Robert Klempfner, is director of the Israeli Center for Cardiovascular Research, and director of the Cardiovascular Prevention and the Cardiac Rehabilitation Institutes at Sheba Medical Center, Raman Gat, Israel. In this article he discusses the uses of remote technology and telemedicine in cardiac healthcare, and how this has been an important tool for cardiologists during the pandemic.
How has remote care technology changed the delivery of cardiac healthcare?
On the one hand, remote care technology has been able to enhance existing cardiology services by facilitating greater communication with and delivery of care to patients. One such example is the work we have done at Sheba Medical Center, partnering with remote care automation developer Datos Health to introduce a remote cardiac rehabilitation program. Working with Datos, we transformed our cardiac rehabilitation program from an on-site service that (even before the current pandemic) was restricted in its growth prospects due to limited physical space, into a new service for tele-cardiac rehabilitation that significantly increased patient adherence to exercise programmes, resulting in improved patient outcomes. While remote cardiac rehab is not a novel concept, earlier programmes were limited in size and scope. Due to the versatility of the Datos platform, what began as a local initiative for Sheba’s cardiology patients has since expanded to become a national program available to all patients in Israel and fully reimbursed by all local payers.
On the other hand, remote care and telemedicine has also enabled the creation of entirely new services, opening up new potentially lucrative revenue streams for hospitals while improving patient care with a selected payer system. One example is disease management in heart failure. It is now possible to combine multidisciplinary care with remote capabilities—including sensors, chat, video capabilities and the possibility of incorporating data from pacemakers—to optimise care for heart failure patients.
We have also seen significant changes in the so-called “small touches” of cardiac care. Those simple-yet-important routine issues that previously required patients to attend hospitals in person are now being resolved without the need for lengthy commutes and tiresome processes, resulting in an overall improved experience. A prime example is the development of remote pacemaker clinics. With the data from pacemakers, cardiologists can initiate video consultations with patients while drawing up additional information from their organisation’s information system, streamlining the entire process.
What are the benefits of using remote technology—and what are some of the drawbacks?
The primary benefit of remote technology is the ability to deliver the highest standards of care anywhere, without geographical or time restrictions, bringing the required specialist to the patient without the need for unnecessary travel. Using the example of heart failure management, physicians can now be empowered with access to a whole range of data that was not previously available—vital signs, data from various medical IoT devices and patient-generated outcomes—consolidated on one screen. At a glance, they can now see what is really happening to the patient between scheduled cardiology visits, whereas in the past, this information could only be recorded retroactively. Analysing levels of activity, blood pressure, heart rate and exercise performance within the rehabilitation program, physicians can now better understand the interactions between all these different elements, such as the relationships between mood, medication and exercise.
The biggest drawback of remote care is that it cannot fully replicate the experience of in-person human contact. Human interaction in medicine is not just the science of diagnoses and consultations, but also the human touch—a simple hand on a shoulder or physical examination —small gestures providing a feeling of comfort that cannot be remotely translated. While video consultations are obviously preferable to phone calls or text messages, they have not yet (and possibly never will) match or replace the experience of physical interaction, much like the many family get-togethers that took place via Zoom this year rather than in person.
What do you see as the future for remote technology in cardiology? In a post-COVID-19 world, will practice return to pre-pandemic models, or will remote care persist?
The first thing to establish is that the changes that have occurred are here to stay and we will not revert to a pre-COVID-19 world. While the past year has been an unmitigated tragedy, positive things have emerged because important lessons have been learned and barriers lowered. Prior to COVID-19, there were numerous services that healthcare providers were sure could never be transformed into remote settings. Not only did this happen, but it was not as challenging as we initially feared. The result—both in Israel and the USA—is that a number of these services are providing high rates of satisfaction and so there is no reason to discontinue them. If it is good for the patient and medically viable, why would we revert to a world where people have to spend hours commuting to consultations that do not require any physical examination? Returning to the example of remote cardiac rehabilitation, we have proven that these programmes can provide a good, if not better, levels of care. Even during the worst periods of the pandemic, when cardiac rehabilitation centres around the world were closed, our patients maintained their exercise programmes at the same intensity and received the same level of care as before the pandemic.
Ultimately, remote care and telemedicine will find the proper clinical scenarios and processes where it is optimally suited. There will be certain clinical situations where physical encounters are maintained, while others will enable excellent care programs that are almost entirely remote. There will also be a number of services providing hybrid programs, offering the best of both worlds, with virtual consultations occurring between scheduled physical examinations.
How would you convince a remote technology sceptic that this is the way forward?
As physicians, we rely on evidence-based medicine. So, to convince doctors that telemedicine works, we need to provide the scientific proof. This will include the use of randomised control trials, as has been done in a number of fields, including cardiac rehabilitation, proving that the program is not clinically inferior (and preferably superior) to the usual care. Another important element is in demonstrating satisfaction. Nurses, physicians and all healthcare providers care deeply about issues relating to usability and satisfaction. Once it has been demonstrated that a programme can attain high clinical value, provides patient satisfaction and is financially viable, it will be embraced.
It is the same when introducing any new technology into medical practice. We need to provide evidence of the benefits, show that risks are minimal, and demonstrate that this is something that patients actually want because the alternatives (such as having to wait months for consultations that do not really require physical interaction) are not satisfactory. This is particularly true for a number of fields relating to rhythm management and electrophysiology, where much of the work involves consultations based on digitally available information, such as ECGs, pacemaker data, lab and echocardiography. In such scenarios, frequent physical consultations are not essential in order to provide proper recommendations. Furthermore, the ability to provide this level of care with top specialists in the field, from any location, is a real game changer.
Drawing on your experience, can you describe any novel uses of remote technology within cardiology?
In terms of new services, we can expect to see a lot more arrhythmia detection solutions integrated with longitudinal disease management programmes. Even today, we are able to connect to home ECG devices and continuous ECG monitoring patches to better detect occurrence of arrythmia, such as after cardiac surgery or following ablation procedures. At the same time, and using the same platform, it is possible to provide evidence-based interventions that have been shown to reduce the occurrence of arrhythmia or heart failure exacerbations. One such example is another collaboration between Sheba Medical Center and Datos Health, in which we are optimising guideline-based medical care in heart failure based on the measurement of symptoms and activity obtained through the data system as well as vital signs. After an atrial fibrillation ablation or following the implantation of a defibrillator, we can implement a programme that tracks the pacemaker and occurrence of arrythmia while simultaneously optimising patient care—the pharmacological management of patient care through optimisation of medication, as well as continuous monitoring of personalised exercise prescriptions or lifestyle changes. This enables us to optimise treatment and target higher risk populations who need more supervision, with the potential opportunity to implement early intervention strategies and prevent adverse events from even occurring.