Conferencing with the Cardiologist: Virtual Visits Bring Patients + Providers Together Between Scheduled Appointments

Within the next decade, about one in five routine healthcare visits could occur virtually. The model may make the most sense for cardiology patients, whose complex conditions may warrant frequent check-ins in with their cardiologist.

Greg Mazanek, MD, sits in a small office at St. Vincent Heart Center in Indianapolis, turns on a computer with encrypted video conferencing technology and begins seeing patients who are more than 70 miles away. A practicing cardiologist for 27 years, Mazanek is an assistant director of St. Vincent Medical Group Cardiology and a pioneer of the hospital system’s telecardiology pilot program.

As the monitor comes to life, Mazanek, who makes a point of wearing his white lab coat for virtual visits, gets the first glimpse of his patient and greets the nurse practitioner who sees patients in Brazil, Ind., every day. The city of about 8,000 residents is more than an hour’s drive from Indianapolis but is home to St. Vincent Clay, a critical access hospital. “The [hospital’s cardiovascular patient] volume is high enough for us to have a presence,” Mazanek says, “but it definitely wouldn’t support a cardiologist full time.”

After introductions, the virtual visit begins. If, for instance, the patient isn’t improving despite the recommended treatment regimen, Mazanek might help the patient and nurse practitioner determine a new course of action. “We use [virtual visits] to enhance care with difficult situations, difficult decision making,” he says. “Also we use it to talk to patients who are going to be coming to Indianapolis for procedures or for more advanced care.”

Despite being less than a year into the pilot, Mazanek says he sees potential to expand the effort. “We’re getting our feet wet on this,” he says. “We’re getting a sense for where this needs to go.”

Telemedicine, or the use of electronic communications such as video conferencing and email to exchange medical information, is on the upswing. There are about 3,500 telemedicine service sites in the United States and more than half of all U.S. hospitals use some form of telemedicine, according to the American Telemedicine Association.

Telecardiology leads the charge

With nearly 1 million Americans using remote cardiac monitors, cardiology has become one of telemedicine’s early adopters. “We’ve been in the virtual side with telecardiology [with transtelephonic monitoring] for 30 years,” says Jonathan Nalli, CEO of St. Vincent Indiana and senior vice president of Ascension Health. More recently, he says, launching telehealth programs in cardiology, stroke and behavioral health has been a way for St. Vincent to provide patients throughout Indiana with access to high-end, Indianapolis-based specialists.

Three hundred miles north in Grand Rapids, Mich., Spectrum Health is two years into its telemedicine initiative, MedNow, with cardiology leading the way. In fact, Spectrum’s first use of telemedicine was bringing a cardiologist to an emergency department that lacked coverage, says Joseph Brennan, senior director of MedNow. “Cardiology has taken the initiative to understand where are the needs,” he says.

By August, telecardiology services were available in three of Spectrum’s eight regional sites, with two more expected to roll out in the next quarter. Patients appreciate local care, says Penny Wilton, MBBS, department chief of cardiology services at Spectrum Health Frederik Meijer Heart & Vascular Institute. “But also, for us as a system,” she says, “it’s very efficient with our cardiologists’ time.”

Three key challenges

Just a few years ago, the equipment needed for telemedicine was costly and cumbersome. Since then, Brennan says, “the technology has gotten significantly less expensive and almost omnipresent,” but challenges to starting and maintaining a telecardiology program—especially provider mindset, reimbursement and logistics—remain.

At Spectrum, it wasn’t easy to get providers to buy-in to the idea of virtual visits, Brennan says. “That has been why we’ve been pushing this rock up hill,” he says. The best way to combat resistance? Find a champion.

“You need those early adopters,” Brennan says. “If you do not have a physician champion in the space, you are dead in the water.”

The reimbursement landscape for telemedicine, while still challenging, is improving. Medicaid and Medicare pay for some telemedicine services, and many states and the District of Columbia require private insurers to cover telehealth the same as in-person services, according to the American Telemedicine Association. Yet with reimbursement rules determined on a state-by-state basis, payments can be spotty. “Patients aren’t going to want to pay cash for [telecardiology],” Mazanek says.

Logistical hurdles to telemedicine include convenience, scheduling and volume. Virtual visits are becoming increasingly convenient as technology advances, but cybersecurity concerns sometimes hamper progress. Mazanek can’t grab his tablet for a quick virtual visit between meetings because he needs to be on the encrypted St. Vincent network. “The [video conferencing] aspect of this, the only reason we need this big machine and the computer screen that we have, is the security,” he says.

Navigating three calendars—the cardiologist’s, the nurse practitioner’s and the patient’s—can make scheduling virtual visits tricky at St. Vincent. Sometimes, Mazanek might have the morning blocked off for virtual visits, when the nurse practitioner ends up needing his help in the afternoon. “It’s an issue of coordinating the scheduling,” he says.

To justify the use of telecardiology, establishing the right volume is key. “The last thing you want is a cardiologist who is twiddling his thumbs for four hours,” Mazanek says. “You’ve got to be able to keep somebody continuously busy while they’re doing this.”

Moving forward

The leaders at St. Vincent and Spectrum agree that, so far, telecardiology has been a positive use of resources and has offered patients greater access to care. Mazanek says he anticipates telecardiology becoming even more important to St. Vincent as the system uses more advanced practitioners. “This will help with collaboration.” And at Spectrum, Wilton says she expects to see a return on the telecardiology investment through declining readmissions.

But that doesn’t mean telecardiology is the right step for every provider or practice. “There has to be a real need for it,” Mazanek says, adding that the ability for telemedicine to provide access to rural patients is a strong reason. It’s a mistake, he says, to launch a telemedicine program just because it’s trendy and good PR. “Get beyond the marketing,” he says.