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Telehealth and home dialysis: Opportunities to improve patient care
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Optimism pervades commencement of telehealth, or telemedicine or telenephrology, for home dialysis in 2019 following an unexpected and unusual outbreak of common sense, cooperation and relative alacrity among the federal legislative and executive branches last year. A reimbursement structure has been finalized, large dialysis organizations are developing pilots for implementation and the topic will be widely discussed during the Annual Dialysis Conference in Dallas.
Important topic
We know this is an important topic for nephrologists and the kidney care team: The session covering telehealth at the Annual Dialysis Conference in 2018 was standing room only as was the session at Kidney Week 2017 meeting. At that session, however, Eric Wallace, MD, and a panel of experts laid out the challenges with jumping on the telemedicine bandwagon: burdensome logistics, significant expenses and limited reach of telehealth. Despite laudable and enormous efforts on what telemedicine could accomplish, few left the room anxious to replicate the experience. Patients still had to travel to a defined “originating site” which required the assistance of staff and an abundance of equipment. The reimbursement to the physician also mandated certain geographic restrictions. Further, the ongoing nationwide electronic medical record debacle had many physicians leery of placing more complex technology between themselves and the patient.
These onerous conditions disappeared on Jan. 1 following President Trump’s signature of the Bipartisan Budget Act of 2018 on Feb. 9, 2018. Seemingly, one can now manage patients on dialysis with similar technology most people use on a routine basis in the rest of their lives, perhaps too frivolously (during work) or dangerously (while driving). Now after three initial, monthly face-to-face visits following training, the monthly physician visit may be done subsequently via telehealth in 2 of 3 consecutive months. Further, the dialysis provider may provide adequate technology to the patient without fear of incurring civil penalties for inducement.
Benefits and concerns
The benefit of decreasing travel and time commitments seems obvious for a group of patients and their caregivers who have learned to manage a complex disease state and complicated procedure, assuming the implementation meets certain criteria (see Table 1). However, some dialysis professionals have expressed concerns such as less frequent face-to-face visits, technology, cost, security and decreased multidisciplinary team interaction.
Does less frequent physical interaction in the dialysis clinic or physician office with the nephrologist impact outcomes negatively? Extrapolation from patients with CKD and other chronic illnesses would suggest not. The current monthly home dialysis monthly clinic visit itself is a vestige of reimbursement and legislation. The standard frequency of clinic visits 2 decades ago at both the academic and community centers in Missouri where my nephrology training occurred was to see stable patients on home dialysis — predominantly patients on PD — once every 2 to 3 months particularly when supply delivery to the patient’s home rather than patient pick-up became the norm.
This abruptly changed in 2004 with the per visit payment to nephrologists for care of patients on dialysis adopted by CMS. With few exceptions, nephrologists would no longer get paid for managing the care of patients on home dialysis unless they performed a face-to-face visit during the month with patients on home dialysis.
With the implementation of the bundled dialysis payment system in 2011, mandated by the Medicare Improvements for Patients and Providers Act of 2008, the laboratory visit could no longer be performed remotely for the convenience of the patient and many on home dialysis have made two or more visits to their dialysis center every month since. In sum, the monthly home dialysis clinic visit and clinic laboratory visit are a recent and artificial creation born of regulation and performed in the current manner for economic reasons. This seems counter to the goal of home dialysis.
No study has shown that monthly, in-person clinic visits improve outcomes in this patient population. Nor will one be forthcoming. The opposite is likely true. Few surprises manifest in home dialysis clinic visits. Routine, on-demand contact — by phone, email and texting — with the staff throughout the month is the norm. If a physician encounters a high frequency of problems during monthly home dialysis clinic visits, this should be a warning sign.
Untethering home dialysis patient contact away from a certain time and place once a month where both the patient and the physician must be together expands the immediacy and timeframe of patient care, if not the intimacy. After work? Sure. Early in the morning? You bet. Want to show me the trouble with cannulation? Let’s start 5 minutes before you attempt. Exit site looking red and painful? Let’s take a look. Going out of town next week? No problem. Telehealth may also free time for the staff to make more home visits to patients who are struggling rather than consuming time administering large ambulatory clinics for routine well visits.
Several studies have suggested that only a small fraction of physicians are currently performing or interested in performing telehealth even when remuneration is present. Therefore, the widespread adoption of telenephrology for the patient on home dialysis likely rests not just on availability and income generation, but on two factors not considered by CMS: supplementary services available by the continual presence of connectivity in the patient’s home (see Table 2) and, as alluded to earlier, the extra time physicians and nurses will have away from a rigid ambulatory clinic structure.
I have often told my patients and their families that my goal is to transform ESRD into an annoyance from a disaster. Home dialysis is one strategy for this. Adding telehealth lessens that annoyance.
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- Brent W. Miller, MD, is the Michael A. Kraus Professor of Medicine and clinical chief of nephrology at Indiana University School of Medicine in Indianapolis, Indiana. He is also a member of Nephrology News & Issues’ Editorial Advisory Board.
Disclosure: Miller is a consultant for the Fresenius Medical Services Scientific Advisory Board for NxStage Medical.