Cardiovascular Disease and Telehealth – Past, present and future

Cardiovascular disease is a major cause of morbidity and mortality responsible for 1 in 5 deaths in the United States ¹. Significant disparities exist in delivery of care and preventive measures ². Technology has disrupted many if not most industries, but health care remains an outlier relatively resistant to application of new technologies. Telehealth has been in our toolbox for many years but prior to the COVID-19 pandemic, use of telehealth was limited in most fields of medicine. Some providers considered telehealth substandard care and patients were unfamiliar with remote interactions. Other barriers included limited reimbursement, licensing restrictions and lack of broadband access ³. The COVID-19 pandemic changed the attitudes toward telehealth and reduced many of the barriers ⁴. It is now clear that telehealth has a significant role and will remain a component of our delivery of medical services going forward.

Given these circumstances, the American Heart Association scientific statement on the role of telehealth in cardiovascular disease is both timely and informative. This comprehensive document outlines the current “state of the art” regarding telehealth applications in cardiac disease, stroke and peripheral vascular disease and more importantly presents structural, procedural and institutional strategies to overcome barriers and improve delivery of health care through telehealth. The breadth of telehealth applications applied to cardiovascular disease is both impressive and encouraging. In cardiac disease, remote home monitoring already plays a key role in management of risk factors and heart failure although the evidence for improved outcomes has been elusive ⁵. Real time remote consultations for acute stroke evaluation has increased utilization of reperfusion therapies, reduced time to treatment and improved identification of patients likely to benefit from thrombectomy ^6,7. Telerehabilitation and in-hospital stroke consultations add to the benefit of telehealth across the spectrum of stroke care ^8,9. Monitoring patients remotely with synchronous and asynchronous technologies along with wearable devices to monitor physiologic parameters such as temperature are changing the landscape of wound healing particularly in the setting of limb ischemia ¹⁰. The authors appropriately plea for further research in many of these areas to further define the role of telehealth, establish the relationship to improved outcomes and increase integration of telehealth in cardiovascular treatment.

What is perhaps even more striking about this document is how little we know about telehealth in cardiovascular disease and how much more needs to be done. Despite the many examples of real time, store and forward, remote monitoring and wearables applied to cardiovascular disease, the impact on outcomes remains unclear. Acute stroke evaluation through telestroke has been shown to result in outcomes equivalent to in-person care ¹¹, however other telehealth interventions such as home monitoring for heart failure have produced mixed results ⁵. In part, this likely represents the difficulty of studying telehealth in this arena given the complexity of the disease and the many factors contributing to the measured outcomes. Telehealth requires additional expenses and resources, in some cases adding substantial costs to medical care. Without demonstration of an impact on outcomes the cost effectiveness of telehealth is uncertain. The promise of telehealth to reduce disparities and deliver care to underserved populations is clear, but obstacles such as the digital divide, broadband distribution and digital literacy must be overcome to achieve its full potential ¹². The proliferation of wearables and home monitoring devices will result in a flood of patient generated information transmitted to providers and requiring management. Interfacing this information with the medical record, reviewing ongoing results and responding to emergencies may require new technologies and interfaces to assure the provider is not overwhelmed and the patient generated information is properly integrated.

Telehealth has inherent limitations, particularly with real time evaluations that depend upon results of a physical examination ¹³. Not all medical problems are optimally evaluated or monitored by telehealth. Telehealth interactions are more successful in some specialties such as behavioral health ¹⁴, and even within a specialty there may be variations in the adequacy of remote evaluation ¹⁵. The medical community owes it to our patients to assure that they are receiving a level of care that achieves the goal of quality medicine. In some situations, that might require an in-person visit. When an in-person visit is not possible, telehealth, even with its limitations, may be superior to no care at all. Monitoring of telehealth quality and outcomes is essential to understand appropriate utilization and institute improvements ¹⁶. It is incumbent on the medical profession to determine where and when telehealth care is sufficient rather than assuming all patients are equally suitable.

In addition to more research regarding outcomes and appropriateness of telehealth we should be moving toward enhancing medical care through telehealth. Wearables, devices and home examination aids may be engineered and adapted to give us information similar to what could be attained during an in-person visit. In addition to history and examination, a provider uses all information available such as body language, intonation, facial expressions to add to the objective signs and symptoms during an in-person visit. Information gleaned from video possibly enriched and expanded using artificial intelligence then viewed through the lens of analytics offers the vision of telehealth as not just the equivalent of in-person care but something better and higher quality. The hybrid care delivery model described in the statement combining information from home monitoring, home devices and real time evaluations offers another view of improving our existing models of care through telehealth. This is the promise of telehealth for the future of cardiovascular disease and medicine.