“You don’t need a room to do rheum” – Canadian rheumatologists and virtual care

Canadian rheumatologists are conducting virtual visits to a significant degree during the COVID-19 pandemic but most are not using video – which many feel is the best platform for this specialty – and the majority are still not comfortable with telemedicine.

These were a couple of the conclusions that emerged from a discussion of telemedicine and virtual care at the recent annual meeting of the Canadian Rheumatology Association (CRA) framed as a “great debate”. As those who have attended annual meetings of clinical medical societies know, these debates are often positioned with amusing graphics, good-natured personal attacks, and protagonists often asked to defend positions opposite to their true beliefs.

When one cut into this particular confection there were some productive insights about virtual care and rheumatology. More came from the numerous comments posted in the associated chatroom during the debate.

In the debate, Dr. Tommy Gerschman, a pediatric rheumatologist in North Vancouver and member of the CRA telehealth working group described telemedicine as “excellent care in brand new, patient-centred packaging.” In BC, Dr. Gerschman said rheumatologists last year provided about three-quarters of their visits virtually during the pandemic period – a far higher percentage than any other specialty.

A survey by clinicians from the rheumatology division of The Ottawa Hospital and presented at the conference as a poster showed that 89% of patients said they were satisfied were satisfied with phone visits undertaken during the first 3 monhs of the COVID-19 pandemic.

In the debate, Dr. Alexandra Saltman, a Toronto rheumatologist, noted that clinicians can take a number of measurements remotely such as weight, blood pressure and swollen joint counts. She also said evidence suggests use of virtual care is not likely to miss serious diagnoses or issues when used in rheumatology.

Tasked with arguing against telemedicine, Dr. Brent Ohata, co-chair of the CRA working group on telehealth argued “we’re not ready as a community ready to provide telehealth,”. He noted that providing virtual care properly requires training, specialized knowledge, proper equipment and preparation – on the part of the patient as well as the rheumatologist.

Dr. Ohata said a survey of Canadian rheumatologists done in December found that while respondents said about 47% of their current patient appointments were being done by phone, only 19% were done using video. Even during the pandemic, the remainder (34%), were being done as in-person visits. In addition, the survey showed only 45% of rheumatologists said they were comfortable or very comfortable using telemedicine.

“The gold standard in virtual care is video,” said Jocelyne Murdoch, a Sudbury occupational therapist with advanced training in rheumatology who has been using telemedicine since 2008. In another session at the conference, Dr. Ohata agreed that rheumatologists felt they could provide better virtual care through video than over the phone.

Dr. Ohata also presented data showing that while 66% of rheumatologists indicated they could evaluate swollen joints visually, there were a number of other investigations by rheumatologists that could be done in virtual visits that were not.

Murdoch who was also asked to argue against the value of telemedicine said the supports needed to provide telemedicine in rheumatology are not yet present. She noted that in rural and remote areas many clinicians and patients do not have access to to high-speed internet connections required to do virtual video visits.

Murdoch also noted how informal many patient visits have become since the pandemic and switch to virtual visits. This issue was underscored by a number of anecdotes from participants in the virtual chat room during the debate who described patients expectations of being able to meet virtually with their rheumatology while in the most unusual circumstances.

While other physicians have also voiced similar concerns about inappropriate patient behavior during virtual visits one should note this is not all one-sided – as evidenced by the case publicized this past weekend of the surgeon who tried to contest a traffic ticket in court via Zoom, while preparing to perform surgery in the operating room.

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Teledermatology: Every picture tells a story (#AAD17)

One can imagine the era of modern telemedicine beginning with dermatology.

“Hey, I have this rash. Mind if I e-mail you a picture so you can tell me how to deal with it”?

While teledermatology can actually be a far more complex and sophisticated interaction between patient and doctor, that core ability to send an image of the key diagnostic feature is what has led some dermatologists to be involved in telemedicine for almost two decades now.

And with telemedicine and virtual medicine now entering prime time, it is not a surprise that more dermatologists are focusing on teledermatology as a way to allow more people to access quality care.

What is somewhat more surprising is that fact that after two decades of practice, the dermatology specialty still lacks a good remuneration model and more importantly agreed upon standards for how quality care should be delivered.

The recent annual meeting of the American Academy of Dermatology (#AAD17) meeting in Orlando provided a snapshot, if you will, of all these issues. Not only was teledermatology the focus of at least two educational sessions, it was also the subject of one of the plenary named lectures.

In her plenary presentation, Dr. Carrie Kovarik (@carriekovarik), associate professor of dermatology at the University of Pennsylvania and a

teledermatology pioneer, gave a blunt assessment of telemedicine in her specialty.

“There are people in the middle who see teledermatology as a good thing when it is used to provide quality care and provide access,” she said in an interview published in the conference newsletter. “Unfortunately, there are also people on one end of the spectrum who think this is a way to make a lot of money and sell products. Then there are people at the opposite end who are afraid that telemedicine is eventually going to take away their patients.”

If that was the bleak overview of telemedicine within the speciality, Kovarik’s assessment of how unprofessional and unethical websites are exploiting patients by offering teledermatology services was worse. “We have businesses that have scaled-up teledermatology using non-dermatologists, anonymous apps and apps where the patients have to self-diagnose.”

Despite the potential value of teledermatology for improving access to underserviced areas and populations through the U.S., in her speech Kovarik noted only 12 States currently reimburse specialists for the “store forward” approach in which pictures of a patient are assessed after they are taken.

Another challenge is that in many instances the patient’s primary care provider receives no payment for helping facilitate the process by, for example, taking high-quality images of the patient for the dermatologist to assess.

However at the end of the day, despite all these challenges, Kovarik predicted it would be harder and harder for dermatologists to avoid telemedicine.

The key she said was to ensure the quality of care provided is the same as that seen in a face-to-face encounter.

 

Why telemonitoring can’t clear the RCT hurdle

For many advocates of digital medicine, the gold standard of randomized controlled trials can sometimes lack a certain luster.
The most recent example of this is the failure of a large, well-conducted study to show the benefits of telemonitoring and telehomecare with patients who have chronic heart failure.
Even as Canadian networks such as the Ontario Telehealth Network (OTN) expand their use of remote monitoring and coaching for patients with the clear-headed conviction that such an approach can reduce re-hospitalizations and even mortality rates for those with heart failure – large trials say otherwise.
There is no conundrum here. The big trials are measuring outcomes in a telemonitoring group against those receiving usual care without telemonitoring, whether or not patients randomized into the telemedicine group use the technology effectively or at all. So, the positive results from patients who work with providers to use the technology appropriately are cancelled out by those who, for whatever reason, choose not to use the telemonitoring tools.
Let’s look at this in most recent randomized controlled trial – the Better Effectiveness After Transition – Heart Failure (BEAT-HF) study reported at the high-profile American Heart Association (AHA) scientific sessions in Orlando.
In BEAT-HF, 1,437 individuals age 50 or older who were hospitalized in one of six academic health systems in California and receiving active treatment for decompensated heart failure agreed to participate and were randomized into the trial.
Those in the study group had regularly scheduled telephone coaching from a nurse practitioner on managing their condition as well as telemonitoring of weight, blood pressure, heart rate and any symptoms. They were compared with those who receive no telemonitoring or remote coaching.
The primary outcome measured was the 180-day, all-cause hospital readmission rate, with secondary outcomes of all-cause readmission and mortality being measured at 30 days. No significant differences were seen between the two groups in the hospital readmission rates at either 30 or 180 days.
But when the researchers looked at those in the intervention group who actually participated in the majority of calls with the nurses and who provided their data on a regular basis, large benefits were seen, with significant reductions on both hospital readmission rates and in mortality compared with those not using the technology.
These findings demonstrate the difficulty in empirically demonstrating the benefits of an intervention when positive outcomes are dependent on patients consciously making use of the tools being evaluated.
“Patients who stay in the program are probably more likely to take better care of themselves,” was the comment made by Dr. James Januzzi Jr. from Massachusetts General Hospital, who commented on the BEAT-HF meeting in an interview.
“The whole point of this kind of intervention is to engage, educate and motivate patients to improve their behaviours and self-management skills,” commented Dr. Ed Brown, CEO of the OTN in a recent online post.
Given that the very nature of RCTs is to randomize patients and not select in advance those likely to benefit from an outcome, it is not surprising the findings have been as they have.
But these findings are useful for tempering the enthusiasm of those who feel remote medicine and digital interventions cannot help but work well.
As Dr. Micheal Ong, head of the BEAT-HF study group, noted, what the study has shown is that telemonitoring is not appropriate with all heart failure patients after hospital discharge.
More work needs to be done to assess who is likely to have issues in using new technologies to be monitored in their home and help motivate them to take better care of themselves.