Telemedicine Helps Cardiologists Extend Their Reach
During a recent set of telemedicine consultations, Joaquin E. Cigarroa, MD, a cardiologist at Oregon Health & Science University in Portland, was able to establish relationships with 4 new patients and their families, conduct a physical examination using an electronic stethoscope, review the patients’ laboratory results, and develop a care plan. The best part was that the patients, who all live in coastal Lincoln City, Oregon, were able to skip the 3-hour drive to Portland through traffic and often fog.
“Patients love it,” said Cigarroa. They only need to make the trek to Portland when they need advanced diagnostics or procedures.
For Cigarroa and his colleagues at Oregon Health & Science University, providing such off-site care is “critical to providing patient-centered care,” he said. He explained that ≈60% of the patients admitted to the cardiovascular service line at Oregon Health & Science University’s hospital are from outside of the Portland metro area, and many are from rural regions of the state. He and his colleagues have increasingly made use of Oregon Health & Science University’s telemedicine portals, which can even be used to perform echocardiograms, to care for patients closer to their homes.
“It’s compassionate to the patient and their family to maintain them in their community and only transfer them if they need procedural or other capabilities not available in their environment,” Cigarroa said.
Increasingly, cardiologists across the country are leveraging technology to provide remote care, whether through virtual visits and exams, consultations, or continuous monitoring using a growing array of implantable or wearable devices. These tools are allowing cardiologists to extend their geographic reach, helping them to identify cardiac problems before they become catastrophic, and affording them tools to help smooth care transitions. But as with any new technology, hurdles still exist, such as reimbursement and integrating these tools into care.
A number of factors, including improved technology and policies that aim to reduce rehospitalizations, have boosted interest in the use of telemedicine in cardiology, said Danielle Louder, program director for the Northeast Telehealth Resource Center based in Augusta, Maine. Northeast Telehealth Resource Center is part of a network of telemedicine technical assistance centers across the United States funded by the Health Resources and Services Administration to assist clinicians and healthcare facilities using telehealth technologies.
“Cardiolology is one of those areas where telemedicine is gaining a lot more interest,” said Louder. “At the same time, it is also a specialty that has flown under the radar and has been doing telehealth for many years.”
For example, cardiologists have long sent devices such as Holter monitors and event monitors home with patients to gather data on heart rhythms over days or even months. Emergency services also routinely use cardiology consultations to guide prehospital care decisions, she noted.
“That’s really telehealth,” said Louder.
Emerging evidence also indicates that primary care electronic consultations with cardiologists can reduce emergency room visits. A study that included 36 primary care physicians and 590 patients found that asynchronous electronic consultations with a cardiologist could resolve about two-thirds of cardiac concerns without a specialist visit and reduced cardiac-related emergency visits during the 6-month follow-up period.
Remote monitoring of cardiac patients has also gained traction as many implantable cardiac devices now continuously collect and transmit data back to clinicians, said Javier E. Banchs, MD, director of electrophysiology and pacing at Baylor’s Scott & White Memorial Hospital in Temple, Texas. In fact, the Heart Rhythm Society has now made remote monitoring of implanted cardiac devices the standard of care. Clinical trials have shown that these devices may benefit patients by helping detect arrhythmias or device malfunctions more quickly, reducing hospitalizations for arrhythmias and strokes, and eliminating the need for some clinic visits.
“[Remote monitoring] really took off with implanted devices like pacemakers and defibrillators,” said Banchs. “You can take care of patients continuously.”
More recently, wearable monitors have entered the scene, providing data on movement or chest impedance, said Banchs, who explained these devices can allow remote diagnosis or be used to predict decompensation in patients with chronic heart failure. Even more promising are implantable devices that can detect hemodynamic abnormalities before symptoms develop. The CHAMPION trial showed that an implantable pulmonary artery pressure sensor could reduce hospital readmissions among patients with heart failure by 37% over 6 months.
Despite the promise of telehealth in cardiology, hurdles to wider use of these tools remain in the form of inconsistent reimbursement policy and implementation challenges.
A recent analysis suggested that 6.8% of nonspecialty US hospitals are participating in a telecardiology programs. Interviews conducted with 36 hospitals participating in telemedicine efforts of any specialty found that the programs help them boost access to care and keep lower acuity patients at home. Many programs reported using a one-time funding source to get their telemedicine programs off the ground, but many also reported that reimbursement challenges have hampered their efforts.
Some physicians have also been slow to embrace the technology.
“There is a large group of skeptics and there are reimbursement issues,” said Banchs.
Medicare currently only reimburses for virtual telehealth visits for patients in rural areas, with a few exceptions, and only 0.2% of beneficiaries in 2014 used a telehealth service, according to Gary Capistrant, policy chief at the American Telemedicine Association.
“Medicare is one of the poorest payers of telehealth,” Capistrant said. “That’s a major barrier.”
A few Medicare programs do provide wider coverage, for example, Medicare Advantage plans and a Medicaid pilot, according to Capistrant and Louder. Congress is currently considering legislation that would expand Medicare coverage for telehealth, Capistrant noted, and the changes could go into effect as early as 2017.
Organizations such as the Veterans Health Administration and Kaiser Permanente, which act as both providers and payers, have been quicker to embrace telemedicine, Capistrant noted. Additionally, <30 states require private insurers to cover telemedicine as they would in-person visits, he noted.
“Providers are adopting telemedicine more,” Capistrant said. “Consumers are demanding it more.”
The types of telemedicine services covered also vary from state to state, Louder noted. For example, live video visits may be covered, whereas phone calls are not. Reimbursement rates also may be lower for telehealth visits, Louder said.
Although coverage remains a concern, the technology is rapidly improving as vendors work to develop tools that seamlessly communicate with electronic health records, Louder noted. Many resources are available to help clinicians and facilities new to telemedicine get started. The National Telehealth Resource Center can help clinicians find their regional organization, which can provide tool kits or can connect more experienced telehealth users in their specialty, Louder said.
“Please don’t re-create the wheel, there are protocols out there,” Louder said.
Banchs encouraged clinicians to make use of such resources, as well as resources and guidelines available from cardiology societies.
“There is no way around it, we need to embrace it,” Banchs said. “Patients and payers are demanding this kind of technology. The sooner you [put protocols in place] the better prepared you will be to embrace it.
The National Telehealth Resource Centers (http://www.telehealthresourcecenter.org/) provides monthly telehealth webinars and information on regional centers.
The Northeast Telehealth Resource Center’s Telehealth Resource Library (http://netrc.org/resource-library/), which contains peer-reviewed articles and other resources.
The Center for Connected Health Policy (http://www.cchpca.org/), a telehealth policy resource center.
The National Telehealth Technology Assessment Resource Center (http://www.telehealthtechnology.org/), which evaluates telehealth tools.
American Telemedicine Association (www.americantelemed.org)
- © 2016 American Heart Association, Inc.