Imagine sitting in your primary care physician’s office. A nurse checks your vitals and performs an electrocardiogram (ECG). When it’s time to see the doctor, the nurse wheels in a stand with a monitor and video cameras up to the exam table. On the monitor, your cardiologist says hello.
The nurse places an electronic stethoscope over your heart and lungs. The cardiologist listens to the lub-dub of your valves snapping shut and sees the acoustic sound waves. He asks you to turn your head to the right. Using the high-definition camera, he studies your carotid artery.
Next, he examines you for edema, zooming in on your legs. The doctor reviews your recent test results. You ask questions, and he replies, throwing in advice about nutrition and exercise — all from his office hours away.
Scenarios like this play out across the country each day. As technology improves, virtual visits — or teleconsultations — like this one are becoming increasingly common for cardiovascular care. Telecardiology, a branch of telemedicine, employs modern technology for real-time, remote diagnosis and treatment of heart disease. It can be used to evaluate heart disease, congestive heart failure, cardiac arrest and arrhythmias.
Telecardiology’s applications are extensive and can occur before, during and after hospitalization, giving it the power to increase access to cardiovascular care not only in rural regions but also within cities’ underserved areas. Somewhat ironically, this off-site care is aligned with a more patient-centric approach to care. It makes care more accessible, thereby increasing care overall and improving outcomes.
For patients who live hours from a cardiologist, teleconsultations for initial and ongoing visits offer time- and money-saving benefits.
Joaquin E. Cigarroa, M.D., cardiologist at Oregon Health & Science University (OHSU) in Portland, has a number of patients who live on the coast. He sees both new and follow-up patients remotely for exams and evaluations by linking into systems at off-site facilities.
The experience, like the one described earlier, mirrors most aspects of an in-person consultation. “I get data equivalent to what I get in person, and the patients only have to come to Portland if they need a procedure, which isn’t very often. They don’t have to drive the wet, cold roads unnecessarily,” Dr. Cigarroa says.
Vicki Campbell, a resident of Yachats, Oregon, knows these benefits firsthand. She used to drive three hours to OHSU for tests but has since been able to see Dr. Cigarroa, her cardiologist, from her local doctor’s office for treatment of early heart failure. “It’s like being in his office, just like being there with him,” Campbell explains. “It was a lot less stressful, and it certainly saved me money. You don’t have to go through a lot of rigmarole getting ready to make a trip.”
Brian Plechaty from Depoe Bay, Oregon, also met with Dr. Cigarroa remotely to see if he had a heart condition. His local physician, Robert Oksenholt, D.O., and Dr. Cigarroa coordinated tests and blood work before Plechaty met with Dr. Cigarroa.
“What struck me as amazing was the quality of the picture on the screen. It’s like a very high-definition picture that you’d be hard-pressed to find in today’s TVs. It’s very crisp, really clear, almost like it’s real,” Plechaty describes. “It saved me a long drive. It’s a real traffic mess in Portland.”
Although technology facilitates effective remote exams, there are limitations. “You don’t have the tactile sensation to feel pulses in the leg and to feel how warm the patient’s extremities are. You have to develop other senses,” Dr. Cigarroa explains. “As telemedicine evolves, in addition to electronic stethoscopes, we’ll begin to use ultrasound technology, so although I can’t feel the arteries, I can see them.”
Telecardiology is also helping patients in smaller, rural hospitals by connecting them to larger, more specialized care centers. Teleconsultations and the transmission of echocardiograms and other tests allow general physicians to connect with specialists in real time for the diagnosis and treatment of heart conditions ranging from congenital heart disease in newborns to cardiac arrest.
For example, in North Dakota’s rural areas, it’s difficult for heart patients to receive timely care. Some remote areas have a doctor shortage while others lack specialists and emergency or ICU care. But with hospital-to-hospital care, if a patient with chest pain visits a small local hospital, she can visit with a specialist via video.
In many instances, a patient can even be hospitalized in his rural hometown while receiving treatment from an off-site cardiologist. The specialist follows him through electronic monitoring equipment and prescribes appropriate intervention for the on-site doctor and nurses. Realtime ultrasound imaging transmission even allows cardiologists to guide sonographers for diagnosis and treatment. As a result, people are able to remain in their communities, rather than traveling to a large care center hundreds of miles away.
Following hospitalization, doctors can use telecardiology to monitor patients with heart failure. Alfred Bove, M.D., Ph.D., past president of the American College of Cardiology and professor emeritus at Temple University School of Medicine, has researched cardiology-related telemedicine since 1998. Specifically, he has focused on monitoring patients with heart failure to maintain their health.
In the late 1990s, this meant patients would send their blood pressure, pulse rate, and body weight to their providers via a desktop computer and the Internet. Today, the system relies on smart phones, apps and voice recognition. Patients dial an 800 number then recite their blood pressure, pulse and body weight measurements. The system translates that into numerical data for doctors or nurses to provide feedback to the patient.
“When we first started this, none of the health care providers were interested because there was no way to get reimbursed. Insurers only recognized patient-doctor direct contact. Most of our work was funded by research grants,” Dr. Bove says.
Now the benefits for chronic disease management are more evident. “For conditions like heart failure, chronic angina, heart rhythm abnormalities, if one can keep them stable, the patient can stay better and health care won’t have as many acute care instances,” Dr. Bove says. In fact, studies show that ER visits, hospitalizations and total days spent in the hospital are lower for patients using telemedicine reporting.
This telemedicine system is ideal for heart failure or hypertension patients who are stable on medication but need surveillance to maintain their health. Patients stay in communication with their physicians, regardless of their location. Physicians can detect daily or weekly changes and address an issue before it becomes a larger health concern. For example, if a patient starts retaining fluid, the doctor can see that in the numbers and adjust medication.
With telemedicine reporting, the patient is essentially part of the health care team, which requires patient education and cooperation. “We need to educate patients on what the proper numbers should be and what it looks like if those numbers are out of whack. They have to be motivated to do it and have to report numbers once, twice a week, maybe more,” Dr. Bove says.
Patients also need to know how to take the measurements and use the technology. But first, physicians and nurses need to be educated on how to teach and motivate the patients to participate. “The technology is way ahead of
us. We need to educate care teams and patients,” he adds.
In the future, implanted devices will monitor levels, eliminating the need for patients to measure and report, Dr. Bove explains. When levels aren’t where they should be, the patient will receive a notification text message that includes instructions about what to do.
Although most telemedicine applications began in remote areas where specialized care is not available, telecardiology benefits patients throughout the country. Dr. Bove, for example, works in north Philadelphia. Though patients are in the middle of a city, they are not receiving the care they need. But through telemedicine, patients and specialists can connect wherever they are.
That said, telecardiology for at-home monitoring has been slow in its growth, partially because there’s no clear-cut reimbursement system. “Almost all the things we see grow are driven by economics. For a long time, there wasn’t much of an incentive because we’re in a fee-for-service model,” Dr. Bove says. “But larger health care systems are seeing the benefits, and advanced insurers see the value in this. The majority of resources are coming from integrated health care systems with doctors, the hospital, sometimes multiple hospitals, all coming together. It’s for more of an outcome-based or equality-based system.”
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) supports quality-based outcome and performance-based data, and the Affordable Care Act (ACA) fosters an equality-based system — all of which support the benefits of telemedicine. If the new administration repeals the ACA, it’s possible some of the models would revert to fee-for-service, which could slow the expansion of telemedicine. But with heart failure as one of the largest cost generators, private insurance companies are seeing the cost benefits. In addition to improving the health of the patient, telecardiology saves money on medical expenses.
For telecardiology and teleconsultations to expand further, it’s essential for health care systems to create the infrastructure. “Telehealth is just a technology. You have to have the infrastructure. You have to create a system of care with strategic approaches to telehealth in order to do this,” Dr. Cigarroa says. This includes methods to maintain privacy and confidentiality of medical data. It’s not as simple as using an app and FaceTime; the equipment must be certified to ensure privacy. Doctors must make sure the data is recorded in medical records and that the data they acquire adheres to privacy and confidentiality requirements.
Legislation also plays a role when it comes to teleconsultations. “Depending upon what state you’re in, these virtual health platforms do, in fact, have disadvantages from a legislative perspective that restricts reimbursement,” Dr. Cigarroa says. “Oregon is ahead of many states. It used to be you couldn’t use telehealth in metropolitan areas; it used to be restricted to rural areas.”
He adds: “Having telehealth capabilities but not having a way to adequately pay for it means you won’t be able to scale it. Many insurance plans cover it, but you have to have policies that define telehealth. It has to be similar to when you see someone in person.”
Regardless of the hurdles, Dr. Cigarroa believes the use of telecardiology will continue to increase. He poses this as food for thought: “What percentage of your shopping do you do in person at bricks-and-mortar stores now versus in the past?”