Editor's Note: While on-site at the American College of Rheumatology 2014 Annual Meeting in Boston, Massachusetts, Medscape spoke with Daniel L. Albert, MD, professor of medicine and pediatrics at Geisel Medical School, Dartmouth College, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, about his experience treating patients in rural New Hampshire using telemedicine, particularly those patients with musculoskeletal complaints that require a thorough physical exam.
The Rise of Tele-rheumatology
Medscape: There is a lot of interest in telemedicine these days, and you have experience using it to assess and manage patients with conditions that might not easily lend themselves to remote management, specifically patients with musculoskeletal disease. What has been your experience with telemedicine in these patients?
Dr Albert: We have been doing it for several years now. We have learned what we should have known from the beginning, but it is certainly clear to us now that it is a very doable proposition. You need relatively minimal equipment—basically just video conferencing equipment. The only major limitation is the educational level of the presenter, which is usually a nurse. That individual needs to be trained to be able to evaluate the physical examination components that we pay attention to as rheumatologists—for example, joint counts and tender points.
If you have a knowledgeable presenter and a willing patient, most of the time it goes very well. Under optimal conditions, in about 80% of the patients we see, we could do at least some of their care by telemedicine. If you have a patient who is very noncommunicative or from whom it is difficult to elicit a good history, then it becomes more troublesome. Some patients object to it because they just want a hands-on approach.
The "hybrid model" has worked best for us, in which there are several telemedicine sessions and an in-person session, which helps individuals who are still confused about (or are not yet comfortable with) the technology. The hybrid approach works and is actually the major way that telemedicine is being used around the country. Telemedicine is new for the rheumatology community, but it is not new for internal medicine or family practice.
Medscape: How widespread is the practice of telemedicine, and specifically tele-rheumatology?
Dr Albert: Places that do a lot of telemedicine are those that have large rural areas, such as Alaska. In Alaska they do it differently, with non-nurse, non-physician health-promoting individuals, but that is not going to be the model for rheumatology. Telemedicine is also being practiced in Canada, but they use physicians as the presenters. That won't work for the United States either, because physician time is too valuable to use them in that kind of ancillary role. Places in the Midwest use an approach that is similar to ours. In North and South Dakota, they have the hybrid model, although they don't yet incorporate tele-rheumatology.
The Patient's View
Medscape: How have the patients responded? Are there certain patients who tend not to prefer telemedicine, or in whom it isn't appropriate?
Dr Albert: Most patients who participate really like it, and it does not discriminate by age. Some of the older individuals really like it. They are used to Skyping with their grandchildren and are quite comfortable with that technology. Some of the younger people don't like it, so it doesn't really discriminate on an age basis or a gender basis.
If the patient is extremely complicated, or if there are additional data or nuanced findings that we can only obtain from a physical examination, we don't use this approach. But I am in Hanover, New Hampshire, where we have patients driving 2-4 hours each way to see us, often in bad weather, and it is literally impossible to get to us. For them, it becomes the only solution to the problem, not just a temporizing solution. It is going to be greatly used in the future.
Medscape: Is telemedicine covered by insurance?
Dr Albert: There are some billing issues. Many commercial insurances won't pay for it. Medicare will pay for it, but Medicare doesn't compensate very much. So it may be a financial difficulty for some medical centers to engage in this.
It doesn't require much in the way of startup money. The technology is available in most medical centers that have videoconferencing. You can't use Skype because it isn't HIPAA compliant, but you can use some proprietary videoconferencing software. The one we use is Vidyo®, but there are many of them.
Logistics of Tele-rheumatology
Medscape: Can you take me through the logistics now that we are talking software? Do patients make an appointment, and then you, your nurse, or whoever is the host do this out of your office? How does it work?
Dr Albert: It is doneat my office with my own computer, with a little button television camera (similar to GoPro®). It sits on top of my computer, and I have Vidyo software on my computer, with a telephone hookup to another video computer wherever the patient is being seen. By and large, the patients are being seen in their local hospitals or doctor's office. They come in, and the nurse registers them, takes their vital signs, does their medication reconciliation, and collects any other background data that we need. The nurse comes on the screen and gives me all the data, and I type it into our electronic medical record (EMR). The nurse then brings the patient in, unless the patient is already sitting there, and we talk, and I record the data. I make some recommendations, and then the patient leaves and I finish up and document the encounter. The encounters are shorter than normal encounters because they don't include much physical examination. Instead, we have good data that confirms the diagnosis the vast majority of the time. Very infrequently is the wrong diagnosis made with telemedicine.
There are times when we cannot make the diagnosis and the patient needs to see us in person, and sometimes we can't make the diagnosis even when we do see them. We have been able to start disease-modifying drugs and antirheumatic drugs in a substantial number of patients, and rarely have we had to change them. That validates that we can do this in a reliable way, which was a concern for many people. We are always apprehensive about making a mistake. Patients need to be reassured that mistakes are rarely made.
You have to get used to it. We are starting to have our fellows attend the videoconferencing with us to learn how to do it. There are a couple of methods you use. You can have the patient stand up. You can have the patient wave his or her arms and make a fist to validate the clinical findings. You can ask questions about opening doors and jars, and things of that nature, which, along with the history, can circumvent the need to do a physical exam.
Medscape: When you offer recommendations or make a diagnosis through telemedicine, do you recommend that patients see a doctor (or you) in person as soon as possible?
Dr Albert: This is an ongoing issue. We only ask patients to come back for an in-person evaluation if they want it or if we feel uncertain about the diagnosis. That happens in only about 20% of the patients we see. The others are followed longitudinally. Some people think that the first evaluation ought to be an in-person evaluation, but we do our first evaluations through telemedicine, and it hasn't been a problem. However, I can understand the comfort level for some providers in seeing patients initially in person, and then following them with telemedicine. You can do it both ways and evaluate how well it works.
If we are uncertain about what is going on, we ask them for an in-patient evaluation.
Telemedicine Visits at Home?
Medscape: You said that most patients go to their local medical centers or to some kind of office to participate in telemedicine. For people who are in extremely rural areas, can they do this from home, assuming they're able to acquire the software?
Dr Albert: Yes. I think that is where it is going. We will definitely want to have the visiting nurses equipped with the technology and have them go to the patient's home, set it up, and do the visit on a one-on-one basis.
I don't expect that patients will have the kind of protected software that is needed to do this on their own. It is proprietary and costs money. Who is going to pay for it? It will have to be done in a supervised situation in some way, shape, or form, but it doesn't have to be done in a medical center. It can be done with a visiting nurse and a simple laptop. All I have to do is boot up a few different pieces of software: an EMR, and in some cases the EMR of the institution where the patient physically is. Keep in mind that if the patient is across state lines, you have to be licensed in the other state. That is important. I set it up so that I can see myself as well, to make sure that the patient can see me and that the camera angle isn't cutting off my head. Telemedicine might not be for someone who is totally computer-illiterate, but it isn't that hard, either.
Medscape: Can you take me through your study? What were your objectives and what did you find?
Dr Albert: Our fellow, Dr Zsolt Kulcsar, is working toward an MPH degree and came up with this study. He looked at our institutional telemedicine encounters, including those in which the diagnosis was changed. He looked at the encounters in which we prescribed certain medications and whether we continued those medications or had to change them. He looked at patient and physician satisfaction scores. He has a lot of data, some of which was presented in the poster, showing that tele-rheumatology has increased access to effective arthritis care in rural regions.
Medscape: Is there anything about rheumatology that either lends itself to telemedicine or that makes it more challenging in terms of interactions with patients and the specific conditions you are dealing with?
Dr Albert: Rheumatology is one of the last fields that one might consider for telemedicine because we are so hands-on. This was a demonstration project, showing that even the most clinical exam–dependent subspecialties can do this if they do it with the right infrastructure. It is a good example of how broad the reach of telemedicine can be. It is very empowering for patients, many of whom are very challenged by getting to major medical centers—physically, economically, or because of time and distance. A big problem in rheumatology is access. We have 3-month waiting lists. Telemedicine dramatically increases our ability to care for more patients.
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Cite this: Does Telemedicine Work in 'Hands-on' Specialties? - Medscape - Dec 03, 2014.