MODERATOR: Welcome to Mayo Clinic COVID-19 Expert Insights and Strategies. The following activity is supported in part by an independent medical education grant from Pfizer, Inc., and is in accordance with ACCME guidelines.

RAVINDRA GANESH: Hello. Good evening, and welcome to another episode of Telehealth Basics Online. This is Dr. Ganesh and Dr. Hurt, and we're going to talk about telemedicine management of COVID-19 positive patients.

RYAN HURT: [INAUDIBLE] we neither of us have a disclosure that's relevant to the current talk. So our objectives-- so after you participate in this online CME, so objective one is to discuss why telemedicine lends itself to the care of COVID-19 patients. You should be able to recognize the potential role of the multidisciplinary team in the virtual management of COVID positive patients, and then looking at and examining the use of remote monitoring technology in the virtual care of COVID positive patients.

So one of the things that we think about is, how did other countries respond to these early days of the COVID pandemic? And so clearly, one of the interesting examples of this is, how did we respond in the United States versus other countries, like South Korea? The reason it's interesting is because both countries had their first real confirmed cases of COVID, January 20th, 2020. So we're going to show some progression here as of July 9th, 2020. So there are some differences obviously-- US population's about 330 million.

As of July 9th, we've had over 3 million confirmed cases, and then death-wise in that per population's 9,000 approximately per million. And then deaths, we've had about 135,000 deaths, and about 410 per million. So when you compare us with South Korea, a population of about 51 million-- and remember, South Korea is a more densely populated country-- 13,000 confirmed cases, right? Versus what we have, and it's 260 per million versus almost 10,000 per million. Deaths have been 288 deaths confirmed-- only six per million.

So really the question is, why the differences? And so you see here on this graph-- so this is March 6, 2020. Again, both countries had cases early on. Remember, thinking that Korea has that population density that's very high. So they clearly had a lot of early cases in March-- and we can see that here in the blue lines, Korea. And we recreated this-- USA is that lighter blue. So next slide shows what's happened. So this is March 17th, pretty quickly. Korea's cases actually started to level off, March 17th 2020.

In the United States, that's when we started to have some of our increase in cases, right in the middle of March. So what's happening today, and probably in the near future here, is this-- in the United States, we have seen an exponential rise in cases, and Korea has really flattened the curve to absolutely nothing. So the big question moving forward is, why the differences? So a question for you to think about here, just to kind of get some active learning going on-- which of the following is not a critical part of an infectious disease pandemic response?

Not-- remember, not part of it. So A, targeted testing of symptomatic patients only; B, rapid response to positive testing; C, quarantine isolation of positive cases, also with known exposure as well; D, contact tracing; or E, population compliance with public health measures? So give me a few-- I'll give you 10 seconds here to think about that and think about your answer. Dr. Ganesh, what do you think? There you go. So targeted testing of symptomatic patients only. So clearly, we know COVID has a significant asymptomatic population, and so this would not be a critical part of ID pandemic response.

So back to that question I asked earlier is, why have other countries been more successful than the United States? So if you think about the health care systems in other countries, a lot of these health care systems in Germany, in Taiwan and South Korea, are more centralized health care systems in general, so they have centralized ability to respond to positive tests, but also, they have a centralized system of testing, right? Testing is widely available in some of these countries.

They have centralized health care system. And the other key is, when they do tests, the results are available within 24 hours, right? So a lot of times, here in the United States, we've been hearing that it's taken five, six, seven days for patients that have been positive to get their results back, and they may not have been educated about good quarantine practices when they got the tests to begin with. So they may be out, you know, living normal life, exposing all kinds of people to it before they even get the test results back.

The rapid response-- this is one of the key things that Dr. Ganesh is going to show on the team that he is managing, is rapid response. Once the test is positive, the patients need to be notified immediately-- and in these countries, in these centralized systems, they've been able to get the test back within 24 hours, and then respond quickly to the patients, and then obviously quarantine them, right? So if you get the results back in 24 hours, you reach out to them, you quarantine them, and isolate these cases. That allows for the contact tracing to be effective.

They've shown in lots of modeling that, if you do not get the contact tracing done in the first 24, maybe at the most 48 hours, contact tracing is very difficult, right? So once we rapidly test individuals within 24 hours, get the test results back, respond to the positive cases, quarantine them, then we can effectively trace those positive cases. If you go beyond a few days, the ability to act accurately and effectively trace becomes virtually impossible. And the other thing is compliance-- clearly, the United States-- you know, some of this has been polarized by politics, but compliance to masking protocols, compliance to other things has been difficult in the United States, where other countries, it has not. There's a question 2-- I'm going to let Doctor Ganesh do question 2.

RAVINDRA GANESH: So what we did is we tried to create a centralized team based on the gaps that we identified based on our study of differences between South Korea and America, and I'd like to ask you guys what you think one of the benefits of having a centralized specialized team is-- A, the flexibility to rapidly enact changes; B, to ensure expertise and best practices of care; C, ensure standardization of patient care so that we don't have pockets where people are getting either better or worse care; D, to streamline the communication system, thereby reducing hand offs and errors; or E, all of the above? Going to give you guys 10 systems as well, and then we'll talk about what this all means.

So the correct answer as per me is all of the above, and we designed a team to respond to coronavirus positives called the COVID Frontline Care Team. And this was, in our institution, a group of general medicine physicians and nurses to manage these outpatient COVID-19 positive patients. We were developed in conjunction with Infectious Disease, who helped us with identifying what needed to be done, and then we operationalized that. We continually met to reassess the best available evidence and to ensure that we're providing the best standard of care we could to these patients, and we also reassessed our process to make sure that we were doing it the best way that we could.

We collaborated with the remote patient monitoring group here-- and this is a key distinction between telemedicine and telehealth in that we were able to provide patient monitoring, and actively manage these patients from home-- and to date, we've managed over 2,500 patients with COVID in an outpatient telemedicine setting. So what do we do exactly? We focus on those topics that we identified as things that are necessary for an effective public health response. As soon as we get the results, we tried to notify patients, and often, we get this done within six hours.

Being the group that gets all of these positive results, we can often see patterns, and we report centrally clusters of either employers or places people have been, or commonalities, so we can further investigate those. We real-time notify our infection control department to minimize spread of COVID within the hospital and clinic, and for potential investigation thereof; and also occupational health, because as you can imagine, medical professionals are high impact individuals where it comes to spreading coronavirus.

We also have a surgical team that we prescreened their patients for, just to make sure that, when we're intubating someone or doing any other air flow generating procedure, that these people are tested and are not coronavirus positive. If someone tests positive, we try to interrupt their itinerary and refer anything that's non-emergent. If it is emergent, it would get done under adequate maximal personal protective equipment. We also monitor these patients in an outpatient setting because we know that folks with coronavirus can get sick.

It often follows a fairly predictable pattern, which we'll talk about later, and we have vital sign monitoring to catch these changes. We also follow people who have been in the hospital and have the potential to continue to be compensate in the outpatient setting, and we coordinate retesting and release from isolation. And the fact that we have all of this done within one group, with good communication, clear guidelines, really eliminates a lot of error. We're highly integrated. We integrate with the folks from infectious disease, kind of helping to do diagnostic pilots of both testing, and also to investigate appropriate intervals between care or isolation.

We do education with our CFCT RNs to make sure patients get the right information about how to isolate, how to prevent other people from getting infected, and also what symptoms to look out for that could be dangerous to them. When people have symptoms, they have a number to call us, or they'll alert on the remote monitoring, and we can triage their escalation and care to either the emergency department or to an urgent care department, thereby conserving resources.

A lot of times, we can evaluate these people over the phone and recommend symptomatic management, and keep them out of a health care setting. This is vitally important in terms of both conserving PPE as well as reducing the risk of infection to health care workers. Being a central group, we also provide a hub of patients for research and that, if someone would like to research our coronavirus patients, there the whole IRB and group devoted to this, but we do provide a central window for patients to get into research studies and other things like that.

We mentioned earlier our role in identifying clusters, and we pass these on to the public health department for appropriate investigation and control; and then we do do some amount of isolation, return to work, and return to campus for patients who may be at higher risk-- for example, if you're immunocompromised or if you've had-- if you need to have a surgery or air flow generating procedure. We do this on a more granular level by having one of our MDs or-- we're getting some nurse practitioners to do a virtual visit with a patient.

So once you get the results saying that you're positive for coronavirus, one of us calls you, and we ask questions about any urgent warning signs that would require you to be seen immediately. If you have any of those, you're going to be triaged to the ED or to an urgent care clinic; and then we also assess symptoms which gives us an idea as to the severity of your coronavirus disease. We can do this at two times, either at a time of positive result notification, or two days after discharge when we check on people to ensure that they're not having recurrence of symptoms or any worsening that would make them need to go back in.

The next touchpoint is from nursing, for education and symptom assessment, and this is actually one of the most important parts of our program because there is so much misinformation out there on both the media and the news, and we have our nurses check in with our patients a couple of times. And last, we provide 24-hour medical coverage with an MD, so if the patient calls in and alerts our nursing, someone's available to offer triage as to whether the patient can stay home or if they need to be seen urgently.

Looking at our population, we're covering the Rochester and Mayo Clinic Health Systems patients, so we're covering most of Minnesota, the western part of Wisconsin, and the northern part of Iowa. Out of our first 828 patients, we found a fairly even distribution between females and males, and also the ethnicity was a little bit different from the statewide figures. If you look at the statewide figures, about 90% of Minnesota is not Hispanic or Latino; but in our population, actually 20% of our patients were Hispanic or Latino, and this actually reflects the early impact in the meatpacking plants in the state.

And down here in the state, it kind of covers our spread-- Wisconsin, Iowa, Minnesota were the majority of our patients. The other thing we do when we interview people on that initial MD call is to assess their risk factors. Over the six months or so that we've known the coronavirus, there's been a lot of work done to kind of assess what risk factors predict worse outcomes. So here's a list of all the things we ask for, and as you can see, there's kind of a wide range of results.

Things we found the most commonly in our patients are-- older age being a risk factor, diabetes being a risk factor, asthma, and current smoking. So the question arises as to why [INAUDIBLE] monitoring these patients? Can we just see them and release them? Well, it actually all kind of correlates to how this virus operates. So COVID is actually biphasic in terms of how it operates. In the first week, there is this whole viral syndrome-- fever, cough, runny nose, fatigue, nausea, vomiting, diarrhea. It is very similar to the flu.

Most people recover and do absolutely fine. In the second week however, kind of starting around the seven-day mark, folks may develop shortness of breath, and this seems to be an immune-driven phenomenon against both the heart and lungs. The shortness of breath can worsen, and often, hypoxia precedes actual patient reporting shortness of breath, and we've seen this multiple times on our remote monitoring; and it can get severe enough to require people to go to the ICU, with the average ICU admission time being somewhere from 12 to 18 days after initial symptoms.

And they often wind up on mechanical ventilation, and that often happens between 15 to 19 days, so it's a very delayed phase from the initial infection, which is why we have to monitor these people going forward. Looking at our population of the initial 828 patients we had, we sent 138 to the ED for evaluation, and 55 of them got admitted, and tend to be once again in that kind of higher risk group between age 40 to 80. One of the things that we do is, we use remote monitoring technology to kind of create a hospital-at-home approach where patients are monitored and checked in on without actually being in a health care setting.

So this allows them to both isolate and be taken care of. I'm not going to go too much into detail here, but there's a picture of the kit that we use. It's a Honeywell kit, and they send patients all of this. So they have a tablet that can record your vitals, and all of these devices are connected via Bluetooth. There is a blood pressure cuff, there is an oxygen sensor, there's a thermometer, and there's a scale. In the grand scheme of things for our patient population, the two that we found to be the most important are the thermometer and the oxygen sensor, because these vitals are the ones that really predict patient decompensation.

In the interactive care plan, which is a lower level of monitoring for people who are not quite as high risk, we allow them to access a questionnaire via the Epic My Chart, and what they do is, they record their symptoms and vitals twice a day. We provide them with a nonmedical grade thermometer and oximeter. From our internal data and experience, these people tend to do a lot better, and we don't have quite as many escalations from this group. Looking at our overall team, we have a census from June 22nd, and these were the patients who we're actively following.

So we're following about 850 patients here, of which 435 were being followed with a non-technology arm, with just the initial call from the physician and the calls from the nurse for follow up. In the technology arm, we had 178 on the actual intense remote patient monitoring; and 250 were being followed by the low intensity monitoring, the interactive care plan. And by doing this, we actually made it so that we could use fewer resources to manage these patients-- we managed 850 patients with pretty good monitoring.

And if you were to do this in an inpatient service, this would be the equivalent of somewhere about 30 teams. Instead, we're able to do it with remote monitoring, 24 nurses, and four doctors, and provide a pretty good job doing that. I want to go back just a second here. This practice is scalable, and when we started off, we had very few patients-- we actually started with about 50 total, and we've been able to ramp it up over the course of the months as COVID has become more prevalent in the Midwest.

And we have the ability to scale this up if we get to 1,000, 5,000 patients. We just need to add the appropriate amount of resources to staff it. Another part of what we do is, we look at the data. And this is our intrinsic data board, where we kind of log the risk factors of symptoms and demographics of our patient, as well as kind of where these outbreaks are occurring. And this is Rochester, there's Minneapolis, and it kind of shows you where people are having more outbreaks.

Say for example Austin was to have an outbreak-- their dot would be getting bigger, and that'd allow us to focus more detail on what's going on there, and to call their local public health department with whatever insights we come across. So in conclusion, telemedicine is really suited to the care of COVID-positive patients. Lots of advantages. It can reduce infection transmission, it allows us to assess for decompensation using remote monitoring, and either triage them to stay at home with supportive care or get them to come in for the appropriate level of care, whether it be the emergency room or an urgent care setting.

By doing this, we're reducing emergency medicine utilization and leaving the ED for patients who need it. We're conserving personal protective equipment in a time when personal protective equipment is a valuable and scarce resource, and we're using our nurses to the fullest extent of their license to take care of this larger group, so we can efficiently conserve our physician resources and allow for care of a large group of patients by a small group of physicians. And our nursing resources have been our greatest help in this. I'm going to turn back over to Dr. Hurt for a little bit so he can talk about a few more of the practice related impacts of this practice.

RYAN HURT: So thanks, Ravi, and just some comments too about how Dr. Ganesh and our team has really responded to this pandemic, right? So one of the other important points is across the country right now, you know, primary care practices have been struggling, and you know, and so I think this is one of the areas that just shows how primary care physicians-- and we're general internists and general internal medicine, nursing staff-- have partnered with infectious disease.

Because early on in this, when they approached us to form this team, IB was trying to accomplish these tasks, and it is clear there was a lot fewer of them than us, and so I think this really shows how a general internist in a time of crisis and in the pandemic has really shown how flexible we are as internal medicine physicians, as well as nurses. And so we've been able to respond, and have been able to use our skills as both outpatient doctors as well as inpatient doctors, to be able to take care of these patients at a very high level.

And as Ravi, Dr. Ganesh, pointed out, really have been able to prevent overutilization of the hospital resources. That slide's perfect, showing how we've used a few physicians, you know, times three or four nursing staff, and to be able to take care of a significant number of patients and using remote monitoring when the patients are at risk, keep these patients at home-- and really that hospital-at-home sort of philosophy has been really something that's been novel.

The question is, you know, as telemedicine is really prior to COVID really hasn't taken off, and I feel that the pandemic has shown all the value of telemedicine. Initially, I can just tell you as the vice chair of the practice here in general internal medicine, I really was kind of skeptical of telemedicine, you know, prior to COVID. We had some ability to contact patients, but really, I think that the pandemic has shown its value. We've been able to connect with patients, we've been able to reassure patients, we've been able to risk stratify patients, and we've done this completely using telemedicine.

And an important point is, obviously, we've been able to keep us safe here, talking to patients, and be a distance and using telehealth. So I think hopefully this will really show the value and accelerate its use in the future, and we're learning how we can apply this to other practices as well. So for instance, when we're bringing patients to come here to our institution, perhaps reaching out to them before they even come, doing a brief history, figuring out-- how can we optimize, you know, who they see while they're here, like subspecialty care, and trying to help optimize their appointments, getting to know them early on.

And that can actually help with our efficiencies as well in our clinic, and it's certainly something that can be scalable to other practices. Telehealth's an emerging industry for sure. Their projections are at least $30 billion in 2020-- I expect obviously that to be a lot more. And I think one of the biggest questions we all have, as we conclude in this talk, showing you how we implemented telemedicine, is you know, what's going to happen to regulation in the future? Are we going to be able to go back after COVID, which is certainly a ways away, but can we go and actually implement a lot of these strategies we've learned and put that in the future of medicine?

Is the government going to allow us to do that? Are they going to ease some of the state-to-state restrictions we had? I've read some good things, and thought about, you know, are we going to eventually just have a unified license that allows us to practice across state borders? These are things that I think, questions that are important that are going to have to be answered, and I think, by us providing data and showing our successes, will help with some of that. I do think telemedicine has a role in the future. We'll figure out where best it is outside of COVID, and hopefully the government regulations will allow us to pursue these opportunities without significant restrictions.

RAVINDRA GANESH: I want to echo what Dr. Hurt said about telemedicine being the wave of the future. In the last six months, we've accomplished more with telemedicine and creating use guidelines across state lines than we have in the previous 10 years, and I hope that COVID continues to be a catalyst for development of a more remote management system. And this will be particularly useful in other spheres-- for example, patients who need home visits, because they're not mobile.

For example, patients who we see here at a destination medical center, and they have to go home. Do they have to come back to see us, or could we have a video visit with them to make sure they're still doing OK? And I really enjoyed the opportunity to participate in this talk, and I'm sure Dr. Hurt did as well, and we can't claim to be experts on telehealth-- we're learning as we go, but we hope you enjoyed hearing our experience in how we created this program.

[INTERPOSING VOICES]

RYAN HURT: Thank you. Sorry, Ravi. Yeah, thank you, and certainly reach out if you have questions. But thanks for the opportunity.

RAVINDRA GANESH: Thank you.