The University of Alabama at Birmingham Medicine’s Red Mountain Home Dialysis Training Unit is piloting a three-year telemedicine trial for peritoneal dialysis patients, funded by a $180,000 grant from Baxter International. Forty patients speak with their UAB Medicine physician via videoconference from their hometown county health department, where their blood will be drawn and sent for lab testing as part of a “virtual visit”. They will complete six monthly face-to-face visits and another six months of telemedicine evaluations for comparison.
I spoke with Eric Wallace, MD, an assistant professor in the Division of Nephrology and director of the UAB Peritoneal Dialysis Program, about the pilot.
NN&I: Can you provide some background information on you and this study? Do you have any prior experience with telemedicine?
Eric Wallace, MD: I am an Alabama native. I did all of my training at the University of Alabama at Birmingham with the only exception being my nephrology fellowship which I did at Vanderbilt University. After fellowship I came back home and have been at the University of Alabama at Birmingham since 2012.
When I graduated from fellowship, I was given the opportunity to participate in the UAB Home Dialysis program largely based on the circumstance that the director of home dialysis was going on sabbatical to Africa. I very quickly became passionate about home dialysis really because my patients on home dialysis were so passionate about it. It was within the first three months of being at UAB that I noticed that many of my patients drove over an hour each way to see me once a month.
While at Vanderbilt, my home dialysis mentor, Dr. Thomas Golper, had introduced me to a new way of viewing the impact of chronic disease on a patient’s life by showing me the BOLDE study. In this study, quality of life was measured by the Illness Intrusiveness Ratings scale. The idea is that chronic disease not only impacts patients through the direct symptoms of the disease but also in every moment they have to spend caring for that disease.
Home dialysis patients already spend an extraordinary time caring for themselves, and then to add on the time away from family and loved ones spend in waiting rooms and doctor’s offices had to have a negative impact on their overall quality of life. Furthermore, patients on dialysis usually do not just see their nephrologist, they have to go to a myriad of other physicians, thus adding to their burden of disease.
That being said, I decided to try and design a program to reduce the amount of travel time needed to drive to see me for those living remote to the dialysis unit. Hence the telemedicine.
It was easier said than done. Telemedicine, far from being just a “Skype” or “Facetime” visit, as I shortly found out, had a slew of regulations that went with it. It was not reimbursable at the time that I conceived the study. There were HIPPA regulations and compliance issues within a large university setting. There was the issue of where would the patient go to be seen in their home town. I had no experience in telemedicine but over the next three years of trying to design and implement the program, I got a very good education on the matter.
When I designed the program I insisted on two things: 1) Every patient, irrespective of if they had a computer or internet connection, had to be able to participate, and 2) Everything I did in an in-person visit, I had to be able to do remotely. Through the partnership of the Alabama Department of Public Health, DaVita Kidney Care, and the University of Alabama at Birmingham, that is exactly what we did.
The cross over study is designed around this telemedicine model. Patients who are enrolled in the study spend 6 months driving to visits in the standard fashion and fill out quality of life surveys during this time. Then the cross over to the telemedicine arm where they come for an in person visit followed by two telemedicine visits. This is then repeated. The quality of life on the telemedicine arm will be compared to that of the standard of care arm.
NN&I: Why do you think telemedicine is an important option to offer home dialysis patients?
Wallace: Telemedicine is important to home dialysis patients for multiple reasons. In order to answer the question you must define what telemedicine means in home dialysis. For the home dialysis patient I think there are two broad categories that can be applied: 1) Replacing the face-to-face 2) Remote monitoring/ management
Replacing the face-to-face visit with a telemedicine visit would mean improved access to care for those living remotely from their dialysis unit. Furthermore, it should translate into improved quality of life for those patients as they would have to spend less time away from loved ones, job, etc. Finally this may improve outcomes as there would be less tendency to miss monthly visits, so it might lead to more medical oversight.
Remote monitoring, which is the use of Bluetooth-enabled devices such as weight scales and blood pressure cuffs, and now therapy monitoring, may be able to improve quality of life by further reducing the amount of time home dialysis patients need to care for themselves by eliminating the time-honored flow sheet.
Remote monitoring may improve outcomes by providing better quality data for physicians and nurses to review and act upon. It may improve outcomes by reducing technique failure rates and reducing peritonitis rates and relapses. Finally it may reduce cost by allowing for inventory management and reductions in hospitalizations.
All of these are theoretical benefits as there is very little quality data on which to rely when it comes to home dialysis and telemedicine.
NN&I: How does a typical telehealth visit work? Are you using technology in the dialysis machine itself to get information about your patients? How do you receive blood work, blood pressure readings, etc.?
Wallace: In my typical telehealth visit, the patient presents to their home county health department. These health departments are equipped with a telemedicine cart which has a high definition camera for interactive videoconferencing, an encrypted network, a hand-held high definition camera, and a blue-tooth enabled stethoscope.
The patient comes into the room and we discuss how their therapy is doing and any symptoms they may be having. After this we will discuss the data they have kept on how their therapy has been going. These are detailed on flow sheets which are faxed from the county health department to our dialysis unit. After this, I perform a standard physical exam including auscultatory exam of heart, lungs, and abdomen. The patient’s exit site is examined using the hand held, high definition camera. After this, the nurses provide the same nursing and nutrition education that the patient would have received in person. Finally, the patient has their labs drawn, and these are then shipped to the dialysis organization’s central lab. Documentation on the visit is done in the patient’s electronic medical record. Lab values are followed up when resulted and then any changes in medications or therapy are phoned to the patient. So everything that I do in person, can be done remotely.
NN&I: Currently you are using telehealth centers set up throughout Alabama. Can you provide some information on how these centers operate?
Wallace: The centers which I use are the county health departments. I needed a way to provide care in multiple sites. I could have designed my program to have provided some of this care from the home but this would not have allowed me to get monthly labs. Furthermore, not all of my patients had home computers or adequate internet. Thus providing the service in centers across the state made more sense for my patients. Furthermore, by tagging my program onto an existing and growing telemedicine network which was being used for multiple projects, I didn’t have to cover the costs of the telemedicine equipment at each and every center.
What is provided to these centers through the study is the same cost they would bill to insurance in today’s reimbursement scheme. This is called the originating site fee. This fee covers the nursing staff, the phlebotomy, and use of the telemedicine equipment, although the nurses at the Alabama Department of Public Health have been more than giving of their time.
NN&I: There has been some criticism that the Centers for Medicare & Medicaid Services has not designated the home as a certified telehealth center. Do you think it is viable that people can have these visits in their own homes one day? What obstacles prevent that currently?
Wallace: I do think ultimately the home would provide even more freedom and improve quality of life for patients than going to another medical facility. But there are some real barriers to this. First, Internet access is not 100%. A study of the American Community Survey showed that individuals older than 65, those of African American race, and those living in rural areas had less access to Internet and were less likely to have a home computer. These are the demographics that have increased risk for End-Stage Renal Disease.
Furthermore, those in rural areas are the ones currently most in need. There are already pre-existing disparities in the use of home dialysis. So as not to increase disparities if telemedicine were to be used with the patient’s home as a presenting site, I feel that Internet and the equipment needed to provide these visits in the home would have to be provided if the patient didn’t have access.
Perhaps there could be a hybrid model where if you had the equipment and access at home, you could do this, otherwise you still would have the option to go to a medical facility close by.
Another issue with home as an originating site is that the peritoneal dialysis patient still needs blood drawn monthly. Unlike home hemodialysis patients who routinely can draw their own labs, how might a peritoneal dialysis patient accomplish this without going somewhere to have labs drawn? One way would be to train a caregiver in phlebotomy. With advances in technology, perhaps in the future a finger stick may be enough to produce a result for the labs in the patients home, and then have that result transmitted to the home dialysis unit.
Finally, it depends on how much of a physical exam is being done. Interactive video conferencing alone may not be sufficient to be able to determine subtle changes in volume status. For this do you provide every patient with their own blue-tooth stethoscope? Technology will likely decrease the cost and space needed to provide this type of service in the patient’s home.
There would be big benefits to doing a face-to-face in the patient’s home. One would be reducing the patients travel time even further. However, another huge advantage is that there would be no need for third party payers to provide an originating site fee, thus this would cut the cost of providing telemedicine visits.
Finally, a distinction should be made that an originating site is a term that really applies to the physician-patient visit when being billed. Thus all of the above applies only to the face-to-face. Remote monitoring should be and can only be done in the home. Furthermore, should a physician currently wish to see a patient in the patient’s home that can be done now as long as the interactive videoconferencing is encrypted and as long as the visit is not being billed to insurance.
NN&I: Are you currently only seeing peritoneal dialysis patients virtually, or are you also meeting with home hemodialysis patients?
Wallace: It is currently not possible to see home hemodialysis patients in this manner. The biggest reason is that regulations stipulate that the vascular access must be seen in person. Even when the home dialysis Monthly Capitated Payment codes (90963-90966) were adopted in January of 2016 home hemodialysis was excluded because of the need to evaluate the vascular access. Still in the future the hope would be that this barrier too could be overcome. Ultrasounds can be used remotely to evaluate the vascular access. Auscultation of the vascular access can be done remotely. And the thrill can be palpated by the patient or remote health care provided. More studies are needed to evaluate the best ways to examine the vascular access remotely such that home hemodialysis visits can safely be provided in this manner.
NN&I: Imagine there were no payment or policy obstacles. How do you think we could use telehealth for dialysis patients in the next 10-15 years?
Wallace: If there were no regulatory, payment, policy, or technological obstacles, I see telemedicine transforming the way we provide care for home dialysis patients. First, I see that patients would only need to be seen in person quarterly with every other visit being a telemedicine visit unless the patient was deemed unstable. I see the patient’s having improved quality of life because they would not have to sit and wait in a waiting room for a physician. They could merely wait their turn in the comfort of their own home for the home dialysis team to do their telemedicine evaluation. I see the patients not having to fill out flow sheets every day and their data streaming into the dialysis unit and with sentinel events being evaluated early preventing hospitalizations instead of waiting until their monthly visit to be evaluated.
I also see the consolidation of home dialysis care. Four studies have shown that in very small home dialysis units the outcomes are worse than those going to home dialysis units with more than 20 patients. This may be due to the fact that with more volume comes more experience and a greater chance for nurses and physicians to maintain the skills needed. In Network 8 (Tennessee, Mississippi, and Alabama) greater than 30% of home dialysis units have less than five patients. With telemedicine care, may be consolidated into a smaller number of centers, or we can create a hub and spoke model with smaller units such that outcomes can be improved without increasing the burden on patients with ESRD.
Finally, as I also participate in the care of patients with rare genetic diseases most notably that of Fabry disease, rare disease care would benefit from telemedicine. The formation of centers of experience and hub and spoke model should be adopted for rare disease care (In this I include transplant, pediatric subspecialties, and rare diseases) in the United States. These models have already been shaped in large part by the European Committee on Rare Diseases. In the United States we are only starting to form these models of care. However, telemedicine can serve as the bridge across the geographic divide between patients with rare disease and their center of experience.