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Melanie Cole, MS (Host):   Technological advancements in Telemedicine have paved the way for safe, secure, face to face pediatric cardiology visits in the comfort and convenience of a patient’s home. The St. Louis Children’s and Washington University Heart Center offers telemedicine visits for pediatric heart patients from infants to young adults. Welcome to Radio Rounds with St. Louis Children’s Hospital. I'm Melanie Cole, and today we’re discussing the pediatric heart center telemedicine program. Joining me to discuss when and how to use this service is Lisa Roelle. She’s a physician assistant in the division of pediatric cardiology at Washington University specializing in pediatric electrophysiology. Lisa, it’s a pleasure to have you join us today. During this pandemic there's been a big shift to telehealth. How have you and your team been evolving care for your patients during this time? How has the pandemic transformed the way you offer care to patients? How has it encouraged healthcare systems be creative and more innovative in their ability to deliver essential non-COVID care?

Lisa Roelle, PA (Guest):   Hi, well thanks for having me. With the COVID-19 pandemic, Washington University really accelerated their launch of telemedicine visits throughout the organization. We as a division of cardiology kind of took hold of this opportunity and rapidly implemented our own telemedicine clinic for our patients. So here in pediatric cardiology and more specific in pediatric electrophysiology, we’ve been routinely utilizing the excellent resource of telemedicine to complete new and established visits for our patients. We think that with the COVID-19 pandemic, we’re offering an additional service or an adjunct service to their in person visits so that patients who don’t want to come into the hospital or into the clinic are able to still see their providers at regularly scheduled intervals.

Host:   What a great program. So tell us Lisa when is it appropriate to schedule a telehealth appointment? What services can be best administered with telehealth?

Lisa:   We have been able to see a wide variety of our patients throughout the cardiology department. Also with EP we’re seeing all of our inherited arrhythmia kids that are not interested in coming to the hospital or that live a great distance. So patients that live greater than 60 miles or 60 minutes away from the hospital sometimes opt to have telemedicine appointments that are offered to them. So we’re seeing our patients that have a family history of known arrhythmias, patients that are having super ventricular tachycardia and are in need of a consultation for discussing possible ablation therapy. We’re also seeing our established patients whom we’ve known for several years either with or without a device. So patients that might have an implanted loop recorder, an ICD, or a pace maker. We receive remote transmissions and are able to pull those up in real time while we’re on a video visit with our patients. We still love to see them in person. We want to see them in person, but this is a great tool to use to see them during the year when things like a pandemic arise and they can't come into the hospital out of safety.

Host:   So doesn’t a cardiologist need to do a physical exam? Tell us how you can do limited physical exam, order tests to be done before and after the visit, and potential tools that you can use in the future.

Lisa:   Traditionally as cardiology providers we like to listen to the heart. We, of course, do that every time we see the patient, but there's a lot that can be assessed just by seeing the patient on video. You're able to calculate a respiratory rate, determine if the child is comfortable or in distress, look at their skin color—are they pale, cyanotic, or do they have good skin color? You can even assess volume overloaded if needed. So if they're having edema or swelling, that can be shown on a video visits. Some families have pulse oximeters or blood pressure cuffs at their house for vital sign measurements which can be used during a visit or before the visit. We’re always looking to new technology advancements that will allow us to auscultate heart and lung sounds and hope to implement this as we can.

In regards to testing, we are able to do a comprehensive chart review before the patient comes to the hospital. If they're a new patient, we’re able to look at their previously done testing by their referring cardiologist or their primary care provider. We can see EKGs, echocardiogram results, Holter monitors or loop recorders that are sent home for the patients. When we see them and we don’t have pre-visit testing, we will then order the testing to be done at one of our ancillary facilities or at a local facility if the patient’s down in an area that is not in the St. Louis region. Through the chart review, we’ve been able to determine if a patient needs an ECG or a Holter monitor sent out prior to their appointment. We then get those results before the appointment and are able to pull them up and share the screen with the patient so that they can see their results and we can discuss them in real time.

Host:   That’s so great for patients Lisa. So what can they expect during a cardiac telemedicine visits? A lot of things that families want to know is is this a difficult thing for families to set up? Does it require a lot of technology? What’s involved for the families?

Lisa:   Sure. It’s actually quite simple. Washington University has put in a lot of effort to making this transition into telemedicine as seamless as we can for both the patient and the providers. What the patient needs is either a computer with a webcam or a phone or tablet as well as a good Wi-Fi connection so they're not using up their own data and also to ensure a good connection during the video visit. When the patient is scheduled for a telemedicine appointment, we’ve also had them enrolled in our MyChart patient portal. All patients will access their video visits through MyChart, and they're able to click one simple button on their appointment desk which then takes them directly into Zoom, which is the interface that we’ve been using here at Washington University primarily. They don’t have to put in a meeting ID or password. They just have one simple button to click and then they're in the waiting room waiting for their physician. From a provider standpoint, we are then alerted that the patient has checked in similar to when they come in to the office and they check in at the front desk. We’re able to use the electronic medical record and our clinic schedules to access that same Zoom meeting and start our video visits.

Host:  So tell us a little bit about what your patients are thinking about this. You’ve been doing it for several months now.  What do they think about these virtual visits?  

Lisa:   We’ve actually been sending out informal surveys to all of our patients that have had a telemedicine visit. We’ve overall gotten a great response. The majority of patients are happy with a quality of care that’s been provided. They rate it similar to the quality of care that they’ve received in an in-person appointment. They also enjoy the ease of use for a telemedicine appointment and found that scheduling telemedicine was just as simple as scheduling a regular cardiology appointment in person.

Host:   Are you providing telemedicine for all the clinics at the heart center?

Lisa:   The electrophysiology physicians have three scheduled clinics a week. So Tuesday, Wednesday, or Thursday mornings. Then our general cardiologists have set schedules as well that their scheduling team is aware of and will place their patients into as appropriately.

Host:   So Lisa, do you need to be an established patient to be seen in the telemedicine clinic? Please tell us how a provider can have their patients seen in the telemedicine clinic.

Lisa:   You do not have to be an established patient. We have been accepting new consults and new patients as we’re able to get records from the referring providers that will allow us to give a comprehensive care visit and consultation to the patients. If you're a provider that’s wishing to schedule your patient into a telemedicine clinic, you're welcome to call the cardiology office and speak one of the schedulers. Our physicians are easily reached by email if you have a specific question and you want to know whether or not your patient would be a good fit for their telemedicine clinic.

Host:   Lisa, tell us about some of the things you’ve learned while setting up this telehealth. Some of the challenges and some of the things that maybe surprised you.

Lisa:   In regards to challenges, we occasionally have patients that have connection issues or have difficulty with the technology. What we’ve done on our team is we have specific people who work with the patients to set up their MyChart accounts and to walk them through the process of how to get on the video visit and to complete their telemedicine appointment. We are also on call at the time during the clinics to answer any phone calls that the patients may have as they're trying to access it. We’ve been able to field a lot of the troubleshooting things such as microphone use or poor video connection and still be able to complete our appointments as scheduled. Overall our patient reception has been very good to launching our telemedicine program. The patients are eager to try something different, especially if they have to travel a great distance to see us. It helps with interval visits between our in person appointments. I was pleasantly surprised with how many patients were interested in doing telemedicine.

Host:   Well I'm sure they were. As we wrap up, will you still use this after the pandemic? Tell us about the future of telemedicine at the heart center.

Lisa:   100%. We are working every day to fine tune the process and to create openings in our schedules where we can more broadly offer telemedicine clinics throughout the cardiology department and the heart center. As I said, our EP physicians have established clinics three days a week and we’re working to make that more division wide. As a final thought I’d like to add to our referring providers that our telemedicine program is here to stay. What we love most about it is that it’s increasing accessibility to our cardiologists and specialty clinics during COVID-19 and beyond. It also offers an option for patients who may live greater than 60 minutes away for their interval visits between their in person cardiology appointments. We want to let you know that the patients and the referring providers are going to receive the same level of quality of care that they’ve always had with our cardiologists through telemedicine. We think it’s easy to use and an excellent adjunct to our continuum of care.

Host:    That’s great information. What a great program. Thank you so much Lisa for joining us today. To consult with a specialist or to learn more about the pediatric cardiology services at St. Louis Children’s Hospital, please call the children’s direct physician access line at 1-800-678-HELP or you can visit stlouischildrens.org to get connected with one of our providers. That concludes this episode of Radio Rounds with St. Louis Children’s Hospital. Please remember to subscribe, rate, and review this podcast and all the other St. Louis Children’s Hospital podcasts. I'm Melanie Cole.