Telemedicine in Vascular Surgery Practice

Introduction

Telehealth technologies offer opportunities to improve the access to vascular care and enhance continuity of care. Many vascular surgeons are already using store-and-send options to review CT images generated at distant hospitals to triage symptomatic aortic pathology. This capability allows referring physicians to access expeditiously the expertise of larger aortic centers. Recently, the COVID-19 pandemic forced all medical and surgical practices to adapt to telehealth systems to evaluate and follow patients. ^, The adoption of telehealth over the past two decades has been slow but is now accelerating.

Other examples of tele-technologies impacting cardiovascular care include home monitoring of blood pressure, blood glucose, cardiac rhythm, and INR measurements for chronic oral anticoagulation. In addition, some advanced vascular wound care centers review images recorded remotely by patients and healthcare providers on cellphones and transmitted for review and advice. Although many of these communications do not meet current Protected Health Information (PHI) security recommendations, the practice is still common.

In this chapter, we review briefly the history of vascular telehealth. The impact of the COVID-19 pandemic has increased the urgency of using telemedicine. Various options are evolving, and the reimbursement schemes continue to adapt. Although several simple methods of telehealth are discussed, we present a more advanced telehealth option for vascular care that has been developed over 5 years: the remote or distant vascular patient consult or office visit. This model of vascular telehealth may be conducted at an affiliated regional multispecialty clinic, an emergency department, or hospital equipped with telehealth transmission equipment and trained tele-presenters.

Finally, we review data on patient satisfaction and also emphasize the challenges of establishing a vascular telehealth program. We share lessons learned. Establishing an effective vascular telehealth program requires attention to several principles. The details of technology and reimbursement will change, but the key principles will remain. These concepts facilitate success in caring for patients via telehealth technologies.

History Of Vascular Telehealth

In the past several decades, the concept of telehealth to evaluate and treat vascular patients emerged, especially in rural areas. Virtual wound care evaluation was instituted in some practices. Transporting CT scan images from rural areas to major medical centers became common, allowing vascular surgeons to quickly evaluate aortic catastrophes such as ruptured aneurysms and arterial dissections. Virtual postoperative visits have also added to improved outcomes. ^,

Although the benefits of quicker access were clear, past services were not reimbursed for the most part. Before the COVID-19 pandemic, a more analytical look at vascular telehealth began to appear. The savings in time and expense for travel by patients was documented. Patient satisfaction was high, and Medicare and some private payers began to reimburse for visits beyond a certain geographic distance, usually 25–50 miles.

The COVID-19 pandemic catapulted telehealth for all kinds of medical care to the forefront. Prior to the pandemic, less than 1% of vascular care was facilitated by tele-technologies. At the peak of the COVID-19 pandemic, up to 60%–70% of vascular surgery clinic visits became virtual. At the time of this writing, the rate of virtual clinic visits is in the 30%–40% range, and will probably remain at this new set point. Certainly patients appreciate the convenience of telehealth, and vascular specialists are learning a more focused, efficient style of practice.

The Strategic Urgency

The aging population is rapidly multiplying the number of patients with vascular disease. The prevalence of peripheral arterial disease, aortic aneurysms, carotid artery disease, and venous thromboembolism with post-phlebitic syndrome is increasing. Unfortunately, these demographic changes in vascular disease are occurring concurrent with a growing healthcare provider shortage. Over 40% of vascular surgeons are over 55 years of age. Their retirement in the next decade, without adequate residency graduation replacement, may strain clinical access to care. Consequently, tele-technologies have become obvious as a partial solution to this issue.

The COVID pandemic propelled the need for telemedicine for all specialties. In-person clinics were suddenly reduced. Many practices reported that patient visits and procedures were reduced by 25%–50%. The use of advanced telehealth carts in clinics was essentially lost because patients would not come to the office. Consequently, vascular surgeons resorted to smartphones and apps, like doxy.me . Insurers agreed to reimburse for telecommunication visits by almost any device and any location including home, although the reimbursement for smartphone calls was less than more formal telemedicine visits in a remote clinic.

Developing The Optimal Telehealth Practice

Most vascular practices are likely to adopt several telecommunication methods IF reimbursement covers all of them. All of these methods have their pros and cons.

The simplest is using a smartphone to interact directly with a patient. FaceTime can add some visual information. Vital signs depend on whether the patient has in-home monitors, e.g., for blood pressure, heart rate, blood glucose. Any medication reconciliation has to be done by the provider. Finally, reliable broadband in remote rural areas can be problematic, and reimbursement for time spent interacting with the patient plus review of chart and documentation is relatively low for the time spent. Nonetheless, the immediacy of access is excellent for both the patient and the provider.

The next level of telehealth options is a variety of stand-alone vendors. Some examples include: doxy.me , DrFirst.com , careclix.com , medici.md , myremedy.com , snap,md/technology/ , zipnosis.com , zoom.us/healthcare . In addition, during the COVID-19 crisis, covered healthcare providers were allowed to use popular applications for video chat, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Zoom, or Skype. Each of these has some unique functionality, connection to electronic health records (EHRs), and billing mechanisms.

Finally, the most sophisticated telehealth systems are advanced mobile telehealth carts that are used in clinic, emergency department, and hospital wards. These devices are generally set up by a medical assistant or nurse who reconciles history and medications, records vital signs, and can perform explicit parts of a physical exam with an electronic stethoscope, EKG, and continuous wave Doppler to provide arterial sounds. These carts are more expensive than less advanced telecommunication systems (e.g., smartphones and stand-alone computer programs) mentioned previously. However, they allow for a more complete exam, provide high-definition images, and the visits are reimbursable at parity with an in-person visit if properly documented.

The next section discusses the complexities of organizing the most advanced telehealth systems that are likely to become more prevalent in the future. In addition to the larger telehealth mobile carts, smaller portable telemedicine units are under development and will be ideal for home or nursing home visits.

Organizational Steps And Required Resources

The organizational steps and resources required to build a vascular telehealth system are relatively complex and require the coordination of providers, information technology experts, scheduling personnel, and billing staff. Each has to work concomitantly over time to bring an advanced telehealth system to fruition and to maintain it.