5 Steps to Swiftly Transform a Large Community Cardiology Practice to Virtual Visits

A regional community cardiology program can pivot from conducting nearly all in-person visits to 95% virtual visits in a matter of weeks — and preserve a high standard of care in the process. How Cleveland Clinic achieved this transformation early in the COVID-19 pandemic, then safely transitioned back to adding in-office care, is detailed in a recent article in the European Heart Journal.

“The COVID-19 pandemic forced the healthcare system to confront new challenges for all inpatient and outpatient services,” says corresponding author Umesh Khot, MD, Head of Regional Cardiovascular Medicine at Cleveland Clinic. “We wanted to share how our large practice rapidly and successfully embraced dramatic changes.”

Regional practices speedily shift gears

Cleveland Clinic’s Section of Regional Cardiology provides care to the greater Cleveland/Akron area in Northeast Ohio, with 64 cardiologists practicing at nine hospitals and 18 outpatient clinics. When the state of Ohio declared a national emergency on March 9, 2020, the Section of Regional Cardiology’s practice patterns shifted as follows:

• From March 2 to 18, 46 providers saw 427 patients/day, on average, with 99.7% being in-office
• By April 17, 45 providers saw 340 patients/day, with 95% being virtual

In general, the almost exclusive use of virtual visits continued through the end of April, at which point the proportion of in-office visits gradually increased again as safety precautions for these visits were put in place.

Steps to safe pandemic practice

“We identified five key actions that facilitated our health system’s rapid changes during the pandemic,” explains the paper’s first author, Gautam Shah, MD, a staff cardiologist in the Section of Regional Cardiology. “These can be adapted to any size healthcare facility.”

1. Weekly multidisciplinary virtual meetings were instituted. Representatives from all members of regional cardiology practice — including physicians, advanced practice providers, nurses and administrators — met to share their experiences from individual sites and develop strategies for new processes. These meetings fostered prompt execution of changes as well as uniformity throughout the regional offices.
2. Virtual visits were inaugurated. Patients scheduled for outpatient visits were contacted via telephone or through Cleveland Clinic’s secure online patient-provider messaging portal and asked to change from an in-office visit to either a video or telephone visit. All personal patient fees were waived, with payment handled solely through billing of patients’ insurance. For patients insisting on an in-person visit, the provider was asked to determine the need for it.
3. Patients with in-office visits were screened at multiple points: (1) The day before a visit, nurses checked the patient’s electronic medical record for a recent emergency room visit for flulike symptoms; those with such a visit were contacted for further screening. (2) Fliers at clinic entrances were hung to warn against entry by visitors who had symptoms consistent with COVID-19. (3) In the office, a medical assistant took temperatures and questioned patients on travel history and the presence of high-risk symptoms.
4. Key aspects of an in-office experience were maintained virtually. It was determined early on that successful visits had a flow that was valuable to preserve. Thus, on the day of the visit, an administrative assistant called the patient to check in and verify insurance information. The call was then transferred to a medical assistant for patient intake, with patients asked to provide blood pressure measurements, heart rate, height and weight as available. Soon after, the provider contacted the patient to conduct the visit itself. Based on provider report, the administrative assistant called the patient for checkout, to schedule required testing and follow-up.
5. New safe office practices were established. Physical distancing was ensured by limiting the number of patients being seen, rearranging chairs and encouraging patients to leave immediately after seeing their provider, with testing and follow-up scheduled via a phone call from an administrative assistant. Additional regular cleaning of touch surfaces was instituted. All employees were required to wear a facemask and protective eyewear, and all patients were required to wear a facemask.

An ongoing process

The authors emphasize that, moving forward, they continue to remain vigilant and are ready to adapt to new developments in the pandemic to ensure ongoing care to patients and the community.

“Our health system continues to evolve to meet the challenges brought on by changing circumstances, such as new SARS-CoV-2 variants,” says co-author Ankur Kalra, MD, Medical Director of Clinical Research for Regional Cardiovascular Medicine at Cleveland Clinic. “Being able to quickly institute new practices allows us to rapidly respond to new developments while maintaining optimal patient care.”