The COVID-19 Pandemic Has Changed Cardiac Telemedicine and Patient Monitoring, But What Will Happen Post-Pandemic?
COVID-19 has greatly impacted the health system since early 2020. In March, many states enacted stay-at-home orders. Many hospitals and health systems temporarily halted elective medical procedures in an effort to mitigate the risk of COVID-19 transmission; preserve personal protective equipment (PPE), hospital bed capacity, and equipment; and allow shifts in healthcare staffing patterns.1
During this time, the use of telemedicine vastly increased. During the first quarter of 2020, the number of telemedicine visits increased by 50% compared to the same period in 2019, with a 154% increase in visits observed in the last week of March 2020 compared to the same period in 2019.2 As a result, the Centers for Medicare & Medicaid Services enacted emergency policies related to telemedicine that, among other changes, allowed virtual visits to be conducted from patients’ homes rather than in a healthcare setting.2,3
Patients with cardiac conditions are at an increased risk for COVID-19-related morbidity and mortality. Emergency department admissions for heart failure and heart attacks have notably decreased, which may be due to patient reluctance to visit healthcare facilities during the pandemic.4
Remote patient monitoring cardiac devices offer a safe solution to telemedicine during the pandemic.4 The Zio XT monitor is a prescription-only, single-patient-use, continuously recording electrocardiogram monitor that can be worn up to 14 days. It is indicated for use on patients who may be asymptomatic or may suffer from transient symptoms such as palpitations, shortness of breath, dizziness, lightheadedness, presyncope, syncope, fatigue, or anxiety.5
In response to the pandemic, iRhythm expanded its home enrollment for its Zio single-use cardiac monitors, shipping the devices directly to patients’ homes for application and use.6 This home enrollment option reduces potential patient and staff COVID-19 exposure by eliminating office visits, removes the need for cleaning or reusing returned monitors that may have been exposed to the virus, and ensures patients continue to receive access to cardiac care during the pandemic.7
Andre Gauri, MD, FHRS, a cardiologist and electrophysiologist at Spectrum Health in Michigan, discussed how COVID-19 has impacted cardiac care, the role of home monitoring and telemedicine, and the healthcare changes that are still ahead.
Q: How have the surges in COVID-19 infections affected your patients, patient volume, and practice?
A: When COVID-19 hit the United States, we at Spectrum Health went into partial shutdown mode and limited care to only emergent cases.
We saw what was happening in New York and Detroit where the healthcare system was extremely overwhelmed. Although we had many COVID-19 patients in the spring, we never really overwhelmed our system. Patients were scared to come to the hospital, so many people were deferring care. We quickly realized, in a matter of a few weeks, that we could and needed to safely take care of patients who were not dealing with COVID-19. We had the bandwidth to open our doors again to do more elective and semi-elective procedures. Although we observed a major dip in elective care initially, by mid-May 2020 we were able to successfully ramp up to normal volumes.
When COVID-19 surges occurred again in the fall of 2020, the system was much more prepared given the experiences and lesson learned from earlier in the year. On the cardiac side, very few cases were postponed even though we had almost three to four times as many COVID-19 patients in the hospital compared to the spring. The fact that much of the cardiac care was same-day discharge and not requiring a hospital bed allowed us to care for patients despite a high hospital census.
Q: Can you discuss your process for implementing telemedicine? Were there any challenges?
A: When the pandemic first hit and most medical groups went into a shutdown, we were only seeing emergent patients in person. Almost everyone was at home seeing patients virtually. On my team of eight electrophysiologists, we had one person assigned to the hospital, one to the office, and the rest were seeing patients virtually.
There’s a famous saying, “Don’t let a tragedy go to waste,” and the pandemic really made providers quickly focus on developing alternatives to care for our patients. We went from seeing a very limited number of patients through telemedicine—approximately 5% of patients mainly in rural areas—to seeing 80% of our patients via telemedicine in a matter of days to weeks. [Learn more by watching Dr. Gauri share how he and his team maintained continuity of care amid the COVID-19 pandemic at https://www.irhythmtech.com/providers/webinars/gauri-acc.]
Our existing telemedicine platform wasn’t built for that volume, and technical issues surfaced at first. Patients didn’t have the right software, didn’t have good Wi-Fi, and had difficulties connecting. In talking to colleagues across the country, many people struggled with this as well.
Cardiac electrocardiogram monitoring technologies like Zio by iRhythm also allowed us to mitigate patient concerns about coming to the hospital. Because Zio allows for home enrollment of monitors and sends a comprehensive report at the end of the 14-day patient wear period, we were able to eliminate the need for patients to travel. Zio was instrumental in helping Spectrum make the transition to remote care and telehealth easier. I was really proud of our leadership team coming together, stepping up, and allowing the changes in telehealth to take place that provided continued patient care.
Q: How have you or your team thought through the different monitoring modalities available as you think about adapting to COVID-19?
A: As an electrophysiologist heart rhythm specialist, many of our patients require monitoring. When COVID-19 started, only urgent patients were coming in the clinic. As we moved to telemedicine, we questioned how we were going to care for patients remotely if we saw they were having symptoms that warranted a cardiac monitor. The Zio monitor really helped us continue to care for and monitor our patients without them ever leaving their homes. That was a tremendous benefit to the arrhythmia patients, driving 98% patient compliance, which in turn provided us with more accurate data.8
Another advantage of using these single-use Zio patches is that concerns of transmissible diseases were essentially eliminated. Reuseable Holter monitors require additional cleaning and sterilization due to COVID-19 concerns and possible risk of transmission to both staff and patients.
Q: With COVID-19, have you seen any new patient types?
A: Researchers are seeing more patients with cardiovascular symptoms stemming from COVID-19, ranging from chest pain to palpitations to presyncope or syncope as well as myocarditis. These are just some of the symptoms that COVID-19 “long-haulers” experience. We anticipate a whole new heart patient population from this group in the future.
Q: Are you seeing a decline in cardiac health in patients delaying care?
A: Absolutely. In the electrophysiology space, patients who develop atrial fibrillation that is poorly controlled can develop a weakened heart muscle that is related to their atrial fibrillation, known as a tachycardia-induced cardiomyopathy. Patients were having symptoms and not seeking medical attention in the appropriate time frame, coming in with later rather than early presentations of cardiac diseases. When they finally came in due to significant difficulty breathing or walking, they had already developed congestive heart failure.
Delayed presentations also occurred with heart attacks and strokes. A complication from a late presentation of myocardial infarction could be a ruptured papillary muscle, or ventriculoseptal defect, but we rarely see those because most people who have a heart attack present early and get revascularized immediately. We were seeing a tremendous increase in these rare cases because patients weren’t coming in for medical attention and not getting revascularized.
These patients are the secondary COVID-19 casualties: They didn’t have a problem directly related to COVID-19, but they did develop significant morbidity as a result of not seeking medical attention during the pandemic. Because Zio can be applied at home by the patients themselves, cardiac monitoring does not have to be deferred. Patients will have clinically better outcomes with earlier treatment. In recent clinical studies, Zio was able to detect atrial fibrillation in moderate-risk patients earlier, supporting the prevention of serious cardiac events after diagnosis. Active monitoring with Zio also led to fewer hospitalizations for bleeding and fewer total hospitalizations.9
Active, early monitoring with Zio can help patients stay home and out of the hospital.
Q: What are patients’ sentiment now in resuming care?
A: Fortunately, patients are feeling more comfortable as we learn more about the virus—knowing that if you’re safe, wear a mask, and wash your hands, you can still leave your house. We did a lot of public service messaging around continuing to see your doctor if you’re having problems. We tried to educate patients that if they’re having acute medical issues, they should not delay care. I think that was very helpful in making patients feel more comfortable seeking medical attention.
Still, as we return to in-person care, there are a number of cases that are better suited for remote monitoring; not all cases involve acute medical issues. Our augmentation of telemedicine has freed the in-person resources for the most critical cases.
Q: Where do you foresee the role of cardiac monitoring going in 2021? What patient behavior changes do you anticipate post-COVID-19?
A: Cardiac monitoring with iRhythm’s home enrollment has been very helpful. If I’m seeing a patient who lives many miles from our office, I’m now seeing that patient via telehealth. Instead of having to come to get a monitor placed in person, we can do home delivery and home enrollment with Zio. We have developed a system where we can more broadly expand telehealth solutions to patients long-term, not just during the pandemic. There’s clear benefit to both the patient and the system here.
Q: Will telehealth increase in popularity or revert to pre-COVID-19 levels?
A: At our peak, we were seeing probably 70% to 80% of our patients via telehealth. We’ve learned that many patients would rather see a provider in person if given the choice. The doctor-patient relationship is extremely important yet somewhat diminished via telehealth. Obviously, not being seen at all is worse than being seen over a computer, but I definitely think there’s a fine balance.
At the end of the day, there are many people who just want to leave the house and see their doctor in person. I think we will find a balance where maybe 20% to 25% of patients will be seen via telehealth, and the rest would still be seen in person—time will ultimately tell.
Q: For 2021, the American Medical Association released new Current Procedural Terminology (CPT) codes that address longer-term cardiac monitoring. Will this change the way you care for patients?
A: We have been long-term users and early adopters of long-term cardiac monitoring with iRhythm’s Zio monitor. For the first several years, this was a real struggle mainly because of insurers not covering the test because it didn’t have a CPT code. Often, patients would get stuck with bills or have to do a lot of backend work to settle their bill in an agreeable fashion. This really is amazing technology that we’ve been using for almost 10 years now, and I’m so grateful that this payment barrier is finally gone.
I have used many devices over the years, including other mobile cardiac outpatient telemetry systems and patch-type extended Holters. In terms of insurance coverage, it’s the type of device that poses potential coverage concerns not the specific device brand. The biggest advantage of the iRhythm products is the format of their device reports. They are structured in an intuitive and concise fashion with clinically relevant information readily available. This significantly reduces the time it takes [me] to interpret a report and make necessary clinical patient care decisions.
Every single atrial fibrillation patient I treat usually has several monitors over the course of their care—pre-ablation, post-ablation, and follow-up. I’m not necessarily going to order more monitors now, but I think it’s going to be a lot easier for patients since they are not going to face insurance payment barriers.
Q: What long-term changes do you see taking effect? How do you see the pandemic shaping cardiac care?
A: From a regulatory and technology standpoint, I see change occurring at a much faster pace. Some of the regulatory restrictions on telemedicine hopefully will no longer exist. There has been a huge boon for third parties developing telehealth technologies that are more patient- and healthcare system-friendly. Many of our patients are elderly and are not very technologically savvy, so you have to make it very easy for them to use. These technologies will allow more real-time health data to be shared with providers and hopefully allow for earlier detection of disease and better management of chronic illnesses such as heart failure and diabetes.
Meredith JW, High KP, Freischlag JA. Preserving Elective Surgeries in the COVID-19 Pandemic and the Future. JAMA. 2020 October 5 [Epub ahead of print]
Koonin LM, Hoots B, Tsang CA, et al. Trends in the Use of Telehealth During the Emergence of the COVID-19 Pandemic — United States, January–March 2020. MMWR Morb Mortal Wkly Rep. 2020;69(43):1595-1599.
Centers for Medicare & Medicaid Services. Medicare Telemedicine Health Care Provider Fact Sheet. Available at https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet. Accessed December 16, 2020.
Miller JC, Skoll D, Saxon LA. Home Monitoring of Cardiac Devices in the Era of COVID-19. Curr Cardiol Rep. 2020;23(1):1.
iRhythm. Zio XT Indications, Safety & Warnings. Available at https://www.irhythmtech.com/zio_xt_precautions. Accessed December 16, 2020.
- iRhythm. COVID-19 Update Center. Available at https://www.irhythmtech.com/covid19response. Accessed December 16, 2020.
- iRhythm. Telehealth & Home Enrollment with Zio. Available at https://www.irhythmtech.com/products-services/telehealth. Accessed December 16, 2020.
- iRhythm. iRhythm Technologies Announces Data from MSTOPS Clinical Trial to be Presented in a Late-Breaking Scientific Session at American Heart Association 2020. Available at https://investors.irhythmtech.com/news-releases/news-release-details/irhythm-technologies-announces-data-mstops-clinical-trial-be. Accessed December 21, 2020.
- iRhythm. The Zio Service. Available at https://www.irhythmtech.com/providers/zio-service. Accessed December 16, 2020.