New information regarding COVID-19 continues to emerge daily. This content was based on the sources available at the time of writing.
Telemedicine is not a new concept, with roots in efforts from NASA and the Nebraska Psychology Institute in the late 1960s, according to a paper in the International Journal of Environmental Research and Public Health.1 Since then, physicians and researchers have been exploring the best ways to use technology to connect with hard-to-reach patients, such as those in rural or impoverished areas or those with mobility challenges, and to integrate additional modalities like telemedicine ECG.
But adoption of telemedicine was slow up until the onset of the COVID-19 pandemic. For cardiologists and others, telemedicine offered a way to maintain contact with patients who stayed at home to protect themselves and healthcare workers from the spread of the virus. Virtual care platforms quickly proliferated to fill the need, and survey data from the American Medical Association suggest there's no going back: in March 2022, nearly 85% of physicians who responded said they were using telehealth, and 70% said their organization was motivated to continue doing so.2
However, that same survey also showed that only 8% were using remote patient monitoring technologies, which would include things like smartphone cameras, blood pressure cuffs, pulse oximeters, and body weight scales. There was no mention of telemedicine ECG, but with continuing advancements in technology—especially among consumer wearables and interpretation algorithms—it may be increasingly feasible to collect such information without bringing patients to the office. That may be particularly useful for patients with conditions like atrial fibrillation or heart failure for which ECG can provide management-changing information.
Renewed Interest in Telemedicine
Over the past few years, professional societies have brought a renewed focus on the potential of telemedicine. The American Heart Association (AHA), for one, recently released a scientific statement in Circulation on the use of telehealth in the management of cardiovascular disease, touting its use for communicating with patients, diagnosing and monitoring disease, and performing follow-up.3
It's also possible to remotely monitor cardiovascular risk factors, medication adherence, and symptoms using tools like blood pressure monitors, smart pillboxes, home ECGs, pulse oximeters, and pulmonary artery pressure monitors, the AHA authors say, noting that combining home ECG measurements with symptom reporting may enhance the evaluation of chest pain.
Shortly after the pandemic started, leadership from the American College of Cardiology (ACC), including past president Athena Poppas, discussed whether this resurgent interest in telemedicine—driven by necessity and supported by changes to government regulations and reimbursement structures—would last. In a Journal of the American College of Cardiology commentary, Poppas and her colleagues wrote, "It can and must." By the end of March 2020, just weeks after the World Health Organization officially declared a pandemic, 75% of all outpatient encounters had moved to telehealth, according to a survey of cardiology practices.4
Poppas and her colleagues highlight the potential for telemedicine to integrate both communication and clinical data to guide patient management: "For example, during a telehealth visit with a patient with hypertension and atrial fibrillation, digital tools (e.g., Bluetooth blood pressure cuff, wearable electrocardiography monitor) can provide directly measured blood pressure and heart rate and rhythm to inform clinical decision-making in real time." 4
Remote ECG and Heart Rate Monitoring Devices
In September 2020, the AHA and ACC teamed up with the Heart Rhythm Society and other professional organizations focused on heart rhythms to provide guidance on telehealth and arrhythmia monitoring in the context of the ongoing pandemic and beyond.5 Virtual management of non-COVID-19 patients, the authors say, can include features like mobile devices recording ECGs, as well as remote interrogation of implantable devices.
The electrophysiology community is well suited for this type of effort, they stress, because "all preobtained data, including ECGs, ambulatory ECG monitoring, cardiac imaging, and coronary angiography can be adequately reviewed electronically. Digital tools such as direct-to-consumer mobile ECG and wireless blood pressure devices can be used to further complement the telehealth visit without in-person contact."
The guidance document provides a list of FDA-approved and other remote ECG and heart rate monitoring devices, including handheld devices, patches, and smartwatches, that can provide data to be integrated into the clinical workflow.
ECG Data Management Systems Grow More Important
Although telemedicine ECG, as well as a patient-measured ECG brought to a doctor's office, holds promise when it comes to patient management, it also raises questions about how all of that information will be handled and worked into clinicians' day-to-day practice to improve care delivery.
Fortunately, technological solutions have been developed to help with the huge amount of data. ECG data management systems integrated into electronic medical records can incorporate ECG readings both taken in clinical settings and obtained by patients at home using personal wearables or a device sent by their doctor. Scalable cardiology information systems incorporate interpretation algorithms powered by artificial intelligence and machine learning to provide a means for physicians to make sense of the torrent of information flowing in.
Some concerns have been raised about the quality and accuracy of ECG data obtained from consumer wearable devices, which are not held to the same technical standards as medical devices, but there is evidence that the information is comparable to what can be obtained in the clinic when it comes to detecting certain rhythm abnormalities. A review in Current Emergency and Hospital Medicine Reports found that FDA-approved devices "demonstrated their noninferiority when compared to standard procedure" for identifying primarily atrial fibrillation and atrial flutter and that non-approved devices have also performed well for this purpose.6
There is limited evidence about the use of wearables for diagnosing other conditions that can be picked up on the ECG, but the review authors still see them as a potentially promising and cost-effective supplement to the 12-lead ECG to bring the technology to parts of the world with fewer resources. "Their continuous monitoring abilities as well as ease of use and overall convenience may also improve patient compliance and provide a more comprehensive clinical picture," they write.
Stay on top of cardiology trends and best practices by browsing our Diagnostic ECG Clinical Insights Center.
Remaining Challenges and Looking to the Future
Hanging over the discussion about the great potential for telemedicine, and for obtaining remotely measured ECG, are several concerns and challenges. Among these are disparities in technology accessibility across demographic groups, increased anxiety due to findings that may not be clinically meaningful, and security concerns regarding protecting private health data.
Moreover, the AHA notes in its scientific statement, "several factors such as technological infrastructure, reimbursement, and limited patient digital literacy can hinder the adoption of remote care."
The website for the ACC's telehealth platform designed specifically for cardiologists, called Heartbeat Health, provides some resources for clinicians looking to deal with some of these issues, such as pieces on coding and billing for telehealth and on reimbursement for remote patient monitoring.7
The multi-society heart rhythm guidance acknowledges many of these same issues, with the authors arguing that "all stakeholders should collaborate to address these challenges and promote the safe and effective use of digital health during the current pandemic." But, they also have an eye on practice after the pandemic ends, saying the situation "may serve as an opportunity to evolve current technologies into indispensable tools for our future cardiological practice."
Although telemedicine is not likely to replace the need for in-person care, it can be an important complement. As Poppas and the other ACC leaders write in their commentary, "The technology to support true virtual care exists, the opportunity is ripe, and the promise is great. We believe that cardiovascular clinicians can and should lead the virtual care era."
Resources:
- LeRouge C, Garfield MJ. Crossing the telemedicine chasm: have the U.S. barriers to widespread adoption of telemedicine been significantly reduced? International Journal of Environmental Research and Public Health. December 2013; 10(12): 6472-6484. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3881125/
- American Medical Association. AMA survey shows widespread enthusiasm for telehealth. AMA-assn.org. https://www.ama-assn.org/press-center/press-releases/ama-survey-shows-widespread-enthusiasm-telehealth. Accessed January 9, 2023.
- Takahashi EA, Schwamm LH, Adeoye OM, et al. An overview of telehealth in the management of cardiovascular disease: a scientific statement from the American Heart Association. Circulation. November 2022; 146: e558-e568. https://www.ahajournals.org/doi/10.1161/CIR.0000000000001107
- Poppas A, Rumsfeld JS, Wessler JD. Telehealth is having a moment: will it last? Journal of the American College of Cardiology. June 2020; 75(23): 2989-2991. https://www.jacc.org/doi/10.1016/j.jacc.2020.05.002
- Varma N, Marrouche NF, Aguinaga L, et al. HRS/EHRA/APHRS/LAHRS/ACC/AHA worldwide practice update for telehealth and arrhythmia monitoring during and after a pandemic. EP Europace. February 2021; 23(2): 313. https://academic.oup.com/europace/article/23/2/313/5855898
- Kamga P, Mostafa R, Zafar S. The use of wearable ECG devices in the clinical setting: a review. Current Emergency and Hospital Medicine Reports. June 2022; 10(3): 67-72. https://link.springer.com/article/10.1007/s40138-022-00248-x
- American College of Cardiology. Heartbeat Health: a telehealth platform built for cardiology. ACC.org. https://www.acc.org/HeartbeatHealth. Accessed January 10, 2023.
