What Optimal Virtual Care of Heart Disease Looks Like

Transcript

Host:

Hello, everyone. It’s a pleasure to be here to discuss this interesting and pertinent topic of telemedicine and the virtual care of heart disease with Dr Ami Bhatt. Dr Bhatt is the Director of Outpatient Cardiology and Telecardiology at the Massachusetts’s General Hospital Heart Centre, and an Associate Professor at the Harvard Medical School.

This podcast was sponsored by Novartis Pharmaceuticals Corporation, and the speakers were compensated for their time. Statements in this podcast reflect the medical expertise and opinions of the presenter.

Dr Bhatt, many thanks for joining us today. Could you please provide an overview of telemedicine, including a summary of unmet need in direct outpatient cardiology?

Dr Bhatt:

Virtual care has become essential to the infrastructure of cardiovascular care delivery. Although previously used as an occasional adjunct to in-person care, virtual visits are now routinely used for outpatient clinical care, and remote in-hospital consultation. It leads to both provider and patient satisfaction, and really has the potential to transform care globally. So today we’ll be talking about cardiology specifically as the ideal sub-specialty for developing a reproducible structure for health information technology.

We are immensely data driven, and most guidelines have algorithms to provide comprehensive patient care, so telemedicine now enables clinicians to continually manage large populations at a distance rather than with in-person care alone. This includes team-based phone calls, virtual video visits, asynchronous symptom checks for stable angina or heart failure, at-home vital sign monitoring with medical-grade digital and wearable devices and, importantly, technology such as Bluetooth-enabled devices now allow us to use heart rate, blood pressure, weight, oxygen saturation, even activity monitoring, to create a real-time, individual cardiac fingerprint, providing insight for the cardiac care team. So, what we are now moving towards is the widespread dissemination of telemedicine enabling frequent assessment and high-touch interventions, especially in areas lacking access to traditional care.

Fortunately, or unfortunately, the COVID-19 pandemic has certainly brought many of us to a new level of understanding of telemedicine, so we will try to progress from that level of advanced understanding, and really talk more about adoption.

Telemedicine itself is defined as the use of electronic information in telecommunications technologies to support and promote long-distance clinical healthcare, patient and professional health-related education, and public health and health administration, so this covers really all of health, as we discuss it. It’s important to recognize, though, that telehealth is not a disruptor of the practice telemedicine; it augments traditional delivery of healthcare, and it really enables us to develop a more agile, and continuous mechanism of care provision, and that is what engages the patient more strongly as an equal partner in their care, and that is where we are headed in the future of healthcare. We are moving from fraternalistic to partnership when it comes to healthcare.

So, I always like to start by talking about a case, and this is actually a patient who just is coming in next week to see me. This is a 60-year-old man, and he had some undiagnosed dyslipidemia, probably actually diagnosed maybe 20 years ago, but not actually followed because he wasn’t great at keeping up with primary care, and had some hypertension that was being managed, although not optimally managed, again, because of the lack of compliance. He was also overweight, though not obese, and had a lot of anxiety and stress in life; multiple jobs, and a family to take care of. He came in during COVID times with a myocardial infarction.

Now, importantly, after the immediate episode of care, we were then still, during the 2020 pandemic, trying to learn how to best care for these patients after the hospitalization. And so we rapidly instituted for him the use of virtual cardiac rehabilitation, so using the video, and using some asynchronous mechanisms, we were able to talk about nutrition, exercise habits, which medications were for what part of his atherosclerotic disease care, and start to engage him in advocating for himself.

We then continued, once virtual cardiac rehab was completed, some nutrition counselling. And in that nutrition counselling our nutritionist actually found that it was very helpful to look around the kitchen of this patient to get a sense of what kind of foods they were buying, and also could afford to buy, to really help give very directed and specific nutritional information that they could act upon.

We then recognized that he did have some depression, as many individuals do with cardiovascular disease after that first presentation with a heart attack. And so he did receive behavioral health counselling for depression, which is still ongoing for him. And lastly, the hypertension was still a little bit challenging to manage, and he was having a tough time optimizing those medications on his own and, therefore, we actually had a Bluetooth blood pressure cuff, which was provided to him at his home and then would upload to our nurses here and interestingly we have many patients now who have active Bluetooth blood pressure cuffs at home, and our nurses every Monday are able to scan those patients who are working on improving their blood pressure management by really getting to ideal medical therapy, but doing it virtually with our nursing team, referring to our physicians when necessary and then working on those medications and the understanding of adherence with these individuals. So his virtual care continues, however, next week he’ll be coming in to see me in person, and that really emphasizes that blended nature of virtual and in-person care to be able to develop and maintain the relationship. This is really enhancing the atherosclerotic cardiovascular disease paradigm of care, which now makes us far more able to deliver holistic care addressing all the different issues of atherosclerotic cardiovascular disease that are going to improve his long-term outcomes.

When we think then about who these patients are, we first have to ask, ‘what do they want?’ And so, if we look at our patients, they are ready for change and they are ready for convenience. In every other aspect of their lives, we have made things available 24/7 and we really offer them at the touch of a button, whether on a phone or a computer. And so our patients want improved access, they want optimal convenience, they want accessible education that they can understand, and they can learn from quickly. They most certainly want home-based care, especially in 2020, a personalized approach, and a holistic investment in all the things that matter to them.

When we think about the practice of telemedicine in cardiology and what the current use cases are, there are several. So, one of the most common ways our practices that started to use telemedicine is to use it for review of data. When patients have a test like an ultrasound or a stress test that is completed at the practice or the institution, the follow-up of those results can absolutely be virtual. Oftentimes, you have all the data that you need to be able to have a meaningful conversation.

Patients state that that is very helpful because just getting a report is a lot of cardiovascular data that they don’t necessarily understand, and getting a phone call saying, ‘hey your test looks great’, doesn’t really engage them in that advocacy process and the understanding of their disease. And so a review of data actually takes probably about 50% of a telemedicine practice when it first begins.

There are patients and doctors who use it for routine follow-up. It is used for follow-up of symptom management, especially in heart failure practices and, increasingly, there is now a growing trend towards using it for preoperative and postoperative management. Right now, decreasing exposure to the institution, especially in the setting of the COVID pandemic and potential resurgence, but also making patients have to take fewer days off work leading up to a period of time where they’ll be taking sick leave, and on the far end of postoperative follow-up, allowing us to have many more touch points to go over medications, symptoms, expected recovery, and really lessen the number of urgent visits or emerging visits that we have that are unplanned in the postoperative setting.

If we know what the patient thinks, increased convenience, improved education, the ability to incorporate family which they really enjoy, the ability to contribute to their community, and the decreased cost and time of travel, the next question is. ‘what do we see the provider advantages as, and do the providers see that?’ So the first things that we know from telemedicine research right now is that telemedicine really does reduce no-shows; people are more likely to show up for a virtual visit than an in-person visit for a variety of reasons.

It does also improve adherence, both adherence to compliance with visits, adherence to medications, and adherence with lifestyle. It allows us to increase clinic capacity, so if we think about the number of clinic rooms we have, we have a static number of rooms and a static number of appointments during a day, even fewer oftentimes nowadays in the COVID pandemic. This now allows us to really maximize the use of in-person visits for those individuals who need some sort of acute adjustment in their medical care or an exam, and perhaps even an admission or a procedure, allowing those who are stable for follow-up to stay in the comfort of their own home, but also allow us to really get in urgent patients faster in the in-person clinic.

There is definitely increase in physician flexibility, which is very important to our physicians and nurses right now, and the extended clinic hours allows our patients to still be able to get care at times when perhaps originally, we didn’t have clinics open. The last thing to kind of think about is what is the bottom line of improving access, improving quality with telemedicine, and it’s really that, for the providers, this has resulted in increased engagement between the patient and provider in terms of their relationship, their increased opportunities for the patient to see the care team as part of the extension of the provider, and to be able to access a clinician, where perhaps they would have had to wait a little bit longer in the past.

From the patient perspective, there are many patients who have clearly said this is the hospital, the practice, the individual provider saying to me, ‘I respect you and your time and the cost, and instead of making you come to our brick-and-mortar institution, we really appreciate that you respect us enough to come to us when appropriate.’

So, there are challenges with the provider adoption, and we said we would talk about pitfalls. It is important to recognize that virtual visits and in-person care are always both available to clinicians as needed. That then means that you won’t miss something because you are going to bring them in if you are uncertain once you see that individual and clinical acumen doesn’t change over a video. Physicians and nurses really have the ability to understand what a patient looks like, and whether they are sick or not sick much quicker than they realize, and we see physicians and nurses noting that as they start to use telemedicine.

It is important that clinicians are willing to try the different mechanisms of telemedicine, and find out what works best for them where some people may like the asynchronous sending through the patient for the questionnaire and having it returned each week with the weights, with the activity level, and seeing when things are changing.

Others may really like to have the in-person video visit to review the most recent echo, and so it’s important for physicians to recognize that they will have a certain comfort level, and that’s okay, and that each patient will have a certain comfort level. And therefore, how much we use virtual care in addition to in-person care, will vary based on diagnosis, based on clinician, and based on patient.

If you run a practice, that is probably the most important thing to recognize is that some patients will prefer virtual care and others won’t, and at the same time, with your own clinicians, there will be certain clinicians who perhaps want 100% virtual during the COVID pandemic and are still 90% virtual, whereas others who ran back to being basically in-person all the time, as much as is physically possible. That’s okay. There is a bell curve distribution of those who will be early adopters, those who will not adopt, and the majority of your practice will likely have some sort of a blend of in-person and virtual care.

What is important as cardiovascular administrators is that we provide the technology in a user-friendly mechanism, the at-the-elbow support to ensure that clinicians and patients have immediate help with technology when needed, and the work flows to allow providers to still have autonomy and, at the same time, choose the highest quality care delivery mechanisms to provide care for these cardiovascular patients long-term.

When we look at whether or not providers are satisfied with virtual visits, there have been many studies throughout the United States. We have done some at our institution as well, and we really do find that nearly 80 to 90% of providers say that virtual visits are easy to use, that video quality is good, and 75 to 80% of patients agree with the same. Importantly, those patients are of all ages. There are grandparents out there that are very facile with FaceTiming their grandkids and therefore can also Zoom us very easily. There are also younger patients that sometimes we make an assumption maybe they’re very comfortable with technology, but would actually prefer the in-person visit, and so we have to remember that our implicit biases can’t be involved in deciding who is going to partake in virtual care.

We’ve moved to a care paradigm globally, which involves continuous monitoring and management, and then episodic pre-planned escalation of care is needed. Lifelong care requires a multidisciplinary approach and careful consideration of surveillance intervals, emphasizing safety and optimal resource utilization, and then timing medical therapy, percutaneous and surgical intervention.

To do that well, we really need increased touch points for the patients in a way that is convenient and engages them, and also is not a burden on the brick-and-mortar system, the number of clinic rows, and the utilization of services at the hospital.

It’s important to recognize that blended care with virtual and in-person visits does provide increased medical oversight while it enhances patient experience and at the same time we can really provide access to care in areas that may not have had care previously.

Host:

Thank you for providing this extensive and informative answer. It would now be great to hear your thoughts on how the opportunities for telemedicine can be enhanced with digital devices, such as wearable technology.

Dr Bhatt:

As we move forward with telemedicine, there are opportunities to enhance our telemedicine care with digital devices, and today we’ll address what those devices are, and talk about some cases of how those devices can be used.

When we think about devices, we need to think about which devices, operational considerations, and then what the patient experience might be. Those devices may include medical-grade devices, such as remote monitoring used by heart failure practices or electrophysiologists. It may also include Bluetooth blood pressure cuffs, and weight scales at home, but may extend then to using wearables in the community, digital stethoscopes, or digital EKG monitors.

It is important to recognize that for each of these arenas, there are some that are FDA approved, there are many that have not year gone through the process. And so we’ll talk about them in general, and I’m certain that this field will change, and there will be many more opportunities for us to discuss particular digital devices at our own practices and institutions.

The first thing we need to do when setting up a telemedicine practice, and the extension of digital devices, is determining which patient groups are going to best benefit from the use of these devices. Some of the classic arenas in which there has already been both practice and research, are the hypertension patient who has Bluetooth blood pressure cuffs at home, the heart failure practice that has weights at home, either written on a list and called in to the physician, or sent in through the patient portal, or now with Bluetooth blood pressure cuffs and Bluetooth weight scales allowing us to combine that information in our heart failure management.

It is important to recognize that these paradigms already have a blended approach with in-person care, such that there can be times where we notice a rise in weight gain in a patient with heart failure, and may either bring the patient in for care or send nursing services for IV diuresis in the home.

Similarly, in the electrophysiology realm remote monitoring has been around for many years. It is one of the first versions of telecardiology that we’ve had, and that kind of monitoring is now being extended to the use of algorithms, and maybe the first arena where we use artificial intelligence to assess when a patient may be at risk for their next event.

We can start with a case example, and we’ll use a heart failure patient that I saw just recently to talk about how we can set this up in the home. This is an individual who had come in from multiple admissions for idiopathic dilated cardiomyopathy at a young age – only 25 years old – and this young man had a lot else going on in life at the time and, therefore, was oftentimes coming in recognizing that he had not been adherent to therapy. We had not completely achieved guideline-directed medical therapy because of a loss of a follow-up, or that there had been some nutritional indiscretions that had occurred prompting him to have an admission.

For these patients we emphasize that team-based care in heart failure has been essential and therefore that team-based care can still occur, be it both in virtual and in-person visits. For him we set up a system that was based on asynchronous communication of weights through a patient portal. That patient portal needed to be an app on his phone, and not just on a computer. He found it very tedious to do this on a computer, however, the application on his mobile phone for the patient portal made his compliance much better.

With those daily weights, we were able to then call him and talk about how to alternate his medication dosing, we were able to engage with him using video visits to be able to look at the medications that he had at home and make sure that we were increasing and decreasing the correct ones, and he was putting certain bottles away when not necessary. Initially, one would think that this level of intense care for a large heart failure population could be very challenging. However, it turns out that really after the first few visits, most of these patients get the rhythm of how to take care of their health in a way that incorporates technology, just like they do in a majority of the other aspects of their lives.

On the provider side, what we did need, however, were workflows for data streams. If there were blood pressure readings coming in regularly or weights coming regularly, who was looking at those, when were they screening it, who was being alerted to those measurements that were out of range, and then whose responsibility was it to be able to reach back out to the patient? And which was the best way to reach that patient?

That kind of workflow administration set-up is essential to the success of using devices in the digital arena. This was only with a digital device that had already existed and been in use for many years prior. When we then move forward and start thinking about the use of digital stethoscopes in the community, I think the use of digital handheld ultrasound by the patient is probably much further away, although ultrasound use in local community centers or emergency rooms may actually be helpful. We recognize that there is an entire other layer of data that is going to come in that may not be something that’s familiar to a nursing practice or to the physicians even and, therefore, that is where thinking about partnering with companies who provide those kind of digital devices to ask them to do a first cast of what is sick and what is not sick, what is an alert and what is not an alert, is really necessary for us to be able to take the technical nature of digital devices, and take it further to that next realm.

Host:

Thank you – that’s certainly very interesting. In the patient case you discuss you mention that the patient preferred his phone, or accessing the app on his computer. How did those insights come to the discussion? Is this a shared decision-making component? How do you assess the social determinants of health in a patient, if they are in fact appropriate for a digital or telehealth approach?

Dr Bhatt:

So, that’s a great question. One of the challenges in providing virtual care is understanding what the patient is actually able to do with you. And so, one of the first steps we have is just a conversation with the patient about what kind of technology they use in their regular life. That gives us a sense of whether or not they are more familiar with mobile apps, they’re comfortable with the computer, do they have a laptop with a camera at home, and do they use wireless in their home or do they usually go to a local coffee store, which is where they might access wireless. And so that kind of a conversation is the first thing that we do to get a sense of what their capability might be.

The reason that we talk about it in a non-medical sense to start is because we’re really thinking about introducing patients to a new blended mechanism of care, and for all patients there is some blended mechanism of virtual care that’s likely possible. We just want the patients to be very comfortable with what it is we’re going to ask them to do, and then ease into different versions of that care as they are able.

When we think about setting up their home for success, it’s actually really important to make sure that you have somebody who goes out to the home, or at least virtually visits the home, and gets a sense of what kind of technology they need and have. If you are really going to build a digital device suite, I strongly recommend actually sending somebody like a visiting nurse on your team out to the home to help set up the scale; to set up the Bluetooth blood pressure cuff, to demonstrate how those work, and how they upload into the system.

It may seem like a lot of work to have one individual go there and do that, but the benefits, and the ease of use, and the likelihood of success increase tremendously. That’s not always necessary. People oftentimes have that one person they know, whether it’s in their family or in their friend’s group who’s good with technology, and you can often do the virtual set up virtually for those individuals, either themselves or with somebody who is tech savvy who is around the house.

Host:

Thank you. How do you assess patients based on social determinants of health and how do you change or modify your approach according to that assessment?

Dr Bhatt:

So, if we look at the COVID pandemic and we look at who accessed virtual visits during the pandemic, there are many studies that we have seen, and a lot of them suggest that those areas that have challenges in terms of access to care may also be the areas where there is some challenge in access to broadband. If we are offering both virtual video visits, as well as virtual telephone calls, it is interesting that race and ethnicity can influence your likelihood of having a virtual phone call rather than a virtual video visit.

We also note that socio-economic status can make you more likely to use a telephone visit rather than a virtual video visit.

As we move forward, a few things to think about are, is a telephone visit just as good as a video visit? And it really depends on the reason that you’re using that touch point. If it’s simply to discuss weight and talk the patient about which medications they’re taking, it may be adequate. Others may say that it’s actually more helpful to always see the patient and, therefore, we should strive to get all patients on to a video visit to provide optimal virtual, and then in-person, blended care.

The challenges of broadband and access are not limited to the medical profession, and we find that our colleagues in education are also fighting for broadband to be able to enable school systems to offer Zoom schooling, especially during the COVID pandemic. So there is an opportunity for us to advocate along with other communities in order to be able to provide access in the areas where patients may need this kind of healthcare the most. In the meantime, there are opportunities for partnership.

If we think about employers, if we think about local community partnerships, whether those are community centers or community hospitals, the opportunity to have wireless access, and potentially telemedicine stations locally, to be able to offer advanced cardiac care is a potential starting point that some institutions have already started to look into.

Host:

You mention community hospitals as well as obviously specialty care. I am curious about how you envision multi-specialty teams collaborating on interpretation of all this data, or potentially the inner meaning based on that data, specifically with the primary care practice. How do you envision disseminating down information to them for chronic care management beyond necessary specialty visits?

Dr Bhatt:

One of the greatest things that has happened because of the rapid uptake of virtual care, especially in the United States, over the past several months is that I think it really has brought the primary care physicians and the cardiologists closer. It enables us to be able to communicate more readily with data that is apparent in the electronic medical record, and can be shared and communicated about between the primary care doctor and the cardiovascular physician. So, for example, those individuals who have continuous glucose monitors, those individuals who have the previously mentioned Bluetooth blood pressure cuffs, we can really create an entire set of parameters that we want each individual patient to adhere to, and we can then note when they may fall outside of that parameter, and take responsibility, whether in one practice or another, to be able to help achieve the right guideline-directed medical therapy to get the patient back in range. And so it’s actually much more fluid than having in-person visits with a note sent to somebody else, but rather having an almost an entire platform where this kind of digital information is shared between practitioners.

Host:

Thank you. I’m sure this is on the minds of a lot of clinicians listening who are not as well versed in telemedicine as you are. How do you advise clinicians to stay aware or up to date on recently approved or available apps or devices as they become available?

Dr Bhatt:

One of the hardest challenges for us in medicine is to keep up with everything that is constantly coming at us. That’s true for continuing education and knowing our field, and now we’re adding to that the need to understand digital devices; which ones are FDA-approved, what the approved use cases are, and how they may apply to our practice.

I don’t think each individual physician or nurse should be necessarily doing this alone. If they have a great passion, I would take that person, encourage them to find out what’s happening, and have them be a leader in your practice to bring that kind of information back in, and start to think about where multiple providers may be interested in using those devices.

It is most certainly a challenge, and there are many groups out there. The American College of Cardiology, the American Heart Association, the American Medical Association, amongst many others, have very nice lists of approved blood pressure devices, recommended FDA tools, and so it’s nice to be able to rely on those larger institutions.

However, I really do think that you need a champion for telemedicine and digital health within your practice or your institution, no matter how big or how small, who is going to be able to digest this information and bring it to the rest of the group in a way that everybody can have a discussion and understand what the right next step is for that group.

Host:

Many thanks. It would now be great if you could discuss the importance of using virtual visits as preventative medicine and its relevance to well patients.

Dr Bhatt:

There are many individuals who are increasingly interested in promoting their own heart health, and in preventing cardiovascular disease.

However, there is a challenge of access to cardiovascular practitioners in the United States and, therefore, virtual visits are an ideal mechanism for us to be able to reach out to those communities, and provide preventative care while, at the same time, saving in-hospital care and clinic-based care for those patients with more urgent needs.

Many individuals may ask, ‘who is the ideal preventative-medicine patient for virtual care?’ And the answer is really whichever patient population is willing to see the practitioner virtually, and that the practitioner has a comfort level with when discussing their potential disease.

When setting up a virtual preventative medicine service, it’s important to think about which patients that service will provide care for. Some of the most common groups are those with a history of premature coronary artery disease in the family, as well as those with a history of genetic cardiovascular disease. Increasingly, we also have cardio-obstetrics programs that are using primarily virtual care for those individuals who don’t have known cardiovascular disease, but may develop risks during their pregnancy. 

Let’s start with the case of a patient that I saw last week in clinic. She’s a young woman with a history of coarctation of the aorta. I care for adults with congenital heart disease. That narrowing in her aorta has been fixed. However, she has residual hypertension, for which she’s been managed for many years.

Now, she came to me in her first trimester of pregnancy. For these individuals, we know that there may be a risk of developing further hypertension in pregnancy, and even a risk of pre-eclampsia or eclampsia and, therefore, we set up a system to be able to care for her during pregnancy. We now, in cardio-obstetrics, throughout the country, have several programs of virtual care for these individuals, where even women who may not already have hypertension, but either have risk factors for hypertension or a family history, may start to have blood pressure cuffs into their homes where they can upload their blood pressures to the cardio-obstetrics practice in order to catch pregnancy-induced hypertension as early as is possible without making the pregnant woman come in repeatedly for in-hospital visits.

This connection during pregnancy has also been helpful for individuals who have known cardiovascular disease, and enabling them to obtain what is essentially preventative care during their pregnancy, and ensure that they are both reassured about their care, but also alerted to changes in care that may be necessary during pregnancy.

Increasingly, there are individuals who want preventative care who may also offer to use their own devices at home to provide you with information. This has likely happened to many providers already. This includes wearables, as well as potential digital devices that are already offered on the market, and directly marketed to consumers.

Importantly, there are ethics associated with the use of this data. By the patients sharing their data with you, they have already decided that you are privy to this kind of data. However, on the provider side we do still have a certain lack of clarity as to if we had asked for data from wearables, then we have opened the door to be able to analyze that data and be responsible for what is sent to us. However, when we have not specifically asked for that data to be sent, it is not very clear what our legal obligation is and, therefore, that area of this field in preventative medicine will continue to grow over the next months to years.

If we are going to take patients’ wearable data into account for part of preventative medicine, it’s important to start thinking about a system for obtaining that data, understanding it, and then being able to process it with your patient. If you are going to do that, I would strongly recommend some shared decision-making and documentation as to what the purpose of that data may be.

In the meantime, the use of virtual visits as video visits are extraordinarily helpful in the preventative-medicine field. For individuals who have a history of coronary artery disease in their family, the ability to discuss diet, exercise, nutrition, the ability to directly converse with multiple members in the family because we know that habits that are shared with other individuals in the family are more likely to be adhered to, and the ability to engage patients who are interested in preventative health at the time that they are engaged.

One of our greatest challenges is that the interest in one’s own heart health may wax and wane along with how busy people are, and so being able to get a preventative-medicine patient in at the time that they are proactively interested in thinking about their cardiac health is ideal for us as practitioners to help prevent future disease in these individuals.

One of our biggest challenges is that the chronic disease burden of atherosclerotic cardiovascular disease risk factors including hypertension, diabetes, overweight, obesity, truncal obesity, metabolic syndrome all exist in some of the populations that are at highest risk for facing social determinants of health.

In these lower socio-economic status patients, or those with at risk race ethnicity, we do recognize that there’s a need for increased access to cardiovascular preventative services. Using virtual care is an excellent way to be able to reach into these communities, however, continue to pose the problem of needing wireless services or broadband to be able to truly reach these populations.

Host:

That was excellent. We are really grateful to Dr Bhatt for providing us with her expert insights and experience around telemedicine, and the promise it holds to improve the management of cardiovascular disease. Thank you for listening to this podcast.

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