A study at Dartmouth-Hitchcock Medical Center, which provided telemedicine services to the predominantly rural populations of Vermont and New Hampshire, showed that although patient and provider satisfaction with the model were high, approximately 19% of patients seen via telemedicine were not appropriate candidates, either because of an unclear diagnosis or substantial disease complexity. This suggests the need for triage mechanisms that minimize such inappropriate referrals.3
For Elizabeth Kessler, MD, MS, a pediatric rheumatologist at Children’s Mercy Hospital who co-authored the study there, the training of the clinical “telefacilitator” — often a nurse — at the patient site influences the types of patients she will see remotely. “For example, the nurse facilitator who I work with spent time in the rheumatology clinic learning how to perform a joint exam and distinguishing between active and inactive arthritis,” she explained.
“Using her examination in addition to what I am able to visualize, I feel comfortable making changes in patients’ medications. If the facilitator did not have this training, seeing such patients and making treatment changes may not be appropriate.”
Barriers and Solutions
Whereas the benefits of telemedicine are clear — including improved access, outcomes, and patient satisfaction, and lower costs, for example — there are also multiple potential barriers. Insurance reimbursement is one of the primary issues, although progress has been steady if sluggish in this area. “Currently 29 states have mandated that commercial insurance cover telemedicine encounters. However, rates of reimbursement vary and depend on where the patients are located for the visit, what services are covered, and the type of provider who is seeing the patient,” and such variability can be a deterrent, according to Dr Kessler.
Dr Peoples agrees that inconsistent insurance coverage can be challenging and anticipates that “most insurance companies will need to cover telemedicine services in order to remain competitive as choices for patients. Some patients can also advocate for telemedicine services to be covered, and that can be helpful when it is coming directly from the patient.”
Another drawback inherent to the modality is the possibility that technological problems may arise. Although Dr Peoples does experience these occasionally, the responsive IT support team for telemedicine is able to resolve such issues promptly. Additionally, she points to challenges related to the doctor not being present to examine patients in person. Similar to Dr Kessler, however, she provides ongoing training to the remote nurses regarding the physical exam.
During the teleconsultation, she is on the screen talking with the patient during the entire visit. “I perform the history, direct the physical exam in real time, discuss the diagnosis, and review in great detail the treatment plan,” she explained. “Patients are given ample time to ask me any questions they may have, and they are also given informational handouts after the visit, both about the disease and the medication.”
Despite the success stories, skeptics remain. “Reservations among rheumatologists exist about whether visits can be effectively conducted via telemedicine. Therefore, future research needs to address the ability to perform an accurate musculoskeletal exam via telemedicine,” said Dr Kessler. “Comparing process and outcome measures between patients seen in traditional in-person clinic visits versus those seen by telemedicine would be another way to ensure that telerheumatology visits can provide high-quality care.”
Dr Peoples emphasized the need for continued efforts to expand insurance coverage of telemedicine services. She and her colleagues are “currently working to outline specific outcome measures for rheumatology in the context of telemedicine, and we are also working with other telemedicine specialties to improve how we deliver telemedicine care to our patients.”
Dr Aggarwal touched on considerations pertaining to physicians’ motivation to offer teleconsultations: “Another issue is – Why would rheumatologist do telemedicine if they are busy in their own clinic due to the national shortage of rheumatologists? So there should be some incentive for them to do this,” by offering better reimbursement, for example, or allowing the physician to work from home.
“Telemedicine reaches patients who are in dire need of rheumatology care,” said Dr Peoples. “It is extremely rewarding to take care of patients in this setting because you have the opportunity to make a tremendous impact since many of them would otherwise not see a rheumatologist.”
Summary and Clinical Applicability
Telerheumatology can improve healthcare access, patient outcomes, and costs, although it presents several potential obstacles. Expanded insurance coverage of this modality will be necessary to greater numbers of patients in need of specialty care.
- Kessler EA, Sherman AK, Becker ML. Decreasing patient cost and travel time through pediatric rheumatology telemedicine visits. Pediatr Rheumatol Online J. 2016;14:54. doi:10.1186/s12969-016-0116-2
- Salaffi F, Carotti M, Ciapetti A, et al. Effectiveness of a telemonitoring intensive strategy in early rheumatoid arthritis: comparison with the conventional management approach. BMC Musculoskelet Disord. 2016;17:146 doi:10.1186/s12891-016-1002-2
- Kulcsar Z, Albert D, Ercolano E, Mecchella JN. Telerheumatology: a technology appropriate for virtually all. Semin Arthritis Rheum. 2016 Jun 3. doi:10.1016/j.semarthrit.2016.05.013 [Epub ahead of print]