Cardiovascular Care: The Ideal Model for Telemedicine & Digital Health Care Delivery

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After decades of overcoming the hurdles of provider and system adoption, the COVID-19 pandemic has catalyzed the widespread utilization of telemedicine with unprecedented urgency. Previously an occasional adjunct to in-person care, virtual visits will now replace routine outpatient cardiac clinic visits for an undetermined period. In-office visits will be reserved for urgent presentations and those requiring a physical exam. Fortunately, cardiology presents itself as the ideal foundation for developing a reproducible structure for health information technology to support virtual care delivery.

Ami Bhatt, MD, director of Outpatient Cardiology and the Adult Congenital Heart Disease Program, and Jaclyn Pagliaro, MPH, clinical research coordinator in the Cardiology Division at Massachusetts General Hospital, explain that since cardiology is remarkably data-driven, most cardiology guidelines offer algorithms to complement comprehensive patient care. These guidelines, combined with clinical review of data and remote doctor-patient interaction can create safe and high-quality care delivered within the patient's home.

Additionally, the field of cardiac monitoring and treatment devices is one of the most advanced in the medical subspecialties. This affords cardiologists with an existing framework for the mechanisms and workflow for remote data collection and analysis, as exemplified in electrophysiology, heart failure, cardiac rehabilitation and most recently, in cardio-obstetrics. The ability to integrate additional tracking mechanisms into existing workflows through virtual care has been preliminarily successful in several health systems.

Broadly, the value of digital health and telemedicine can be best described as addressing three important treatment areas:

• Preventative care
• Chronic disease management
• Early detection in high-risk, high-resource-utilization populations

Preventative Care

Social determinants of health limit access to care, a problem compounded by the current pandemic. Women and minorities are disproportionately affected by cardiovascular disease and new models of care delivery at this crucial time require planning to reduce implicit bias. Barriers to health care are varied and can include, though are not limited to:

• Financial barriers
• Lack of access to transportation
• Inadequate assistance in creating nutritious meal plans
• Shortage of behavioral health providers

Delivering care in the communities where patients live is essential. Accountable care organizations now use population health management to identify high-risk patients and engage coordinated care teams and case management. The addition of community partners including nonprofits, religious organizations, patient navigators and buddy programs have increased the delivery of health care directly to the community.

However, as physician and nurse capacity for providing care has become outstripped in many of these areas, the case management and community partner mechanism will soon be overwhelmed, particularly with attempts to maintain social distancing. Telemedicine improves access for these at-risk patient populations and helps patients maintain a connection to healthcare during this challenging time.

Digital health monitoring with wearables, asynchronous screening tools, virtual visits for medical management and behavioral health and heart-healthy native language education will revolutionize the delivery of care in the face of social barriers to health. Importantly, hospital-community partnerships in the virtual care model may create new capacity which was not previously realized.

Chronic Disease Management

Chronic cardiovascular disease management presents the ideal environment for digital health and telemedicine innovation. Remote data collection enables clinicians throughout the country to continuously manage large populations at a distance, rather than fewer patients with episodic in-person care alone. Patients with chronic disease benefit from decreased stress, saved time and finances, while also remaining productive members of their local community, which is essential to pandemic recovery.

The visibility of telemedicine patients in at-risk communities can further promote healthy habits and encourage others to engage in preventative care, thereby causing a ripple effect within those communities. Accessible technologies like wireless devices for heart rate, blood pressure, weight, oxygen saturation and activity monitoring create real-time individual cardiac fingerprints. These data provide insight for the care team and offer the patient an opportunity for self-advocacy right now. Advanced monitoring and complex systems for creating a remote digital cardiac assessment are meanwhile underway.

High-Risk, High Resource Utilization

Complex cardiovascular disease is a leading area of resource utilization and contributes to skyrocketing health care costs in the U.S. Digital health allows early detection of decompensation leading to rapid and targeted intervention. This has been well-established in heart failure and arrhythmia monitoring programs, leading to decreased or shorter hospital admissions for heart failure and early detection of atrial fibrillation, which contributes significantly to stroke risk and decompensated heart failure. Novel technologies are now assisting early assessment of progressive valvular disease and digital monitoring has begun in high-risk cardio-obstetrics populations, an essential mechanism to diagnose and treat pregnancy-induced hypertension and preeclampsia. There is hope that this will eventually aid in decreasing the impressive maternal mortality rate from cardiovascular disease in the U.S.

The Future of Telemedicine

Telemedicine will undoubtedly be deeply integrated in the future of cardiovascular health care delivery. The implementation of telecardiology can lessen physician burnout, dismantle the physician-patient hierarchy and allow patients to more rapidly meet their cardiovascular health goals. Closer monitoring can also improve chronic cardiac disease management and decrease the rate of hospital admissions, thus reducing the overall cost of health care. By increasing access to subspecialty medical care in previously marginalized, high-risk populations, telemedicine will lead to patient empowerment and increase health literacy within the community. A well-designed outpatient cardiology experience which leverages telemedicine including digital health acquisition and virtual remote care delivery is essential to deliver safe, high-quality comprehensive cardiac care, now more than ever. The blending of in-person episodic care and virtual continuous care will increase access and efficiency while decreasing hospital resource utilization and saving patients' own resources as well. Most importantly, in this new normal of social distancing, telemedicine will help the doctor-patient relationship flourish, and after years of bringing the patient to health care, we will finally bring health care to the patient.

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Learn more about the Cardiology Division at Mass General