Transforming community cardiology practice to virtual visits: innovation at Cleveland Clinic during the COVID-19 pandemic

The first case of coronavirus disease 2019 (COVID-19) in the USA was reported on 19 January 2020. Over the ensuing months, the virus spread throughout the country and a national emergency was declared on 13 March 2020. There was a significant burden on healthcare services related to the pandemic, with a parallel decline in patients seeking healthcare services for non-coronavirus-related illnesses. There was also uncertainty among healthcare systems to provide non-coronavirus-related care while keeping patients and healthcare providers safe. These circumstances beckoned a rapid transformation of healthcare delivery to provide ongoing care while ensuring safety of both patients and providers. It became pivotal to embrace technological advances, which vastly depended on virtual platforms.

The Cleveland Clinic Section of Regional Cardiology comprises 64 cardiologists practicing at 9 hospitals and 18 outpatient clinics. After a lockdown was declared in the state of Ohio on 09 March 2020 the regional cardiology practice underwent a rapid transition with a commitment to continue providing care to the people of greater Cleveland/Akron area. Between 2 and 18 March, on an average 46 providers saw 427 patients per day, of whom 426 (99.7%) were in-office visits and only 1 (0.3%) was a virtual visit. Subsequent to the declaration of a national emergency, the number of virtual visits increased to 202 (79%) by the end of March and by 17 April, 45 providers saw 340 visits per day of which 325 (95%) were virtual visits (Figure 1).

Figure 1.

Visit breakdown—number of outpatient visits per day in the regional cardiology offices at Cleveland Clinic from 02 January 2020 to 02 July 2020.

The following steps facilitated this rapid transition of services to virtual care.

Frequent virtual meetings of members of regional cardiology practice

Weekly multidisciplinary virtual meetings of all members of the regional cardiology practice were initiated. These meetings had representation from physicians, advanced practice providers, nursing, and administrative staff. The purpose of these meetings was to encourage exchange of information and ideas from all regional cardiology sites. This helped with the identification of successful steps taken at individual sites and paved the way for their systematic application across the entire region. The weekly meetings ensured prompt execution of strategies, and early identification and elimination of pitfalls. This also ensured uniformity across the spectrum of all the regional offices.

Transformation to virtual visits

Administrative assistants with the help of providers and nurses were required to screen upcoming outpatient visit schedule up to 4 weeks for their offices. The purpose of this screening was to classify patients into two categories: appropriate for virtual visits (video/telephone) or need for in-office visits. They were asked to contact the patients via telephone or through MyChart (secure online patient–provider messaging portal) and explain the need to move in-office visits to virtual visits. Patients agreeable to video visits were given instructions to download the video platform used by Cleveland Clinic. Patients who were unwilling for video visits were offered telephone visits. Patients were informed of Cleveland Clinic’s virtual-visit reimbursement policy—bill the patients’ insurance for the visit waiving all personal patient fees. If patients insisted to be seen in person, the provider was asked to assess the need for in-office visit.

Screening for high-risk patients prior to their in-office visits

For patients scheduled to come for in-office visits, we implemented a three-step screening process to identify and appropriately direct high-risk patients. The screening steps were:

1. 1. Nurse screening: Nurses were needed to screen electronic medical record of patients scheduled to come to the office a day prior to their visit. Patients with recent emergency-room visits for flu-like symptoms, fever or elevated white count were contacted via telephone to screen for high-risk symptoms and signs prior to their visit.

2. 2. Patient self-screen: Fliers were attached at the entrance of healthcare centres to help patient’s self-identify high-risk symptoms for COVID-19 infection prior to entering the facility.

3. 3. In-office screening performed by medical assistant: included temperature screening, review of contact history, travel history, and screening for high-risk symptoms and signs.

Patients identified as high-risk were asked to contact their primary care physician and were given an information sheet about testing for COVID-19 infection.

Maintaining the ‘in-office’ experience

There are a lot of steps and people involved to deliver a successful in-office visit for the patient. This includes an administrative assistant to check in patient, a medical assistant to room the patients, perform patient intake, record vital signs, and reconcile medications. The provider then sees the patient and, at the end of the visit, asks the administrative assistant to schedule follow-up appointments and required testing. We implemented the following steps to maintain this flow virtually and keep the in-office visit experience for the patient during their virtual visits (Figure 2).

Figure 2.

Encounter flow—maintaining ‘in-office’ experience during virtual visit. BP, blood pressure; MA, medical assistant; PSS, patient service.

On the day of the virtual visit:

1. 1. Administrative assistant called the patient to check in the patient and verify insurance information.

2. 2. The call was then transferred to a medical assistant who performed patient intake. Whenever available, patients were asked to provide their blood pressure, heart rate, height, and weight using home blood pressure machine and scales. Detailed medication reconciliation was performed and updated in the patients’ electronic health record. Patient was then informed that the provider will contact patient around the time of their scheduled appointment on the virtual-visit platform preferred by the patient.

3. 3. The provider contacted the patient for the visit. Patients were requested to keep a 30-min window before and after their scheduled visit time for the provider to get in touch with them.

4. 4. The provider informed the administrative assistant about the required testing and follow-up appointment. Administrative assistant subsequently called the patient to make these appointments.

Safe practices in the office

To allow for physical distancing Cleveland Clinic required 6-ft distance between patients in the waiting rooms, limiting the number of patients that could be accommodated in the offices. To account for this, patients were informed to come to the office no sooner than 15 min prior to their scheduled visit. Waiting rooms were rearranged to maintain 6-ft distance, while maximizing the number of patients they could accommodate. During check out, patients were given the option to be called back by the administrative assistant to schedule follow-up visits and testing to avoid patients congregating in the office. The office room was cleaned after each visit. Chairs in the waiting rooms were cleaned each time they were used, and all commonly touched surfaces including door knobs and elevator boards were cleaned every 60 min. Disinfectants were used to clean all these areas. All Cleveland Clinic employees and patients were required to wear a facemask. Cleveland Clinic employees were also required to wear protective eye wear.

Conclusions

The COVID-19 pandemic challenged the healthcare system to transform its practices over a short period of time. Both in hospital and outpatient services needed to be modified to continue healthcare delivery to patients. Telehealth and virtual visits became an important method of getting in touch with the patient in the comfort of their homes. We give an example of how a large practice rapidly and successfully embraced such a change and was able to safely and creatively modify practices to ensure optimal patient care. As the COVID-19 virus continues to spread with mutant variants, the healthcare system continues to evolve and innovate to overcome challenges and ensure the best care for patients.

Conflict of interest: none declared.

Data availability

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.