By the time Christine Peoples, MD, examined the patient, the middle-aged man had suffered for years with severe psoriatic arthritis without proper medical care.
Mobility limitations made it difficult for the patient to travel, and gaps in his care had worsened his condition. But thanks to a two-way screen at the University of Pittsburgh Medical Center (UPMC), Dr. Peoples was able to assess the patient through telemedicine, resulting in targeted medication and follow-up treatment.
Without telemedicine, the patient would have likely continued to deteriorate, said Dr. Peoples , a rheumatologist who practices at the Arthritis and Autoimmunity Center at UPMC Bedford Memorial Teleconsult Center in Everett, Pa., and the Arthritis and Autoimmunity Center at UPMC Northwest Teleconsult Center in Seneca, Pa.
“Now, he’s able to go back to work,” Dr. Peoples said. “He’s able to focus on his life, instead of day-to-day pain with no solution in sight. It’s really nice to reach patients who truly need the services of a rheumatologist in a serious way. [Through telemedicine], we are providing academic rheumatology care to patients regardless of where they live.”
Across the country, more rheumatology practices are employing telemedicine to treat patients, particularly physicians at academic medicine centers that have the resources to launch comprehensive units. The technology is a way to bridge the shortage of rheumatologists in rural areas and reach patients who cannot access specialty care for rheumatic conditions, proponents say. A 2013 study in Arthritis & Rheumatism found that many smaller micropolitan areas have no practicing rheumatologists, with some patients having to travel more than 200 miles to the nearest rheumatologist ( 2013 Dec;65:3017-25 ).
Telemedicine is growing by leaps and bounds, and rheumatology is a key specialty in which to use the technology, said Jonathan Linkous , chief executive officer for the American Telemedicine Association.
“Telemedicine is growing rapidly,” he said. “Clearly, it is expanding both in terms of the number of consultations and the breadth of services involved. For example, tele-rheumatology was certainly not a big area to be looked at in years past, but it’s one more area that is starting to expand.”
Research is lacking regarding how prevalent tele-rheumatology has become in the United States and whether it’s as effective as face-to-face visits. In a recent analysis of 1,468 potentially eligible tele-rheumatology studies and literature, only 20 addressed direct provider to patient contact that influenced or had the potential to influence clinical care, according to a November 2016 review in Arthritis Care & Research ( doi: 10.1002/acr.23153 ). Of the 20 studies, the majority of articles involved tele-rheumatology use in Europe or Great Britain, said study author John Allen McDougall, MD, a postdoctoral fellow at Yale University, New Haven, Conn. According to the literature, the most common condition treated through telemedicine was rheumatoid arthritis. Little information existed on telemedicine use for gout or the treatment of connective tissue diseases, Dr. McDougall said.
“The first major finding was that there’s really not much out there as far as high quality research that supports or contradicts the use of tele-rheumatology in wide distribution,” Dr. McDougall said. However, “in general, the conclusion of the authors was a qualified, ‘Yes,’ that [tele-rheumatology] has potential and should go forward.”
Increasing access, saving time
UPMC has operated a tele-rheumatology program for nearly 3 years that connects rural patients with their specialists. Teleconsult centers located in underserved areas within western and central Pennsylvania serve as central bases for patients to undergo a video examination. On the other end of the screen, Dr. Peoples uses high-level audio and video technology to discuss the patient’s history, direct nurses, make diagnoses, answer questions, and prescribe treatment to patients.
“Patients comment about how much easier it is for them and what a difference this makes in their health care,” Dr. Peoples said. “[Tele-rheumatology also increases] the ability to have regular follow-up care. I see them every few months for their condition and manage it. You can really establish a long relationship with patients just as you would if you saw patients in person.”
At Dartmouth–Hitchcock Medical Center (DHMC) in Lebanon, N.H., rheumatologists are achieving similar results through telemedicine use.
The medical center’s tele-rheumatology unit began in 2011 in collaboration with a critical access hospital with the aim of increasing specialty access for patients in northern New Hampshire. Dartmouth also operated a telemedicine clinic from 2012 to 2013 in southern Vermont after a well-established rheumatologist retired and the search for another specialist was underway.
Between October 2011 and December 2014, 176 patients were seen via tele-rheumatology between the New Hampshire and Vermont sites over the course of 244 tele-rheumatology patient visits with Dartmouth providers, according to a study published in the June 2016 Seminars in Arthritis & Rheumatism ( 2016 Dec;46:380-5 ). Patients lived on average 99 miles from DHMC and 22 miles from the remote clinic site, the study found. The top diagnosis for patients during the tele-rheumatology visits was inflammatory arthritis.
During the study period, Dartmouth tele-rheumatology services saved patients an estimated $26,938 on travel for consultations and allowed patients to save an average of 200 driving miles per session. Physicians reported being satisfied with the encounters 57% of the time, according to the study. However, providers reported that 19% of the patients seen via tele-rheumatology were inappropriate for the visit type, largely because of unclear underlying conditions and cases that were too complex.
For the vast majority of doctors and patients studied, the tele-rheumatology visits were positive and aided patient access, said Daniel Albert, MD , section chief of rheumatology at DHMC and a tele-rheumatologist.
“There are some limitations, there’s no question about that,” he said. … [However], right now there are way too few rheumatologists to care for patients with rheumatic disease. We’ve tried to improve that with [nurse practitioners and physician assistants], but this is another way of addressing that need.”
A number of pediatric rheumatologists are also using the benefits of telemedicine. Children’s Mercy in Kansas City, Mo., launched a pediatric rheumatology telemedicine clinic in 2013 that links children in Joplin, Mo., with rheumatologists at Children’s Mercy, about 160 miles away. Patients treated via telemedicine at the Joplin site missed less work and school and saved money on food, compared with traveling to Kansas City for treatment, according to a 2016 study published in Pediatric Rheumatology ( doi: 10.1186/s12969-016-0116-2 ).
“This is much more convenient for patients,” said Elizabeth A. Kessler, MD , a pediatric rheumatologist at Children’s Mercy and coauthor of the study. “It saves them time and money. With the training of the tele-facilitator, I believe that we’re able to provide them with equivalent care compared with if they were in-person.”
Is tele-rheumatology right for all settings?
But tele-rheumatology may not be appropriate in all practice settings or the right method for all rheumatology patients, doctors say.
As the Dartmouth-Hitchcock study noted, patients with complex diseases or unclear underlying conditions do not make good candidates for telemedicine visits. In addition, opinions are mixed about whether physicians and patients should have an established relationship before telemedicine visits occur and what such visits should entail.
Anchorage, Alaska-based rheumatologist Elizabeth Ferucci, MD , uses telemedicine for follow-up patient care only. Like many rheumatologists in Alaska, she travels to field clinics in larger communities throughout the state twice a year to treat patients, said Dr. Ferucci, a rheumatologist for the Alaska Native Tribal Health Consortium. Because some patients need to be seen more than twice a year, Dr. Ferucci conducts follow-up visits every 2-3 months via video.
“For rheumatology, we began using telemedicine video teleconsultation for follow-up of patients in remote villages or rural communities in early 2015,” she said. “We use it for follow-up visits, and the main goal is to avoid the costs and inconveniences associated with patient travel for a simple follow-up visit.”
However, Dr. Ferucci notes that having a trained telemedicine presenter capable of performing a joint examination in the room with the patient is not always possible because of high staff turnover and the more than 200 villages served. Often the two-way video includes only the patient and physician.
At Dartmouth-Hitchcock, Dr. Albert’s practice accepts both initial and follow-up patient visits. He acknowledges that tele-rheumatology is best used for follow-up care, but explains that limiting the center’s telemedicine use would leave some patients without treatment.
“Because the constraints of getting to Dartmouth are so great, we don’t want to impose that restriction on patients,” Dr. Albert said. “However, in general, it is preferable to do an in-person consultation first to clarify the physical findings.”
Dartmouth has used both nurses and medical assistants as presenters during tele-rheumatology after developing a web-based training video series targeted at presenter education. Nurses at UPMC are also trained as telemedicine presenters, and telemedicine visits are only used for follow-up care, Dr. Peoples said.
At Children’s Mercy in Kansas City, telemedicine visits are restricted to follow-up care and include a nurse facilitator at the virtual site. However, the type of conditions and stages of disease examined through the technology has grown since the telemedicine services started, Dr. Kessler said.
“What we feel comfortable seeing has expanded since the time we initially started the clinic because some of the patients, when they were having flares, could not come to Kansas City for financial reasons,” she said, adding that she has since examined children with lupus, vasculitis, and active arthritis through telemedicine.
She stresses that in-person visits should depend on the patient, the circumstances, and the physician’s comfort level.
”You need to be realistic,” she said. “There are times when I’ve said to families, ‘I would like you to come to Kansas City because I’m a little unsure about your exam findings.’ There are definitely some patients who do more of a hybrid approach where they come to Kansas City and are also seen by telemedicine.”
Barriers slow telemedicine progress
Amid its benefits, challenges for tele-rheumatology, such as reimbursement and licensure obstacles, remain.
Currently, commercial insurers pay for telemedicine at varying rates, making it difficult for doctors to consistently be paid, Dr. Peoples said.
“A lot of insurance companies do cover telemedicine visits, but still, a lot don’t,” she said. “I do think that in order to remain competitive, insurance companies overall are going to have to start covering these services.”
At least 32 states and the District of Columbia have parity laws that require commercial health insurers to cover services provided through telehealth to the same extent as those services are covered in person, according to an Aug. 15, 2016 Health Affairs policy brief. However, how private insurers pay and what services they cover vary widely.
Likewise, Medicaid reimbursement for telehealth largely depends on individual state Medicaid programs. Under Medicaid, only 9 states reimburse for store-and-forward services, while at least 16 states have some sort of Medicaid reimbursement for remote patient monitoring, according to the Health Affairs report. Medicare payment for telehealth meanwhile, is clouded in restrictions. The Centers for Medicare & Medicaid Services reimburses for synchronous communications only and does not cover store-and-forward services or remote patient monitoring for chronic diseases, except in Alaska and Hawaii. The patient must be present at an originating site for the visit and cannot be home to receive the services. In addition, CMS reimburses for telehealth only when the originating site is in a Health Professional Shortage Area or within a county outside a Metropolitan Statistical Area. In 2016, CMS expanded its coverage of telehealth to include several new codes including, end-stage renal disease–related services for dialysis, advance care planning services, and critical care consultations furnished via telehealth using new Medicare G-codes.
It’s worth noting that rheumatologists who are salaried employees of academic medical centers, as is the case for all rheumatologists interviewed here, don’t handle the billing for their telemedicine services, and so have not experienced the payment challenges that smaller practices may face.
Mr. Linkous of the American Telemedicine Association believes that reimbursement for telemedicine will improve as health care heads toward value-based payment systems.
“In terms of reimbursement, with the move away from fee-based systems to value-based systems, it really opens the door because for many of the services, you no longer write out a bill with a code associated with it,” he said. “You are paid on the basis of keeping people well. That’s a great positive incentive for using telemedicine.”
Differing licensure requirements across states also are a challenge for doctors practicing telemedicine. The process to obtain licenses and navigate varying credentialing processes can be a headache for health providers and delay approval.
The barrier has led to model legislation by the Federation of State Medical Boards ( FSMB ) that aims to make it easier for telemedicine physicians to gain licenses in multiple states. Under the Interstate Medical Licensure Compact , physicians designate a member state as the state of principal licensure and select the other states they wish to gain licenses within. The state of principal licensure then verifies the physician’s eligibility and provides credential information to the interstate commission, which collects applicable fees and transmits the doctor’s information to the other states. Upon receipt in the additional states, the physician would be granted a license.
As of January, 18 states had enacted the compact legislation, and at least 4 states had introduced the legislation. In 2015, the Health Resources and Services Administration awarded the FSMB a grant to support establishment of the commission and aid with the compact’s infrastructure.
A new normal for the future?
Dr. Albert notes that tele-rheumatology programs can succeed only with adequate resources, time, and staff.
“To set up Skype or Facetime on Apple is nothing; you just click on it,” he said. “To set up tele-rheumatology requires a fair amount of administrative substructure that has to be generated in terms of who’s going to do the documentation? Who is going to do the billing? Who is going to do the credentialing? Where is the credentialing going to be validated?”
The equipment required for telemedicine visits also requires a significant amount of time and regular maintenance, Dr. Peoples said. At UPMC for instance, the tele-rheumatology program has an information technology team that assists with technology glitches, changes, and updates, she said. That’s why it’s helpful to have the support of a large academic medical center with the sufficient resources to build a telemedicine program, she added.
In order for more practices to consider tele-rheumatology, more research about cost-effectiveness and best uses of the technology use would be useful, Dr. McDougall said.
“The main question that policy makers are going to want to answer is, ‘What’s the return on investment? Does this make sense for my practice?’ ” he said. “The methods reporting in tele-rheumatologist [literature] is lacking.”
But regardless of barriers, telemedicine experts say the technology will likely continue to expand and transform the way rheumatologists are practicing and patients are receiving care.
“Tele-rheumatology will never replace an in-person exam,” Dr. Ferucci said. “But my vision is that it will be able to improve the quality of care for patients living in rural and remote locations, by allowing for more frequent visits and adjustment of medications, which are necessary to achieve the goal of treat-to-target for RA and other rheumatologic conditions.”
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