The SARS-CoV-2 pandemic has exacerbated the already difficult problem of how to deliver health care safely and efficiently. One solution that has risen to the forefront is telemedicine. The U.S. Department of Health and Human Services estimates that since March 2020, nearly half of all patient interactions have taken place online. However, the concept of telemedicine is not new. In fact, remote medical care has been described in medical journals as early as 1879, when doctors first started to telephone patients at home for check-ins. Since then, the introduction of extensive telecommunication networks has made it feasible to rapidly scale video-based telemedicine practices in urban areas. Still, adequate patient participation remains a large barrier to wide-spread adoption. Moreover, the lack of telecommunications infrastructure in smaller, rural communities limits their ability to participate. Only by adequately addressing these issues will wide-spread adoption of telemedicine be possible. Failing to do so will negatively impact our patients' health for many years to come.

I spent the past year in north-central Washington evaluating these key challenges in relation to rural patient monitoring and cardiovascular disease. In hearing about the difficulties that some communities faced in accessing cardiovascular care, I saw how asynchronous telemedicine visits posed a unique opportunity to improve the delivery of care. With the help of a local cardiologist, I implemented a novel asynchronous visit protocol for a cohort of patients with stable coronary artery disease. This protocol helped cardiologists triage concerning symptoms, such as chest pain, dyspnea, exertional intolerance or medication side-effects, without formally seeing the patient. Each asynchronous visit was then compared to the patients' formal clinic visits to gauge accuracy and potential use for future virtual check-ins. While the asynchronous visits demonstrated good sensitivity for the general detection of symptoms, further work was needed to improve specificity for true cardiac symptoms. In follow-up, many patients expressed a strong bias against these virtual visits, although this perspective did start to shift around the time of the statewide lockdowns in March 2020 – perhaps due to fear of contracting SARS-CoV-2 in the hospital setting.

In speaking with patients, the preference for in-person visits seemed to be multifactorial. Many described the computer screen as a barrier between themselves and their physician, while others stated that they thought telemedicine led to subpar care. Various factors have been shown to influence patient perspective on telemedicine, including what patients are told to expect, overall logistics of use and perceived usefulness of the service. These factors depend principally upon effective communication with patients – a task that requires each health care worker to engage the patient in meaningful conversation. In practice, physicians or advanced practitioners would introduce the concept of telemedicine as an alternative visit type. Then, a medical assistant or nurse coordinator would follow up with the patient to explain logistics, schedule the telemedicine visit and answer remaining questions. This approach showed promise for our cohort in north-central Washington and deserves further evaluation in a larger hospital network (1).

Beyond the patient perspective, this project also identified systemic issues, such as limited internet access, that would affect broader implementation of telemedicine visits. This limitation disproportionately affects rural communities, with nearly 25% of rurally located adults reporting limited access to high-speed internet as a major problem in their community. As we move towards technology-based visits, we must advocate for communities that lack the infrastructure to participate. Reassuringly, government funding for such infrastructure has already started to increase due to the SARS-CoV-2 pandemic. For patients that cannot afford internet access or electronic devices, alternative solutions might leverage existing processes, such as those developed in pharmacies for COVID-19 symptom screening and antibody testing. Questions remain as to whether such services could be converted to formal telemedicine visits in the future. Only by developing such solutions can we ensure that rural communities receive equitable care in relation to their urban counterparts.

Telemedicine offers the chance to provide effective care remotely, but patient participation and rural telecommunications infrastructure remain key barriers to widespread adoption. The field of cardiology stands to benefit if these barriers are adequately addressed, given the ease of which patients could be followed remotely and even asynchronously. This added efficiency is especially important when considering the worsening imbalance between supply of cardiologists and demand of enlarging patient panels. As we continue to integrate telemedicine into our regular practice of medicine, we must still be mindful of our patients' perspectives and work to actively include communities with otherwise limited access.

Acknowledgements

I would like to thank Gautam Nayak, MD, for his help in conceptualizing and implementing this project, as well as Dianna Osborne, RN, for her help in organizing and sending out the asynchronous visits.

References:

1. Bates, K., Titus, B., Israel, M., Osborne, D., & Nayak, G. Asynchronous Cardiology Visits in Rural Washington: A Quality Assessment with Wide Ranging Implications in the Era of Covid-19. Telehealth and Medicine Today. 2020; Pub Status: Submitted.

This article was authored by Benjamin R. Titus, BS, medical student at the University of Washington School of Medicine in Seattle, WA.