Clot Chronicles: Telehealth and COVID-19

Good morning, I’m Dr. Umberto Campia. I’m a cardiologist and vascular medicine specialist at Brigham and Women’s Hospital. Thank you for joining me for Clot Chronicles. Today we will be talking about telemedicine as it applies to our current cardiology but also to our medical practice, particularly with regards to our new challenge with the COVID pandemic. 

First I would like to start with the definition of telemedicine, which is also referred to as a virtual care or telehealth or eHealth. And telemedicine is the distribution of health-related services and information by an electronic information and telecommunication technologies. It allows long-distance patient and clinician contact, also care, advice, reminders, education, possibly intervention, monitoring, and remote admission. 

Telemedicine also allows patients, in remote locations, to access medical expertise quickly and also efficiently without having to travel. Another advantage is that it provides more efficient use of limited expert resources who can see patients in multiple locations, wherever they are needed, without having to leave their facility. It also offers reduced cost solutions to delivering remote care when and where it is needed without having to build-in staff specific facilities.

Telemedicine has become a highly relevant way to deliver care now in the presence of the COVID-19 pandemic. And it represents a powerful tool that has multiple applications in these challenging times. It allows in-patient communication in settings of strict isolation requirements. It allows for remote management about patients to limit the exposure of healthcare workers and reduce the use of personal protective equipment. It also allows remote help to primary care and other specialty providers in patients who may have cardiovascular issues and that may not be willing to go to the hospital. It also allows for remote education with rapid dissemination of new knowledge. And we know now that in the COVID epidemics, data are becoming available on an hourly basis, basically. 

Now, the Brigham has done important steps in the last few weeks to implement as much telemedicine as possible in a way that allows both improved management of inpatients and outpatients. With regards to the inpatient arena, the steps that have been taken by the Brigham include the preparation of video intercom in both rooms. These rooms have iPads that have always on videos that are connected to dedicated laptops. And these iPad and laptops allow video communication between patients and their caregivers and the teams. They improve patient’s social connections because patients often are isolated from visitors, and they also have limited contact with staff.

They also reduce the need for personal protective equipment. The other benefits that are associated with telemedicine that has been implemented at the Brigham include the virtual review of results of imaging studies and other diagnostic tests. This helps to reduce the exposures of physicians that are in the reading rooms or in the testing labs and also the exposure of technologists, nurses, or healthcare workers. Also, telemedicine at the Brigham has implemented virtual rounds for clinical teams. So instead of having a group of 4, 5, 6 people moving around the floors and going from room to room, there is now the possibility of having a small team on each floor that will bring dedicated device on rounds and use it to initiate an audio conference with the patient and the small team. And the other teams members are connected remotely, and the visual conferencing feature will allow for the visual assessment of patients. 

The other aspect that has been implemented heavily recently at the Brigham is the use of virtual specialty consults. eConsults are short documented curbside consultation that are usually provided in the Epic system that we use for medical records. And these eConsults only require a chart review. And they are usually addressing specific questions such as the patient has this EKG abnormality – is this of any relevance, and should the patient follow with a cardiologist? Or the patient had an echocardiogram that showed the presence of an abnormality in the aortic valve – when should the next echocardiogram be ordered? And these eConsults are usually provided within 24 to 48 hours, so that rapid communication and response is obtained. 

The other virtual specialty consults that have been implemented are the audio- and video-based consults for both outpatients and inpatients. We talked earlier about the inpatients, and we are going to focus now on the outpatient settings. The common use of telephone in the communication and also the possibility of using video-based communication has been relatively slow in cardiology practice until now with the pandemic. The first question that one should have is which patients are appropriate? 

Usually patients that are established and that are known to be stable and they present for a scheduled follow-up visit. For instance, the patient that has stable coronary artery disease that has been asymptomatic on his current treatment and just needs to have an assessment. Also new patients can be consider candidates and appropriate for the virtual clinic. Usually these are patients that are known to be stable and that have a known referral questions. Also, patients who are referred for a virtual visit should not have a need for a specific physical exam. If a patient requires any ancillary tests such as an electrocardiogram or is expected to have abnormal findings, probably these patients should not be appropriate for the virtual cardiology clinic and should be referred for a full visit. 

Now once the patient has been deemed appropriate, what technology should one use? The most commonly used, so far, is probably the telephone. However, there may be limitations in the telephone call. There are limitations with regards to the ability of the patient to provide clear history by telephone. Sometimes the patient may have speech impairment. Oftentimes, patient may have language barriers, and, at this time, an interpreter has to be provided. And, this may not be available in all institutions. 

Also, the patient’s privacy should be protected, and this applies to any technology that is used. If available, audio- and video-based consults offer additional benefits on top of the telephone such as the ability to look at the patient have some form of also physical exam. Many times patient may show the color of the skin or the presence of other findings. And a major limitation of many of these audio-/video-based devices is the lack of HIPAA compliance. 

To summarize, the virtual cardiology clinic is benefiting from telemedicine. And in the setting of the COVID pandemic, every aspect of patient communication and patient evaluation may be potentially benefiting from the use of these technologies. We are learning on a daily basis. And I think that after the critical phase of this pandemic is behind us, we will be using the telemedicine opportunities with much better sense of their potentials and their limits. 

Thank you so much for your attention. 

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