by Gaurav Jain, MD; and Eric Wallace, MD
In the day-to-day battle of COVID-19, telehealth has emerged as an unlikely hero. However, the details of telehealth implementation and impact on staff and patients alike are still to be determined and are particularly important with respect to the care of nephrology patients.
The beneficiaries of telehealth programs are different based on the implementation strategy and targeted goal of the project. Poor planning without examining staff roles and views will have a long-lasting detrimental effect on the success of telehealth, while those programs that are planned and implemented with consideration could stand to change the way we practice nephrology forever.
During the COVID-19 crisis, CMS has made numerous changes to make access to telehealth easier for nephrology practitioners.
• Telehealth regulations and billing considerations have been modified under the 1135 waiver and CARES Act which has significantly increased the sustainability of telehealth;
• In-center dialysis units can now be a site by which to perform telehealth visits for the monthly capitated payment (MCP), which prior to COVID-19 was only allowed in critical access hospitals;
• The home is now an appropriate originating site for video visits, and the rural/urban restriction which was a major operational hurdle has been removed; and
• State licensing requirements and the restrictions on videoconferencing platforms have been eased.
These are welcome changes, but telehealth implementation without planning creates challenges. Patients with ESRD, particularly those receiving in-center dialysis, are not given the luxury of social distancing. They face uncertainties about the exposure to COVID-19 in their dialysis units and have been affected adversely by this crisis in a number of ways, including rescheduled surgeries for vascular access and peritoneal dialysis catheter placement and rescheduled or canceled clinic visits with physicians for management of comorbid conditions.
For hospitalized patients with ESRD and acute kidney injury who are either persons under investigation or confirmed COVID-19, providing timely dialysis has been challenging in the setting of limited staff and resources, such as personal protective equipment. There is also concern some state and hospital policies limit access to a ventilator for patients with ESKD should they be hospitalized at a time of peak COVID-19 cases.
The nature of providing dialysis care has an in-person component that requires at least some direct interaction with the patient and requires a team approach. In the in-center dialysis paradigm, the dialysis nurses and patient care technicians do not directly benefit from telehealth, as they physically need to be in the dialysis unit. The physician, advanced practice professionals, dietician and social worker can potentially provide their services via telehealth. As this creates an inequity, the use of telehealth for in-center rounding should be used judiciously. The presence of physicians and medical directors in the units is uplifting to the rest of the team, and helps build good morale, and likewise can help destroy it if a telehealth approach is used for all encounters.
However, under extreme COVID-19 settings, telenephrology can enable nephrologists to care for in-center dialysis patients and improve efficiency of nephrologists by eliminating the need for travel to and from dialysis units while they care for hospitalized patients and cover for sick colleagues. Furthermore, it allows for the ability for asymptomatic quarantined staff to contribute to the workforce during quarantine. In our nephrology division at the University of Alabama Birmingham, COVID-19 patients with ESKD are dialyzed in a dedicated area on a terminal shift. Telenephrology allows the physician to evaluate and manage them in a timely fashion. However, there remains an in-person component of rounding at these units.
Telehealth has also assumed a role for inpatient care of patients on dialysis as well. Rural facilities may have limited or non-existent inpatient nephrology care even though outpatient dialysis units exist and ESRD patients live in these areas. When these patients need inpatient hospitalization or dialysis, they have to be transported long distances with emergency medical transport to larger hospitals, thus exposing multiple health care workers unnecessarily. Telenephrology programs offered by UAB and Emory Healthcare in Atlanta, in partnership with Sanderling LLC, are pioneers in inpatient telenephrology, allowing the provision of consultative care and dialysis to many patients in rural hospitals. This reduces unnecessary travel and providing back-up and support for community nephrologists. Furthermore, at UAB, iPads are being distributed in COVID-19 rooms to implement video isolation to allow for examination of patients and provide necessary consultative services without having the consultant to enter the room. This ensures judicious use of personal protective equipment and limits exposure for health care workers, with minimal disruption in access to care for the patient.
Other uses of telenephrology have demonstrated clear benefits in the ambulatory setting. The renal transplant clinics at UAB are evaluating more than 90% of our patients via telehealth. Our app-run chronic kidney disease clinic and dialysis modality education class have also been effective in delivering services using telehealth. Innovation is possible as well by considering the implementation of drive through injections of erythropoietin stimulating agents and lab draws for our patients with CKD.
Unfortunately, telehealth has the possibility of increasing disparities in access to care. Telephone visits have been a very useful way of providing care to patients in the ambulatory setting and have been necessary specifically for patients who may not have access to the technology required for videoconferencing. This is most prevalent in the socioeconomically disadvantaged and elderly who comprise a large percentage of our CKD population. Medicare policies do allow for reimbursed telephone visits but not at the same rate as an MCP visit, thus creating a disparity in care. Telehealth programs that have not planned for interpretation services also can lead to disparities in care in the hearing-impaired and non-English speaking populations and further drive a larger wedge into health care disparities.
Using telehealth during the COVID-19 crisis provides a number of advantages in fighting the spread of the virus. Congress sees its value in mitigating risk to patients and staff.
There are lessons to be learned as we face the peak of this disease in the United States. First, when this COVID-19 health care crisis is over, we must maintain the telehealth strategies that we now have in place. This will require legislation to ensure that after the removal of the 1135 waiver, all of the work that has gone into telehealth is not in vain. The rural/urban restrictions must remain a thing of the past and the home and dialysis units must continue to be an originating site. We must maintain this infrastructure for possible secondary rises in COVID-19 cases once the social restrictions have been loosened, and for the impending threat of any other pandemic. In the post COVID-19 era, we see advantages of maintaining use of telehealth in kidney care both in the inpatient and outpatient settings.
• Reduce patient travel to dialysis clinics, particularly for home dialysis patients and those in nursing homes; and
• For the nephrologist, a decrease in windshield time leading to improved availability, especially in rural areas as well as quality of life and efficiency. In the inpatient setting, it offers back up for nephrologists who are in small practices and cover many different hospitals at large distances from each other.
Second, we must look at team equity when deploying telehealth strategies to ensure ethically that we do not implement measures that do not put one health care worker at risk to benefit another.
Finally, one of the priorities of establishing telehealth in our practice was to reduce disparities in care; some of our existing telehealth policies and planning, however, can actually increase disparities in access to care. We must find ways to ensure all patients have access to adequate broadband and technology required for videoconferencing. Until then, we must continue to allow for telephone-only visits to provide equal access to care to all. We must assess the comfort level of our patients with telehealth and continue to engage them. We must also determine outcomes care provided by telehealth, and improve our methodology based on these studies. We must strive to improve health literacy but also technology literacy, and allow innovative strategies, to engage a health care system that can meet needs in a multitude of settings, including patients’ homes.
How we care for our kidney patients will never be the same, nor should it be after what we have learned in this national emergency.
Gaurav Jain, MD, FASN, is an associate professor of medicine in the division of nephrology and director of ambulatory nephrology at UAB Medicine in Birmingham, is the medical quality and safety officer, patient experience officer, and is co-director of the Home Dialysis Program. Eric Wallace, MD, FASN, is an associate professor of medicine at UAB Medicine, serving as medical director of telemedicine, is co-director of the Home Dialysis Program and is co-director of the Fabry and Other Rare Genetic Kidney Disease Clinic at UAB.
Disclosures: Jain and Wallace report no relevant financial disclosures.