Expanding the benefits of telehealth to the clinic

Editor’s note: CMS is developing new regulations that will give nephrologists and other physicians more flexibility in using telehealth to communicate with patients. NN&I talked with Chicago nephrologist David McFadden, MD, about his telehealth clinical trial and what he hopes to accomplish.

NN&I: What first got you interested in telehealth?

David McFadden, MD: I attended a telehealth conference 2 years ago conducted by myowndoctor.com. After the conference, I realized that virtual visits could be integrated into the dialysis clinic. At that time, I was rounding at six different dialysis units with three shifts and two nursing homes with dialysis units. The furthest distance between the units were more than 1 hour. Therefore, a significant amount of my time was being spent driving from one dialysis unit to another. It was difficult to make four visits a month and spend adequate time with each patient. I felt there had to be a better way and virtual visits could be the answer.

NN&I: CMS now pays for four visits a month for nephrologists to visit patients in the clinic. Why make changes now?

McFadden: Hospitalization of [end-stage renal disease] ESRD patients uses a significant amount of Medicare dollars and is a key target in the integrated care demonstration taking place right now. Spending more time with each ESRD patient, I believe, should decrease the hospital admissions.

NN&I: Is it reasonable to expect that both the patient and nephrologist will be happy with the virtual office visit?

McFadden: Over the past 13 months, I have used virtual visits in my dialysis unit. I and my patients have been happy with the increased time spent with each other that virtual visits have allowed. For example, I made morning shift rounds at my breakfast table instead of driving to the dialysis unit to visit my patients.

NN&I: What is the intent of your current study?

McFadden: I hope to prove that for in-center dialysis patients, one face-to-face comprehensive and three non-comprehensive visits via telemedicine, will decrease or equal the end-stage renal disease patient hospital admission rate as compared to four face-to-face visits a month.

NN&I: How will this study be built?

McFadden: In one control group, 15 patients at one dialysis facility will be seen by the nephrologist face-to-face once a month for the comprehensive visit. The remaining three visits will be non-comprehensive using telemedicine. In the second group, 15 patients will be seen by the nephrologist four times a month face-to-face.

NN&I: What outcomes data will you review?

McFadden: At the end of 6 months, we will look for a difference in the admissions rate to the hospital between the two groups. If the telemedicine group admissions rate is equal or less than the non-telemedicine group, this supports that telemedicine can be used in the dialysis facility and should be reimbursed by CMS. This would give the nephrologist more time to concentrate on the sicker patients.

NN&I: How would virtual visits affect the quality of life of the nephrologist?

McFadden: Burnout among nephrologists has gain a great deal of attention recently. Virtual visits to the dialysis unit will decrease the workload and therefore burnout. For example, I can round on the morning shift at six dialysis units and a nursing home without leaving my home. It would take me more than 2 hours to drive to each facility. This can be done for the afternoon and evening shift.

If a nephrology group would designate one nephrologist to round on all their patients a month for three non-comprehensive visits, this would save the group a significant amount of time. Finally, CMS may eventually reimbursed four quarterly face-to-face visits a year and allow the remaining visits to be done by telemedicine. This would have a major impact on how we practice nephrology and therefore improve the quality of life for the nephrologist.

NN&I: Do you have any concluding thoughts on this study?

McFadden: Virtual visits can be integrated in all dialysis units today. I feel nephrologists would welcome telemedicine as one tool in providing better care for their ESRD patients. Hopefully, this study will influence Medicare to reimburse virtual visits in the dialysis unit.