Virtual Health During a Pandemic

Along with its heavy toll of morbidity and mortality, the coronavirus disease 2019 (COVID-19) pandemic has disrupted healthcare systems worldwide impacting the care of non-COVID cardiovascular diseases, including heart failure (HF). This challenge presents an opportunity to leverage virtual health (VH) in ensuring effective and safe care for patients with advanced HF.¹ At our institution, we balanced the deferred/cancelled face-to-face HF visits with rapid adoption of virtual visits (VVs)— from 0 to 159 in 5 weeks— while employing several novel VH technologies with overall positive results.

In this perspective, we present ways in which commercially available VH technologies can be used to optimize care for the advanced HF population. We also discuss some potential barriers and creative solutions.

Urgent Care Setting

An automated web/phone-based tool could guide HF patients with concerning symptoms to determine the need for self-isolation/symptom monitoring, urgent VVs, or presenting to the emergency department (ED).² By providing safe virtual options to seek medical treatment, patients are more likely to promptly access the needed care while reducing unnecessary—and at times risky—ED visits.

Outpatient Care Setting

Follow-Up Visits

During the pandemic, outpatient face-to-face encounters are replaced with VVs or redesigned as virtually enhanced future visits. The latter innovative strategy includes use of supplemental e-visit forms to be completed by patients in advance of appointments. Patients can verify medications and record symptoms, which helps providers preplan the visit. This is particularly advantageous considering that patients are more likely to have their medications on hand while conducting VVs, as opposed to face-to-face encounters where the high rate of incomplete medication reconciliation jeopardizes safe guideline-directed medical therapy optimization.³

As for older and less tech-savvy patients, the help of a caregiver or support staff can be sought to review their medications and complete the e-visit form. Subsequent virtual or face-to-face encounters will be more efficient and effective. Furthermore, VVs are enhanced by integrating remote patient monitoring (RPM) data (including weight and blood pressure). In fact, trended home vital signs may provide a better gauge for guideline-directed medical therapy optimization as opposed to the snapshots obtained during face-to-face encounters which are susceptible to multiple sources of error.

New Patient Consultations

As advanced HF specialists, we often receive consultations from cardiologists, and therefore, initial face-to-face assessment may not be necessary. Virtual consults with the aid of store-and-forward technologies can help discern subsequent steps including the need for face-to-face visits. Furthermore, a HF specialist can virtually provide real-time guidance for referring ED physicians, thus obviating the need for some face-to-face visits/hospital transfers. For less urgent cases, the concept of asynchronous e-consultation is gaining traction where community practitioners pose clinical questions to HF specialists through a web-based platform, to which specialists provide guidance at a later time.⁴ This is distinct from curbside consultation where inaccurate/incomplete data is often hastily provided.⁵ Depending on local coverage/reimbursement, the avenue of e-consultation could allow direct new patient-to-provider consultation for purposes of establishing care or requesting a second opinion. Beyond the pandemic period, this avenue of VH is poised to address the widening gap in access to specialists care in the United States, particularly in rural and underserved areas.⁶

Inpatient Care Setting

When conducting inpatient consultations, an advanced HF specialist can substitute face-to-face evaluation with virtual assessment aided by video intercom and hemodynamic data review. In patients with suspected COVID-19-related cardiac complications, point-of-care ultrasound devices can be placed in patient rooms, and the treating team can acquire images for review by advanced HF specialists. At our institution, we piloted a program of dispensing point-of-care ultrasound devices to critical care units after brief training of residents to perform basic thoracic examinations. Initial results are encouraging with rapid adoption of point-of-care ultrasound and commensurate reduction in formal imaging studies. Accuracy of studies and impact on outcomes need to be tested.

Importantly, because most hospitals have restricted visitor access during COVID-19, the use of in-room video conferencing with patients and family can be instrumental in facilitating critical conversations, including treatment decisions and advanced care planning. Upon discharge, early follow-up can be arranged via telemedicine to ensure safe transition of care, monitor adherence, and uptitrate guideline-directed medical therapy after establishing clinical stability and resolution of congestion.⁷ As these postdischarge VVs encompass the core elements of traditional face-to-face encounters, it may be safe to extrapolate a similar positive impact in reducing HF hospitalizations.⁸

Provider-to-Provider Communication

Daily rounds and consultations are routinely performed face-to-face which compromises physical distancing and risks staff exposure. At our institution, we have used audio/video conferencing tools to replace face-to-face rounds and multidisciplinary meetings. Early experience suggests rapid uptake with higher attendance, engagement, and productivity.

Potential Barriers and Proposed Solutions

Cost and reimbursement are major impediments to VH utilization. Fortunately, the U.S. Department of Health and Human Services and private insurers have recognized the vital role of VH, which will facilitate wider adoption.¹ The increased upfront cost of establishing VH infrastructure will be mitigated by subsequent reduction in face-to-face encounters, no-show rates, and improved outcomes. In fact, VVs have become a reliable source of revenue for healthcare institutions particularly when other routine activities are halted/deferred.

Importantly, in community/rural centers where resources are shunted to the care of patients with COVID-19, the use of telephone-based VH is often sufficient for most HF routine follow-up needs. With time, centers can upscale their VH practice to include audio-and-video communication tools, even if starting with personal applications like Zoom, Facetime, Skype, etc. Although the use of a dedicated Health Insurance Portability and Accountability Act-compliant method is certainly preferred, the Department of Health and Human Services has provided exceptions for using personal tools during the pandemic to facilitate widespread adoption of VH while institutions build capacity for sustained use of Health Insurance Portability and Accountability Act-compliant technology.^1,9 When needed, partnering with academic centers to provide support in patient follow-up may be warranted. This collaboration is facilitated by new Department of Health and Human Services rules of easing licensing limits of practice across state lines and the requirements for prior doctor-patient relationship.⁹

Another barrier is lack of consistent access to broadband network with patients living in rural areas. This can be navigated by planning visits in advance, at times when network availability is expected. The ease of carrying out VVs from a provider standpoint allows more flexible scheduling including after-hours when needed. In many rural areas, federally qualified health centers are equipped with the necessary VH tools to facilitate such visits.¹⁰ Despite this upside, there will remain vulnerable populations (poor, homeless) without access to VH technology. Finally, hospitals should take a proactive role in providing RPM equipment to high-risk HF patients to monitor their clinical status and prevent decompensation. Fortunately, the Department of Health and Human Service’s new guidelines provide expanded coverage to RPM tools with more flexibility for their utilization.¹

Importantly, several previously considered obstacles are becoming less pertinent. For instance, the perception that older patients are nonamenable to VH is challenged by the Veterans’ Administration’s experience showing the majority of older patients have a positive attitude to VH.¹¹ Furthermore, unease about lacking long-term outcome data of VH overlooks mounting evidence supporting efficacy and cost-effectiveness of RPM in HF; a well-established form of VH.

To meet the demands of increased VH utilization, several workflow optimizations should be explored. Self-quarantined providers could contribute to VH by running VVs, providing e-consultations, and reviewing RPM data. Furthermore, older or recently retired clinicians unable to participate in front-line work can assist on these VH tasks. Looking ahead, we await development of newer VH technologies including the application of artificial intelligence/machine learning tools, the fast-growing wearable industry with rich biometric data and evolving home-diagnostic tools to enhance provider-patient interactions.

Conclusions

Advanced HF care is challenging when face-to-face encounters are limited and potentially risky. It is time to leverage VH to redesign healthcare delivery to be more efficient, more convenient, and safer for our most vulnerable patients.

Footnotes