Design and Initial Results of the Minneapolis Heart Institute TeleHeart Program
Goals and Vision of the Program
Telehealth is an emerging care delivery method that is defined by the use of electronic information and telecommunication technologies to support and promote long-distance clinical health care, patient and professional health-related education, and public health.1 Telehealth is emerging into chronic condition management and settings outside of the acute care hospital.2 The American Heart Association has recognized telehealth as critically important in the future of cardiac care—both to reduce the burden of disease and costs.3 However, there are limited reports of successful implementation of cardiac telehealth programs beyond heart failure monitoring and acute care settings.4 We report the design and initial results of a regional cardiac telehealth system, the Minneapolis Heart Institute (MHI) TeleHeart program.
The MHI has 36 clinic outreach sites across Minnesota and Wisconsin, ranging from 8 to 129 miles from the primary hospital, Abbott Northwestern Hospital in Minneapolis, MN (Figure). Many outreach sites have cardiology presence once a week or more, but more distant and rural sites may have on-site cardiologist presence only once or twice a month. These more distant rural sites were experiencing significant delays to cardiology appointments (range, 2.5 to 7.5 weeks) or challenging travel requirements for timely access to outpatient cardiology consultation, particularly in inclement weather.
Therefore, the MHI TeleHeart program was designed to improve patient access to care in rural Minnesota by decreasing wait times and travel for specialty cardiovascular care. The program was also designed to enhance regional partnerships and increase cardiovascular subspecialty availability at rural locations.
Local Challenges in Implementation
There were several barriers to program development and implementation.
Logistical: How will the physical examination be conducted? How does the group staff the visits?
Acceptance: Would patients be willing to see a physician across the screen? Would referring providers trust and use the service? How could these visits be integrated into the busy schedule of a cardiologist?
Quality of care: Would care be as high of quality as an in-person visit? Would outreach sites be receptive to this care model—viewing it as acceptable quality for their patients?
Financial: What are the financial risks and benefits to the rural site, the patient, and the cardiology group?
Logistical challenges were considered and addressed using a team approach with heavy input from regional site schedulers, physician leads, and administrators. The initial model would use an on-site nurse practitioner (NP) to facilitate the examination and clinical care. Visits would be conducted by cardiologists who were scheduled in imaging (reading echocardiograms, cardiac CT, or cardiac MRI), allowing time to be alerted and to staff visits. TeleHeart visits would be supplemental to on-site presence, ideally adding service to allow once a week clinic consult access to rural locations and therefore help initial acceptance. Other concerns about acceptance to some degree could only be addressed after implementation (patient satisfaction, physician referrals to this type of practice). A patient satisfaction survey was performed on initial participants to assess patient acceptance and care quality. The local site would keep all associated testing fees/revenue and rooming charges, whereas the cardiologist would receive the professional consult fees. Open and honest communication and feedback between local providers, administrators, and the MHI team with ongoing feedback and quality assurance allowed the program to see significant growth and overcome many obstacles.
Design of the Initiative
The initiative was started with 4 regional rural sites, located outside of the Minneapolis metropolitan area (Figure). The program goals and structure were developed in the spring of 2014, with the first patient visit occurring in New Ulm, MN, in June of 2014. The original plan was to expand the program by 2 to 6 sites per year over the first 3 years of the program.
Sites were chosen based on a combination of patient wait times, distance from the MHI, and willingness to participate in a new program. These factors highlight access to care and time and distance saved by both patients and physicians.
Dates of Service
To facilitate the goal of timely access to care, the sites were allowed to request frequency of service. The goal from both the cardiology group and rural site perspective was to provide at least once a week coverage (either on-site or via telehealth). These were determined by site and ranged from weekly to biweekly.
Models of Care Delivery and Workflow
Three different physician support models for our TeleHeart partner sites have been developed to facilitate the visit in an efficient and effective manner and to be able to conduct an adequate physical examination. The original model used a NP (employed by MHI, traveling to the rural site) to conduct the rural portion of the visit. As the number of sites has expanded, to be more cost-effective, the team elected to use local providers to facilitate the visits. On the day of the assigned clinic, the cardiologist is assigned to an imaging reading position at MHI. The cardiologist is aware of the patient visit schedule for the day by electronic medical record and carries a mobile phone that is called by the rural on-site provider when the patient is ready. Any visit type, whether a new patient, follow-up, or ASAP can be scheduled for an MHI TeleHeart visit. There were no specific criteria or limitation to what type of patient (or symptom or diagnosis) could be seen using a TeleHeart visit.
NP/physician assistant Model: (Our original model; used at: New Ulm, Blue Earth, Olivia, Faribault, and Baxter.) The NP/physician assistant is at the designated site and performs a history and physical examination and doing chart preparation for the TeleHeart clinic visit. After completing the history and physical examination, the NP or physician assistant calls the staff cardiologist to review the patient’s case and stays in the room during the TeleHeart physician–patient visit. This provider is then able to place orders and summarize the after visit details to the patient.
Registered nurse (RN): (Our preferred model; used at Glencoe, Litchfield, Fairmont and Fargo.) The RN is part of the local site staff and is able to perform the chart prep required before the TeleHeart visit. The RN supports the service by assisting with the physical examination with an electronic stethoscope, brief history, vitals, and medication reconciliation and placing verbal orders after the visit. This model will potentially allow transition to more urgent visits in the future.
Licensed practical nurse/certified medical assistant Model: (Used at Pine City.) Some rural sites do not have a local NP/physician assistant or RN available to support the program, visits or patients. In this situation, the local site provides a licensed practical nurse or certified medical assistant to support the service. Physical examination is performed with the assistance of an electronic stethoscope set at preassigned locations and directed verbally and visually by the cardiologist.
Each MHI Outreach site was made aware of the opportunity to participate in the MHI TeleHeart program (Figure). Specific sites were approached based on distance from MHI, infrequent on-site service, and were given the opportunity to learn more about the program. As the overall program developed and expanded, 2 nontraditional MHI rural Minnesota sites approached the practice to inquire about the possible addition of MHI TeleHeart services. If a rural site was interesting, the MHI team traveled to the site to review initiation, technological needs, goals of the program, and to assess service interest.
Cardiac subspecialists in electrophysiology, structural heart disease, vascular disease, and advanced heart failure were added to established sites in a similar structure and fashion to the general cardiology sites.
Additional Program Considerations
Other access opportunities became available through telehealth.3 For example, Telehealth-based cardiac CME lectures on Preventative Cardiology and Advanced CHF treatments have been provided to the Olivia Hospital.
Implementation of the Initiative
After the initial MHI TeleHeart patient visit in June 2014 at New Ulm Medical Center, 3 additional original sites began patient visits in August (Olivia, MN) and October (Cambridge and Faribault, MN) of 2014. A fifth site was added in 2015 (Blue Earth, MN) and 3 in 2016 (Glencoe, MN; Pine City, MN; and Fairmont, MN). Subspecialty consults with Electrophysiology, Advanced Heart Failure, Vascular, and Structural/Valve cardiologists began at Baxter, MN, and Faribault, MN, in 2015.
The adoption of the program was swift in 3 sites of the 4 original sites—New Ulm, Olivia, and Faribault—with weekly TeleHeart visits. Many factors contributed to this initial success, including motivated local sites and administrators, ongoing feedback, long travel distances (New Ulm Medical Center—MHI 93 miles each way, Faribault Clinic—MHI 50 miles each way, and Olivia Hospital—MHI 96 miles each way), and long patient wait times for on-site cardiology consultation (New Ulm 5.5 weeks, Blue Earth 7.5 weeks, and Olivia and Faribault >2.5 weeks).
However, Cambridge did not grow and subsequently terminated services in 2016. This likely was related to closer distance to MHI (48 miles), the Medicare metropolitan reimbursement rules (Cambridge is considered part of the metro, whereas Faribault is not), frequent on-site cardiology presence (multiple times per week), and, therefore, short in-person wait time for a cardiology consultation.
Additional barriers to site development included patient and scheduler education and provider education on the presence of the service. Importantly, no significant technological barriers have been observed. Only 2 visits out of 1004 patients over 2.5 years were canceled or changed because of a technology issue.
Success of the Initiative
Five goals of the TeleHeart program have been achieved. First, patient access to cardiology care in rural settings has improved. Clinic appointment wait times have decreased from a range of 2.5 to 7.5 weeks to <1 week in each site at 5 established general cardiology TeleHeart sites. Second, physician travel has decreased, and, in fact, the program was sufficiently successful at Olivia Hospital that we transitioned to exclusively TeleHeart visits, by mutual agreement. Patient travel has decreased. Third, patient satisfaction scores have been high. A pre- and postvisit survey was responded to by 100% of the initial 366 patients as a way to assess feasibility of the program and provide feedback and quality control. On postvisit surveys, the willingness to refer to the service was 98%, and 99% of responders felt this service made it easier to see a cardiologist. Fourth, steady site and visit growth has been observed. We are now live in 8 general cardiology sites, with 2 more scheduled to begin in 2017. Patient volumes have steadily increased per year (2014: 107; 2015: 375; 2016: 522), for a total of 1004 patients in 2.5 years. Finally, the concern about elderly cardiac patients being willing to use a technology-based novel care model was assessed. The most common age group to use the service were septuagenarians. Postvisit survey responders reported that 96% of patients felt the visit was at least as good as an in-person cardiology clinic visit.
Cost and reimbursement concerns have been a limitation for many telehealth sites across the United States.2,3 In review of our program, we found 48% of visits were new patients (historical outreach new patient visit percentage was 18% to 23% at these sites). These data would suggest that the best patient type would be new patients. However, the service was also convenient for cardiac patients who require close follow-up (post-myocardial infarction or congestive heart failure admission, for example). This particular program was set up to minimize physician time demands to the cardiology practice in that patients were added into a normal day workflow. Downstream revenue assessed in MHI TeleHeart patients at 9 months revealed a contribution margin of $3950 per patient. These are encouraging, yet preliminary, cost assessments, and further study is warranted on the cost/benefit of telehealth programs. There are strengths and weaknesses to each model detailed above. To expand the service to more sites, the licensed practical nurse/MA or RN models allow local providers the opportunity to participate and have cost and availability advantages but more challenge with the physical examination portion. All 3 models were well received, and our group’s review suggests that the RN model provided the best combination of access, cost, and provider scope of practice.
Translation to Other Settings
The current MHI TeleHeart program is an outpatient consultation service for new, established, or urgent rural patients to be seen in a timely manner. The program has already expanded into cardiology subspecialties, which in fact may be even better served by telehealth (a rural patient who needs a cardiac procedure: the pre- and postprocedure visit can be done via telehealth, saving multiple trips to the metro location). In addition to improved cardiovascular access for rural patients, telehealth offers an opportunity to facilitate triage of the cardiac patient, a benefit that has already been noted by our patients and providers. One could easily imagine an inpatient or emergency department–based cardiac triage system based on this model and technology. The impact on patient care, cost containment, and appropriate resource utilization is promising.
Additional efforts to lower cost and facilitate remote physical exams need to be considered. For example, we are training the TeleHeart program NPs in the use of handheld ultrasound.5 Ultrasound acquisition by the local provider with subsequent image transfer to the cardiologist may facilitate care, test selection, and appropriate use.
For programs seeking to develop a telemedicine approach to cardiac care, we would recommend a systematic assessment of several key factors: (1) patient access in rural locations (wait times); (2) number of outreach locations (scope of access issues); (3) travel time to specialty care, not just distance traveled by provider and patient (may be longer in densely populated urban areas with traffic or weather concerns); (4) logistics of staffing the visits for the practice (size of the group, flexibility, and availability of providers for scheduled or ASAP visits); and (5) relationship building/strengthening with current partner sites or potential development of new partner sites.
Summary of the Experience, Future Directions, and Challenges
In summary, cardiac telehealth seems to be a powerful tool to expand access to cardiologists in rural areas. Cardiac telehealth can shorten wait times to specialty appointments while decreasing physician and patient travel. Challenges around payment of telehealth visits and specifically the Medicare reimbursement in metropolitan areas may prevent the growth of these programs. Cardiac telehealth systems focusing on urgent or emergent patient triage need to be considered and pursued. Further cost analysis (including total cost of care), in addition to payment reform for these visits, on both regional and national levels is paramount to future success. Our results indicate that cardiac telehealth is well received by patients and providers and has promising implications for the future of cardiac care delivery and cost containment.
We acknowledge Robert G. Hauser, MD, Timothy D. Henry, MD, and Barb Andreasen for assistance with program development and article preparation. Technological components of the program were provided to the rural sites through grant funding obtained by the Abbott Northwestern Hospital Foundation.
Source of Funding
This project was supported by the Minneapolis Heart Institute Foundation.
The Data Supplement is available at http://circoutcomes.ahajournals.org/lookup/suppl/doi:10.1161/CIRCOUTCOMES.117.003904/-/DC1.
- © 2017 American Heart Association, Inc.
- 1.↵Health Services and Resources Administration. Telehealth Programs. http://www.hrsa.gov/ruralhealth/telehealth/. Accessed March 14, 2017.
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