Telehealth at the Cardiovascular Institute of the South (Part I)

VDM talks with Craig Walker MD Clinical Editor, Vascular Disease Management; Clinical Professor of Medicine, Tulane University School of Medicine, New Orleans, Louisiana; Founder, President and Medical Director, Cardiovascular Institute of the South, Houma, Louisiana; Chairman of New Cardiovascular Horizons Conference.

Tell us about how the telehealth program started at Cardiovascular Institute of the South (CIS).

About four years ago, we elected to invest financially in a telemedicine program. Our goals were the following:

1.  We wanted to improve communication with our patients. Our center is staffed 24/7 by certified cardiovascular nurse practitioners with cardiologists on standby. All calls to CIS come via our telemedicine program. This means that when a patient calls, the initial contact is with a cardiovascular provider. Most patient questions can be answered immediately. Urgent problems can be handled more quickly. We wanted to make calling our center the path of least resistance for patients to obtain medical advice and help. We also wanted to enact a practice in which patients scheduled for hospital-based procedures would be called the night before to answer any questions and to make sure the patient was taking the appropriate medications. We also wanted all patients called at home following discharge to again answer questions, check medications, and arrange additional follow-up. We have found that this has dramatically improved patient satisfaction and has resulted in better outcomes with less readmissions. We have found that many patients (approximately 20%) were not planning to withhold or to take medicines as recommended prior to the procedure and had not obtained essential meds such as antiplatelet drugs post procedure (approximately 25%) despite written instructions. Occasionally these errors were because of cost of medications but often it was because “some family expert” had advised them against taking statins or antiplatelet medications. This pre-monitoring has allowed us to cancel several procedures where patients were taking medicines such as coumadin or metformin with diminished renal function (which could result in lactic acidosis following contrast administration).

2. We wanted to leverage our cardiovascular expertise in remote areas such as rural hospitals and offshore oil rigs (where urgent care may be greater than 8 hours away) with no direct access to sub-specialty care. We worked with a company called InTouch Health that provided us with medical robots that allow physical examination of patients and direct communication with the patient and providers. This has proved extremely useful with life-saving results. It has also been advantageous to rural hospitals as many patients that previously required transfer to tertiary hospitals can now remain at the rural hospitals for care.

3. We wanted to improve the physician call schedule. Often, on-call physicians are awakened throughout the night to address minor problems that can easily be handled by certified cardiovascular nurse practitioners. Our physicians now have to handle only urgent problems necessitating particular expertise. This has helped with the problem of physician burnout. 

We have found that our telehealth program has resulted in improved outcomes and lower overall costs.  Because patients have their questions immediately answered, there is less confusion and appropriate therapy. Patients are far less likely to simply go to an emergency room where there are increased direct costs as well as the costs associated with the routine testing that is often performed. This has become tremendously important to CIS as we participate in Medicare’s Bundled Payments for Care Initiative (BPCI).

Today we are dealing with Covid-19 (SARS-CoV-2), which is highly contagious. Our ability to utilize our telehealth program has been crucial. Our immunocompromised patients can be seen in their homes. We can evaluate patients with symptoms as an initial screen and if further therapy is required these patients can be seen in remote areas of our clinic away from other patients with providers wearing appropriate protective apparel. I think it is important to understand that patients with advanced cardiovascular disease still need careful monitoring and attention as Covid-19 doesn’t protect against heart disease, peripheral vascular disease, or cancer. This has allowed our practice to remain in close contact with our patients without the risk of additional exposure to the virus.

How frequently are patients being contacted post-procedure?

Our goal is to contact 100% of patients pre- and post-procedure. We are presently reaching approximately 95%.

You mentioned use of a robot to connect with patients on oil platforms. Can you share more about that aspect?

There are big oil platforms throughout the world that are located on the seas. Workers live on these platforms while at work for weeks at a time. The most common condition requiring medical transfer to a hospital from these rigs is chest pain. Even when weather is ideal, transfer from these rigs takes many hours. When the weather is inclement, and helicopters can’t fly, the delays can be days. By having a robot on these rigs to perform history, give physical exams, and provide access to an ECG, many of these patients can be started immediately on appropriate medications that may alleviate symptoms and or improve likelihood of survival.

How has telehealth affected your peripheral vascular disease population?

We are a large referral center with patients coming from around the world for treatment of their peripheral vascular disease. Telehealth allows me to visualize ulcers, wounds, and gangrene pre- and post-procedure with archived wound images. We can follow patients without a need for the patient to travel (as that is inconvenient and costly). This has allowed us to start antibiotics in some cases where infection was apparent and in other cases where wound healing had stalled, it allowed us to obtain non-invasive tests to determine if further intervention was necessary.

Tell us about new technologies for aortic aneurysm.

The Heli-FX EndoAnchor (Medtronic) is basically a corkscrew that is placed at the top of the graft to hold the graft in place. There is some evidence that routinely using this device may increase the number of patients who experience sac shrinkage. My guess is that we may be missing a subtle proximal pressurization of the aneurysm sac that can be resolved with a device that fixes the endograft to the aortic wall in the same manner as in surgical repairs. We need to find a way to resolve the expanding aneurysm and the need for intervention, particularly intervention due to proximal neck problem.

How long has the telemedicine system been in use at CIS?

We first started designing our system approximately 4 years ago. Our program was the “first of its kind” so we had to design from the ground up. We needed to determine the space needed, design of the area, connectivity, staffing requirements, and vendors with whom we should work. We had to establish a budget and determine financial feasibility. Remodeling of our present space to facilitate our center took around 8 months. Our center has been operational for approximately two years. It started slowly but now we are now handling almost 40,000 calls a month prior to coronavirus.

How many people are handling that first point of contact?

It varies based on many issues. We have utilized computer-based learning to understand typical periods of greatest need and have applied artificial intelligence algorithms to help guide staffing. At peak use we may have 30 or more people working while at other times as few as five. As emergencies don’t always correlate with computer modeling, we have back up contingencies in place for times of increased need. Our center accepts calls for all of our CIS practices.

CIS is a large organization. Is telehealth something that a small group could implement, or would you recommend that it be done on a large scale?

Basic telemedicine can be instituted relatively easily on an individual basis with patients that have advanced mobile phone technology. Advanced telemedicine that attempts to achieve the goals that we had set requires far more planning, commitment, and investment. I believe that our program design is scalable and could be designed to cover additional practices.

How are patients reacting?

Patients have had an overwhelmingly positive opinion of telemedicine. Some older patients without smart phones have experienced difficulty.

Any final thoughts?

I admit that I was a bit skeptical as to whether or not we would achieve our initial goals that we had set for our telehealth program. I now can’t imagine how we practiced without it. Telehealth pleases patients. Telehealth improves care. Telehealth lessens overall healthcare costs. Telehealth improves referrals. Telehealth improves physician’s quality of life, and now that there is reimbursement for teleconsults, telehealth pays for itself. I can’t imagine how much more difficult it would have been for our practice in this Covid-19 crisis if we had not established this program. Telemedicine has the potential to dramatically improve healthcare outcomes while simultaneously lowering costs and pleasing patients. Telemedicine will be essential in the future.

Part II will share a visit to the virtual center at the Cardiovascular Institute of the South.