Tips for Successful Telehealth Visits in EP: Interview with Kenneth Civello, MD

In this interview, EP Lab Digest speaks with Kenneth Civello, MD about his experience implementing telemedicine visits for his EP patients amid the COVID-19 pandemic. Dr. Civello is an electrophysiologist with Louisiana Cardiology Associates at Our Lady of the Lake Physician Group in Baton Rouge, Louisiana. Included here are the edited transcripts of our interview, which took place on April 21st, 2020. 

Tell us about first making the switch to telehealth visits at Our Lady of the Lake Heart + Vascular Institute.

We had been doing telemedicine or telehealth visits — I actually prefer the term “telehealth” better than telemedicine — pre-COVID-19. Like a lot of electrophysiologists, we perform ablations on patients who have to travel far distances to see us. Therefore, we were already set up to do follow-up visits with post-ablation patients that may live greater than an hour away or for those patients in whom it was cumbersome to get to the office.

So we had the software, cameras, and technology to transition. It had actually been a goal of ours in our group to increase our telemedicine visits this year and had it as incentive criteria. It’s interesting because pre-COVID-19, we were getting the numbers, but it did not look like we were going to reach what we needed. Within two days of COVID-19, we had reached our goals pretty successfully! So without COVID-19, what we accomplished with televisits in four weeks would have taken probably four years.

What video technology is primarily used?

We are on Epic, so we use Epic video, and as long as patients can download the Epic app, they are able to use MyChart to connect with us on video visits. With the Epic app, they are allowed to do eCheck-in as well as verify their medications, insurance, and consent.

Having an app does allow you to do additional things with telemedicine. But as you might imagine, downloading an app is very difficult for some patients. You’re asking a patient to remember their Apple ID and password as well as email address and password (some patients don’t even have email), and to use a confirmation code to then set things up. For those patients who cannot download an app, there is other software that we can use to help them connect with us.

Televisits are either HIPAA compliant or non-HIPAA compliant. If something is HIPAA compliant, it does not necessarily mean that it’s within your EMR. There are a lot of video platforms that are HIPAA compliant. For instance, there is one called Doxy.me, and Doximity has one. I’ve also worked with a company called SutureHealth to help with telemedicine visits. You can be HIPAA compliant but outside of your EMR. The camera in the video is just a vehicle within your EMR to get the patient to you. But as long as you’re using a HIPAA-compliant system, you can use another vehicle which may not require an app download or may have better connection than what your EMR has. Non-HIPAA compliant methods include FaceTime, Duo, and Zoom. 

In this acute phase, I do feel that these provide value, because it is very hard to get patients onboarded with downloading of apps on their phone. So this allows you to call a patient and have them pick up the phone. I can’t tell you how many patients who I’ve called via FaceTime, and the first thing I saw was the inside of their ear! I think for elderly patients, it’s a great opportunity. But it is a little bit cumbersome, because you have to get a burner email address for FaceTime and a burner phone number for Google Duo, so it does require a little bit of backend support from your practice in order to get those set up.

What types of visits can be seen via telehealth?

We initially were just going to do follow-up visits, but we soon heard from patients who were sitting at home and had realized they hadn’t seen their cardiologist in over a year, or from patients who had some risk factors and were making a new commitment to health. So we are doing new consults, follow-up visits, and wound checks — we’re pretty much doing everything. I would say pre-COVID-19, I was seeing between 35 and 42 patients a day. With televisits, I’m now probably seeing 20 patients per day.

What have been some of the initial lessons learned?

I think one of the initial lessons learned is that you need to create a “geek squad” within your office. Most of the technicians, medical assistants, and nurses that we have here are tech savvy. So we use them to help onboard these patients — they can help them learn how to download the apps and do a dry run before the call to give the patient confidence that they are able to connect.

I think what also really helped me is that I wrote an email early on to all of my patients explaining to them why we were doing video visits, how easy it was going to be, and what to expect. I sent a blanket email to all my patients, letting them know this is why we were doing it and that it was going to be easy.

How is your practice handling EP cases in the lab during the pandemic?

We quickly realized that while we were in the hospital or while we were seeing COVID-19 positive patients, we were going to be at risk of bringing a possible infection back to the office given the fact that we could have been infected as physicians and be asymptomatic carriers. So we divided our practice of 24 physicians into four teams of six. Then we’ll start in the hospital and do a seven-day rotation. As soon as your seven-day rotation is completed, then you’re confined to your office or to your home doing televisits for 14 days. After that, you come back for another week, do clinic, and then go back into the hospital.

At least at this point, we’re trying to have just the hospital physicians do procedures. But there are times, such as if it’s an elective generative change that needs to be done, that we are allowing the clinic physician to come in and do the case.

What challenges still exist with telehealth? For example, have there been any issues with reimbursement?

It’s too early to say whether or not we’re going to have an issue with reimbursement. I try to make the televisit the same type of care as an in-person visit. I actually feel I do a better job with my care via televisits — the patient is not rushed, and I’m not rushed. I also feel that you see a personality in the patient that you normally don’t see in the office — they’re in their easy chair at home, and they’re comfortable. There are a lot of patients I didn’t even know were funny, and I crack up laughing because you can really see their real personality. It’s also a good time to go into nutrition, exercise, and preventative measures to help patients stay healthy during this crisis. I will say that people don’t complain as much, and I don’t know why we’re seeing that. So, we’ll see how that pans out after this is over. Financial issues are a big deal for just about everybody right now, and so I do worry about patients being burdened with copays.

Do you plan to continue with the telemedicine approach?

Yes, I think telehealth is here to stay — it’s a new normal. I think we can all relate to life before Amazon Prime, whereas now you sort of expect two-day delivery! There are so many advantages of telemedicine from a patient perspective. I think it’s also easy from a transportation perspective — patients don’t have to travel long distances. I live in Baton Rouge and we have a lot of traffic, and patients really stress about the traffic.

With telehealth, I think you’re able to see patients more frequently. For patients who have poorly treated blood pressure, you’re able to stay on top of their needs by seeing them often with telemedicine, whereas before it was more difficult for them to get to you. So I do think it’s going to be the new normal.

What key tips can you share to help ensure a successful transition to telemedicine?

I would say the key in transition is to do a lot of work ahead of time. Meaning that if you think about a visit, there is probably a two week before touch, a one week before touch, and then the day of touch. What I mean by that is two weeks before you may want to send an email to a patient via secure method to tell them this is coming up and what to expect from you (not from your practice) to put them at ease.

A week before, it’s important for someone in your organization to touch base with that patient to make sure they’re comfortable downloading the application (if there is an application that is needed), and that they’re ready to check their blood pressure, send their wireless blood pressure recordings, and send their remote monitoring (if we’re doing remote monitoring on a patient).

On the day of, your nurse or medical assistant calls the patient. They get their pulse, weight, and blood pressure, reconcile their meds, and ask them if they have any complaints. Then you jump on the call after that.

Then there is the post visit, which for me is mainly sending out a quick note to the patient saying these are the things we spoke about. Everyone doesn’t always remember what we tell them — patients probably take away about 10-15%, so just a small paragraph of high points is needed. Also, if they’re on a non-HIPAA compliant platform, take that time to urge them to sign up for the HIPAA-compliant platform on the back end. At that point, they’ll become a believer in telemedicine. So I think it is easier for them to take the leap into saying that they want to do this in the future.

Also, when I’m scheduling routine follow-ups, I will tell the patient that in six months they’re going to have a follow-up visit, and it’s the patient’s preference of whether they want a remote or in-person visit. This is for those patients who don’t need testing and things like that.

Is there anything else you’d like to add?

I think it’s an exciting time and there is tremendous opportunity for physicians to get to places and reach patients who were previously not accessible. For instance, as electrophysiologists, we often feel that atrial fibrillation ablation is underpenetrated in smaller markets because there is no EP presence. By using telemedicine, we’re able to get into small towns and areas that we were previously not able to get into. I think it’s going to create tremendous opportunity in the future, and we are going to use the lessons we’ve used over the past few months to scale up. So I think this is going to be a time we look back at and be glad we went through it. 

For more information, and to see our recorded video of this interview, please visit: https://bit.ly/3cYyk9f

Disclosures: Dr. Civello has no conflicts of interest to report regarding the content herein.

Update from Dr. Civello: May 2020

1. As of May 2020, we have moved toward HIPAA-compliant platforms and have encouraged our patients to sign up for MyChart, our ER messaging platform. 
2. Since our in-office visits are starting to increase, we are attempting to alternate every other patient between an in-clinic and video visit to allow for lower volumes in the office and promote social distancing. 
3. We have continued to recommend televisits for patients who do not need or are not comfortable coming into the office. 
4. From a setup standpoint, we purchased an LED ring light and phone stand, which helps to keep the camera steady and brighten your image. 
5. One final tip: When conducting televisits, we recommend looking at the camera on your phone (not the screen) to allow for more eye-to-eye contact.