Telemedicine in Nephrology

The COVID-19 pandemic presented unique challenges to both patients trying to obtain medical care and physicians providing the care. During this unprecedented time, telemedicine gave many patients a safe and convenient option to access medical care. In a recent AJKD core curriculum, Koraishy and Rohatgi present a comprehensive review of various platforms available and discuss the patient-centric benefits of telenephrology—especially for patients with a geographic disadvantage in access to care. When it was published in February 2020, few could have imagined the impact COVID-19 would have on medicine, and fewer could predict that by one month later, there would be widespread utilization of telemedicine. Here we discuss some of the challenges posed by telemedicine platforms and urge thoughtful discussions to implement best-practices surrounding the use of telemedicine to ensure it remains sustainable.

The adoption of telemedicine in nephrology occurred rapidly following the COVID-19 pandemic, and it did not give us enough time to identify pros and cons. With easy-to-use virtual platforms, patients can receive consultative services without having to travel. Hospitals can continue to offer services to patients.  Nephrologists are providing critical outpatient services from the safety and comfort of their homes. However, our experience suggests that a successful telenephrology visit requires reliable home blood pressure monitoring and ability to obtain blood work (which requires patient contact with a lab, healthcare facility, or visiting healthcare professional). Finally, we find that volume assessment, a cornerstone of nephrology, is particularly challenging to perform via telemedicine.

Telemedicine also leads to unique ethical challenges.

Number of patients per nephrologist by US hospital referral region, along with location of nephrology fellowship training programs. Abbreviation: ESRD, end-stage renal disease. Figure 1 from Koraishy and Rohatgi, AJKD. Reproduced with permission from American Society of Nephrology from The US Nephrology Workforce 2015: Developments and Trends. Geographical Distribution of Nephrology Fellowship Programs and ESRD Patients per Nephrologist by Hospital Referral Region, 2011.

From a societal perspective, it might worsen inequities for patients who either do not have access to smart devices or have difficulty using them. From a patient standpoint, some may not feel comfortable sharing confidential information with their physicians over a virtual platform, and it is not yet clear how shared decision-making is impacted. Similar reimbursement structures between telemedicine and in-person services offer a financially viable pathway for many practices affected due to COVID-19 pandemic. Still, it might also disincentivize physicians and health systems from returning to in-person examinations. The risk of COVID-19 infection and rapid adoption of telemedicine also can cause uncomfortable interactions between providers and raise difficult questions: How do we decide which providers should perform only telemedicine services to mitigate their risk of infection?

For telemedicine to remain sustainable, in addition to ensuring patient safety, it must be equitable. The Centers for Medicare and Medicaid Fee Schedule for 2021 now proposes continued coverage for telemedicine services for at least the next year. The debate is no longer whether telemedicine should be adopted; instead, we must identify its role in patient care once the COVID-19 pandemic subsides. There is an urgent need to identify best practices surrounding telemedicine to ensure that our patients continue to benefit from this platform.

Advantages, disadvantages, and ethical challenges posed by telemedicine services.</span

– Post prepared by Vishnu Potluri and Nathaniel Reisinger @nephrothaniel, AJKDBlog Contributor.

 

To view Koraishy and Rohatgi (FREE), please visit AJKD.org.

Title: Telenephrology: An Emerging Platform for Delivering Renal Health Care
Authors: Farrukh M. Koraishy and Rajeev Rohatgi
DOI: 10.1053/j.ajkd.2020.02.442

Articles in the Core Curriculum aim to give trainees in nephrology a strong knowledge base in core topics in the specialty by providing an overview of the topic and citing key references, including the foundational literature that led to current clinical approaches. 

 

 

 

 

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