Bridging Gaps in Patient Access to Rheumatologists With Telemedicine
Telerheumatology can improve healthcare access, patient outcomes, and costs
Although it was previously considered a futuristic concept fraught with practical difficulties, the delivery of healthcare via telemedicine has now become quite common. It is especially popular in the realm of specialty care, including rheumatology, psychiatry, endocrinology, and more. For people who lack access to such care, this model can mean the difference between effective and inadequate treatment – or no treatment at all.
That is certainly the case in Pennsylvania, for example, where the University of Pittsburgh Medical Center (UPMC) has developed a robust telemedicine program now offering approximately 60 specialties to patients in various parts of the state. The program debuted in 2006 with stroke and psychiatry services, with rheumatology consultations being added in 2012.
Telerheumatology Reaches Patients with Limited or No Access
“We started offering telerheumatology because there are several geographical areas where there are UPMC facilities but no rheumatology services, and many patients had to drive several hours to come to Pittsburgh,” said Rohit Aggarwal, MD, MS, a rheumatologist, associate professor of medicine, and medical director of the Arthritis and Autoimmunity Center at UPMC.
Such distance can lead many patients to stop seeing their rheumatologist, resulting in insufficient management of their disease. “There were delays in both diagnosis and treatment of patients, even those with severe rheumatological disorders,” he told Rheumatology Advisor.
Dr Aggarwal's colleague, Christine Peoples, MD, a rheumatologist and clinical assistant professor of medicine at UPMC who conducts the most teleconsultations among the 133 UPMC telehealth providers, notes that an estimated 40% of patients in Pennsylvania who need to see a rheumatologist would end up not seeing one if telemedicine visits were not available. Instead, they can go to one of the UPMC facilities in the western and central parts of the state, where they can connect with one of the specialists at the university via videoconferencing.
“There is a shortage of rheumatologists, both in Pennsylvania and across the country. However, the need for rheumatology care is increasing,” Dr Peoples told Rheumatology Advisor. “Telemedicine represents a solution to provide the much-needed care to those patients who cannot travel 1 to 4 hours to see a rheumatologist. In addition, rheumatology patients have significant mobility issues due to their arthritis.”
In a new study of pediatric rheumatology patients at Children's Mercy Hospital in Kansas City, Missouri, those who saw a doctor from a remote telemedicine outreach site cut their travel distance by nearly two-thirds, missed less time from work and school, and spent less money on food than they would have if they had traveled to the main site.1
Telerheumatology Can Improve Patient Outcomes
Not only does this modality improve access and convenience, it may also improve patient outcomes. In a study published in BMC Musculoskeletal Disorders in April 2016, researchers compared 21 patients receiving intensive treatment via telemonitoring with 20 patients under conventional care.2
The results showed the telemedicine group had superior outcomes vs the conventional group in several areas: a higher percentage achieved remission at the 1-year mark (38.1% vs 25%, P <.01); median time to remission was 20 weeks vs more than 36 weeks for the conventional group; and they had greater improvements in functional impairment (71.4% vs 35%), radiological damage progression (23.8% vs 10%), and comprehensive disease control (19.4% vs 5%).
Dr Peoples sees a variety of patients via telemedicine, most commonly those with rheumatoid arthritis (RA), psoriatic arthritis (PA), osteoarthritis, severe gout, Sjogren's syndrome, and systemic lupus erythematosus (SLE).
She has had numerous patients for whom telemedicine was extremely helpful, including one with severe PA who had not been treated by a rheumatologist for a significant amount of time. Dr Peoples has now been treating the patient for almost 2 years. “He told me he now ‘has his life back' and can play with his children,” she reported. “Another one of my patients went for years without a diagnosis for her symptoms and she now has the correct diagnosis, is on appropriate treatment, and is able to see and play with her new granddaughter.”
Dr Aggarwal, whose telemedicine patients most often include those with RA, Sjogren's, and mild SLE, adds that they see all kinds of patients — except those needing only pain management or a specific joint injection. He describes a patient with severe RA who could not travel out of town for rheumatology care. She “was being treated with steroids and nonsteroidal antiinflammatory drugs (NSAIDs), only leading to joint damage, whereas she needed disease-modifying antirheumatic drugs and a biological drug,” he said. “She significantly improved after starting methotrexate and the subsequently required biological drug, and she is now doing great with her rheumatoid arthritis in low disease activity.”
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 to minimize such inappropriate referrals.3
For Elizabeth Kessler, MD, MS, a pediatric rheumatologist at Children's Mercy Hospital who co-authored the study, 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, 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]