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Date September18,2018Subject: GeorgiaCouncilonLupusEducationandAwareness
TelemedicinePilotprojectandFeasibilityReportTo AmericanCollegeofRheumatologyFrom: ChristopherReed,Co-Chair
KimSchofield,Co-ChairPurposeToprovideyouwithasummaryofthetelemedicinepilotprogramtodeterminethefeasibilityatelemedicineprograminDoughertyCounty,Georgiaforpersonswithlupus.BackgroundTheAmericanCollegeofRheumatology(ACR)wasfundedbytheCentersforDiseaseControlandPrevention(CDC)toimplementseveralactivitiestoimprovelupuseducation,awarenessandaccesstoearlydiagnosisandtreatmentandawareness.1TheGeorgiaCouncilonLupusEducationandAwareness(GCLEA)2receivedfundingtoplanandimplementatelemedicine3pilotstudyforpersonslivingwithlupusinruralsouthwestGeorgia.4ThestudylinkedprimarycarepractitionersinruralsouthwestGeorgiawithrheumatologyspecialistsatEmoryUniversityHospitalandEmoryUniversitySchool
1TheprojectdescribedwassupportedbyGrantnumber6NU58DP006138-01-02;CFDAnumber93.068,DevelopingandDisseminatingProgramstoBuildSustainableLupusAwareness,Knowledge,SkillsandPartnerships.2 TheGCLEAistheonlystatesponsoredmandatedentitycreatedtoimprovethelivesofGeorgiaresidentswholivewithlupusbyimprovingpubliceducationandawareness,improvingaccesstoresourcesforpatientsandfamilymembers,anddevelopinginformationthatwillinformcurrentandfuturepublichealthefforts.ItishousedintheGeorgiaDepartmentofCommunityHealthandfrequentlypartnerswiththeDPH. 3TheAmericanTelemedicineAssociation(2017)definestelemedicineasthe:“useofmedicalinformationfromonesitetoanotherviaelectroniccommunicationstoimproveapatient’sclinicalhealthstatus.Telemedicineincludesagrowingvarietyofapplicationsandservicesusingtwo-wayvideo,email,smartphones,wirelesstoolsandotherformsoftelecommunicationstechnology.”AmericanTelemedicineAssociation.(2017).Retrievedfromwww.americantelemedicineassociation.com.4 AnalysisandEvaluationoftheGCLEAPilotStudywasconductingbySineadYoung,Ph.D.ofYoungeConsulting,LLC.
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ofMedicine(Emory).SincetheGeorgiaDepartmentofPublicHealth(DPH)hasasystemofsitesthroughoutGeorgiathatcooperatewithtelemedicineconsultationsforavarietyofhealthconditions,GCLEA’sstudyassessedthefrequencywithwhichprimarycarepractitionersinsouthwestGeorgiasawlupuspatientsandtheirperceptionofthevalueoftelemedicineintheirpractice.TheGCLEAalsoconductedanassessmentofattitudes,behaviorsandbeliefsofvariousrheumatologiststhroughoutthestatebeforethepilotconsultationexperience.Onegovernmenthealthclinic,DoughertyCountyHealthClinic(Clinic)whichcurrentlyspecializesinobstetricsandgynecologytelemedicineconsults,agreedtoexpandconsultationstoincludepersonswithlupus.First,theClinictrainedrheumatologistsfromEmoryonthewaysinwhichtelemedicinecanbeusedtodiagnoseandtreatlupus;thelogisticsofexaminations,andfundingmechanismsfortheClinicandrheumatologistsasapartyofthestudy.Next,fivewomenfromsouthwestGeorgia,whowerepreviouslydiagnosedwithlupus,agreedtobeexaminedbytherheumatologistsattheClinicusingthetelemedicineequipment.Datacollectedonthesepatientsbeforeandafterthestudyincludedtheirperceptionoftelemedicinebothbeforeandaftertheconsultation,age,race/ethnicity,insurancestatus,currenttreatmentplanandcurrenttraveltimetoseearheumatologist.Theresultsofthisstudyaresetforthinthefollowingreport.DiscussionIn2016,theGCLEAandLupusFoundationofAmerica,GeorgiaChapter,convenedastatewideworkshopofpublichealthprofessionals,educators,medicalproviders,socialworkers,researchers,andcommunityactivists.5OneofthegoalsoftheworkshopwastocollaborateandcreatetheGeorgiaActionPlan-waystoencourageandfacilitatepublicandprivateactiondesignedtocombatlupus.AkeycomponentofthePlanistoimproveaccesstocareandservicesforpeoplelivingwithlupusbyconnectingpatientsandrheumatologistsusingtelemedicine.6AnenvironmentalscanoftelemedicineinGeorgia,conductedforGCLEAbyHighlandNonprofitConsulting,LLCin2017,indicatesthatthereareeducationgapsamongrheumatologistsandpatientsontheuses,benefits,administration,andlogisticsoftelemedicine.Basedonthefindingofthescan,thebenefitsoftelemedicine,accordingtothescan,isthatittreatspatientswhowouldnototherwisehaveconvenientaccesstoaspecialist,butalsoitcanteachothermedicalprovidersaboutthediagnosisandtreatmentoflupus.
5 FundingwasprovidedbyagrantfromtheCentersforDiseaseControlandPrevention(CDC)andsupervisionwasprovidedbytheNationalAssociationofChronicDiseaseDirectorsandtheLupusInitiative.TheGCLEAhasreceivedthisfundingthreeyearsinarow. 6 TheLupusFoundationofAmerica-GeorgiaChapterestimatesthatthereare55,000Georgianslivingwithlupus.TheGeorgiaSocietyofRheumatologistsandtheAmericanCollegeofRheumatology(ACR)indicatethatthereare109rheumatologistsinpracticeinGeorgiawhoarequalifiedtodiagnoseandtreatlupus.AlargemajorityoftheserheumatologistsarecenteredinmetropolitanAtlanta,particularlyinthenorthernsuburbs.
3
Telemedicineequipmentexiststhroughoutamajorityofthestate.TheGeorgiaPartnershipforTelehealth(GPT)7,astatewidenon-profittelehealthnetwork,reportsthatithasprovided130,000patientencountersusing40differentspecialties,asrecentlyas2013,andhasthecapacitytoprovidethesameserviceto106ofGeorgia’s159counties.TheGeorgiaDepartmentofCommunityHealthusestelemedicineequipmenttoprovideservicesinsomeclinicsthroughoutthestateforpatientsonMedicaid.TheClinicusestelemedicinetoprovidemedicalservicestothosewithinfectiousdiseases,womenwithhigh-riskobstetrics,andwomenandchildrenintheWomen,Infants,andChildren’snutritionprogramorWIC.TheDoughertyCountyHealthClinic,aclinicrunbytheGeorgiaDepartmentofPublicHealthinAlbany,DoughertyCounty,Georgia8,usestelemedicineequipmenttoeducatepregnantmothersaboutprenatalhealthandthebirthingprocess.Theyhavetwounits,oneofwhichismobile.Theclinic,alsoknownastheTelemedicineOriginatingSite(OriginatingSite),alsoperformsprenatalpatientexaminationsandconsultationsbycommunicatingviathetelemedicineequipmentwithDr.C.AnnePatterson,anOB/GYNinSandySprings,Georgia.Dr.Patterson,whoisdefinedastheDistantSiteProvider(ProviderSite),canusethetelemedicinestethoscopetolistentothepatient’sabdomen,alaptoptoviewultrasounds,aDermascope9toviewrealtimeimagesoftheepidermis,electrocardiograms,sonograms,andmedicalrecordsinrealtime.Allequipment,withtheexceptionofthetelemedicinestethoscopeandDr.Patterson’slaptop,ishousedandprovidedtotheOriginatingSite.The“PregnancyCenteringModel”,asitiscalledhashadpositiveresultsandtheClinicdepartmentreportsbetterpregnancyoutcomesthanneighboringcounties.Inadditiontothepre-natalprogram,theClinicusestelemedicineequipmenttotreatchildrenwithsicklecellanemia.TheOriginatingSiteusesaTelemedicinePresenter,usuallyaregisterednurseorlicensedpracticalnurse,toassistwiththeexaminationofeachpatient.AllparticipantsintheexaminationaregivenindividualizedaccountnumbersfromGPTwhichholdsacopyofthepatientconsentformandHIPAAforms.AllmedicalrecordsarehousedelectronicallyattheOriginatingSite.TherearenosetcriteriaforwomenandchildrentobetreatedorusethetelemedicineservicesprovidedbytheClinic.Dr.Pattersoniscompensatedusingapatient’s
7 GPToperatesanOpenAccessNetworkthatconnectsoperationalstatewidetelemedicineproviderprogramswithtelemedicinepatientcliniclocations. 8DoughertyCountyhasapopulationof89,502basedonestimated2017US.Censusrecords.It’sdemographicsareasfollows:70.2%BlackorAfricanAmerican,27%White,2.9%HispanicorLatino,.3%AmericanIndian,.9%Asian,and1.3%tworacesormore.Themedianhouseholdincomefrom2012-2016was$33,605.00.Thirtypercent(30%)ofthepopulationlivesbelowthepovertylevel. 9Dermascopesarecomputerizedpolarized-lightvideomicroscopethatuse,insomecases,lenseswith×20to×70factorsofmagnificationtoviewsegmentsofapatient’sepidermis.AntonellaTosti,MD;FernandaTorres,MD;CosimoMisciali,MD;etal.,FollicularRedDots:ANovelDermoscopicPatternObservedinScalpDiscoidLupusErythematosus.ArchDermatol.2009;145(12):1406-1409.doi:10.1001/archdermatol.2009.277;“Thedermoscopehasbeenknowntorevealstructures[ontheepidermis]notvisibletothenakedeye...”KittlerH.,PehambergerH.,WolffK.,BinderM.Diagnosticaccuracyofdermoscopy.TheLancetOncology.2002;3(3):159–165.doi:10.1016/s1470-2045(02)00679-4.
4
privateinsurancecarrier10,Medicaid11,PeachCareforKids,oronaslidingscale.TelemedicineOriginatingSites,liketheClinicmaybillafacilityfeetotheinsuranceprovider.12TheClinicanditscountyseat,Albany,GeorgiawerechosenasthepilotsitebecauseDoughertyCountyandthesurrounding39countiesthatmakeupsouthwestGeorgiaaresomeofthepoorestcountiesinGeorgia.Outofthethreerheumatologistsinthisarea,onetakesgovernmentfundedhealthinsuranceandhisofficeisoveranhourawayfromDoughertyCounty.Theothertworheumatologistsinthe39countyareadonottakegovernmentfundedhealthinsurance.Therefore,manypatientsareforcedtoseekcarefromrheumatologisthoursaway,waitmonthstoseelocalrheumatologists,seekcarefromanothertypeofmedicalproviderornocareatall.DiscussionontheTelemedicinePilotStudyMethodAtotaloffivewomenlivingwithlupusvolunteeredtoparticipateintheAugust31,2018,pilotstudyattheOriginatingSite.Volunteers,alldiagnosedwithSystemicLupusErythematosus,wererequiredtocompleteconsentformstoparticipateinthestudyaswellasacknowledgetheirunderstandingoftheirprivacyrightsviatheHealthInsurancePortabilityandAccountabilityAct.Volunteersweregivenapre-pilotsurveyandapostpilotsurvey.Eachvolunteersawoneoftworheumatologists,Dr.S.SamLimofEmoryUniversitySchoolofMedicineandGradyHealthSystemorDr.AlizaLipsonofEmoryUniversitySchoolofMedicinewhowerehouseattwodifferentProviderSites.Drs.LimandLipsoncommunicatedwitheachpatientusingallofthetelemedicineequipmentavailableexceptthetelemedicinestethoscopewhichwasnotavailabletothephysicians.Whilebothdoctorswereabletovieweachexamination,onlyonedoctorconductedtheexaminationandeachpatientwasonlyawarethatonephysicianwasconductingthatexamination.13EachrheumatologistandpatientwereassistedbyNurseValeniaMilling,theTelemedicinePresenterattheDoughertyCountyHealthClinic.Eachexaminationtookonaveragetwenty(20)minutes.Drs.LimandLipsonweregivenpostpilotsurveys.
10Commercialinsurancecarriersaremandatedtocovertelemedicineservicesandreimburseprovidersinthesamewayitwouldin-personmedicaltreatment,pursuanttotheGeorgiaTelemedicineActof2005.O.C.G.A.§§33-24=-6.4,43-34-31.11“GeorgiaMedicaidwillreimburseforlivevideowhentheserviceis“medicallynecessary,theprocedureisindividualized,specific,consistentwithsymptomsorconfirmeddiagnosisofanillnessorinjuryundertreatment,andnotinexcessofthemember’sneeds.”GADept.ofCommunityHealth,GAMedicaidTelemedicineHandbook,p.2,(Oct.2014).(AccessedSeptember2018)).12GADept.ofCommunityHealth,GAMedicaidTelemedicineHandbook,p.48,(Oct.2014)(AccessedSeptember2018). 13 ThetelemedicinehasamechanismallowinguptofourphysicianstobeconnectedwiththepatientfrommultipleProviderSites.Eachphysiciancouldhidetheirparticipationfromviewofthepatient.
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ParticipantDemographicsAtotaloffive(n=5)AfricanAmerican/Blackwomenvolunteers,livingwithLupusparticipatedinthepilotstudyonAugust31,2018.Theparticipantsrangedinagefrom39to67yearsofagewithanaverageageof57yearsold(seeTable1).Themajorityofparticipants(n=3)reportedhavingbeendiagnosedwithSystemicLupus.OneparticipantdidnotreportwhattypeofLupusshewasdiagnosedwithandanotherparticipantreportedhavingDrugInducedLupus.Allfivevolunteersreportedcurrentlyhavinghealthinsurance,havingarheumatologist,andbeingtreatedbytherheumatologistinthelast12months.
Table1
AccesstoMedicalProvidersThreeparticipantsreportedtravelingatleast120milestovisittheirrheumatologist.Twoparticipantsreportedtraveling10milesorundertovisittheirrheumatologist.TwoparticipantsreportedthattheydonotseearheumatologistfortheirLupus.OneparticipantreportedseeinganinternistandtheotherreportedthatshedidnotseeanyoneforherLupus.Twoofthethreeparticipantsreportedhavingheardabouttelemedicinepriortothepilot.Oneofthefiveparticipantsreportedusingtelemedicineinthepast.
6
VolunteerPreandPostPilotSurveyResultsWhenasked,“Telemedicineprovidesthesamequalityofcareasaninpersonvisit?”TwoparticipantsStronglyAgreedandtwoparticipantsAgreed.Oneparticipantreported,“Don’tKnow.”Postpilot,threeparticipantsreportedStronglyAgreeingandtwoparticipantsreportedAgreeingthattelemedicineprovidedthesamequalityofcareasaninpersonvisit.Whenparticipantswereasked,“Ifnorheumatologistswereavailableinyourarea,howlikelywouldyouagreetoallowyourhealthcareprovidertouseatelemedicinesystemtotreatyourlupus?”Atpre-test,twoparticipantsreportedbeingverylikelyandatpost-test,threeparticipantsreportedbeingVeryLikely,andoneparticipantreportedbeingLikelytousetelemedicinetotreattheirLupus14(seeTable2).Table2
VolunteerPatientConcernsUsingTelemedicineLackofface-to-facetimewiththerheumatologistwasthemostendorsedconcernofthepre-test.(seeTable3).1516Table3
Pre-TestEndorsements
Post-TestEndorsements
1 FutureoncallaccesstotheRheumatologist
3 1 LackoffacetofacetimewiththeRheumatologist
14 One respondent did not answer all of the post test questions. 15 Two respondents did not answer all of the post test questions. 16 Lack of face time is possibly a result of the age range of the participants and the possible limited experience with online technology and social media. In addition, participants may feel that the absence of physical contact diminishes the examination.
012345
VeryLikely Likely NeitherLikelynorUnlikely
Unlikely VeryUnlikely
LiklihoodofUsingTelemedicinetoTreatLupus
PreTest Post-Test
7
1 Comfortwithtechnology
1 Other:NoPhysicalExam.InPersonHandson
OpenEndedResponsesfromPost-TestWhatdidpatientparticipantslikemost? Whatdidpatientparticipantslikeleast?
• Talking • Sheisnotinperson/nothere• Friendly• Ifeelveryconfidentwiththisprogram.• ConcernwithwhatImayneedhelp• Convenience
• Beingabletofaceandtalkwiththerheumatologistasifinanofficesetting(questions/answers)
• Ilikedit
MedicalProviderResponses Inaseparatesurvey,medicalprovidersinsouthwestGeorgiarespondedtoa
surveyabouttreatingLupuspatients.Atotalof(n=25)providersresponded.Themajorityofrespondents(n=11)werenursepractitionersfollowedbyphysicians(n=9),physicianassistants(n=4)and‘other’(n=1).Table4 Table5
Atotalofsixor24%ofhealthcareprovidersreportedusingsomeformoftelemedicine.Whenasked,“Doyouthinktelemedicineprovideseffectivecoordinationofcarewithoutcompromisingqualityorpatientoutcomes?”All(N=24)100%oftheprovidersreported‘yes’(seeTable8).Themajorityofmedicalprovidersreportedseeing10orlessLupuspatientsayear(seeTable7).Whenasked,themajorityofrespondents(n=19)reportedincreasedaccesstophysicians’referralnetworkasan
9
11
4
1
HealthCareProviderSurveyRespondents
Physician NursePractitioner
Physician'sAssistant Other
15
5
PrimaryAreaofPractice
FamilyPractice InternalMedicine
8
advantage.BenefitsandchallengesofusingtelemedicinetotreatLupuspatientsarereportedinTable8.
Table6
Table7
Table8
MainAdvantagesofUsingTelemedicinetoTreatLupus?
MainBarrierstoUsingTelemedicinetoTreatLupus?
0
10
20
Yes No
Areyoucurrentlyusinganyformoftelemedicinetotreat
patients?
0 5 10 15 20
Lessthan1011-20 21-30 31-40 41-50
Greaterthan50
0
2
4
6
8
10
12
14
16
18
20
0246810121416
9
FutureProjectionsMostprovidersStronglyAgreedthatifapatientpresentedwithsymptomsofLupus,theywouldknowwhentorefers/hetoarheumatologist(seeTable9).ThetoptwoendorsedconcernsforusingtelemedicinewereMedicarecoverstoofewtelemedicineservices(n=10)andWereceivenoreimbursementsforatelemedicinevisit(n=10).ThemajorityofhealthcareprovidersreportedbeingVeryLikelyorSomewhatLikelythattheywouldusetelemedicinetotreatpatientswithLupus(seetable9).TheleastendorsedconcernswereManagedcarecompaniespayinglowerratesfortelemedicinethanin-personcare(n=3)(seeTable10).Themajorityofhealthcareprovidersprojectthatthreeyearsfromnow25%orlessofpatientswillbeusingtelemedicine(seeTable11).
Table9 Table10
Table11
0
5
10
15
StronglyAgree Agree Disagree StronglyDisagree
ConfidenceinReferringtoaRheumatologist
024681012
Managedcarecompaniespayinglowerratesfor
telemedicinethanin-personcare.
Medicarecoverstofewtelemedicine
services.
Wereceivenoreimbursementforatelemedicinevisit.
SignificantConcernsRegardingReimbursementofTelemedicine
129
2
Threeyearsfromnow,whatpercentageofyourpatientswillbe
usingtelemedicineservices?
Lessthan25% 25% 50% 75% greaterthan75%
10
Table12
MedicalProviders’Open-EndedResponses
• Iworkforpublichealth-wewouldrefertotheirPMDandthePMDwouldrefertorheum.Luckily,wehaveaspecialistinThomasville.IworkaweekendamonthintheERinThomasCounty.Weusetelemedicineonstrokealertsandontheinputsidetheyhavebeenusingtelemedtohaveneuroconsultationanditseemstoworkwell.ItwasveryefficientandeffectiveintheER.
RheumatologistsResponses
ElevenrheumatologistsrespondedtoasurveyregardingthetreatmentofLupuspatients.Whenasked,whereisyourpracticeislocated,themajority(90%or10outof11)ofrheumatologistspracticeinmetroAtlanta.PatientTravelTimeandNumberofPatientsTreatedWhenasked,“Whatpercentageofyourpatientstravelmorethananhourtovisityou?”Themajorityresponsesrangedfrom25%to50%(seeFigure1).Themajority(90%or10outof11)ofrheumatologistsreportedencountering50ormorepatientsperyear.Figure1
024681012
Verylikely Somewhatlikely
Somewhatunlikely
Notlikely
Ifavailable,howlikelywouldyouusetelemedicinetotreatlupuspatients?
00.51
1.52
2.53
3.5
lessthan10%
10% 25% 50% 75% greaterthan75%
11
FeasibilityofTelemedicineWhenasked,“Doyouthinktelemedicineprovideseffectivecoordinationofcarewithoutcompromisingqualityorpatientoutcomes?”Themajorityofrheumatologists(n=9)reported“yes.”AdvantagesandBarriersWhenasked,“WhatarethemainadvantagestousingtelemedicinetotreatLupuspatients.”Thenumberoneendorsedadvantagelistedwas“Bettercoordinationofcare.”TheadditionalresponsesarelistedinFigure2.Interestingly,whenaskedaboutthemainbarrierstousingtelemedicinewere“Coordinationofcare”and“QualityofCare.”
Figure2
Advantages
TelemedicineConcerns
Figure3
Barriers
Whenasked,“Whatisyourmostsignificantconcernregardingreimbursementoftelemedicineservices.”Themostcommonresponseswere“Wereceivenoreimbursementforatelemedicinevisit”and“Managedcarecompaniespayinglowerratesfortelemedicinethaninpersoncare.”
024681012
012345678
12
Figure4
FutureofTelemedicinetoTreatLupusWhenasked,“Threeyearsfromnow,whatpercentageofyourpatientswillusetelemedicinetomanagesomeoralloftheirhealth?”Themajorityofrespondentsreportedlessthan25%(seeFigure5).Therheumatologistswerealsoasked,“Howlikelyareyourpatientstousetelemedicinetotreatlupuspatients?”(SeeFigure6).Themajorityofrheumatologistsreportedbeing“VeryLikely.”Figure5
0 1 2 3 4 5
Managedcarecompaniespayinglowerratesfortelemedicinethanin-person
care.
Medicarecoverstofewtelemedicineservices.
Wereceivenoreimbursementforatelemedicinevisit.
0 1 2 3 4 5 6 7
lessthan25%
25%
50%
75%
greaterthan75%
Other(pleasespecify)
13
PatientInsuranceCoverageWhenasked,“WhatpercentageofyourLupuspatientsusegovernmentfundedinsurancesuchasMedicaidorMedicare”ThemajorityofRheumatologistreportedbetween25%to40%(seeFigure7).Figure6
OpenEndedResponses
• Foundphysicalexamdifficultviatele-medicine.• IhaveseveralyearsofexperiencewithtelemedicinethroughGeorgia
TelehealthchampionedbyJohnOxendine• Ithinkitwillgiveaccesstopeopleindireneedandurgentneed.Itshouldnot
replacevisitstothedoctor!• NeedLogisticalData
0 1 2 3 4 5 6
Verylikely
Somewhatlikely
Somewhatunlikely
Notlikely
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5
lessthan10%10% 25% 40% 50% 65% 80%
greaterthan80%
14
ConclusionsOverall,thehealthcareproviderssurveyedseemedreceptivetotheuseoftelemedicinetotreattheirLupuspatients.Careandcoordination,inadditiontothequalityofcarewerekeyfactorsthatneedtob
SummationofResponsesfromRheumatologistswhoParticipateinthePilotStudyTheStudywasDrs.LimandLipsonfirstchancetousetelemedicinetoexaminepatientsanddeterminedthatthiswasawellperformedpilotstudythatwhenconductedinarealscenariocanbeaneffectiveoptionandalternativetoservicescurrentlybeingprovidedtoundertreatedlupuspatientswhovisitemergencyroomsandurgentcarecenters.Bothdoctorsfoundthattheabsenceofsomemedicalrecords,labrecords,andtheseofsomeexaminationtoolsmadetheexaminationlessduplicativeofaliveexamination.Dr.Lipsonfoundthetelemedicineexaminationalittlemoredifficultthananin-personexamination.Bothdoctorsdonotbelievethatthetelemedicineexaminationwouldhinderdiagnosisortreatmentoflupus,butDr.Lipsonsuggestedthatsomein-personsvisitswouldlikelybeneededonoccasion.Bothdoctorsthatthelargestconcernwithtelemedicineisthepossibilityoftechnicaldifficultiesandthetransmissionofelectronicmedicalrecords.Dr.Limindicatedthattheuseoftelemedicinetotreatlupuspatientsisahugewin,andbetterthanthealternative.Hebelievesthatsomeofhisconcernscanbeworkedoutthroughimprovementsinoptimization,standardizationofthenurseparticipationandexaminations,training,bettercoordination,andpartnershipswithlocalproviderswhocancoordinatecarethatcannotbeprovidedusingthetelemedicineequipment.
TechnologyConsiderationsTelemedicine(alsoreferredtoas“telehealth”or“e-health”)allowshealthcareprofessionalstoevaluate,diagnoseandtreatpatientsinremotelocationsusingtelecommunicationstechnology.Telemedicineallowspatientsinremotelocationstoaccessmedicalexpertisequickly,efficientlyandwithouttravel.Sincelupusrequireslifetimeattentionofseveralphysicians,telemedicinecanbeimplementedtoimprovehealthservicestolupuspatientsespeciallytheoneswithremoteaccesstohealthpractitioners.GiventhatDPHandFederallyQualifiedHealthCentersinGeorgiahavemadeanefforttoequipremoteclinicswithtelemedicineandtheequipmentcostsforrheumatologistsislimitedtothecostofthestethoscopeandcomputer,thebenefitfaroutreachesthecost.BasedonsomeofGCLEA’sresearch,therearesomeimportantconsiderationstonote,includinguseoftechnologyandspecialequipmentneededtoimplementtelemedicineacrosshealthcarelocations.
Product/ServiceMarketplaceIntheearly2000’s,astudywasconductedbytheGeorgiaLupusRegistryaimingtoexpandtheexistingknowledgesurroundingLupusina“targetedpopulation”( “TheIncidenceandPrevalenceofSystemicLupusErythematosus,2002–2004:The
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GeorgiaLupusRegistry”).From2002-2004,twospecificcountiesinGeorgia,FultonCountyandDeKalbCounty,weretargetedtoconductfurtherresearchonlupus.Withthepopulationsofthecountybeingmajoritywomen,andmajorityAfricanAmericans,thestudyconcludestheincidenceratebeing5.6per100,000people17Thestudyconfirmsthatthecasesamongblackwomenaretriplethecasesamongwhitewomen.Also,thecasesfoundforwomenwereninetimesthecasesfoundformen18SimilarstudieshavebeenconductedinareasofSanFrancisco,California,Manhattan,NewYork,andsoutheastMichigan.19Yet,therehavebeennostudiesconductedintheruralcommunitiesinournation.ThereisashortageofhealthcareprovidersintheruralregionsofGeorgiathathavetheexpertisetotreatpatientswithLupus,contributingtotheneedfortelemedicinefortheunderservedpopulations.
ResearchWhiletheGCLEA’stelemedicinepilotstudyforlupuspatientsisknowntobethefirstofitskind,telemedicinestudieshavebeenconductedonpatientswithothermedicalconditions.Dr.SamuelG.Burgess,etal.conductedastudythatwaspublishedin1997connectingruraldermatologypatientswithdermatologistsusingtelemedicine.20Burgessstudied87patientsovera17-monthperiodandconfirmedthattelemedicineiscost-effectiveandaresourcefuloptionforpatientswhocannoteasilyaccesshealthcarefornecessaryroutinecheck-ups.
Conclusions,RecommendationsandActionStepsTelemedicineisthefuture.TowersWatson.comreportedin2014thattelemedicinecouldpotentiallydelivermorethan$6billionayearinhealthcaresavingtoU.S.companies.21Thereportindicatedthatoutofonethousand(1,000)companiessurveyed,22%wereusingtelemedicinein2016andthatnumberincreasedto37&in2017.BasedonthefindingsfromtheTelemedicinePilotinDoughertyCountyandthesurveyresultsofhealthcareprovidersinsouthwestGeorgiaand
17Lim,S.S.etal,TheIncidenceandPrevalenceofSystemicLupusErythematosus,2002-2004.Arthritis&Rheumatology2014,66:357-368.http://onlinelibrary.wiley.com/doi/10.1002/art.38239/abstractMichiganregistryarticle:Somers,E.C.etal,Population-BasedIncidenceandPrevalenceofSystemicLupusErythematosus.Arthritis&Rheumatology2014,66:369.18Id.19Dall’Era,M.,etal.TheIncidenceandPrevalenceofSystemicLupusErythematosusinSanFranciscoCounty,California:TheCaliforniaLupusSurveillanceProject.,Arthritis&Rheumatology:2017,69(10)1996-2005;Izmirly,PM,etal.TheIncidenceandPrevalenceofSystemicLupusErythematosusinNewYorkCounty(Manhattan)NewYork:TheManhattanLupusSurveillanceProgram.,Arthritis&Rheumatology:2017,69(10):2006-2017;Housey,M.,etal.IncidenceandprevelanceofsystemiclupuserythematosusamongArabandChaldeanAmericansinsoutheasternMichigan:theMichiganLupusEpidemiologyandSurveillanceProgram.AmericanJournalofPublicHealth:2015,105(5):74-9.20iBurgiss,SG,etal.Telemedicinefordermatologycareinruralpatients.TelemedicineJournal.1997,Fall:3(3):227-33.21CurrentTelemedicineTechnologyCouldMeanBigSavings.(2014);https://www.towerswatson.com/EN-US/PRESS/2014/08/CURRENT-TELEMEDICINE-TECHNOLOGY-COULD-MEAN-BIG-SAVINGS
16
rheumatologiststhroughoutthestate,theimplementationoftelemedicineisfeasibleandfulfillsagreatneedamongstpatientswithLupuslivinginGeorgia.Therearesomedrawbacks.Certainly,ourrheumatologistswerenotabletosufficientlycomparewhetherornottheneedfortactileexaminationsislimitedbytelemedicineandtheuseofatelemedicinepresenter.Alargerstudywouldneedtobeexecutedtodeterminewhetherthesamequalityofcare,dianogisandtreatmentisgiventoeachpatient.Anotherdrawbacktothecurrentsystemoftelemedicineisthatthecurrentmodellimitstheabilityofrheumatologiststoeducatenursepractitioners,physicianassistants,andphysiciansonhowtodiagnoseandtreatLupus,aninteractionthatwouldcertainlyimprovetheefforttocombatLupus,becausethetelemedicinepresenterisusuallyaregisterednurseornursingassistant.OnedrawbacktoconductingabroadertelemedicinepilotinsouthwestGeorgiaisthefactthatwesimplydonothaveavastunderstandingofwhatpercentageofthepopulationislivingwithlupus.Inordertoeffectivelyimplementtelemedicine,thereareseveralconsiderationsthatneedtobetakenintoaccount:
Þ EducateLupuspatientsabouttheirexpectationsincludingthelimitationsandbenefitsoftelemedicine;
Þ EducateandtrainLupuspatienthealthcareprovidersonhowtousetechnologyandbillingpoliciesandprocedures;
Þ Conductorretrieveaheatmapstudytodeterminewherealargerpilotstudyontheuseoftelemedicinetotreatlupuspatientswouldbemostbeneficial;
Þ Collaborateandbuildarelationshipwiththelocalphysicians,rheumatologistsandcitizenstobuildaleveloftrustinthecommunity;
Þ Expandthepilotprogramtoincludepersonslivingwithlupuswhoarenolongerutilizingcurrentservicesprovidedtolupuspatientsacrossthestate;
Þ ExpandtheLupusRegistrytodeterminediseaseprevalence;Þ Workwithinsurancecompaniestodeterminewhatcostsarecoveredand
howwecanengagecompaniestoinvestinequipment;Þ Reviewprevioustelemedicinepilotstudiestocomparecostsbenefitanalysis
andpatient-physiciansatisfaction.Þ WorkwithentitiessuchasAreaHealthEducationCenters,GeorgiaBoardfor
PhysicianWorkforce,GeorgiaSocietyofRheumatology,andtheAmericanCollegeofRheumatologytopromoterheumatologyasamedicalspecialty,andencouragegreaterusoftelemedicineasaviabletool.