COVID-19 telehealth preparedness: a cross-sectional assessment of cardiology practices in the USA

The COVID-19 pandemic has forced healthcare practices to augment their methods for healthcare delivery to remote, virtual and non-face-to-face services. As such, the interest in telehealth technologies, such as video-visitation, has come to the forefront with practices, hospitals and institutions organizing their strategies around how to implement telehealth for patient care [1,2]. Due to the nationwide COVID-19 shutdown on 17 March 2020, the Centers for Medicare and Medicaid rapidly announced the coverage of telehealth and parity (equal reimbursement for patient care via telehealth and face-to-face office encounters), which catalyzed an immediate acquisition of technology platforms [3]. While there was an anticipated and rapid roll out of telehealth services from small clinics to large healthcare systems, and across urban and rural practices, key questions arise regarding how practices were prepared for video-visitations, how such services are viewed within various practice models, and what impact the quick shift in reimbursement had on telehealth preparedness [4].

In a recent pre-pandemic cross-sectional study of over 6000 hospital systems in the USA, Jain and colleagues analyzed the American Hospital Association Survey (2018) and demonstrated that less than half of all hospitals had existing telehealth services with significant variation in access to these services with hospitals in 25 states reporting telehealth in less than 50% of hospitals [5]. While respondents of such national surveys commonly represent large, tertiary, non-profit, teaching hospitals, the availability of telehealth in a heterogenous sample that includes private practices, rural systems and smaller clinics has yet to be evaluated. Understanding the nature of varying practice settings is critical to improving patient and provider access to tele healthcare.

Furthermore, the current literature has yet to evaluate the integration of telemedicine platforms into the electronic medical record (EMR) [6]. Despite the widespread existing EMR infrastructure, telemedicine is being adopted with a large diversity of platforms [6]. Yet, answering a key question regarding the effectiveness and utility of telemedicine-EMR integration may lead to increased usability of telemedicine nationwide.

In order to address these gaps, the American College of Cardiology (ACC) innovation section [7] surveyed US cardiovascular (CV) professionals regarding their perspectives and preparedness for telehealth. Using this survey data, we aimed to assess trends in telehealth implementation and to develop a better understanding of common barriers of adoption in cardiovascular practices.

Materials & methods

An online, 31-question, multiple-choice and qualitative survey (Supplementary Appendix) was sent to ACC cardiology practitioners in the USA to assess telehealth understanding, preparedness and expectations and to gauge the barriers of telemedicine adoption. The survey was open from 10 April 2020 to 28 April 2020. This time period was chosen due to the COVID-19 shutdown and the rapid acquisition and utilization of telehealth nationwide. The survey was distributed using two platforms: the ACC social media channels and online resources including MemberHub, COVID Hub and Twitter; and CardioSurve, a 437-person listserv of ACC members and Fellows (FACC) currently practicing in the USA. A total of 186 CardioSurve panelists completed the survey for an overall response rate of 43% (186/437) from this platform. The ACC postings on social media channels generated 156 additional participants for a total of 342 respondents.

The survey was developed and validated through an iterative, consensus driven process involving a multidisciplinary team of cardiovascular clinicians and employees of the ACC. A team of cardiologists from the ACC innovation section designed the original survey that was then reviewed by the ACC’s survey design experts. Once finalized, the survey was then distributed.

Survey questions focused on demographics, current and anticipated practice patterns, integration of video visitations into the EMR, impact of the COVID-19 pandemic on telehealth adoption, reimbursement and deployment barriers. Demographic characteristics included time in clinical practice, practice setting, distribution of patients and reimbursement types, as well as background knowledge base of telehealth. Participants were asked a variety of questions with varying formats, with response choices including yes, no or not sure and anticipated percentage of events such as eligible visits for telehealth and visit cancellations, with answer choices ranging from up to 10%, up to 25%, between 25 and 50%, more than 50% and not sure.

This survey and study design was not sent to an institutional review board given a lack of patient information or protected health information. The ACC conducts survey research based on the Council of American Survey Research Organizations Code of Standards and Ethics. The study was conducted consistent with generally accepted scientific principles, the principles of qualitative research and the principles of the Declaration of Helsinki, which typically does not require institutional board review. The ACC is dedicated to disseminating research results and to conducting research in a manner that does not pose harm to human subjects.

Statistical analyses for comparisons were performed using χ2, Mann–Whitney and one-way analyses of variance as required. Analysis of responses was performed using IBM SPSS Statistics for Windows Version 27.0 (NY, USA). Geographic and chart data visualizations were created with Tableau (CA, USA), and additional graphs were created with Microsoft Excel (WA, USA).

Results

Demographics

In total, the survey was completed by 342 CV-professionals. 92% were physician cardiologists (315/342) who completed the survey from 303 different practice zip codes across 42 US states (Table 1) A distribution of number of respondents by state can be found in the Supplementary Appendix (Figure 1). A majority, 55% (188/342), of respondents’ work settings consisted of a CV group or multispecialty group, with 52, 24 and 18% employed as part of a hospital, physician group or university-owned practice, respectively (Table 2). Over half of providers had been in practice greater than 15 years (186/342). The practice setting was identified as 17% in rural settings and 51% in urban settings (Table 2).

About 75% of clinicians anticipated that more than 50% of outpatient visitations would need to be cancelled or rescheduled due to COVID-19, while 60% anticipated that more than half of such patients were eligible for telehealth as an alternate service.

Defining telehealth

Formally, telemedicine refers to three distinct modes of remote patient care delivery: providing traditional rural access; direct to consumer live video; and remote patient monitoring. However, most respondents defined telehealth as primarily live (synchronous) video visitations (94%), mixed definitions were commonly answered and included remote patient monitoring, review of medical records (asynchronous) and the use of mobile health smartphone applications in 61, 52 and 48%, respectively. Table 3 lists some qualitative feedback regarding telehealth understanding and utilization. Participants cite concerns regarding the administrative and logistical burden of telehealth amidst ever changing guidelines and reimbursement proceedings. One participant shared that “[..] private insurance company rules vary by company and by state, so it is very difficult to understand individual company guidelines. ACC should be able to assist in setting up general guidelines for coding and billing for private companies and Medicare”. Another shared an optimistic viewpoint, explaining how “Major insurance companies and Medicare have relaxed regulations and are now reimbursing for telehealth due to the COVID-19 outbreak. I believe it will increase accessibility and provide too undeniable of a value to go away after the pandemic ends. The challenges will be to make sure patients who cannot use telemedicine (e.g., non verbal, non-English speaking or demented patients) or cannot access it (e.g., elderly or rural patients) do not get left behind”.

Interestingly, variations in reimbursement and mode of delivery were cited as both barriers and opportunities for telehealth implementation, thus influencing how participants defined telemedicine.

Telehealth acquisition & patterns of utilization

About 64% of practices currently use telehealth for outpatient visitations with 12% stating both for outpatient and inpatient encounters. At the time of survey completion, among those using telehealth, 92% were currently on the platform for less than 2 months. About 8% of respondents were early adopters with telehealth usage for the past year or more. About 22% of respondents were not using telehealth at the time of the survey. Regarding the type of telehealth products, 37% of respondents were utilizing non commercial products or those embedded in other software (i.e., FaceTime^®, EMR system, MS Teams or Google^®). A 34, 24 and 9% identified commercial vendors including Zoom, Doxy.me and Skype, respectively, as their telehealth platform of choice.

In terms of clinical workflows, 90% of all respondents stated that they are willing to provide telehealth services from home with 76% willing to use their own personal devices to provide telehealth visitations. Interestingly, clinicians with less than 15 years’ experience were more likely to currently be using telehealth (86%) than their counterparts with >15 years’ experience (70%). In general, 67% anticipated telehealth for a follow-up patient will take between 15 and 30 min per visit. Interestingly, 87% stated that non-MDs such as registered nurses and nurse practitioners should be able to use telehealth for patient interactions.

EMR integration across practices

Overall, 69% of respondents stated that their institution required telehealth to be integrated within an EMR before utilization (Figure 2A). About 46% of the respondents indicated that they would use telehealth even if not integrated (Figure 2B). A 23% of users had integrated telehealth in their EMR, whereas 10% did not have integrated telehealth into EMR. A 46% would use telehealth even if not integrated into the EMR. A combined 31% stated they were either not sure regarding integration or would not use telehealth regardless of integration. On subgroup analyses of practice setting, urban practices required EMR integration more often than rural practices (78 vs 58%; p < 0.005).

Telehealth purchasing & reimbursement

Ninety percent stated that COVID-19 was the catalyst for their organization to pursue telehealth. Among practices not currently using telehealth, when asked how to purchase telehealth services, the reaction from clinicians was mixed with 49% of those practicing within health systems expecting their institution to purchase video-services. Only 25% stated that physicians or the practices themselves should be responsible for purchase and nearly 18% were unsure with how to purchase telehealth.

Over three-quarters of respondents identified reimbursement uncertainty as the top barrier to telehealth adoption. While 92% of respondents stated that telehealth should be reimbursed by insurance companies, only 68% expressed awareness of telehealth reimbursement regulations in their state (Figure 3B) and even fewer 33% were aware of their states’ reimbursement parity (Figure 3B).

Barriers to telehealth implementation

Participants were asked to select all applicable barriers to telehealth adoption from a list of potential barriers (Figure 4). As aforementioned, the uncertainty of reimbursement and concern for lack of payment for services rendered constituted the top barrier to telehealth adoption (75%), followed by patient interest (54%) and regulatory issues (50%). About 18% reported malpractice as a barrier to providing telehealth.

Discussion

This assessment collected a wide variety of views on telemedicine from CV professionals in various practice settings across the USA during the initial shutdown in the COVID-19 pandemic. Physicians were largely uncertain on how to purchase telehealth services but expected their healthcare system to provide financing. Regarding general telehealth usage, over half of respondents using telehealth have been in practice greater than 15-years, a demographic not usually identified to adopt digital technologies [8]. The integration of video-visit platforms into an EMR does not appear to be a necessity from individual providers’ perspectives; however, institutions appear to mandate this requirement particularly in urban practices more so than in rural practices. Finally, reimbursement is perceived to be the major barrier to telehealth adoption in addition to concerns regarding regulatory issues and patient preference for in-person visits. A nearly unanimous comment was that COVID-19 was the catalyst for telehealth adoption across practice settings.

Rapid implementation of telehealth during COVID-19

Our study observed substantial variation in telehealth usage across rural and urban practices with over 80% of clinicians working in urban locations implementing telehealth. While urban practices are an atypical setting for telehealth adoption, as reimbursement was previously unavailable to such practices, it is representative of a shift in interest, driven by COVID-19, to augment care delivery over video for acute and chronic conditions [5,9]. In subgroup analyses of practice setting, we observed that those practitioners in urban locations required telehealth to be integrated within EMRs more than their rural counterparts. We believe there are two main reasons for this finding. First, it may reflect a need for urban practices to maintain highly effective processes given large patient volumes, which EMR integration may provide. Second, rural practices have been using telehealth regardless of the presence of an EMR and therefore may not require integration into modern EMR systems. When evaluating telehealth adoption and barriers within urban and rural hospitals, Chen et al. suggest that the generally lower population density of rural areas may decrease the demand for telehealth [10]. On one hand, telehealth services can be leveraged to bridge the geographic distance between patients and their care teams, offering an opportunity to improve access and the health status of rural populations [10]. On the other, technologic constraints, availability of suitable devices (smartphones) or limited cellular services may hinder access to telehealth services for rural patients. In this regard, within a large integrated healthcare system in Philadelphia, Eberly and colleagues observed that telehealth visitations between 16 March and 17 April 2020 (during the immediate roll out of telehealth services) were less likely to be successfully completed among lower socioeconomic populations (household median income US$50,000), non-English speaking individuals and older patients [11]. It is plausible that lower socioeconomic status may be related to limited access to updated smartphone devices or adequate cellular services required for telehealth programs [12,13]. While telehealth aims to improve access to healthcare, it may unintentionally magnify healthcare disparities [14,15]. Thus, it is imperative that prior to implementing any digital innovation, consideration on the possible impact on vulnerable populations is crucial to ensure health equity.

A shift in telehealth reimbursement

COVID-19 was certainly a driving factor for the implementation of telehealth. In doing so, it also removed many of the regulatory and payment barriers to telehealth adoption. In response to the outbreak, the US Department of Health and Human Services and the Centers for Medicare and Medicaid rapidly approved the use of telehealth and provided payment parity, removed licensure requirements and provided financial resources for institutions and clinics to acquire new telehealth technologies [16]. Prior to COVID-19, state parity laws for telehealth were variable with nearly half of the states having no payor telemedicine reimbursement structure. Of the states that did enact some form of parity, the type and quantity of coverage ranged from limited to full reimbursement with further variability within the type of private payer payment and among geographic location [17]. While payment parity exists, it may not produce the intended effect as parity laws may be contradictory to telehealth’s cost–effectiveness, in other words, if telehealth can reduce the cost of using resources within a health system, such as a face-to-face visitation, and reduces the number of such encounters, then a service provided through telehealth is contrary for how these services are paid and at the same rate if it were to be face-to-face, and should, in theory, be paid less [9]. By removing parity laws and incentivizing clinics to use telehealth through financial coverage, clinicians can implement telehealth in various practices and to utilize video-visitations in the manner best suited for an individual patient encounter. Our observations were in parallel to this objective particularly when anticipating a high rate of cancellations due to COVID-19. However, we also observed a high incidence of uncertainty regarding parity and what a given practice or institution can expect through reimbursement. While we assume that the short duration of this survey (4–6 weeks) after parity announcement may be a reason for why respondents did not know of a change in legislation, the ongoing implementation of telehealth during COVID-19 and; thereafter, will define what impact parity had on the retention of telehealth as a vehicle of care delivery [18].

Theoretical & practical implications

Telehealth utilization has increased dramatically since pre-pandemic times and have stabilized at levels 38× higher than before the pandemic [19]. By the Fall of 2020, nearly two-thirds of Medicare beneficiaries reported that their providers offered telehealth visits, compared with 18% prior to the pandemic. Furthermore, the number of covered telehealth visits from the health insurer UnitedHealth Group increased from 1.2 million visits in 2019 to 34 million visits in 2020 [20]. As of 23 July 2021, the Centers for Medicare and Medicaid Services have proposed to continue coverage in telehealth services to at least the end of 2023 [20]. In legislature, there have been various proposed bills like the Telehealth Modernization Act and CONNECT for Health Act under consideration that aim to permanently remove geographic restrictions on telehealth [21,22].

A recent American Medical Association survey of clinicians conducted from 1 November 2021 through 31 December 2021 reveals a lot of the practical implications of this critical resource since its initial launch at the beginning of the COVID 19 pandemic. About 65% of respondents agree or strongly agree that telehealth enabled them to provide high quality care [23]. Perhaps more importantly, over 80% of respondents indicate that patients have better access to care since the advent of telemedicine. Interestingly, most physicians from this survey feel telehealth allows them to provide more comprehensive care, with anecdotes referencing use cases such as the fact that ‘at-home blood pressure monitoring has enabled us to diagnose more white coat and masked hypertension’. Telehealth has increased clinician and patient satisfaction more than anticipated, suggesting its utility in further advancing care.

As telehealth becomes more available, clinicians must remain vigilant and consider how the effectiveness of care has changed and if such changes have improved the quality of cardiovascular care [24]. While we need to balance patient experiences and preferences of telehealth over in person visitations, the cardiovascular community is challenged with demonstrating how this shift in care that is now used for triaging, diagnosis and treatment results in safe, effective and efficient care delivery.

Limitations

Several limitations must be taken into consideration as these results are interpreted. First, the respondents represent a convenience sample of self-selected individuals that have interest in or were already using telehealth. Second, the results must be interpreted in the context of an overlap between when the survey was executed and the transition from usual patient care to the shelter-in-place order that occurred in March 2020 requiring practices to engage in non-face-to-face care. Therefore, this may not capture those responses from smaller practices or those who had an interest in telehealth but did not have means to acquire telehealth infrastructures. Third, the reimbursement parity facilitated by the Centers for Medicare and Medicaid was for both telephone and video-visitations. Assuming the implementation of video-visitations takes more time than the approval for reimbursement and the initiation of this survey, it is likely that survey respondents using telehealth may have been using telephone communication as well as video-visitation in their evaluation of patients. Fourth, we undertook this survey during the very initial period of COVID-19, and therefore did not know what to expect regarding the initial transition to telehealth. Given that clinicians responded with uncertainty regarding how telehealth was to be reimbursed, what defined parity for visitations, and how to use time-dependent CPT codes (i.e., new consultations or follow-up visits), we decided, a priori, to ask general questions instead of assuming that physicians knew current reimbursement protocols.

Since we identified variability with how respondents defined telehealth, it is possible that telephone communication was interpreted to be synonymous with video-visitation, which from a reimbursement standpoint, does differ.

Conclusion

This study observed a dramatic increase in telehealth implementation since the onset of the COVID-19 pandemic, initially out of necessity. Despite concern for reimbursement or uncertainty of payment, telehealth was largely adopted by many healthcare providers. Most notably, healthcare systems within urban settings were able to integrate telehealth systems more readily into their EMRs. Furthermore, the adoption of payment parity by the Department of Health and Human Services and Centers for Medicare and Medicaid served as the catalyst for the widespread implementation of telehealth. Further studies are needed to truly understand how the pandemic has catalyzed this healthcare delivery method.

Future perspective

At this rate of growth, telehealth will likely be nearly universal across all health systems within a matter of years. Access to care across all specialties beyond geographic location or local resources will be more readily available. Ultimately, with the constant expansion and breadth of technological innovation in remote patient monitoring, the limits of telehealth are perpetually being redefined. If active measures by policy makers are taken to ensure that telehealth access is made more equitable, then this form of telecommunication has the potential to bridge a large gap in health inequities.