Integration of telemedicine into clinical gastroenterology and hepatology practice

Teleconferencing

Project Extension for Community Health Care Outcomes (ECHO) was originally designed to provide specialist support for treatment of hepatitis C to primary care providers (PCPs) in rural New Mexico and the prison health system. The ECHO model leverages video teleconferencing to provide ongoing assistance from specialists to PCPs for management of cases, treatment plans, and monitoring and also provides case-based learning to increase PCP knowledge and opportunities to participate in research.²⁵ A survey of 29 providers participating in Project ECHO revealed that more than 90% of respondents felt comfortable with management of hepatitis C as a consequence of using the program.²⁶ Subsequently, a prospective cohort study was conducted to compare outcomes of treatment of hepatitis C between the University of New Mexico hepatitis C virus clinic and PCPs at 21 ECHO sites. In the 407Four hundred seven patients who were included in the cohort study,; sustained virologic response was obtained in 57.5% and 58.2% of patients treated at University of New Mexico and ECHO sites, respectively. Response rates did not differ by site according to genotype. Adverse events were lower at ECHO sites, compared with the hepatitis C virus clinic (6.9% vs. 13.7%, respectively).²⁷ With a combination of funding from the state government and external funding agencies, Project ECHO now provides support from specialists to the community for 18 other chronic conditions, including but not limited to diabetes, human immunodeficiency virus, substance abuse, and high-risk pregnancies. Similar approaches have been proposed to create multidisciplinary teams for the management of hepatocellular carcinoma and cirrhosis.²⁸

The Inflammatory Bowel Disease Live Inter-institutional and Interdisciplinary Videoconference Education (IBD LIVE) is a national weekly teleconference that brings together gastroenterologists (adult and pediatric), surgeons, radiologists, pathologists, and medical subspecialists from multiple institutions to discuss the management of complex IBD cases. IBD LIVE is continuing medical education–accredited and is published quarterly in Inflammatory Bowel Diseases. Each 1-hour conference covers two cases equally. After the initial presentation, the moderator summarizes the case and asks faculty to provide their opinion on management. Because many of the cases presented are quite complex, it is common for subspecialists from other disciplines to join the conference to provide clarity.²⁹ The interaction among the various centers has been more than a means of obtaining continuing medical education. In many cases, referrals to other centers have been expedited because one center may offer a service not available at the “home” institution. Providers also use the summary and recommendations to help inform decisions in management of their respective patients. Exchange of ideas has resulted in collaborative research and quality improvement programs without requiring travel and/or absence from clinical duties.
 

Conclusions

The use of telemedicine in the care of patients with digestive diseases is expanding beyond telephone triage to include remote monitoring and self-care, telehealth visits, and teleconferencing. It is inevitable that use of these services will continue to increase to improve clinical care, to provide quality metrics, to increase access to gastroenterology care and tertiary referral expertise, to improve efficiency of health care delivery, and to decrease costs. Investment in telehealth by venture capitalists has increased fourfold from $1.1 to $4.3 billion from 2011 to 2015.³⁰ Unfortunately, barriers to providing health care remotely continue. These include technological barriers for many practices, the requirement for providers to be licensed and credentialed in multiple states and institutions respectively, unique liability concerns, difficulties with reimbursement, and differential access to telehealth services among patients. In addition, patient engagement with remote monitoring has been disappointing, likely because of poor system designs and limited involvement with patients in design of the monitoring systems. It is likely that payers and states will slowly increase reimbursement and ease use of telemedicine as they learn how telemedicine can decrease costs and improve the efficiency of health care delivery.

Dr. Cross is in the division of gastroenterology and hepatology, department of medicine, University of Maryland, Baltimore. Dr. Kane is in the division of gastroenterology and hepatology, department of medicine, Mayo Clinic, Rochester, Minn. This research was supported by the Agency for Healthcare Research and Quality (1R01HS018975-01A1). The authors disclose no conflicts.
 

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