Virtual preparation
Preparation for starting the Cardio-Oncology clinic followed a Virtual-Hybrid Approach (Fig. 1, left). Five overarching factors employing virtual communication methods emerged to ensure the successful launching of the clinic. Team and individual experience and exposure to various areas of interest in Cardio-Oncology were achieved and assessed before and during the pandemic. Far-reaching connections to experts and potential collaborators in the field were developed and exercised. Close contact with the institution launching this clinic was important to determine the resources available; these resources dictated the strategy and potential outcomes of the clinic. Importantly, the expectations of others for the Cardio-Oncology clinic were determined and incorporated. Finally, recognition of the limitations that exist at the destination institution guided care and goal setting.
Virtual inquiry
Before initiating the Cardio-Oncology clinic in the destination institution, existing structures, patient base, and needs in the Heart & Vascular Center as well as the Cancer Center were evaluated, adhering to pandemic protocols (Fig. 1, middle). Pre-existing building blocks for the planned Cardio-Oncology clinic were assessed, and the partner Preventive Cardiology clinic was investigated. We also evaluated characteristics of the cancer center patient population to best position the clinic for success.
Virtual niche-building
Five main aspects of niche-building were pursued. Partnerships with Vascular and Cancer Center physicians, advanced practice providers, and service line leaders were developed to initiate and grow the clinic (Fig. 1, middle). The Cardio-Oncology team and clinic flexibility were demonstrated through openness to taking quicksteps. Presentations were made at Grand Rounds and rounds across the institution in Cardiology, Hematology/Oncology, Radiation Oncology, Surgical Oncology, Internal Medicine, and Family Medicine to promote the clinic capabilities. Collaborative solutions for problems facing fields complementing Cardio-Oncology developed trust and collaboration. Teamwork was developed by leveraging diversity of perspectives and virtual communication technologies, to establish effective patient care despite COVID-19 limitations.
Hybrid care Spectrum
The hybrid F&MCW Cardio-Oncology Clinic was initiated and established in the outpatient setting, in close partnership with the Preventive Cardiology Clinic, Cancer Center, and inpatient Cardiology Consult and Hematology/Oncology teams (Fig. 1, right).
Initial and subsequent visits have been completed in person or by video, with phone visits also available for virtual return visits if patients without adept and available smartphone use have limited ability to appear in person. Virtual patient visits over our first 3 months occurred with the use of telemedicine platforms integrated with Epic (via MyChart for patients and Haiku/Canto for clinicians), or using the Doximity video call function. Patients with in-person appointments are screened appropriately on arrival for signs or symptoms of COVID-19 or exposure, following institutional protocols. Wearing masks is required of all patients, and each patient can be accompanied by a family member; some choose to also wear gloves or face shields. There is sufficient room for maintaining social distancing in the clinic waiting room and hallways.
Innovation
Current innovation in the clinic also includes Virtual Clinician Tools and Virtual Patient Resources (Fig. 2). For clinicians, the links for an AHA CME course on Novel Concepts, Current Debates and Treatment Considerations in Cardio-Oncology, an online Cardio-Oncology Compendium hosting risk assessment clinical decision aids, Cardio-Oncology Drug Regimen and Acronym Databases, and UPTODATE access for reviewing Cardio-Oncology drug information are supplied. For patients, the video from the International Cardio-Oncology Society explaining the Cardio-Oncology subspecialty, American College of Cardiology (ACC) mobile health (mHealth) CardioSmart education app and website, Cancer Heart Talk mini-podcast series accessed via SoundCloud app and website, Cardio-Oncology Frequently Asked Questions, and ChemoCare website are provided for patient-facing Cardio-Oncology and heart anatomy and physiology education, engagement, and awareness. Virtual Resources for Preventive Cardio-Oncology are also made available to our patients. These include the American Heart Association (AHA) Physical Activity Recommendations, AHA Life’s Simple 7 Webpages, American Society For Preventive Cardiology Online Coaching Webpages in partnership with Intervent, and the Become An Ex Smoking Cessation Support Webpages in partnership with Mayo Clinic. The resources are provided in the Epic patient portal MyChart, and more ways to make the resources accessible to a broad and diverse patient population are in development. Future innovation in the clinic will explore contemporary initiatives connecting patients and their safely guarded data with their permission with wearable devices, health information technology, informatics, artificial intelligence, personalized medicine, and additional mobile health (mHealth) applications.
Virtual visit infrastructure and timeline
There was no pre-existing Cardio-Oncology program at the time of launching our de novo Virtual/Hybrid Cardio-Oncology Clinic. The newly recruited Director of Cardio-Oncology was tasked with the responsibility of launching the new clinic, with support from the Heart & Vascular Center clinic administrators, medical director, and Cardiology Division and Department of Medicine leadership. Prior to opening the Cardio-Oncology Clinic, the Heart & Vascular Center initiated virtual conversion then additionally collaborated with Inception Health (MCW’s innovation lab company) over the course of 4 weeks to iteratively develop the clinical informatics infrastructure for virtual visits. The video visits were designed to function using clinician’s personal smartphones, iPads, and tablets, with direct web browser video links from the electronic health record mobile application. Direct video calls through the Doximity mobile application were also approved. Existing Inception Health personnel re-allocated their time in order to adopt and maintain responsibility for the virtual component of all ambulatory clinics across the health system, in partnership with medical and administrative directors of each clinic area, such as the Heart & Vascular Center. No additional costs or hires were pursued to facilitate the development of the virtual visit infrastructure and timeline. Existing resources and personnel were re-allocated to virtual visit design to enable building the virtual clinics in the Heart & Vascular Center. To assist clinicians and billing compliance colleagues, note templates were created for video and phone visits to indicate patient informed consent for virtual visits due to the pandemic, as well as to capture limited appropriate physical examinations, in addition to the amount of time spent on records review and real-time medical counseling.
Initial consults were electronically triaged by either a cardiologist or a cardiology fellow supervised by a cardiologist. Each triage team determined which consults would be appropriate as virtual video visits, versus in-person to occur once the Heart and Vascular Center started re-opening routine physical visits, or whether patients needed to be evaluated urgently in person. During the first week of operation, the brand-new Cardio-Oncology Clinic started entirely virtually with only video and phone visits. As the Heart and Vascular Center re-opened for physical patient visits the following week, from week 2 through the remainder of the first 3 months the Cardio-Oncology Clinic had both virtual and in-person visits integrated throughout each clinic session weekly, based on whether patients were new and whether they had smart device or computer functionality available.
Virtual referral network and process
Cardio-Oncology patient assessment begins within a referral network before the patient arrives at a Cardio-Oncology clinic. Consequently, forming a virtual referral network and enacting a user-friendly virtual referral process was a key component of building the Cardio-Oncology clinic during the pandemic. All referral patterns and networks for our de novo Cardio-Oncology Clinic were built from the ground up. Initial referrals were from within our health system; this quickly expanded to consults from outside of our health system encompassing the entire state. Patients were referred to our Clinic by clinicians or by self-referrals. Some of our local patients connected to us after being introduced to us by their clinicians in other states or through family members in other states who learned about us from their own clinicians or community-based Cardiology society outreach events.
Referrals across the institution and outside of our health system have come to us from the Divisions of Hematology and Oncology, Internal Medicine, Family Medicine, Surgical Oncology/Breast Clinic, and Survivorship Clinics. From the cancer center’s perspective, there may be many “triggers” that would warrant a Cardio-Oncology referral. For example, an abnormal ECG, an abnormal echocardiogram, cardiovascular symptoms, previous cardiovascular history (e.g., coronary artery disease, hypertension, cardiomyopathy) particularly in a patient who previously underwent treatment or is beginning new treatment with cardiotoxic neoplastic medications or radiation therapy and is at high risk of cardiovascular toxicity, or those in preparation for stem cell transplant, or oncologic surgery. Referral protocols were determined based on standard practice, discussions with colleagues in Medical and Radiation Oncology, Hematology, Bone Marrow Transplant, Surgical Oncology/Breast Clinic, Children’s Hospital, Radiation Oncology, Primary Care, and updated literature reviews.
Cancer survivors are at a higher risk than the general population for cardiovascular morbidity and mortality. If a cancer survivor needing to be evaluated is already under the care of a cardiologist, the referring provider can reach out to their cardiologist for guidance on the appropriate CV surveillance. If they do not already have a cardiologist, a Cardio-Oncology consult should be requested. The Cardio-Oncology consult can be placed using a direct Cardio-Oncology button within the universally available Cardiovascular Consult order panel. Referrers can also place a General Cardiology consult and mention the Cardio-Oncology physician by name as requested by the clinician or patient. An E-Consult functionality is also being implemented for those patients who need to be assessed sooner than the next available appointment, or for those patients who may not need a full Cardio-Oncology evaluation, or if referring providers are uncertain. The e-consult can also be placed as a second opinion requested by the inpatient Cardiology Consult team.
The inpatient Cardiology Consult service will continue to directly address inpatient consults from the inpatient hematology/oncology services. The inpatient Cardiology Consult service can collaborate with the Cardio-Oncology Clinic via formal Cardio-Oncology E-consults in the electronic health record Epic if a specific focused question arises regarding Cardio-Oncology relevant to the care of individual currently hospitalized patients that have already been formally evaluated by the inpatient Cardiology Consult service. After a patient has been formally evaluated by the inpatient Cardiology Consult service, if the patient is appropriate for outpatient follow up in the Cardiology clinic with Cardio-Oncology, this should be communicated to the primary Hematology/Oncology service. If appropriate at the time of consultation, the inpatient cardiology consult service can make the follow-up appointment. Oftentimes, this patient population remains in the inpatient setting for several weeks. If this is the case, the Cardiology clinic phone number and clinician information should be provided to the primary service to do so prior to the patient being discharged from the hospital.
Virtual-hybrid multidisciplinary team
It is important to develop a multidisciplinary team and initially focus on allocation of pre-existing resources. Accordingly, some roles among our Cardio-Oncology clinic personnel are shared with other subspecialties. Our virtual-hybrid multidisciplinary Cardio-Oncology Clinic personnel include physicians, a nurse practitioner (NP), a nurse, a research support specialist, medical assistants, pharmacists, administrative assistants, and administrators. All personnel with pre-existing in-person roles and practices re-allocated a portion of their time to the development and practice of virtual visits.
Our clinic and partners consist of board-certified Cardiologists with special training in various cardiac subspecialties (e.g., cardio-oncology, preventive cardiology, heart failure and transplant, electrophysiology, interventional cardiology), who collaborate closely with our cancer experts. Our physicians together specialize in the prevention, diagnosis, and treatment of heart and vascular disorders resulting from side effects of cancer therapy. Our comprehensive team of advanced practice providers, nurses, and pharmacists work alongside our physicians to care for patients from the moment of cancer diagnosis through life’s survivorship journey. The NP typically sees established patients when needed to follow up on imaging, intervention, or diagnostic and management plans, and may also see select new patients. In complex cases, the NP discusses the care of established patients with both the cardio-oncologist and the referring clinician. The nurse assists with patient triage and communications (including addressing patient requests and queries), liaises closely with the nurse practitioner and pharmacists, and educates patients on Cardio-Oncology using virtual materials. Our clinical pharmacists function at the highest level of their advanced training, similar to all clinic personnel, and assist with medication education, review, titration, discussion, and prescription, particularly for heart failure, hypertension, hyperlipidemia, and smoking cessation, as well as commenting on potential drug interactions.
For Preventive Cardio-Oncology, we additionally partner with our dietitians and exercise physiologists to help advise our patients on nutrition and exercise plans, as well as our colleagues in cardiopulmonary stress testing where applicable. Further, in the pandemic, we provide patients with free online coaching options for lifestyle modification (Fig. 2). We also direct patients to AHA webpages with guidance on pursuing ideal cardiovascular health.
Virtual-hybrid patient flow
Once a referral is placed by the designated order buttons in the electronic health record, central schedulers or the Cardio-Oncology Clinic administrative assistant schedule the new patient for a video or in-person visit (Fig. 3). The clinic administrative assistant works closely with our health professionals in our interdisciplinary advanced subspecialty clinic to gather relevant clinical reports and history pertinent to patient appointments. Virtual medical assistants contact patients a few days before their appointments to confirm and troubleshoot virtual connectivity. On the appointment day, medical assistants then ‘room’ patients for virtual or in-person visits by preparing patients for their medical visits (including reviewing medications and in-person or at-home virtual vital signs), and also rechecking virtual connectivity for video visits. The clinician then completes the visit virtually or in-person and introduces the patient to the range of electronic resources available. Following the visit, the clinical administrative assistant arranges follow-up testing and appointments.
Virtual risk assessment
Baseline risk assessment and follow-up start with oncology and primary care [21]. Asymptomatic low risk patients with low-risk treatment plans can have continued assessment and follow-up by oncology and primary care in partnership. Patients who have symptoms, are at high risk based on their history, or are planned for high-risk treatment plans should be referred to Cardio-Oncology for prevention, monitoring, and management recommendations. Recommendations should adhere to society expert consensus, scientific statements, and guidelines for prevention, surveillance, and survivorship, and optimize CVD risk and medications [21]. A putative risk score based on medication-related and patient-related risk factors can be used to guide monitoring and management recommendations for most Cardio-Oncology patients [22], and can be used in a virtual clinical decision aid (https://tinyurl.com/CardioOncCDA) (Fig. 4). Specific risk scores are also available for adults treated with anthracyclines, trastuzumab, or other drugs, or for adult survivors of childhood cancers [9,10,11,12,13].
Virtual management algorithms
Evidence-based management algorithms have been selected or developed as adjunctive resources for inpatient teams. They are available online in a virtual collection for use in the inpatient setting by the inpatient Cardiology Consult service or hematology/oncology teams to assist with diagnosis and treatment of cardiovascular toxicities from cancer therapies or cancer itself. The algorithms cover cardiomyopathy from anthracyclines or trastuzumab, planned chemotherapy with pre-existing cardiomyopathy, neurohormonal therapy or dexrazoxane for cardioprotection, myocarditis, persistent malignant pericardial effusion, hypertension, surveillance after radiation therapy or drugs that cause ischemia, malignant pericardial effusion, and other salient topics frequently encountered.
Virtual community engagement
The local, regional, national, and international community was virtually engaged via social media posts on Twitter (using #MCWCardioOnc on @DrBrownCares or @PrevCardioOnc), podcasts hosted by the MCW CTSI (available on iTunes, Google, and Apple podcast platforms), Heart Success podcast series, and Cancer Heart Talk brief 15-min mini-podcast series (available on SoundCloud). Perspectives were also published for international community engagement in the Women Heart Alliance newsletter, as well as on the AHA Early Career Blog, ACC Women in Cardiology Blog, CardioOncTrain.Com Blog, and PrevCardioOnc.Com Blog. Virtual continuing medical education (CME) presentations were also given at the Wisconsin state ACC annual conference meeting, Midwest ACC annual conference meeting, Southeast ACC annual conference meeting, Brazilian Cardio-Oncology Symposium, and the Ohio State Cardio-Oncology CME conference, then subsequently at the AHA and ACC annual national scientific sessions.
Distribution of patient data
In our multi-subspecialty clinic visits (virtual and in-person integrated and combined; n = 182; 136 new and 47 returns), approximately 50% of patient visits were in Cardio-Oncology, 20% were in Preventive Cardio-Oncology, and 30% were in General Cardiology (Fig. 5a). Overall among Cardio-Oncology visits, 65% were in person, consistent with early and safe clinic re-opening in a hybrid model, with 19% by video and 16% by phone, with the fraction by phone decreasing over time as patients and clinic personnel became more adept with troubleshooting video. Of new patients, 77% were in person, and the remainder by video. No Cardio-Oncology patients presenting in person developed any signs or symptoms concerning for COVID-19.
The most frequent cardiovascular diagnosis or indication for referral was cardiomyopathy (34%) (Fig. 5b). Other diagnoses included decrease in global longitudinal strain, diastolic congestive heart failure, hypertension, myocarditis, dyspnea, chest pain, palpitations, survivorship, risk assessment, and pre-bone marrow transplant, among other cardiovascular diagnoses or visit indications. The most frequent cancer drug was trastuzumab (29%) (Fig. 5c), managed according to a novel algorithm developed in our de novo Virtual-Hybrid Cardio-Oncology Clinic based on the recent publication indicating the safety of continuation of trastuzumab for left ventricular ejection fraction of 40% or greater [23] (Fig. 6). The second most frequent cancer drug was anthracycline (24%). Other drugs included, tyrosine kinase inhibitors (TKIs), immune checkpoint inhibitors (ICIs), endocrine therapies, and investigational therapeutics, among others. The most frequent cancer type in our clinic was breast cancer (42%) (Fig. 5d). These trends in cardiovascular diagnosis or indication and cancer drugs or types were similar in assessments of virtual visits alone, with the most frequent being cardiomyopathy (43%), trastuzumab (41%), and breast cancer (44%), respectively. The findings of similar cardiovascular and cancer distributions in virtual versus in-person visits indicated an optimal qualitative return on resource and personnel investment.
Imaging and medication titration
In our clinic, a distribution of cardiovascular diagnoses determines the imaging needed for each patient (Fig. 5b). Therefore, a number of imaging modalities are useful to our patients (e.g., echocardiography, computed tomography with or without angiography, magnetic resonance imaging, coronary angiography, myocardial perfusion imaging). Our most frequently used imaging modality is echocardiography. The frequency of obtaining echocardiograms has depended on each patient’s condition and cancer treatment. A substantial portion of patients coming to us on trastuzumab have needed an echocardiogram every 1–3 months, depending on the extent of adverse effects on left ventricular ejection fraction (LVEF) or strain In these patients, medication titration has occurred approximately every 2 weeks, and for very symptomatic patients with volume overload, they have often been seen weekly..
In our management algorithms, early referral prior to the onset of symptoms has been emphasized, especially in cancer patients or survivors with a history of cardiovascular disease, cardiotoxic neoplastic agents, or a high risk of cardiovascular toxicity. This has provided an opportunity for us to assess and discuss ways to optimize the benefit to risk ratio of continuing with the current cancer treatment plan, and more importantly how and when to put cardioprotective measures in place to facilitate safe cancer therapy. Such discussions have also resulted in closer monitoring. Some conditions have warranted proceeding to other modalities of non-invasive imaging, such as cardiac MRI if myocarditis is suspected. For cases in which coronary artery disease is suspected, our patients undergo functional assessment of their coronaries with a stress test or anatomical assessment with a coronary CT scan or invasive coronary angiography. In our practice, only exercise stress tests were halted due to the pandemic. Every other form of imaging including rest and stress echo, as well as MRI and nuclear medicine have remained readily available for those with cardiovascular toxicities or individuals considered to be at moderate or high risk. This allowed us to adhere to pre-pandemic imaging recommendations tailored during the pandemic to limit imaging if possible to those who are at higher risk for cardiovascular toxicities or who have already been diagnosed with these adverse effects [1,2,3,4] (e.g., Fig. 6).