Practical Pearls: How I’m Utilizing Telehealth and EHR-Based Tools to Change my Practice

We can all agree that life has now been forever divided into eras of ‘before and after the coronavirus of 2019 (COVID19)’ with a tidal shift impacting our personal lives and every aspect of medical care, including the traditional healthcare appointment. COVID-19 has highlighted the suboptimal risk factor control of our patients that predisposes them to worse outcomes, disparities in access to clinical care, and the multiple inefficiencies of our current healthcare system. With these factors in mind, the fields of cardiovascular prevention and lipidology are poised for a paradigm shift that could translate into improved outcomes.  

Historically, comprehensive risk reduction programs have improved patient outcomes by addressing all aspects of residual risk. However, even before COVID-19, it was clear that we needed more mechanisms to connect with our patients in their time outside the office to affect change in behavior and medication optimization.[1] Prior data have shown the number of touch points or follow-up visits translate into improved outcomes, particularly in the area of nutrition, where referrals to nutritionists and dieticians are under-utilized.[2] The Centers for Disease Control and Prevention (CDC) has recognized and promoted the benefits of telemedicine not only for the benefit of patients, but also to help reduce the burden on healthcare providers, clinics, and hospitals. Data from the MGH Center for telehealth’s Virtual Video Visit (VVV) implementation showed a high level of both patient and clinician satisfaction. [3] The Stanford South Asian Translational Heart Initiative demonstrated that with the addition of only three telehealth visits to a preventive cardiology clinic, patients had significant improvements in lifestyle and cardiometabolic risk.[4]

In our cardiovascular prevention center, which provides a myriad of services including dedicated preventive cardiologists, Certified Lipid Specialists, a dedicated CV prevention nurse practitioner, and a partnership with a dietician, psychologist, exercise program, genetic testing and counseling, we truly escalated our offerings with the use of telemedicine. Our patients participate in a ~6-month program, during which time they work with all members of the team relevant to their specific needs. Telehealth perfectly aligns with all areas of behavioral change, psychological care, and even genetic testing and counseling which do not require much in-person interaction, but actually appear to perform better in the virtual space due to patient comfort and convenience. These visits interpolated with in-person follow-ups for testing and physical examination seem to offer a balance of clinical care and assurance that patients initiate and maintain guidelinebased medication regimens. Since the bulk of lifestyle modification is done in the home, having access to the patient’s home environment can alter the paradigm as well.

Separate from the individual counseling that benefits greatly from the new technology, the use of a virtual educational session and support groups for smoking cessation, women’s heart disease, and other programs have significantly expanded what we have to offer our patients. This can be accomplished with health care providers within one’s own center or partnerships with experts in other divisions or national organizations.

In addition to the programs offered, optimal use of one’s electronic health record (EHR) and pre-visit time is essential. Questionnaires specific to lifestyle guide the counseling and referrals to appropriate specialists.[5] Educational handouts can be directly given to the patients, emailed, or even linked through the EHR for the discharge or after-visit summary. Multiple high-yield patient educational handouts are available through the major organizations, including the National Lipid Association (NLA) patient tear-sheets.

One of the arguments against widespread use of telemedicine is the concept of the “digital divide” creating disparities in access for older adults, those living in rural areas, and those of lower socioeconomic status lacking reliable internet access. However, Pew Research Center surveys from 2019 have shown that in households with an annual income of <$30,000 USD, over 80% use the internet [6] and over 70% have access to a smartphone.[7] While telemedicine originally focused on more acute conditions, it has evolved to include both primary and specialty care.[8] Patients are now able to be connected to an expert that would perhaps not have been feasible due to distance or the need to leave work or arrange child care to make it to an in-person appointment. With increasing insurance coverage for telemedicine visits dedicated to wellness, the disparities in risk factors that emerged during COVID (obesity, hypertension, diabetes, and dyslipidemias) can be optimally targeted. Clinical outcomes of chronic disease management have shown improvement with the addition of telemedicine and remote monitoring technology [9] and can be used to empower patients to make significant improvements to their overall health and prevent disease exacerbations.

Ultimately, advancements in innovation are essential to change the current status of clinical practice, with telehealth and EHR optimization at the forefront. The Chronic Care Act of 2017 took some steps toward easing reimbursement and regulatory restrictions prior to COVID [3], as did the CARES act during the COVID19 pandemic. We hope to see coverage expanded to more diseases and insurance providers for the long term through the legislature of our national organizations. There is little doubt that COVID-19 will forever leave its mark on the world. We hope some benefits can be derived from all of the suffering, with a positive impact on the way we treat our fellow humans, our awareness of our influence on our own health as well as others, and the availability of innovations to improve human health.

Disclosure statement: Dr. Gianos has no financial disclosures to report. Ms. Nahrwold has no financial disclosures to report.

References: 

1. Fain JA. NHANES. Diabetes Educ. 2017 Apr;43(2):151. doi: 10.1177/0145721717698651. PMID: 28340543.
2. Sikand G, Cole RE, Handu D, deWaal D, Christaldi J, Johnson EQ, Arpino LM, Ekvall SM. Clinical and cost benefits of medical nutrition therapy by registered dietitian nutritionists for management of dyslipidemia: A systematic review and meta-analysis. J Clin Lipidol. 2018 Sep-Oct;12(5):1113-1122. doi: 10.1016/j.jacl.2018.06.016. Epub 2018 Jul 3. PMID: 30055973.
3. Donelan, Karen & Barreto, Esteban & Sossong, Sarah & Michael, Carie & Estrada, Juan & Cohen, Adam & Wozniak, Janet & Schwamm, Lee. (2019). Patient and Clinician Experiences With Telehealth for Patient Follow-up Care. The American Journal of Managed Care. 25. 40-44.
4. Vijaya Parameswaran, Kiranbir Josan, Abha Khandelwal, Fahim Abbasi, Rajesh Dash 885-P: Efficacy of a Telehealth Preventive Cardiology Lifestyle Intervention Program to Treat High-Risk South Asians. Diabetes Jun 2019, 68 (Supplement 1) 885-P; DOI: 10.2337/ db19-885-P
5. Beasley J, Sardina P, Johnston E, et al. Integrating a diet quality screener into a cardiology practice: assessment of nutrition counseling, cardiometabolic risk factors and patient/provider satisfaction. BMJ Nutrition, Prevention & Health 2020;3:doi: 10.1136/bmjnph-2019-000046
6. Pew Research Center. Internet/broadband fact sheet. Available at: https://www.pewresearch.org/internet/fact-sheet/internetbroadband/ (Accessed on May 26, 2020).
7. Pew Research Center. Digital divide persists even as lower-income Americans make gains in tech adoption. Available at: https://www. pewresearch.org/fact-tank/2019/05/07/digital-divide-persists-evenas-lower-income-americans-make-gains-in-tech-adoption/ (Accessed on May 26, 2020).
8. Uscher-Pines L, Mehrotra A. Analysis of Teladoc use seems to indicate expanded access to care for patients without prior connection to a provider. Health Aff (Millwood) 2014; 33:258.
9. Kuziemsky C, Maeder AJ, John O, et al. Role of Artificial Intelligence within the Telehealth Domain. Yearb Med Inform 2019; 28:35.
10. https://www.congress.gov/bill/115th-congress/senate-bill/870 (Accessed on Nov 15, 2020)