Telehealth and Home Dialysis

Potential Advantages of Telehealth for Home Dialysis Encounters

Using telehealth for the provision of care to patients with kidney disease is not a new idea, with experiences treating hepatitis C in rural New Mexico extended to nephrology-focused telehealth systems within the Veterans Affairs health care system (3,4). In Australia, telehealth is used widely for patients receiving home dialysis (5,6). However, there remain little data available to compare the quality of care delivered by telehealth with that of traditional care for patients receiving home dialysis.

From the patient perspective, dialysis is a medical intervention with tremendous effect on day-to-day life. No other chronic health condition is as burdensome in terms of time required to receive therapy. Beyond physical and, potentially, cognitive effects, patients treated with dialysis lose independence, and, perhaps most significantly, suffer a loss of time. Decreasing the burden of time spent on visits to providers in clinics may benefit patients from a quality of life standpoint, aligning with patient goals (7,8). Although it is easy to appreciate benefits for patients in rural settings distant from dialysis providers, it is also conceivable that patients in suburban and urban areas will benefit by avoiding the need to brave traffic, public transportation, and/or parking to see their nephrologist. Telehealth can allow greater flexibility in scheduling from a patient standpoint, potentially allowing patients to miss less work time. Telehealth visits may also facilitate patient evaluation during times of limited access to transportation, such as can occur during periods of severe weather or natural disasters. Children and their families may also benefit given the potentially long travel times to see pediatric nephrologists in a dialysis center and limited daytime hours that may result in school and work absences. In summary, providing this additional option to patients can be seen as more patient-centered and equitable care, particularly for patients with limited resources.

For providers, encounters via telehealth may also be desirable, with more streamlined logistics that may allow greater efficiency or more timely patient evaluation during an acute medical event. Home dialysis specialists could share their expertise from a distance with a greater number of patients in regions where such expertise does not exist. Increased efficiency may also allow providers to spend more time with the patient during telehealth encounters. For nephrologists who have their monthly patient encounters in settings where a facility fee is charged, this will no longer be applicable, reducing costs for both the health care system and patients. Providers who previously did not do in-person home visits also may gain valuable insight into the home environment, and they may be better able to modify the dialysis prescription to best suit patients and their lifestyles.

Ultimately, patients still need to have monthly laboratory tests, and they will receive erythropoiesis stimulating agents, iron, and other medications and supplies from their dialysis facilities, making it likely but not essential that, for these logistic reasons, many patients will continue to be seen by nurses and other dialysis facility staff at least once a month. If this in-person visit occurs, it will not always need to be coordinated with the physician schedule, and, in months when this coordination is not feasible, a visit by the patient to a clinic specifically to see the nephrologist would be unnecessary. This flexibility is important, particularly when recognizing that many individuals who select home dialysis do so to increase their time to pursue other activities, including jobs, family responsibilities, and travel and other leisure activities (9).

Potential Disadvantages of Telehealth for Home Dialysis Encounters

Perhaps the most cited concern with telehealth encounters is the inability to fully examine patients, including physical evaluation of volume status and the dialysis access. It is conceivable that these assessments will be more limited during a telehealth encounter. Although some telehealth systems have developed remote capabilities for auscultation and close visual inspection, these systems may not be available for reliable or widespread use. There has yet to be a substitute for palpation, and three-dimensional observations are sometimes lost on a two-dimensional screen; the risk of missing opportunities for timely intervention on volume or access issues is greatest among patients who are not thriving with home dialysis or who have acute symptoms that are better evaluated in person.

Significant costs involved in establishing telehealth systems may be a disincentive for providers to offer this service, whereas differences in patient resources, including reliable internet access, may highlight existing disparities in care. Furthermore, lack of a facility fee may make it difficult for some health care systems to justify the cost of starting a telehealth program. Additionally, providers may find greater efficiency during in-person encounters in the clinic than with telehealth encounters.

As many providers have witnessed with the advent of electronic medical record systems, not all systems are created equally or with physicians' interests in mind. Poorly designed telehealth systems or systems with delays or dropped connections may ultimately frustrate patients and providers alike and lead to lower-quality encounters. A well designed and functioning telehealth system, however, could lead to better retention of patients on the telehealth platform (10).

A concern of utmost importance is protecting the patient’s choice of encounter. Some patients may feel isolated, abandoned, or anxious about being at home without regular in-person visits. Under the Bipartisan Budget Act of 2018, use of telehealth is the patient’s choice, not the provider’s choice. Despite the law clearly calling out patient choice in where patient visits occur, it is conceivable that providers may develop systems that do not offer that choice, citing unavailability of providers at times when patients are available and other logistic issues; accordingly, in the regulation to come, safeguards need to be in place to ensure that patients will not be limited to quarterly visits with their providers if that is not their desire. Similarly, many providers cherish in-person patient interactions, where the subtleties of communication and body language may contribute substantially to patient assessment and patient-physician relationships; accordingly, although a viable option, clinicians also should not be compelled to use telehealth by the dialysis provider. Critically, exposing providers to more screen time and fewer face-to-face patient-provider interactions could further provider burnout and dissatisfaction.

In conclusion, the Bipartisan Budget Act of 2018, in addition to other major effects, allows the provision of telehealth encounters to patients on home dialysis. Although there are many potential advantages and disadvantages to the utilization of telehealth for management of home dialysis in end stage kidney failure and considerable details remain to be determined in regulations from the Centers for Medicare and Medicaid Services, this legislation has the potential to provide patients and providers greater freedom to choose where their care is delivered and for that reason, should be considered a positive change.

Disclosures

Both S.D.B. and D.E.W. are members of the American Society of Nephrology Quality Committee. S.D.B. is the medical director of a Northwest Kidney Center dialysis facility. D.E.W. is the medical director of a Dialysis Clinic, Inc. dialysis facility. Funding for DCI-related research activities is provided from DCI to D.E.W.’s institution.