Remote treatment of patients, so-called telemedicine, has been around since the 1940s, when it was first used for transmission of radiology images. In later years, remote interaction between physician and patient was predominantly used by medical subspecialties such as behavioral medicine and psychiatry, driven by community need and sparse physician resources.
The ability to evaluate patients living in rural areas during strokes or while in remote hospital intensive care units (ICUs) has evolved and been in use for several years. But it doesn’t stop there. Several subspecialties have begun to experiment with remote patient evaluation and treatment, though the numbers are low. Even in medical fields such as general surgery, pediatric surgery and, yes, vascular surgery, the use of telemedicine visits for certain patient encounters like second opinions, postoperative and annual surveillance visits has gained attention.
This is my experience.
OPPORTUNITIES IN CRISIS
The onset of the COVID-19 era has changed the virtual landscape overnight. Social distancing while maintaining social contact has become the norm from a public health and personal safety perspective. I practice vascular surgery in the Yale New Haven Health System (YNHHS). Coincidentally, I had been interested in and had begun establishing telemedicine in my practice several months before the COVID-19 crisis. This stems from the fact some of my practice is in a community/rural setting, and patients often must travel longer distances to get to the office. To address this, I wanted to establish a general vascular surgery telemedicine platform to facilitate patient care and gain direct experience on its feasibility.
While the infrastructure for telemedicine was already in place, provided by the electronic medical record (EMR) system used at YNHHS, establishing this service for my practice was an undertaking that took time and effort. But when the COVID-19 crisis hit the U.S in March, the health systems had to respond quickly. As part of this response, the existing Telehealth Center at YNHHS established a Telehealth Conversion Center, offering guidance for a fast and effective transition to remote care for qualifying patients. As mentioned, the infrastructure for telemedicine was present, but the patients had to be signed up for the platform, which provides access to medical records and enables a conversation via email or messaging with the office and the providers. This platform also gives access to video visits. In addition, patients needed to have the app for this platform installed on their smartphone in order that they be armed with the necessary technical set-up for a video visit.
CO-OPT PATIENTS’ NEEDS
During the first weeks, about 1,000 patients signed up daily for the EMR platform with the help of the YNHHS IT and telehealth departments. and efficient and, within a few days, somewhere in the region of 2,000 televisits were being performed daily throughout the system.
The transition of regular office visits to televisits in the division of vascular surgery was discussed early during the hospital system’s telehealth conversion efforts. While several mostly justified concerns were expressed, providers generally moved toward telehealth visits in a quite rapid fashion. And very soon, all faculty had converted.
The overall experience with telemedicine in vascular surgery was positive both for providers and patients. The opportunity to have a video face-to-face meeting with their vascular surgeon during a time of lockdown and restricted access to healthcare was appreciated by patients and their families, and hope for future telemedicine opportunities was expressed.
Before COVID-19, we had started a collaboration with UT San Antonio and UT Houston to establish telemedicine services for hemodialysis patients. One specified goal was to perform the initial patient evaluation via a televisit. During this, the patient’s history, arteriovenous access options and possible contraindications to surgery would be evaluated. The patient would then be scheduled for access creation. On the day of surgery, a physical exam, vein mapping and additional ultrasound evaluation would be performed. Surgical plans could be adjusted accordingly.
RIDE THE WAVE
The COVID-19 situation has converted this possible scenario into reality as some initial televisits have already occurred. After the lifting of hospital restrictions on semi-elective surgery, the first arteriovenous access procedures were scheduled and performed. While this approach was developed before the current crisis, it will certainly be continued with the goal of assessing its long-term feasibility. Our goal is to alleviate the burden of innumerable office visits, hemodialysis sessions and hospitalizations for this population. We plan to report our experience during the COVID-19 era and beyond.
As is true for other medical subspecialties, telemedicine should be considered a standard part of practice for vascular surgeons. Clearly, certain visit types can be performed safely and efficiently using telemedicine. Especially in rural areas, the time and cost for travel to a doctor’s office can be a significant burden on patients and their relatives. We should all endeavor to decrease these burdens for our patients. By using the telehealth technology that is now widely available, we have the ability to try. After all, if it’s safe, and the right thing, it should be doable.
Uwe Fischer, MD, is an assistant professor of surgery in the vascular division at Yale College of Medicine in New Haven, Connecticut. For the support and collaboration, he thanks Raul Guzman, MD, and Alan Dardik, MD, in the division of vascular surgery at Yale School of Medicine in New Haven; Mark Davies, MD, of the division of vascular and endovascular surgery, UT Health, San Antonio, Texas; and Anthony Estrera, MD, of the department of cardiothoracic and vascular surgery, McGovern Medical School at UTHealth in Houston.