Application of Telemedicine to Kidney Failure Patients

Telemedicine in Kidney Failure: Overview of the Opportunity and Issues

Telemedicine is rapidly becoming a consistent part of health care delivery. While the term “telemedicine” includes any delivery or monitoring of care remotely, including telephonic care, the contemporary definition includes the use of video and the remote delivery of computer data. Telemedicine has historically seen a relatively low adoption rate, largely due to concerns around quality of care delivered without a live interaction and reimbursement issues. As technology and consumer expectations around how their care will be delivered have evolved, there has been a slow but sustained increase in use in many avenues of nephrology care, including in the care of kidney failure patients.

The 2020 COVID-19 pandemic accelerated many nephrologists’ adoption of telehealth for hospital, office, and kidney failure care, for patients treated with both in-center and home modalities. Health systems of all sizes quickly enabled telehealth programs in response to the pandemic, and regulatory waivers provided additional flexibility around the use of telehealth. Despite this rapid expansion of the use of telehealth with dialysis patients, many questions remain unanswered—including understanding the clinical impact and the best practices for implementing a telehealth program.

In this chapter, we will focus on telehealth defined as the ability to remotely monitor and interact with patients undergoing dialysis with the use of audio and video two-way communication. Physicians or other care providers may be in an off-site location, such as their clinic office. Patients may be in free-standing dialysis clinics, at home, or receiving kidney replacement therapy in the hospital.

The general framework required for telehealth parallels the way that patients in intensive care units (ICUs) are monitored by a central physician through eICU systems. Such systems have been described as follows: “tele-ICU delivers technology-enabled care from a remote command center. At its simplest, mobile platforms provide on-demand, two-way, audiovisual (AV) communication between ICUs and the tele-ICU center. Typical infrastructure is more complex and involves a tiered system of fixed AV communication, access to Electronic Medical Records (EMRs), telemetry, and imaging systems for data retrieval and documentation, plus risk stratification and decision support.”

Telemedicine/Virtual Intensive Care Unit: Where Are We and Where Are We Going?

The ability to monitor outcomes and communicate on demand has proven effective and has been associated with increased best-practice adherence, improved patient outcomes, and positive experiences for patients and caregivers in the hospital setting. Thus, the use of telemedicine in the ICU informs the use of similar programs in outpatient settings such as dialysis.

In some parts of the world, a nephrologist is required to be in the facility when dialysis treatments are being delivered. This regulatory requirement is historical and may reflect previous issues requiring a physical presence, such as the use of acetate-based dialysate. This regulatory requirement does not exist in other regions, such as the United States. However, the global COVID-19 pandemic has necessitated a rapid reassessment of the risks and benefits of direct nephrologist supervision versus the need to cohort and sometimes quarantine patients and staff based on COVID-19 status. As a result, the use and evolution of telemedicine have increased dramatically in some countries.

This rapid increase in telemedicine use may help solve the increasingly pressing issue of the declining number of nephrologists worldwide. Telehealth may allow the nephrology community to scale more effectively to provide high-quality dialysis care to a growing population in a wider variety of geographically separate care venues. This is especially true in rural areas where requiring a nephrologist to be physically, as opposed to virtually, present may be a rate-limiting factor in terms of providing access to dialysis. Use of telemedicine may be even more important for the increasing number of patients who dialyze at home.

From a more consumer-oriented perspective, telehealth appears to be a reflection of a broader shift in philosophy around care to become more patient directed. The authors have observed that home-based dialysis modalities have been on the rise, in light of the recent Executive Order in the United States, as well as an increased focus on self-sufficiency among patient populations in managing and directing their own care. Nephrologists must still monitor these patients, and telehealth, remote patient monitoring, and other technology solutions help provide the bridge and connection point between patients and providers in this new paradigm.

The Health Care System in the United States Presents Particular Challenges

According to the Center for Connected Health Policy, all 50 U.S. states and the District of Columbia now reimburse for some type of live video telehealth services. That said, reimbursement for remote patient monitoring, frequently used in the kidney care space to monitor patients using peritoneal dialysis (PD) at home, varies state by state.

Given the increased use of telemedicine for kidney care in the United States both before (mainly home dialysis) and during the pandemic (all modalities), examining the payment challenges by payor type and by modality provides a useful framework for anyone in the dialysis and nephrology space considering implementing a telehealth program.

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  Physician reimbursement:

  • Medicare : Reimbursement for remote dialysis rounding is limited to originating sites and must either be outside the metropolitan statistical area or in an area with a health professional shortage. The vast majority of dialysis patients have traditional Medicare; therefore, CMS has tremendous influence on the reimbursement of telehealth.

  • Medicaid : Reimbursement for telemedicine varies by state. Trends indicate reimbursement for telemedicine is on the rise.

  • Private insurance : There are no consistent standards governing private payors; however, states continue to pass parity laws requiring telemedicine reimbursement.

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  ESRD Conditions for Coverage (CfCs) : Medicare CfCs certify the facility as qualifying for Medicare payment.

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  Health Insurance Portability and Accountability Act of 1996 (HIPAA) : Absent pandemic-related waivers around originating site and telehealth platform choice, best practice is for programs to ensure that HIPAA guidelines are followed at all times, including technology hardware and software selection, as well as in-center patient care.

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  Licensure : Physicians are required to be licensed in the state where the patient is located, not where the physician is located. However, there are coalitions of states that are offering various forms of reciprocity with regard to interstate telehealth licensing. Given the complexity, clinicians are advised to keep in touch with state medical societies in both originating and destination location states if care is being rendered across state lines.

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  Malpractice : According to the AMA Telehealth Playbook , the American Medical Association (AMA) recommends the following to minimize potential risk associated with telemedicine:

  • Include the legal and billing team as early in the process as possible to understand federal, state, and payer requirements and regulations.

  • Identify in which states your clinicians need to be licensed as well as in which states they are currently licensed.

  • Research interstate licensure, including the Interstate Licensure Compact.

  • Check with your malpractice insurance carrier to ensure you are covered to provide telehealth services.

Similar variants of these issues no doubt occur in many countries of the world. However, that is rapidly changing given the evolving technology and pandemic needs.

A Framework for Implementation of a Telehealth Program

As mentioned earlier, there are two specific aspects of telehealth. The first is a variant of traditional telemedicine, which leverages a video visit to facilitate diagnosis and treatment. Here, the essential capability is for a clinician to remotely interact with the patient and/or remote caregiver to allow diagnosis and treatment.

The second aspect focuses on remote patient monitoring, creating a virtual ability for the remote clinician with the same fidelity as if the provider were physically present on site. Achievement of this goal requires access to electronic medical records, telemetrics that provide either real-time streaming or batched submission of data from a dialysis machine or ancillary device, such as a blood pressure cuff or remote stethoscope and some type of virtual presence in the form of audio and video communication. This type of remote patient monitoring will most often be used in the home setting but may also be used with remote care sites and centralized monitoring of in-center facilities.

This framework of both the telehealth encounter and remote patient monitoring requires consideration of the originating and receiving sites. The patient’s location is considered the originating site for the telehealth program. The patient is typically located at either a clinic in the case of in-center dialysis or the patient’s home in the case of home modality patients. The physician’s location is designated as the receiving site. This could be any number of physical locations, including the provider’s office, a hospital location, or the physician’s home, among others. The originating and receiving sites are the two required locations in terms of regulatory and billing requirements. However, if other members of the patient’s care team join the telehealth encounter for interdisciplinary rounding, their locations are additionally receiving locations. This is described in Fig. 66.1 .

Having defined the framework of the telehealth system, we move to define specific use cases or scenarios in which the telehealth program needs to function, as well as the various supports (training, devices, and documentation) required to make the telehealth program effective.

Use Cases

Routine Nonemergent Nephrologist/Interdisciplinary Rounding

A routine use case involves remote scheduled rounding by a nephrologist, which may also include other members of the care team, such as social workers and dieticians. For the in-center hemodialysis scenario, the nephrologist contacts the dialysis unit at a predetermined frequency or has previously established a block of time for telehealth to conduct rounding on one or more patients who are dialyzing in the unit at that time. If there is a single shared device at the location on which the telehealth encounter is rendered, the care team at the dialysis center originates a telehealth encounter with the physician at the designated time. The remote nephrologist uses a combination of the audio/video feeds, information in the electronic medical record, and in the case where remote patient monitoring is in place, real-time data transmitted from connected cyclers, connected peripherals (scales, blood pressure cuffs, glucometers), and/or other medical devices to conduct rounds. Notes and findings are entered into the EMR.

The telehealth device may be manually moved from patient to patient by the facility staff, adhering to proper infection control procedures. In more robust scenarios, clinics would provide telehealth applications on devices at the patient’s chairside or facilitate a “bring your own device” option for telehealth, whereby patients download the telehealth application on their personal smartphone or tablet. The logical flow for such an interaction is detailed in Fig. 66.2 .