Separating tele-rheumatology 'hope' from 'hype' in the COVID-19 era
Telemedicine exploded during COVID-19 lockdowns, but there are sure to be challenges sorting out the technological, legal and logistical hurdles to suit the reality of more widespread tele-rheumatology programs post-pandemic, according to a presenter at the 2020 Congress of Clinical Rheumatology-East.
Daniel A. Albert, MD, a rheumatologist at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., described telemedicine as “cumbersome” in the pre-COVID-19 era. “I hope it is not as cumbersome as before,” he said. “But as for the hype surrounding it now, there are some virtues and some limitations. We need to understand what it is good for and what it is not good for.”
One area where tele-rheumatology will be most beneficial is in rural, hard-to-reach, or otherwise underserved populations, including military members who are constantly moving, according to Albert. It may also have utility when a rheumatologist in a poorly served area retires and an expert farther afield must take over his or her patients until a replacement is found.
To that point, though, there is one problem that tele-rheumatology may not solve: workforce shortages. “We just do not have enough rheumatologists,” Albert said. “There are whole states that do not have a pediatric rheumatologist.”
Regulatory considerations
Another consideration pertains to credentialing and licensure for long-distance or interstate visits. “The provider needs to be licensed and credentialed at the origin site, or the ‘hub,’ and at the patient site, or the ‘spoke’,” he said.
A companion issue to credentialing and licensure pertains to billing. Whether patients are billed based on the hub or the spoke, or both, is a multifactorial equation that is currently marked by uncertainty.
“Documentation of the visit is required at both the hub and spoke sites, which complicates the issues as well,” Albert added.
Electronic medical records present yet another huge hurdle that must be overcome not just by rheumatologists, but by health care systems around the country. “Entirely compatible EMRs would be a great improvement,” Albert said.
Albert offered a final warning about increases in telemedicine use: that a large-scale malpractice suit is almost unavoidable. “It is only a matter of time before providers get sued,” he said. “It is the American way.”
The good news is that regulators are working on these issues. “There is a movement in Congress for telemedicine to be extended nationally,” Albert said. “There are about 20 bills in Congress right now that are pushing to allow telemedicine to persist after COVID. A lot of the regulatory barriers have been dropped.”
Patient perspective
Turning to patient concerns, Albert noted that many individuals — particularly older patients — are uncomfortable with technology. In addition, older patients may also struggle with vision or hearing, which could complicate communications via phone or tablet.
That said, Albert has found that patients feel more comfortable in their own homes and, consequently, are less inhibited about showing or describing their symptoms. This, in turn, can have a beneficial impact on patient show rates for visits. “More people will come to the doctor if the doctor is coming to them,” he said.
Patients also can benefit because telemedicine is cheaper, with no copays or travel expenses to account for.
Regarding clinical issues from the doctor side, Albert stressed that tele-visits will not reduce the anxiety that rheumatologists feel about potentially missing a symptom or making an incorrect assessment of a patient’s status. “The nature of rheumatology is that you are always anxious because the concepts we deal with are always abstract,” he said.
Ultimately, Albert was realistic that some sort of hybrid model — meaning, a combination of virtual and in-person visits — is likely to emerge in the post-COVID era. “You are going to need to see patients in person some of the time,” he said.
This being the case, Albert says if Congress can effectively revamp the rules in the post-pandemic era, both rheumatologists and their patients may ultimately benefit. “This is one of the few good things that have happened since COVID,” he said.
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Albert DA. Telemedicine in Rheumatology. Presented at: Congress of Clinical Rheumatology-East annual symposium; September 10-13, 2020 (virtual meeting).
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