“There is pressure for everyone to move forward [in] this [approach], because it’s the right thing to do for our patients. There is no other way to provide care in some rural locations,” he said.
Rural Rheumatology
In vast Alaska, rheumatologist Elizabeth Ferucci, MD, MPH, uses videoconferencing to see patients at 200 access locations around the state while she may be in her office at Alaska Native Medical Center in Anchorage.
“These locations may be rural clinics staffed by community health aides trained to do certain medical tasks in their villages,” said Dr. Ferucci. Aides are supervised by primary care providers at 30 larger hub clinics across Alaska. She and other rheumatologists spend three days at 12 rheumatology field clinics twice a year. To save airfare costs, the state’s health systems embraced telemedicine in 1999. Her system conducted 2,406 telemedicine visits in the last fiscal year.
Based on focus group data from Alaska Native and Native Hawaiian patients, “we felt that the initial patient-to-provider interaction should be face to face and that patients also should see the same provider on follow-up visits. So relationships, trust and continuity are very important among this population,” she said. Generally, her system uses telemedicine only for follow-up visits.
Telerheumatology has benefits and drawbacks, said Dr. Ferucci. “Using it for a new consultation may reduce wait time to diagnosis for some patients. It can be used for triage. But one big disadvantage would be not having a physical exam on the first visit, and the lack of opportunity to establish that patient-provider relationship at this visit.” Some of her patients do opt for telerheumatology to shorten the wait time for an appointment, but others choose to travel to Anchorage. Each physician has the videoconferencing software on their laptop, a webcam and speakers.
Does telemedicine really save time and money? Alaska’s health systems estimate that of 4,400 telemedicine claims paid by Medicaid, 80% prevented the need for travel, which they translated to $2.8 million in net savings over a six-year period, she said.
Telemedicine has both advantages and unknowns, she said. “Is the quality of care different, better, worse or the same? We don’t know yet. Does improved access translate to improved outcomes in the patient, as we would expect? We don’t know. Is it cost effective? There are very few studies on this,” she said.2
Military Medicine
The U.S. Department of Defense has used asynchronous systems for years to connect consulting specialists to providers deployed around the world, said Dan Battafarano, DO, MACP, division director of Rheumatology at the Uniformed Services University in San Antonio.
