CME: Telemedicine During COVID-19 Outbreak

Announcer:
Welcome to CME on ReachMD. This special activity focusing on COVID-19 is part of a special series titled COVID-19: Clinical Considerations provided by Medtelligence.

Prior to beginning the activity, please be sure to review the faculty as well as the Learning Objectives.

Dr. Mittal:
In light of the current ongoing COVID-19 pandemic, clinic visits have been sharply curtailed and telemedicine visits have grown dramatically. Telemedicine, however, is not without its challenges, so this podcast will review the role of telemedicine during this pandemic and discuss some of the key challenges we face and describe potential solutions.

This is a Medtelligence CME program on ReachMD. I’m Dr. Suneet Mittal from the Valley Health System in New Jersey, and joining me today to explore the use of telemedicine during this COVID-19 pandemic is Dr. Aysha Arshad from Carient Heart and Vascular in Virginia. Welcome, Aysha.

Dr. Arshad:
Thank you very much, Suneet, for this invitation.

Dr. Mittal:
So, Aysha, tell us about your recent experience of performing telemedicine visits in your practice.

Dr. Arshad:
So, I’m a cardiac electrophysiologist, and I’m part of a single-specialty cardiology practice with 15 doctors. We go to 4 hospitals, and we have 7 offices. These offices are in 2 different counties, so my group, because of the diverse geographical range that we cover, has been practicing telemedicine for the last 6 months. During that time, only 2 of the doctors did tele-visits, and I had never performed telemedicine visits prior to this March. With the COVID-19 public health emergency and changes in CMS-related expanded virtual care coverage, our group decided that we needed to quickly adapt and start performing telemedicine visits to our patients who are a particularly vulnerable group just given their age and comorbidities. So, in the week of March 17 when CMS came up with the expanded coverage, our group decided that we would convert as quickly as possible to 100% telemedicine-based visits. So, in the week of March 17, 50% of my visits were telemedicine visits, and the following week 100% were telemedicine visits, so that’s how quickly we had to adapt as a practice to telemedicine. And of course, I used as a resource the 2 physicians who had been performing telemedicine, and that proved to be very useful.

Dr. Mittal:
I think it’s great to hear, Aysha. I myself have been using telemedicine even in advance of the COVID-19 pandemic, but what I’m really seeing now is that for the first time we have an alignment between all the stakeholders. That includes the patients, the hospital systems, the providers, in this case us as electrophysiologists, and importantly insurance carriers, including CMS, and I think we all believe that this will now be to some extent the way some important amount of healthcare is delivered in the future.

So, in your 2 weeks of experience now, which is clearly ramping up quickly, what are some of the biggest challenges you face in actually conducting telemedicine visits?

Dr. Arshad:
So, I think the biggest challenges were basically how to roll this out in a quick and efficient way and have buy-in from the patients as well as our staff. This is a new way of communication. The challenges that I felt that I would have is I’d never practiced telemedicine, I’m not going to be able to examine my patient or get an EKG, and I’m going to have to condense Epic-based data very quickly and transmit that to my patient in an effective way and then make some clinical decisions. These are tools that I had never used in my practice before. We had the luxury of time, the luxury of seeing and touching our patients and making real-time decisions, so we had to quickly adapt and come up with a workflow that worked for everyone. And what we did in our office is we identified a medical assistant who would work with me that day. We identified a platform that would be easy and we could quickly teach our patients how to adapt and interact with us on that platform, so we chose Zoom, which is a cloud-based platform for both video and audio conferencing, and started setting up Zoom-based visits, initially calling the patient a day before to coach them about downloading the Zoom app and coaching them how to use that app and interact with me. So our secretary now would call the patient 10 minutes before the visit, my medical assistant would go through the medicines and review any pertinent changes, and then I would come on the Zoom call, and the patient and I would interact. And I would both make clinical decisions, triage care, and refill medicines, trying to do everything in my power to keep these patients away from the ER where healthcare resources are most needed for COVID and other patients at this time.

Dr. Mittal:
I think you raised many important points, and we have faced many of the same challenges. You know, what platform do we use? You seemed to have used Zoom. We settled on Microsoft Teams largely because it integrated well with Outlook, which is our current e-mail provider, and sits them across the institution. Then you raised the issue of the EMR that still rears its ugly head and still the desire or need in some ways to plug a round peg in a square hole—namely, how are you going to get these telemedicine visits and document them in the EMR? And then, of course, there’s always the billing challenges, trying to make sure that you are remaining compliant in a very rapidly changing landscape. But I think that, like you, everyone is little by little whittling away at these challenges to make this a little bit more attractive.

Now, I think you importantly pointed out that there’s obviously a desire to keep patients from coming into the office. Why has there been such a desire to keep these patients out of the office? And are you actually seeing anybody in the office at this point, or have you converted completely to telemedicine?

Dr. Arshad:
So, we converted 100% of our EP visits to telemedicine, so I’m performing both preventive care, chronic disease management, device management virtually over the phone. The needs of these patients have increased, so the patients that I’ve seen through telemedicine, people have developed chest pain, arrhythmias, device-related therapy, they have needed meds to be refilled, and I feel that we’re providing an important service in keeping these people out of the ER where 2 vulnerable populations could mix, both the infected and in our cardiac patients, who at a time of great stress where there’s an increased amount of cardiovascular events we’re really serving as first line to keep them away from the ER unless it’s absolutely necessary. I have admitted 2 patients to the ER over the last week or directed them to go to the ER, and they were really for critical, life-threatening emergencies.

As far as the cases that we’re doing, the Heart Rhythm Society came up with directives as far as what emergency procedures are and what we should be considering as a community are emergency procedures, so the only procedures that we’ve really performed in the last week are pacemakers; but again, lead extraction for people who are infected or septic or VT storm or uncontrolled arrhythmias, we are prepared to take care of those vulnerable patients in this pandemic as well.

Dr. Mittal:
I agree with you completely. We are working, as you know, in Northern Jersey. Valley is in a hotspot for the COVID pandemic, and we feel that as practitioners it’s critical that we not bring patients into the office because everyone who can be managed from home is just one less person that we put at risk of developing COVID, and as a result, we too have taken a universal approach to managing these patients remotely, and we hope to be able to do so in the foreseeable future.

Now, we all became doctors because we value the patient/doctor relationship, the human touch, and while there’s this euphoria of telemedicine, I think we have to be honest that some things work well, and some things don’t work as well. What’s been your initial experience? What do you think works well, and where do you think there’s still issues with relying on telemedicine?

Dr. Arshad:
So, I think what works well particularly are routine visits and device wound-related checks. I’m very impressed by the quality of the video, and I think this is really going to serve to change the way that I practice in terms of we can really interact with patients without having them come to our office and still take care of wounds very effectively. The other type of patients that I foresee continuing to see on telemedicine are emergent arrhythmia needs that may occur related to patients who have implantable devices, and urgent arrhythmias that I can triage using device-related portals and advise the patients as to what needs to be done, and preventive EP care, so I think these are the 3 main categories of people that I think I’m going to see much less as a result of my increased experience with telemedicine even going into the future beyond 2020.

Dr. Mittal:
Yes, I agree with you. I do feel that most outpatient care could in theory be delivered remotely like we’re doing, but at the same time my enthusiasm is tempered by the fact that we are electrophysiologists, we are in a procedural-based specialty, and it still saddens me that many of the patients that I’m seeing remotely ultimately require a procedure for improvement of their quality of life and I’m not able to offer that to them at this time.

So, I want to remind the audience of the recent guidance statement from the Heart Rhythm Society COVID-19 Task Force that actually provides some recommendations on what and how patients in an electrophysiology practice should be managed. This is a document that is jointly supported by the American College of Cardiology and American Heart Association and speaks to the importance of using telemedicine in our practices during this COVID-19 pandemic but I suspect will also form the platform for subsequent way that care is delivered.

Now, I hear you mentioned you’re in a large practice. There are other cardiologists. I’m curious. Have the cardiologists, that is the non-electrophysiologists in your practice, are they also using telemedicine solutions and using the same platform for delivering that care?

Dr. Arshad:
Yes, so in our group, the majority of the doctors are interventional cardiologists, and they previously have been using telemedicine to discuss vascular care as well as structural heart-related care to people in remote locations, so these cardiologists were already pretty well-versed at using telemedicine to deliver effective and timely care to people with structural heart disease or vascular needs, and so they have been very quick to adapt to the growing need for social distancing and not letting even asymptomatic people come into the office if we can triage care and provide good therapy at a distance, which is the current need.

Dr. Mittal:
That’s great to hear. At Valley my experience has been quite different. In fact, prior to this pandemic, none of our internists, none of our cardiologists or specialists were actually using telemedicine at all, and I’ve been amazed at how quickly we’ve developed institutional support for this—IT has been able to put a solution together—and that how quickly providers and patients have become accepting of this very critically needed technology.

Dr. Arshad:
I agree 100%, Suneet. Also, the fact is that none of us are truly very experienced. We’re just learning this on the fly and being very patient with the first couple of experiences in telemedicine is critical. A lot of my patients are older. They aren’t that familiar with technology. Despite the pre-coaching that we do try and deliver, sometimes the call on Zoom just fails, so in that circumstance I’m willing to either go to another platform or give them additional coaching or even convert it to a telephone call, because as you know, CMS said there are 3 ways right now that we can communicate with our patients—true telemedicine using both video and audio platforms, virtual check-in, which is a brief 5-minute communication, or even an e-visit where patients can give us messages via the portal—so I feel like we should utilize all of the different solutions that CMS has suggested to us during this pandemic.

Dr. Mittal:
Well, Aysha, they say that necessity is the mother of invention, and I think that when it comes to telemedicine and the COVID-19 pandemic, nothing could be truer said.

Well, I’m afraid we’re all out of time. This has been a great discussion, and I hope you found it of value. I’m Dr. Suneet Mittal, and I want to thank Dr. Aysha Arshad for such a stimulating and important topic. This is a Medtelligence CME program on ReachMD.

Announcer:
You have been listening to CME on ReachMD. This activity is part of a special series provided by Medtelligence titled COVID-19: Clinical Considerations.

To receive your free CME credit, or to download this activity, go to ReachMD.com/COVID19Considerations. Thank you for listening.