspect that this current novel coronavirus spread from animals to humans, but cannot identify an exact source. However, the first known infections were linked to a live animal market, and subsequent person-to-person spread has been confirmed.⁴ 

Figure 1 shows a timeline of the COVID-19 outbreak. By mid-January 2020, cases of novel coronavirus were identified in countries outside of China, including the first case in the United States on January 21.^3,4 By the end of January, the WHO declared the outbreak an international Public Health Emergency.⁵ Across the globe, organizations including the United Nations (UN) prepared for continued worsening and spread of the disease. As more resources were enlisted, the WHO formally named the disease
associated with 2019-nCoV: COVID-19.⁶ The United States declared the outbreak a national emergency on March 1, 2020, and the WHO officially declared a pandemic on March 11.⁴ The disease epicenter moved from China to Europe to the United States. Within the United States, New York has so far had the most cases and deaths. At the time of publication, the total number of cases in the United States had surpassed 776,093, with deaths surpassing 41,758.⁴ In addition, the WHO reported global cases had surpassed 2.3 million, including over 162,956 confirmed deaths.⁷

Symptoms of COVID-19 include fever (83-99%), cough (52-82%), fatigue (44-70%), anorexia (40-84%), shortness of breath (31-40%), sputum production (28-33%), and myalgias (11-35%).¹ Emergency warning signs include difficulty breathing, persistent pain/pressure in the chest, new-onset confusion or inability to be aroused, and cyanosis of the lips or face.⁸ The incubation period of COVID-19 is suspected to last up to 14 days, with symptom onset at a median of 4-5 days from viral exposure.¹ Risk factors for more severe disease appear to be age, immunocompromised status, and other underlying medical conditions, including cardiovascular and respiratory disease, and diabetes.¹ Atypical presentations such as delayed fever have been noted in older patients and those with comorbidities.¹ Children have been noted to experience a milder course of illness, though they display similar signs and symptoms to adults.⁹ 

Accurate prevalence and mortality rates have been difficult to achieve due to the limited availability of tests and the presence of asymptomatic carriers. Asymptomatic carriers are thought to be capable of spreading the virus.¹ The disease primarily spreads through droplets, and these droplets can become aerosolized through many ways, including aerosol-generating procedures such as intubation.¹⁰ Current recommendations include facemasks and eye shields for healthcare personnel interacting with positive patients, and the addition of N95 respirators for aerosolizing procedures.¹⁰

Public Health Precautions

As the virulence and severity of COVID-19 became clear, many organizations began communicating public health precautions in an attempt to limit viral spread. Everyday preventative steps include frequent hand washing, avoiding touching the face, covering coughs and sneezes, discarding used tissues, and disinfecting frequently touched objects and surfaces.¹¹ 

The Centers for Disease Control and Prevention (CDC) recommend COVID-19 patients remain isolated at home or in the hospital (depending on the severity of their condition) until they have improved and no longer pose a risk to others. Current CDC guidelines regarding release from isolation include both a test-based and non-test based strategy, and these guidelines are being constantly updated.¹² 

Due to the extended asymptomatic period of disease, many states have issued “stay at home” orders that encourage residents to remain home except for necessary errands such as to buy food or pick up medications. Non-essential workers are encouraged to work from home to further limit crowds.¹² If travel is necessary, it is recommended to remain six feet away from others. Most recently, the CDC has encouraged anyone who must venture outside their house to wear cloth face coverings.¹⁴

Emergent Need to Provide Continuity of Care

As the pandemic worsened prompting updated state regulations, the LIHRC healthcare team was attempting to operate as usual out of Mount Sinai Hospital in New York City. Strict guidelines were enacted, which included social distancing, enhanced contact precautions, and the cancellation of elective procedures. It became imminently clear that the clinic’s cardiac patients were at risk for complications and possible mortality from COVID-19. A telehealth solution was deemed necessary to minimize cardiac patient exposure to the virus, and avoid morbidity and mortality. 

Emergent Changes in Telemedicine Guidelines

Due to the quick progression and spread of this pandemic, telemedicine guidelines were rapidly changing. This situation required the consultation of multiple sources. The LIHRC sought insight from local telehealth expert Terri Seppala (President and CEO of Telehealth Associates, Inc.), who earlier this year had given a telehealth primer to the medical students at NYITCOM, hosted by Dr. Todd Cohen. The LIHRC also consulted updated guidelines posted by various bodies including the American College of Cardiology (ACC) and the Centers for Medicare and Medicaid Services (CMS).

The global pandemic necessitated that CMS broaden telehealth regulations, such as relaxing privacy guidelines and expanding compensation policies. These changes are currently temporary due to the global pandemic, and it is unclear how long they will remain in force. These new guidelines aim to allow more Americans to access health services while maintaining public health recommendations to ultimately limit viral spread. Before this expansion, Medicare coverage for telemedicine was limited to certain patient populations (eg, rural settings) or patients receiving telehealth services while in a hospital or other healthcare setting. Beginning March 6, 2020, the 1135 Medicaid Waiver expanded Medicare to cover telehealth visits, including those from patients’ homes. With these updated regulations, coverage now includes office visits, mental health services, and preventive health visits. Remote monitoring of implanted devices, which provides ECG monitoring, continues to be a covered service.¹⁵

The ACC encourages the employment of telehealth services while advising a number of cautions. It is crucial that physicians confirm that their malpractice insurance covers telehealth encounters. As it is now possible for physicians to treat patients across state lines, providers must be cognizant of regulations in different states. Furthermore, physicians should clearly document in their notes that this is a remote encounter due to the unique circumstances of the COVID-19 pandemic.¹⁶ Documentation should specifically include the duration of the visit, as well as the percent of the visit that was discussion, education, and counseling. Dr. Cohen typically has over 50% discussion, education, and counseling as part of the visit.

Telehealth Capabilities

Many healthcare providers had to quickly enable telehealth capabilities to cope with this unprecedented global crisis. There are many different telehealth platforms available, and physicians should research which options best fit their individual needs and price point. Platforms vary in their voice and/or video offerings, integration with EHRs, and HIPAA compliance. Some platforms allow patients to input information on their own, including medical history, vital signs, and medications. Many platforms now offer solutions to bypass barriers of telemedicine, including cost, technical requirements, and patient ability to participate. While not HIPAA compliant, many commonly used platforms such as FaceTime and Skype allow free audio or video calls in a more familiar setting for patients.

One limitation of telemedicine is the inability to perform a thorough physical exam. This opens a market for easily accessible tele-stethoscopes, so that doctors can hear patients’ bowel, heart, and lung sounds. Still, this cannot substitute for a thorough in-person physical exam. Patients must follow up with in-person visits once the risk of viral exposure subsides. 

LIHRC’s Addition of Telehealth Capabilities

Dr. Cohen has been a pioneer in innovation across the field of cardiology and electrophysiology. He has a longstanding interest in telehealth, and moderated a telehealth primer on January 17, 2020, for over 400 first- and second-year osteopathic medical students. That primer featured Terri Seppala and Todd Stack, Senior Director of Henry Schein Inc./Medpod, the manufacturer of MobileDoc, a roller bag filled with medical diagnostic tools and a computer that links the patient to the medical provider. The utility of the MobileDoc systems along with telehealth essentials were reviewed with the students. Since many of Dr. Cohen’s patients had conditions that placed them at risk if exposed to the virus, an immediate transition to telehealth was essential for patient safety. Video interviews of his clinic’s transition to telehealth were posted on the EP Lab Digest website.¹⁷ 

The LIHRC decided to utilize the Updox platform, as it closely aligned with their priorities of HIPAA compliance and ability for EHR integration. Through this service, patients are able to communicate with the physician via voice and/or video conference. Patients can utilize these services on their phones, tablets, or computers. Patients without a smartphone or computer can still use standard telephones to access their physician. Once the physician starts the video or audio call, the patient has up to ten minutes to answer, at which point the physician continues with interviews and counseling.

Integration of HIPAA-Compliant Telehealth with a VMO

The VMO utilizes a completely cloud-based EHR linked to an electronic fax system (all HIPAA compliant). The electronic fax system offers an inexpensive video solution that links directly to medical records. Figures 2-6 demonstrate how this telehealth system operates. Figure 2 presents the physician view while setting up a patient telehealth visit (call/video chat) using this system. Figure 3 shows the physician view after initiating a patient telehealth visit while waiting for the patient to connect. Figure 4 demonstrates the physician view during the encounter, and emphasizes the ability to take notes and screenshots. Figure 5 illustrates the physician’s ability to screenshot the inspection portion of the physical exam (specifically, for a healing wound). The image may be directly uploaded into the patient’s medical record. Figure 6 is the patient view at the conclusion of the telehealth visit. Table 1 demonstrates the benefits and limitations of this telehealth solution. This system operates efficiently in patients who have either a smartphone or computer with Wi-Fi access.

LIHRC Telehealth Clinic Experience

The LIHRC recognized the physical exam limitations of telehealth and immediately began exploring ways to inexpensively expand physical exam capabilities without the need for additional purchases of attachments or equipment. Many patients already have automatic blood pressure cuffs, thermometers, scales, and the ability to record oxygen saturation at home, making vital signs obtainable. A number of the clinic’s patients have implanted heart rhythm devices such as implantable loop recorders, pacemakers, defibrillators, and biventricular devices. These monitoring devices can send remote readings, allowing the physician to view electrocardiographic tracings on or around the time of the visit. The video component allows the physician to check on numerous physical attributes, including skin coloring, extremity swelling, and wound healing for recently implanted devices. Specifically, the LIHRC was able to identify thyroid asymmetry and asymmetric extremity swelling through video conferences. The telehealth service records the length of the patient-physician interaction and can electronically fax that information into the EHR. 

Finally, the LIHRC explored the use of a smartphone’s microphone (both directly and through a standard headset attachment), and demonstrated some ability to record pulmonary auscultation. Cardiac auscultation was more difficult to appreciate; however, some recording has been achievable using an additional amplification app. Pulmonary and cardiac components of the examination were waived and deemed non-critical during telehealth encounters. 

The LIHRC has successfully rolled out these new services and features to patients. Prior to the scheduled visit, an office member calls the patients to discuss the process and walk them through the interface. Updox has the ability to broadcast appointment reminders and other information to patients via text, email, or phone. These broadcasts reinforce to the patients the importance of punctuality and preparedness for their remote telemedicine encounter. Over the past month, the LIHRC has seen 50 patients using telehealth. There has been a 100% compliance rate of patients being present and on-time for their video appointments. The majority of patients have had no significant issues with the video services and have overwhelmingly responded positively to this change. 

Future measures will assess patient satisfaction with their telehealth experience and seek to identify further areas for improvement. The LIHRC has also shown proof of concept for a system to allow medical students to participate remotely in these telemedicine encounters. This system, called TeleMedstudent^™, is available at www.liheartrhythmcenter.com/telemedstudent.

Conclusions

The COVID-19 pandemic left physicians balancing patient safety considerations with the need for continuity of care. Telemedicine is a practical option for maintaining patient and physician safety while ensuring the delivery of high-quality medical care. Changes enacted by CMS now allow patients to access their physicians under insurance coverage while maintaining public health precautions. Practitioners should consider employing a telehealth model during these unusual circumstances. Additionally, practitioners should use current experiences to help draft contingency plans for a seamless transition to telehealth for deployment in future emergencies. 

Disclosures: The authors have no conflicts of interest to disclose. The authors have no stake in any services mentioned in this article, and the senior author (TC) pays monthly fees for use. 

Note: The images in this article show an author of this paper and a fake scar for demonstration purposes. Permission from Updox was received by the authors to use these images.

View our interview with Dr. Cohen about telehealth: 

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