Taking a Different Bite Into the Telemedicine Debate

Ten years ago, our office had not even implemented an electronic health record (EHR) system, let alone started to think about telemedicine and its potential impact on practice. Today, though, with a shortage of rheumatologists and a growing problem with patient access to care, we are indeed starting to see the potential benefits of utilizing telemedicine in our practice. In some ways, in fact, we are already using it on a daily basis. Through the patient portal linked to our EHR, we are able to communicate with patients from afar, helping a patient who may be flaring while out of town who is in too much pain to travel into the office. I have also had several patients send me pictures of rashes or swollen fingers so that we are able to quickly assess their immediate problems and treat them as necessary. This is just the tip of the iceberg when it comes to the potential of telemedicine, but it’s been an important toehold for us and our patients.

In a small handful of our patients, telemedicine has already made a major difference.

(Note to reader: This story kind of meanders a bit before coming back around to telemedicine, so just bear with me. I promise it’ll be worth it!)

There are a variety of subjects we are taught about growing up that are considered to be somewhat taboo, icky things that most people are uncomfortable talking about except with very close family and friends. Things like lice. Or tapeworms. Or bedbugs. Yes, those creepy, crawling things that can mysteriously show up in your bed without warning and cause a lot of problems.

For some reason, for an unusually high percentage of patients in our practice, bedbugs are a big problem. They are difficult to eradicate and often require expensive treatments that are unaffordable for many of my patients.

My first encounter with bedbugs took place several years ago in a patient who was receiving infusions to help manage her rheumatoid arthritis. During one of our regularly-schedule appointments, this patient admitted to me that she thought she had bedbugs in her house, which alone was a courageous thing to admit. A brief physical assessment showed that she did indeed have active bites on her arms and legs. So what to do? There was no “bedbug protocol” to follow within our practice, so we made the

“In a small handful of our patients, telemedicine has already made a major difference.”

So what to do? There was no “bedbug protocol” to follow within our practice, so we made the decision to hold her infusion until there was no evidence of actual bites to avoid the risk of infection. While I believed (and still do) that it was the right decision, the patient was embarrassed and felt we were punishing her because of something beyond her control. Fortunately, this was a patient who could afford an extermination, and she was able to get her infusion the following week.

This experience prompted our office to begin working on a “bedbug” protocol. Previously, with any known bedbug exposure in our office, we would close off any exam room or waiting area that had been exposed and call in an exterminator. Obviously, this came at a cost to the practice and was inconvenient for patients and providers. Upon further research, though, we learned that there was a local company who had a dog trained to locate bedbugs. This dog could signal to its owner whether there was an infestation or not—yes, a bedbug-sniffing canine! Who knew? Our research in finding this company saved our practice money since we now only exterminate if the dog-sniffing canine tells us that we need to.

So then how exactly does this story tie into telemedicine, our topic for this issue of Rheumatology Nurse Practice?

I recently had a different patient, a 37-year-old woman who has suffered three previous strokes, leaving her with some mental deficits that forced her live at home with her parents. She was diagnosed with psoriatic arthritis several years ago and required appointments every 3-4 months mainly to monitor her labs (her disease was stable).

Approximately 6 months ago, this patient came in for a routine visit and told our staff without prompting that there were bedbugs in her home. The family had been trying a variety of natural remedies without much success since they could not afford the approximately $1,500 cost of a professional exterminator. We were, of course, sympathetic and offered some suggestions, but it also raised immediate alarm bells for our staff and prompted a call to the “bedbug dog.”

How might telemedicine have helped in this patient? Remember, she’s someone with stable disease who mainly comes in for lab testing. There is little need for any sort of physical exam during her routine visits. A telemedicine consult would have been more convenient for her and her family, of course, but it also would have spared our practice of possible bedbug exposure. This would have had benefits to our many patients with contagious diseases who already come into our office immunocompromised and at increased risk of an infection.

We all hear a lot about the potential “big picture” benefits of telemedicine, but this is an example of a smaller yet important case where it could have had an large impact. It’s important when we consider whether telemedicine is a good fit for our practice to investigate how will impact all of our patients—not just the ones who take part in a virtual visit—as well as the team of providers.

AUTHOR PROFILE:
Carrie Beach BSN, RN-BC, is a rheumatology nurse with the Columbus Arthritis Center in Columbus, OH, and the current Historian for the Rheumatology Nurses Society.