Dear colleagues and friends,
I am fortunate to receive the baton from Charles Kahi, MD, in facilitating the fascinating and timely debates that have characterized the AGA Perspective series. Favorable reimbursement changes and the need for social distancing fast-tracked telemedicine, a care delivery model that had been slowly evolving.
Dr. Gyanprakash Ketwaroo
In this month’s Perspective column, Dr. Hernaez and Dr. Vaughn discuss the pros and cons of telemedicine in GI. Is it the new office visit? Or simply just good enough for when we really need it? I look forward to hearing your thoughts and experiences on the AGA Community forum as well as by email (ginews@gastro.org).
Gyanprakash A. Ketwaroo, MD, is assistant professor of medicine at Baylor College of Medicine, Houston. He is an associate editor for GI & Hepatology News.
It holds promise
BY RUBEN HERNAEZ, MD, MPH, PHD
It was around January 2020, when COVID-19 was something far, far away, and not particularly worrisome. I was performing a routine care visit of one of my out-of-state patients waitlisted for a liver transplant. All was going fine until he stated, “Hey doc, while I appreciate your time and visits, these travels to Houston are quite inconvenient for my family and me: It is a logistical ordeal, and my wife is always afraid of catching something in the airplane. Could you do the same remotely such as a videoconference?” And just like that, it sparked my interest in how to maintain his liver transplant care from a distance. The Federation of State Medical Boards defines telemedicine as “the practice of medicine using electronic communication, information technology, or other means between a physician in one location, and a patient in another location, with or without an intervening health care provider.1 What my patient was asking was to use a mode of telemedicine – a video visit – to receive the same quality of care. He brought up three critical points that I will discuss further: access to specialty care (such as transplant hepatology), reduction of costs (time and money), and improved patient satisfaction.
Dr. Ruben Hernaez
Arora and colleagues pioneered the Extension for Community Healthcare Outcomes (ECHO) project, providing complex specialty medical care to underserved populations through a model of team-based interdisciplinary development in hepatitis C infection treatment in underserved communities, with cure rates similar to the university settings.1 The University of Michigan–Veterans Affairs Medical Center used a similar approach, called Specialty Care Access Network–Extension of Community Healthcare Outcome (SCAN‐ECHO). They showed that telemedicine improved survival in 513 patients evaluated in this program compared to regular care (hazard ratio [HR]of 0.54, 95% confidence interval 0.36‐0.81, P = .003).2 So the evidence backs my patient’s request in providing advanced medical care using a telemedicine platform.
An extra benefit of telemedicine in the current climate crisis is reducing the carbon footprint: There’s no need to travel. Telemedicine has been shown to be cost effective: A study of claims data from Jefferson Health reported that patients who received care from an on-demand telemedicine program had net cost savings per telemedicine visit between $19 and $121 per visit compared with traditional in-person visits.3 Using telemonitoring, a form of telemedicine, Bloom et al. showed in 100 simulated patients with cirrhosis and ascites over a 6-month horizon that standard of care was $167,500 more expensive than telemonitoring. The net savings of telemonitoring was always superior in different clinical scenarios.4
Further, our patients significantly decrease travel time (almost instant), improve compliance with medical appointments (more flexibility), and no more headaches related to parking or getting lost around the medical campus. Not surprisingly, these perks from telemedicine are associated with patient-reported outcomes. Reed and colleagues reported patients’ experience with video telemedicine visits in Kaiser Permanente Northern California (n = 1,274) and showed that “67% generally needed to make one or more arrangements to attend an in-person office visit (55% time off from work, 29% coverage for another activity or responsibility, 15% child care or caregiving, and 10% another person to accompany them)”; in contrast, 87% reported a video visit as “more convenient for me,” and 93% stated that “my video visit adequately addressed my needs.”5 In liver transplantation, John et al. showed that, in the Veterans Health Administration, telehealth was associated with a significantly shorter time on the liver transplant waitlist (138.8 vs. 249 days), reduction in the time from referral to evaluation (HR, 0.15; 95% CI, 0.09-0.21; P < .01) and listing (HR, 0.26; 95% CI, 0.12-0.40; P < .01) in a study of 232 patients with advanced cirrhosis.6
So, should I change my approach to patients undergoing care for chronic liver/gastrointestinal diseases? I think so. Telemedicine and its tools provide clear benefits to our patients by increasing access to care, time and money savings, and satisfaction. I am fortunate to work within the largest healthcare network in the Nation – the Veterans Health Administration – and therefore, I can cross state lines to provide medical care/advice using the video-visit tool (VA VideoConnect). One could argue that some patients might find it challenging to access telemedicine appointments, but with adequate coaching or support from our teams, telemedicine visits are a click away.
Going back to my patient, I embraced his request and coached him on using VA VideoConnect. We can continue his waitlist medical care in the following months despite the COVID-19 pandemic using telemedicine. I can assess his asterixis and ascites via his cellphone; his primary care team fills in the vitals and labs to complete a virtual visit. There’s no question in my mind that telemedicine is here to stay and that we will continue to adapt e-health tools into video visits (for example, integrating vitals, measurement of frailty, and remote monitoring). The future of our specialty is here, and I envision we will eventually have home-based hospitalizations with daily virtual rounds.
Dr. Hernaez is with the section of gastroenterology and the Center for Innovations in Quality, Effectiveness, and Safety at the Michael E. DeBakey Veterans Affairs Medical Center and in the section of gastroenterology and hepatology in the department of medicine at Baylor College of Medicine, both in Houston. He has no relevant conflicts of interest.
References
1. Arora S et al. N Engl J Med. 2011 Jun 9;364(23):2199-207.
2. Su GL et al. Hepatology. 2018 Dec;68(6):2317-24.
3. Nord G et al. Am J Emerg Med. 2019 May;37(5):890-4.
4. Bloom PP et al. Dig Dis Sci. 2021. doi: 10.1007/s10620-021-07013-2.
5. Reed ME et al. Ann Intern Med. 2019 Aug;171:222-4.
6. John BV et al. Clin Gastroenterol Hepatol. 2020 Jul;18:1822-30.e4.
