Telemedicine and Nephrology: The Slow Revolution Continues

Almost 25 years after the Texas Telemedicine Project, one of the first major telemedicine initiatives, we are still trying to determine where and how telemedicine fits into modern nephrology.

Increased access to care is just one of many potential advantages of telemedicine. However, at a time of increasing healthcare costs, policymakers and payers ask, “What is the added value?” Furthermore, debates about acceptable means of providing telemedicine care rage on. Legal battles waged between providers of telemedicine and state medical boards have provided further hesitancy on the part of physicians to incorporate telemedicine into their daily practice. Many of the concerns surrounding telemedicine could take another 25 years of study to answer. However, for many patients, telemedicine is not needed for mere convenience or easy access to treatment for sore throats. It is needed to extend substandard access to subspecialty care, as well as expanded treatment options, and it is needed now.

Telemedicine has been primarily used to bridge geographic disparities in access to care, and has been focused mainly on provision of care in rural areas. Approximately 25% of the US population lives in areas considered rural, and rural location has been associated with increased incidence of end stage renal disease (ESRD). Thus telemedicine provides a means to improve access to care where the need is greatest. Luckily, the rural patient is considered the most appropriate recipient of telemedicine visits. In large part, Medicare and Medicaid already cover telemedicine for standard outpatient visits for this population, as do many other private insurers in states with existing telemedicine parity laws. Telemedicine for this population not only serves to increase access to subspecialty care, but also increases the comfort levels of rural primary care physicians who are otherwise practicing in medical deserts with little to no subspecialty support.

While standard outpatient subspecialty visits are covered, coverage of home dialysis follow-up visits is another story. Prior to January 2016, there was no coverage of any telemedicine visits for the home dialysis population. The 90963-90966 outpatient home dialysis codes appeared in January of 2016 as a covered telemedicine code for Medicare. Unfortunately, this coverage excludes home hemodialysis patients (or even peritoneal dialysis patients) with a vascular access as it is stipulated that an in-person face-to-face visit must be provided to examine any vascular access. Still, acceptance of the 90963-90966 codes by the Centers for Medicare & Medicaid Services (CMS) represents a large step for telemedicine in the provision of rural peritoneal dialysis.

Rural patients are the natural focus of telemedicine services, but should rural areas be the only focus of telemedicine? For many patients living remotely from care but in a metropolitan area, the answer is no. Certain super-subspecialized care might only be achieved in tertiary referral centers or university settings. Patients who might fall into this category include those with rare diseases, pediatric nephrology patients, and transplant recipients. These patients currently have no option for telemedicine. Furthermore, for the elderly and those with limited mobility of all ages living in metropolitan areas, telemedicine might limit non-emergent ambulance transport to and from clinic visits and improve the ability of these patients to make appointments that might thwart frequent hospitalizations. This feature of telemedicine is even more applicable for the home dialysis patient population with limited mobility. Unfortunately, owing to CMS’s geographic restrictions on telemedicine, patients such as these do not have access to telemedicine services. Thus a large barrier for many applications of telemedicine lies in the removal of the rural restrictions on telemedicine services.

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Improving quality of care

Telemedicine may be a means to not just improve access to care but to also to improve quality of care through remote monitoring and by facilitating the creation of centers of expertise. Already remote monitoring—such as Bluetooth-enabled blood pressure monitors and weight scales—is being used to improve our ability to manage hypertension, for example. Furthermore, the chronic care management code (90940) allows for reimbursement of remote monitoring in select populations. Notably, however, ESRD is excluded from coverage.

Remote monitoring for the home dialysis patient may provide the means to truly have an impact on outcomes such as hospitalizations. Systems providing real-time evaluation of vital signs and real-time therapy monitoring provide a means to intervene with patients to avoid hospitalizations for hypertensive emergencies and volume overload. Remote monitoring, however, is not without its issues. With remote monitoring comes the need for increased nursing and physician time. Only human or computer analytic interpretation of data and intervention paired with remote monitoring can have an impact on outcomes. Furthermore, questions about liability regarding remote monitoring remain. Carefully designed studies to determine appropriate clinical algorithms that maximize outcomes without overwhelming both nurses and physicians with a massive influx of data are needed to guide the use of these exciting technologies.

Telemedicine may also improve quality of care by serving as a way to link centers of expertise with the patients they serve. Certain types of super-subspecialized care might be best achieved by centers of expertise. In this way, adequate staffing, multidisciplinary teams, and continued education can allow patients to receive cutting-edge care. However, patients may only be able to take advantage of centers of expertise if they can make the commute to one. Telemedicine may serve to bridge this gap, thus enabling centers of expertise to ensure patient access.

The designation of “rare” in the US is defined as affecting fewer than 200,000 patients at any one time. By this definition, home dialysis could also be considered rare. It has been shown in 4 separate studies that larger home dialysis units achieve better outcomes for their patients than smaller units. Much of the advantage of larger units is thought to result from their ability to maintain adequate patient volumes, allowing dialysis staff and nephrologists to hone the skills and knowledge required to care for this relatively small group of patients. Still, a large percentage of home dialysis units have fewer than 5 patients. Telemedicine may provide a means by which smaller home dialysis units might benefit from nursing and physician expertise in larger units to improve patient outcomes. However, currently a home dialysis unit is not a covered originating site according to the Centers for Medicare & Medicaid Services.

Telemedicine may further increase uptake of home dialysis modalities by improving patient comfort and knowledge regarding the modality via tele-education, engagement, and care coordination. More confident providers and patients should be the result of telemedicine-enhanced communication

Much has changed since Jack Moncrief, MD, one of the primary drivers of the Texas Telemedicine Project and pioneers in home dialysis, began the Texas Telemedicine Project. At the time of the project, telemedicine cost over $50,000 per site for capabilities that now can be achieved using technology that many carry in their pockets every day. But the revolution is far from over. Should the patient’s home be considered an originating site? Must each site be required to have the capability to do a full physical exam? How can a telemedicine clinic be incorporated into an already busy physician schedule? What are the liabilities?

The questions don’t stop there. The Kidney Health Initiative (KHI) Workgroup project on Advancing Technologies to Facilitate Remote Management of Patient Self-Care in Renal Replacement Therapy aims to develop an understanding of and solutions to these issues.

The dream of Dr. Moncrief is literally at our fingertips with a new age of smaller, faster, and much less expensive technologies. Opportunities to improve patient care, and access to that care, must be harnessed. It is our obligation to patients to accelerate and through experience guide this slow revolution that holds so much promise to improve their lives.