Telerheumatology: A technology appropriate for virtually all

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Abstract

Background/purpose

Telerheumatology services were developed at Dartmouth–Hitchcock Medical Center (DHMC) to bring specialty care to New Hampshire (NH) and Vermont (VT) where a large proportion of the population lives in rural areas (60%) with limited resources and access to care. We sought to learn what challenges and accomplishments our early telemedicine program has encountered since inception.

Methods

As part of a quality improvement initiative we performed an IRB-exempt retrospective review of patients seen in the telerheumatology clinic at DHMC from October 2011 to December 2014. We also interviewed the participants; including providers, presenters, and patients regarding their experience of care. We assessed both patient and provider satisfaction with the experience.

Results

Between October 2011 and December 2014, 176 patients were seen via telerheumatology between two clinical sites over the course of 244 telerheumatology patient visits. The top diagnosis for patients during the telerheumatology visits was inflammatory arthritis (n = 156, 63.9%). We found 19% of patients to be inappropriate for the visit type for the following two main reasons: the underlying diagnosis was unclear or the disease was too complex.

Conclusion

The use of telerheumatology has successfully increased access to specialty care in rural regions of NH and VT with good patient and provider satisfaction. While telerheumatology improved the access to specialty care, consideration should be given to selecting the appropriate patient for this visit type given that 19% of patients were deemed inappropriate. We propose a triage mechanism to ensure that patients are appropriately paired to the proper visit type in the future.

Introduction

Access to specialty medical care has been, and continues to be a major issue faced by people living in rural settings [1]. One of the major barriers to timely rheumatology care in New Hampshire (NH) and Vermont (VT) is the fact that a large proportion of the population lives in rural locations (60% and 68%, respectively). Access to timely care for patients with inflammatory arthritis is crucial as delays in treatment can lead to irreversible joint damage and subsequent disability. The delay of such therapy by even a few months can result in accumulation of damage which can make the possibility of remission more difficult to achieve [2]. In an effort to overcome the current barriers to access to Rheumatology care, Dartmouth–Hitchcock Medical Center (DHMC) has begun to capitalize on the technology of telemedicine to improve patient access to Rheumatologists for patients living in rural New England.

The field of telehealth has seen explosive growth in the United States due to the need for improved access and coordination of care, coupled with improving technologies [3]. Telemedicine is not a completely new idea or new technology, in fact, several health care systems have been utilizing this technology for years. The role for telehealth has been best established by health systems that service vastly rural areas in an effort to improve access to medical care [4]. The use of telerheumatology has been adopted by several health systems with little published literature on their experience. Guidance for best practices specific to Rheumatology has come from countries outside the United States such as Canada, United Kingdom, and Australia [5], [6], [7], [8], [9], [10]. While these studies try and establish a framework for telerheumatology clinics, the insight and recommendations are not easily transferrable to practices in the United States, as the model of care delivery is variable depending on the setting and often differs from countries abroad.

While telerheumatology continues to expand, it is vital to thoroughly explore both the benefits and challenges associated with this new modality. If we fail to understand the limits of this new technology, we risk poor patient outcomes and satisfaction. In this study, we sought to better understand the quality of care provided via telerheumatology and explore the role of presenter education, and patient appropriateness for telerheumatology.

The presenter is the person who is with the patient in the remote site and facilitates the visit. The presenter׳s level of training is variable and can range from a community health care worker, to a nurse, or a physician. The international models rely on the general practitioner׳s musculoskeletal (MSK) examination proficiency, which is generally considered to be the highest level of presenter skill. In the United States, the presenter is often a member of the clinical staff other than a physician, such as a Registered Nurse (RN), Licensed Nurse Assistant (LNA), Medical Assistant (MA), or health coach.

Dartmouth–Hitchcock (D–H) is a nonprofit academic health system that serves approximately 1.2 million patients in northern New England with Dartmouth–Hitchcock Medical Center (DHMC) as its main campus in Lebanon, NH [11]. DHMC is a 385 bed tertiary care facility that houses multidisciplinary clinics, including the Rheumatology department. Telerheumatology services at D–H have been provided by three rheumatology attending physicians and was initiated in partnership with a Critical Access Hospital which we will refer to as Site #1, in late 2011. The goal of this new program was to improve specialty access to Rheumatology care in northern New Hampshire׳s Coos County, where the nearest Rheumatologist is located more than 65 miles away. After an initial pilot with Site #1 over the course of 18 months, DHMC added an additional telerheumatology site in Southern Vermont (VT) which we call Site #2. The need for DHMC to provide Rheumatology care was created when a well-established Rheumatologist at Site #2 retired with a practice of over 1000 patients. Given our recent experience with telemedicine, we sought to manage the new practice mainly via telemedicine, with two additional in person clinics per month.

While we had some experience providing rheumatology care via telemedicine, and both positive and negative anecdotal experiences, we lacked insight into our patient population׳s experience with telerheumatology care. As such, we launched a quality improvement (QI) project in mid-2013 to better understand the cohort of patients we were serving, and to identify challenges and opportunities for improvement. We sought to better understand the gaps in care using telerheumatology and improve upon our program before expanding to additional sites.

Section snippets

Patients and methods

We evaluated both telerheumatology clinics at Sites #1 and #2 using a clinical microsystems approach to quality improvement (QI). A third year rheumatology fellow participating in an institutional QI initiative performed semi-structured interviews with physicians, presenters, and patients. We assembled a multidisciplinary team including nurses, MAs, physicians, and administrators from the rheumatology clinics, telemedicine program, and remote clinical sites to guide our work. Manual chart

Results

In total, we saw 176 patients over 244 telemedicine visits from June 2012 and December 2014. The majority of the patients seen in the telerheumatology clinics were female (66%) and the average age of the patients was 60 years (Table 1). Patients lived on average 99 miles from DHMC and 22 miles from the remote clinic site. The most common diagnosis seen was inflammatory arthritis, specifically rheumatoid arthritis (47%) and seronegative spondyloarthropathies (17%). Over half of all patients

Discussion

Our study demonstrated that the use of telemedicine in the field of Rheumatology can be an effective tool for the management of a variety of rheumatologic conditions for patients living in rural locations while saving a significant amount of time and money associated with travel with the majority of patients and providers satisfied with the visit. We effectively used telerheumatology to manage patients on high-risk medications (DMARDs, subcutaneous, and infusion biologics), coordinate care, and

Significance/innovation

  • Discusses a relatively new modality to see patients with little published literature on outcomes, satisfaction, and quality.

  • Highlights a modality to improve access to rheumatology care in rural communities.

  • Highlights some pitfalls with this new modality when applied to all patients across the board.

  • Discusses the future use of telemedicine in rheumatology with guidance to other practitioners hoping to engage in this arena.

References (21)

There are more references available in the full text version of this article.

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