Improving Our “Webside” Manners

In a very general sense, telemedicine is the practice of diagnosing and treating of patients through means of telecommunication. Recognizing the likely future growth of telemedicine, the American Telecommunication Association was formed 4 years ago to encourage medical training programs to incorporate telemedicine training into their curriculum. From my perspective, this is an idea that certainly seems timely, yet there are a number of short-term hurdles in our way.

The first is that a reliable computer or mobile device and high-speed Internet access are essential both for providers and patients to make telemedicine work. This is rarely an issue on the provider side, but are our patients truly ready?

Data show that less-affluent seniors with lower levels of education have an improving relationship to technology, though there is still progress to be made. According to a Pew Research Center report, in 2000, only 14% of Americans ages 65 and older were Internet users. In 2017, it was up to 67%. That still leaves a good chunk of older adults who are unconnected, but the gap between “haves” and “have nots” is certainly trending in the right direction.1

We all know that many of our older patients live at or below the federal poverty level and receive their care through Medicare and/or Medicaid. For them, technology is often a luxury instead of a necessity. Even today, I see hospitalized patients who ring for a nurse and speak into the television remote expecting it to talk back to it. Yes, it still happens.

At the 2018 American College of Rheumatology meeting, I attended a lecture that provided a glimpse into the future of medicine in 2030. The presenters predicted an environment where lab results and X-rays could be uploaded immediately into the patient record and a patient could receive a diagnosis and be prescribed medications without any actual input from a healthcare professional.2 While this may sound like a “doomsday” scenario for many of us, the purpose of the presentation wasn’t to scare the audience, but rather to help us realize that the art of medicine is evolving quickly. Don’t forget that it wasn’t so long ago that we were updating paper charts of our patients by hand and had huge files cabinets full of individual records. Not anymore.

As a rheumatology nurse, I see many advantages and disadvantages to the predicted evolution of our profession. Certainly, I recognize that most of us have patients who travel for hours for an in-office visit, which is a huge burden for someone in chronic pain. Many of us also see patients who are homeless, living in a broken-down car, bus station, or homeless shelter. For them, getting any sort of transportation to reach us is a huge challenge, and finding a better system where they could “report in” from somewhere more convenient would be a tremendous benefit.

Then there are the downsides. Certainly for those of us who work in rheumatology, but with other specialties as well, there are some things that we find out only upon a face-to-face examination or discussion with a patient. For instance, I had a recent patient, LT, who had a 20-year history of RA but was regularly nonadherent to her medication regimen for a variety of reasons, including her weight (about 350 pounds), lack of nearby public transportation, and others. LT has been prescribed several biologics during the course of her disease, but due to frequent infections, rarely lasts longer than a few months on any of them.

Last month, LT arrived in my office for a scheduled check-in. She was in terrible pain, with only one DMARD being taken to control her pain. I greeted her like a long-lost friend (“You are here! So nice to see you!), trying to start the visit on a positive note. Despite insurance hurdles, our in-house authorization department was able to get permission to perform lab tests and X-rays while LT was in our office—she’s a patient who almost never will follow up for these once she leaves our walls.

I began my physical exam, not surprisingly finding more than a dozen tender and swollen joints. While LT’s lungs were clear, I noticed a distinct, unpleasant odor coming from her abdomen. Lifting up her belly fold, I found a large abdominal wall infection measuring approximately 18×10 inches with a purulent discharge. I asked LT about this, and she said that while she was aware of the odor, she thought it might have simply been her urine. She then admitted to me that her feet are so painful that she is rarely able to bathe.

I was afraid what I would see when I removed LT’s shoes. She protested vehemently, but eventually let me take a look. Her feet were edematous, and, to my horror, there was one toe nail that had been unattended for so long that it had grown into the nail on the adjoining toe. Not surprisingly, both toenails were infected. Things got worse (OK, maybe not worse, but still pretty bad). LT’s labs came back showing an albumin of 1.0 g/dL, significantly low. She explained this result by saying her diet consisted mostly of cookies because they were cheap and required no preparation. Needless to say, her white count and acute phase reactants were extremely elevated as well. It didn’t take a highly-qualified medical professional to figure out what was immediately needed—wound care, antibiotics, a nutritional consult, and Meals on Wheels through LT’s church were all ordered.

Here is my question to you—if this is a patient who had been limited to telemedicine visits, how many of her issues would I have missed? Of course, I realize that LT isn’t a typical RA patient, but then how many “typical” patients do we see any more? There are so many patients of mine who have layers of defenses or excuses built up that I need to break down to get to the crux of their current issues. I simply don’t think that is something you can replicate through technology.

There are currently 46 states that reimburse telemedicine visits in some capacity.3 I do believe that telemedicine has its place, but it cannot be a replacement to a hands-on physical exam. I look back at all of the advances we have made in rheumatology in the last decades that have moved our practice forward and improved the lives of our patients—things like self-injections and same-day arthroscopic surgeries—but I also hold dear the personal, 1-on-1 time with my patients. That is one thing I hope never goes away.

 

AUTHOR PROFILE:
Jacqueline Fritz, RN, MSN, RN-BC, is Owner and Coordinator of Education at the Medical Advancement Center in Cypress, CA. Her primary responsibility is working as an advanced practice nurse for a large rheumatology practice where she is involved in patient visits, research programs, and infusion center coordination. In addition, she enjoys speaking, teaching, and learning about immunology.

 

References
1. Pew Research Center. Tech adoption climbs among older adults. Available at www.pewinternet.org/2017/05/17/tech-adoption-climbs-among-older-adults/. Accessed January 10, 2019.
2. Mintz S, Stamm T, MacInnes I, Smith B. 2030: A rheumatology odyssey. Presented at ACR 2018; Chicago, IL.
3. Federation of State Medical Boards. Telemedicine policies: Board-by-board overview. Available at www.fsmb.org/siteassets/advocacy/key-issues/telemedicine_policies_by_state.pdf. Accessed January 16, 2019.