Expanding the Scope of Telemedicine in Gastroenterology

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The initial implementation of a specialty telemedicine clinic taught us several lessons that will not only guide this program expansion, but also may be relevant for others introducing telemedicine into their specialty clinics. At first glance, videoconferencing with patients resembles more conventional clinic encounters. However, it adds another angle as many steps from scheduling a visit to implementing recommendations rely on different members at the remote site. Thus, the success of such a program depends on establishing a true partnership with the teams at the various satellite sites. It also requires ongoing feedback from all team members and fine-tuning to effectively integrate it into the routine operations of both sites.

Feedback about the program has been very positive with comments often asking for an expansion beyond gastroenterology. Concerns largely were limited to scheduling problems that may become less relevant if the new telehealth initiative moves forward and enables health care providers to directly connect with computers or handheld devices at the patient’s home. Prior studies demonstrated that most individuals have access to such technology and accept it as a viable or even attractive option for medical encounters.11,12

For some, remaining in the comfort of their own home is not only more convenient, but also adds a sense of security, further adding to its appeal.13 As suggested by the economist Richard Thaler, simple nudges may be required to increase use and perhaps utility of telemedicine or e-consults.14 At this stage, it is the active choice of the referral or triaging provider to consider telemedicine as an option. To facilitate deviation from the established routine, we plan to revise the consult requests by using a drop-down menu option that brings up e-consult, telemedicine, or clinic visit as alternatives and requires an active choice rather than defaulting to conventional face-to-face visits.

Despite an overall successful launch of the specialty telemedicine clinic, several conceptual questions require additional in-depth assessments. While video visits indeed include the literal face time that characterizes normal clinic visits, does this translate into the “face value” that may contribute to treatment success? If detailed information about physical findings is needed, remote encounters require a third person at the distant site to complete this step, which may not only be a logistic burden, but also could influence the perceived utility and affect outcomes.

Previously published studies have demonstrated the effectiveness of video-based interactions and allow providers to address these points to some degree. Remote encounters have established roles in mental healthcare that is less dependent on physical findings.15 Distance monitoring of devices or biomarkers, such as blood sugar levels or blood pressure, are becoming routine and often are combined with corrective interventions.16-18

Recently completed trials showed satisfaction did not differ from conventional clinic encounters when telemedicine encounters were used to manage chronic headaches or provide postoperative follow-up after urologic surgery.19,20 For gastroenterology, telemedicine outreach after hospitalizations not only improved care, but also lowered rates of testing after discharge.21 In patients with inflammatory bowel disease, a group that was not targeted during this initial phase, proactive and close follow-up with remote technology can decrease the need for hospitalization.22

These data are consistent with encouraging feedback received. Nonetheless, it is important to assess whether this approach is superior to established and cheaper alternatives, most notably simple telephone interactions. Video-linkage obviously allows nonverbal elements of communication, which play an important role in patient preference and satisfaction, treatment implementation, and impact.7,8,23-25 Providers described patients as more focused and engaged compared with telephone interactions and valued the ability to incorporate body language in their assessment.26

Telemedicine clinics offered by specialty providers may not improve access as defined by wait times only, which would require adding more clinical time and personnel. However, it can lower barriers to care imposed by long distances between rural areas and facilities with specialized expertise. Even if a remote encounter concludes with the recommendation to visit the clinic for more detailed testing or treatment, explaining the need for such steps and involving the patient in the decision-making process may affect adherence.

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