Telemedicine & Fellowship Education After COVID-19: Q&A with Kanika Monga, MD

How is telemedicine reshaping rheumatology care for a wide spectrum of patients in the era of COVID-19? The Rheumatologist interviewed Kanika Monga, MD, a second-year rheumatology fellow who rotates between Lyndon B. Johnson (LBJ) Outpatient Center/Harris Health System and a private rheumatology clinic at UT Physicians, Houston. She discussed why telemedicine is here to stay as a tool that expands access to care, how rheumatology fellowship training programs may incorporate telemedicine into curricula and why the physician-patient bond must be protected as healthcare embraces this new technology.

Kanika Monga, MD

Q: How and when did you ramp up use of telemedicine due to the COVID-19 pandemic? What type of technology do you typically use?
The stay-at-home order in Houston went into place around March 24. So we tried to ramp up telemedicine immediately. At first, we relied on telephone visits while we were ramping up our televideo visits. At UT Physicians, we use InTouch as our virtual care platform. At LBJ, we use MyHealth.

By April at UT Physicians, we saw 99% of our patients through telemedicine while still maintaining our total patient targets, which were comparable to pre-COVID-19 times. At LBJ, 60–70% of the total visits were seen via telemedicine.

Q: What are some of the benefits and challenges of telemedicine in rheumatology?
The benefits include access to providers and specialists for patients in underserved or geographically distant areas. During the public health crisis, it allows the most vulnerable patient population to continue receiving care at the click of a button. Telemedicine has helped improve patient care by improving follow up and compliance.

For example, in our patient population, mobility can be a major issue because of the underlying disease. So telemedicine improves care for patients who struggle to make it to appointments. Many patients in our county depend on arranged and/or public transportation. Many must request a portion of their day off work—so telemedicine is more convenient.

Challenges include the different available platforms and their usability. Although some patients are tech-savvy, some are not. This [factor] is a challenge, especially when using platforms that have many steps involved. Some [payers] require the use of specific platforms for telemedicine visits, and these may not always be the most user friendly.

Telemedicine also highlights general health inequities that may already exist in the population. Patients who are older, less educated or from a lower socioeconomic household may not have the technology available to enable telemedicine visits.

Also, the component of the physical exam is very important, especially in rheumatology. Measuring skin scores or even assessing for synovitis through telemedicine is a challenge.

Q: How do your patients like telemedicine appointments?
Patients appreciate having the option to do telemedicine visits. They have expressed that it means a lot to them that physicians are willing to try innovation to continue care while maintaining patient safety as a priority.

The patients have been very receptive. They are hoping this technology becomes a long-term part of our healthcare system. [Many] patients have told me that if a telemedicine visit [hadn’t been] offered, they would have likely missed their rheumatology appointment. They are really scared of the current situation with the pandemic. They are not comfortable leaving their house and much less comfortable coming to a healthcare setting.

I would like to emphasize that it’s crucial that patients consent beforehand. They should have the option to opt in or out [of a televisit]. I treasure the bond we share with our patients as we take care of them. I would not want to compromise on the human aspect of medicine. We have to keep our patients at the center as we develop and adopt new protocols. This would include making sure we stay HIPAA compliant, maintain patient preference, [adopt] user-friendly platforms and receive adequate training.

Hurdles regarding receiving proper reimbursement for telemedicine visits from federal, state and private insurers need to be overcome as well. For many insurance plans, telemedicine services can be obtained only through in-network providers. Although some of these restrictions have been loosened or waived during the pandemic, this may be a hurdle for sustaining telemedicine long term.

Q: What role do you see telemedicine playing in the future? Is it here to stay and, if so, how should it be used?
I believe it’s here to stay. The provision of healthcare services and education over a distance through the use of technology increases access and improves care for patients with rheumatic diseases. In the future, this [ability] could mean world experts could be accessed by patients all over the U.S. This [access] would be wonderful for patients, especially those with a rare disease, such as scleroderma, who are not able to travel far distances—whether for physical or monetary reasons—for a consultation.

This [ability] would in no way replace face-to-face visits, but it could be useful when conducted at appropriate intervals and for individual cases. For example, patients with chronic lung disease who are stable, but need to arrange transport to bring them to the clinic over long distances, may benefit from swapping an in-person visit for a televisit from time to time—as long as their disease is stable.

Q: How could rheumatology training programs include more telemedicine education or training for fellows so they feel comfortable using this technology?
Fellows [need] to learn how to triage patients to see which cases are safe to see over telemedicine [vs. those who] would benefit from in-person visits. Triaging is very important, especially for patients with rheumatic diseases. If a patient is flaring or needs to change a biologic medication, those conversations are better made in person and with an appropriate physical exam.

I find that telemedicine visits work best for patients with stable disease and established patients. Gloria Salazar, MD, and Filemon Tan, MD, have been leaders in training the fellows at UT Health Rheumatology. We did receive email modules on how to access the platforms, and we learned how to triage patients by working with our attendings directly.

In the future, I hope telemedicine training becomes an integral part of the fellowship lecture series. It will be a great skill to acquire, a skill our patients appreciate. The technology allows us to change with the times and learn to adapt ways to practice rheumatology while keeping our patients at the center of our care.

Susan Bernstein is a freelance journalist based in Atlanta.