Improving Access to Care, Outcomes Through Telemedicine for Patients With RA

Wendy Marder, MD, an associate professor and clinical service chief of the division of rheumatology at Michigan Medicine in Ann Arbor, Michigan, discusses telemedicine in a rheumatology setting.

Telemedicine has given physicians the ability to deliver care to patients, regardless of where they live. How do you think a program like this can impact overall care?

Dr. Marder:  For rheumatology patients, our biggest challenge, of course, is access with the shrinking workforce. Telemedicine offers us an opportunity to, hopefully, improve access and most importantly care for our stable chronic patients who may live a distance in Michigan.

We have a lot of our population concentrated in a lower part of the state, less populated. "Up north," we call it. A lot of our patients, as in many places, drive a great distance to see us. Not many rheumatologists in other parts of the state.

For us, it offers an opportunity to save people the drive down to see us in Ann Arbor, to provide an opportunity for our stable patients, who may otherwise be doing quite well, to check in with us and not have to make that great distance.

We see it also possibly helping us in terms of pre-screening or triaging patients who don't need to come and see us, and working more with primary care providers or other healthcare personnel to sort out who doesn't even need to see us, or who may not be more urgent. I think there's a lot of opportunity for us.

Rheumatology has been called a key specialty in which to use telemedicine. Why do you think this is?

Dr. Marder:  Well, again, it mostly has to do with looking for ways to alleviate the workforce shortage. The number of new rheumatologists coming through is really not adequate to provide care for the aging population and many retiring rheumatologists, particularly in Michigan, but certainly around the country as well.

The access problem primarily in rheumatology drives all of us to look for other ways to provide care better and to make sure that we can continue to see the patients who need to get in to see us, and provide timely care and certainly specialized care.

We're the only ones who are going to be able to manage scleroderma, vasculitis, and lupus so we need to make sure to preserve our access and to facilitate timely care for those patients who need us.

Rheumatology, like many specialties, when someone needs to be seen urgently, a tertiary care center, like University of Michigan, for example, We need to be able to identify those patients and get them in quickly.

How will telemedicine impact rheumatology care now, amidst the current shortage of rheumatologists, and for the future?

Dr. Marder:  That's a great question. I don't think we know yet. I don't think in rheumatology, or most certainly in Michigan, have started to use telehealth in the way that we need to and in the way that other areas, the VA for example, have used telehealth, particularly programs like Project ECHO, which is out of University of New Mexico where I was a medical student.

There's a great swath of this state that is underserved. Being able to partner with primary care providers in the area is the way that rheumatology is going to probably make the most impact, or hopefully make some impact in states, like Michigan, where there's many areas where there just is not rheumatology care.

Partnering with primary care providers also, as I said, maybe being able to have communication with our stable patients, our nursing. We have so many patients on medications requiring therapeutic drug monitoring. Those visits, those nurse check-ins could be done via telehealth, and we're starting to do that now at Michigan.

That's going to provide a very nice complementary opportunity for us to make sure our patients are doing well and their medications are effective and safe for them. We're trying to just get into the area of telehealth because there is so much potential. I just think we don't know yet how it's going to be most effective for our patients.

We're looking into all different options currently. Our first step is going to be making sure that our therapeutic drug monitoring nurses are first going to try this out for us with our patients. We'll see how that goes. We're certainly looking at it, but our experience so far is still limited.

What is the key takeaway a rheumatologist should know about the importance of telemedicine in a rheumatology setting?

Dr. Marder:  It's still hard to know how this is going to change our practice. Probably, a very important use for it will be to help screen and triage new referrals and possibly help with redirecting any, for example, referrals for musculoskeletal patients that may be more appropriately seen in physical medicine, orthopedics, and perhaps don't need to come into rheumatology at all.

That would help open up access for our patients with lupus, with scleroderma, with vasculitis, or patients who absolutely need our expertise.

That will presumably help in our situation with ensuring that we're able to provide timely access to rheumatology patients. It all comes down to the workforce and being realistic about how many referrals we need to get in urgently. That's our challenge at a big institution, like Michigan, where we get multiple -- many, many referrals daily.

We have to be smart about how we prioritize to ensure our access is in place. I see it, in part, as helping us to effectively triage, helping us to manage long-term stable patients. Those are the kinds of ways that I see, for a university practice like ours, those are the first steps that we're going to try to implement.

I certainly see it as a big role in our future practice, telehealth, but our experience so far, as I said...We're just getting started, really.