Mentorship program and telemedicine for the vascular medicine physician

Changing landscape of clinical vascular medicine: Transitioning to telemedicine

Adithya Peruri, MD

Aditya Sharma, MBBS, FSVM

Marie Gerhard-Herman, MD, FSVM

Esther Kim, MD, FSVM

Randy K Ramcharitar, MD

Telemedicine has been available for many years, but its utilization has significantly increased during the coronavirus disease (COVID-19) pandemic. Many vascular specialists have wondered how telemedicine can effectively play a role in patient care.

The COVID-19 pandemic has led to an emergent need for medical providers to incorporate telemedicine into their practice. Providers have relied on telemedicine either via telephone or video interface to deliver patient care while reducing infectious exposure and limiting viral spread. The recent publication outlining the response of the Society for Vascular Medicine (SVM) Leaders to the COVID-19 crisis outlined the core role telemedicine has played during this time. ¹ Many practices have utilized telemedicine to see new consultations while also continuing to follow chronic vascular conditions. Clinics around the US had similar experiences: The Cleveland Clinic saw a 1000% increase in virtual visits during the pandemic. ² Physicians virtually performed consultations and, of those consultations, more than 80% helped patients avoid in-person visits. ² During the early stages of the COVID-19 pandemic, more than 90% of vascular medicine visits at the University of Virginia were telemedicine and, even now, 50% of visits are virtual. Other established vascular medicine programs nationwide have similar stories. ¹

Although telemedicine has many advantages, there are still many obstacles to its implementation and growth. For doctors, one of the challenges is having a license in the state in which the patient is located. The Federation of State Medical Boards (FSMB) clearly outlines policies and reimbursement rules. ³ Being a subspecialist, vascular medicine physicians often see out-of-state-patients. Recently, the FSMB has issued updated guidance on telemedicine during the pandemic and management of out-of-state patients. ⁴ Telemedicine also requires patients to have access to devices with audio and ideally video capability and be comfortable using these features. About 68% of adults aged 65 years or older have a computer, smartphone, or tablet with internet access, but only 11% of adults aged 30 or older used their smart devices to talk to a healthcare professional in the first 2 weeks of April. ² Another concern is that some patients are not comfortable with meeting their doctor in the background of their home. This can be overcome by first encouraging a telephone visit and then converting to a video visit once the patient is used to the process. ² Other challenges include technological, social, and privacy concerns. The University of California San Francisco identified those who are most vulnerable to suboptimal care through the use of telemedicine, including: patients who are older, poorer, have limited literacy or English proficiency, and racial or ethnic minorities. ⁵ These groups are those also at higher risk of being affected by the virus and its health, social, and economic consequences.

Access to the necessary technology, proficiency in using video conferencing platforms, maintaining HIPAA (Health Insurance Portability and Accountability Act) compliance, and protecting privacy during a telemedicine visit are some of the major challenges of telemedicine. Making high-speed internet access more accessible and affordable, and establishing dedicated telemedicine sites at community hospitals, libraries or health centers would benefit high-risk groups. ⁵ Use of a video conferencing platform that is easy to use, compatible with an array of devices, and protects patients’ privacy is critical. Platforms such as doxy.me, Doximity, Webex, and Zoom have been used successfully.

For vascular medicine, telemedicine can be very useful for routine follow-up of conditions such as peripheral artery or venous disease or for discussing issues surrounding anticoagulation. While there are some ideal conditions for telemedicine, others require an in-person visit. Some physicians have noted a pre-visit checklist is essential to identify which patients may benefit from an in-person clinic visit (Table 1). With any telemedicine visit the medium of communication should be HIPAA-compliant and documentation should be clear, so it can be referenced in future appointments to maintain patient safety and continuity. Telemedicine visits conducted with video are typically more efficient if a patient advocate is present to help hold the camera or provide additional history. ⁶ Patients can use their own devices to measure vital signs, but hospitals/institutions could also loan such devices. After vital signs are obtained, the physical exam can be conducted through a systems-based approach by having the patient point the camera to specific body areas, with or without supplemental lighting. ⁶ Potential physical examination findings are noted in Table 2. Novel data which could be incorporated into telemedicine visits for patient assessment include the use of pedometers to track steps in a patient with claudication and assess functional capacity. By quantifying steps, we can trend treatment response as well.

Table 1.

Pre-visit checklist for a telemedicine visit.

□	Prior to visit, the patient is provided with instructions pertaining to telemedicine encounter
□	Device (smartphone or computer) operational and charged; familiarity with its use
□	Automated blood pressure devices; glucometer operational (if applicable)
□	Physician is licensed in same state from where patient is communicating
□	Physician, staff, and patient setting have minimal interruptions
□	Quiet setting for both parties; microphone and video are clear and operational
□	Proper patient attire which allows for inspection of important items like extremities

Table 2.

Potential patient physical exam elements during a telemedicine visit.

Area examined	Exam elements
Vitals and constitutional	Patient-owned pulse oximeters, heart rate trackers, or automated blood pressure device. Overall general appearance and distress level of the patient.
Head/neck/ears/eyes/throat	Use camera to view and note appearance of external ears and nose, open mouth to camera to examine the throat (use a flashlight if available). Eyes can be examined with a flashlight for appearance of sclera and extra-ocular movements and to assess for Horner’s syndrome or xanthelasma. Ask patient to pull down inferior eyelid to evaluate for pallor/erythema.
Respiratory	General inspection – patient can be asked to breathe and listen for overt or stridor wheezing. Perform Roth test to assess cardiopulmonary function. The Roth test can assess severity of dyspnea, which combines maximal count reached (starting from 1 up to 30 in one’s native language) during a single exhalation and the time taken to reach the maximum count. 8
Cardiovascular	Evaluate peripheral veins to assess intravascular volume (e.g., hand veins should empty only when arm is raised to shoulder level); this requires evaluating the peripheral veins at different levels with respect to the heart. Camera can be brought close to the neck for jugular venous pressure assessment.
Abdomen	General inspection for distention/hernias; the patient can push in each quadrant to ensure no abdominal pain. Can evaluate for prominent abdominal wall collateral veins or striae.
Musculoskeletal	Watch patient movement and report on muscle tone observed. Can evaluate for joint swelling/deformity.
Extremities	Inspect for any nail bed pathology such as sclerodactyly, digital pallor or cyanosis, ulceration, loss of hair, livedo reticularis, and swelling extent (ankle or forefoot). Nailfold capillaries, pitting edema and Stemmer’s sign can be evaluated with patient assistance. Evaluate for presence and extent of superficial venous disease (varicose veins).
Neurological and psychiatric exam	Patient can walk to monitor gait and balance. Assess for pronator drift and partial/modified cranial nerve exam. Also observe level of alertness, speech, visible neurologic defect, mood, and affect.
Skin	Flashlight may be needed for presence of rash, telangiectasia, erythema, skin changes consistent with venous stasis and venous hypertension, and presence of ulceration.

When offering a telemedicine visit, it must first be made clear to patients that those with symptoms suggestive of acute coronary syndromes, decompensated heart failure, pulmonary embolism (PE), arterial dissection, major bleeding, and/or other life- and limb-threatening conditions must promptly report to the nearest emergency room for evaluation.

The primary reason to see vascular patients in clinic is the opportunity to perform a hands-on physical exam. There is currently no telemedicine equivalent for palpation and auscultation. Telemedicine services in community centers where a nurse could transmit sounds from an electronic stethoscope to the physician can overcome this limitation. In-person visits may also be beneficial to those patients with poor health literacy and those without appropriate telephone/internet access.

Wound evaluation and treatment should ideally be done in person. Assessment for active infection, tunneling, gangrene, and limb viability are critical to determining proper and timely management. Diagnosing venous versus arterial versus neuropathic etiology cannot be done effectively over video, and there may be a need to obtain additional imaging such as ankle–brachial index or venous duplex ultrasound. Evaluations for potential critical limb and acute limb ischemia require an urgent, if not emergent, visit and are not suited for telemedicine. New onset leg swelling evaluation should also be done with an in-person physical exam.

Certain initial evaluations for aneurysm management, claudication, newly diagnosed distal deep venous thrombosis (DVT), or asymptomatic carotid or mesenteric artery stenosis can be conducted with telemedicine. Often patients with these conditions have already undergone imaging for the condition under evaluation, and hence most of the visit is for obtaining history and providing counseling and medical management. Additionally, telemedicine provides the opportunity to share our screen and review imaging studies with the patients. Vascular medicine patients often have complex conditions that require a multidisciplinary approach. Telemedicine provides the opportunity for multiple specialists to be present during the same virtual visit.

Many vascular medicine inpatient consults, such as those for uncontrolled hypertension, anticoagulation management for uncomplicated thrombosis, and medical management of atherosclerosis, can be provided via e-consults where good communication between the primary teams, consulting physicians, and patients is imperative. Patients with acute or critical limb ischemia, massive or submassive PE, or DVT concerning for phlegmasia, and acute mesenteric ischemia diagnoses require emergent in-person (bedside) evaluation due to the acuity and threat to life/limb. Complicated connective tissue disease or vasculitis evaluations associated with dissection/thrombosis require detailed physical examinations. Specific questions and physical exam findings are necessary to determine if a patient has a high probability for these conditions and will require an in-person visit for initial evaluation. Follow-up visits on these patients can be through telemedicine. In all of these inpatient and outpatient scenarios, and especially in the context of COVID-19, it is vital to weigh the risk and benefits of conducting a telemedicine encounter. Does the benefit from an in-person evaluation outweigh the risk of potential COVID-19 exposure to the patient or the provider?

Admittedly, digital health has not replaced all in-person care requirements for patients, but it can augment and extend care. ⁷ We have seen that many patients are receptive to incorporating telemedicine into their care. During these uncertain times, telemedicine proves it can help fill in healthcare gaps as we fine-tune its use for future success.