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Rheumatology Advisor: Dr. Elizabeth Kessler talks potential gaps in using telemedicine

A study at Dartmouth-Hitchcock Medical Center, which provided telemedicine services to the predominantly rural populations of Vermont and New Hampshire, showed that although patient and provider satisfaction with the model were high, approximately 19% of patients seen via telemedicine were not appropriate candidates, either because of an unclear diagnosis or substantial disease complexity. This suggests the need for triage mechanisms that minimize such inappropriate referrals.

Telemedicine can improve healthcare access, patient outcomes, and costs, although it presents several potential obstacles. Expanded insurance coverage of this modality will be necessary to greater numbers of patients in need of specialty care.

For Elizabeth Kessler, MD, MS, a pediatric rheumatologist at Children's Mercy who co-authored the study there, the training of the clinical “telefacilitator” — often a nurse — at the patient site influences the types of patients she will see remotely. “For example, the nurse facilitator who I work with spent time in the rheumatology clinic learning how to perform a joint exam and distinguishing between active and inactive arthritis,” she explained.

“Using her examination in addition to what I am able to visualize, I feel comfortable making changes in patients' medications. If the facilitator did not have this training, seeing such patients and making treatment changes may not be appropriate.”

Barriers and Solutions

Whereas the benefits of telemedicine are clear — including improved access, outcomes, and patient satisfaction, and lower costs, for example — there are also multiple potential barriers. Insurance reimbursement is one of the primary issues, although progress has been steady if sluggish in this area. “Currently 29 states have mandated that commercial insurance cover telemedicine encounters. However, rates of reimbursement vary and depend on where the patients are located for the visit, what services are covered, and the type of provider who is seeing the patient,” and such variability can be a deterrent, according to Dr Kessler.

Despite the success stories, skeptics remain. “Reservations among rheumatologists exist about whether visits can be effectively conducted via telemedicine. Therefore, future research needs to address the ability to perform an accurate musculoskeletal exam via telemedicine,” said Dr Kessler. “Comparing process and outcome measures between patients seen in traditional in-person clinic visits versus those seen by telemedicine would be another way to ensure that telerheumatology visits can provide high-quality care.”


Read the full story via Rheumatology Advisor.

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