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On Line for the Bottom Line

An Innovative Study Led by GW Researchers Explores Using Telemedicine to Improve both Care and Costs

By Helen Fields

In a second-floor room on GW’s Foggy Bottom campus, a young woman is sitting at a desk with two monitors in front of her. On the wall above are two TV screens, each big enough to be a credit to any man cave. They’re black, but on request she switches them on and a map appears, panning slowly around the globe. Red icons mark hospitals and remote research stations. Here and there in the water, a white anchor appears.

Susie Lew, MD

She’s waiting for a call from one of those white anchors. The GW Medical Faculty Associates’ telemedicine communications center, where she’s waiting, has contracts to help people on research vessels, cargo ships, and fishing boats handle their health problems when the nearest doctor might be days away. “These people have no recourse — they’re in the middle of nowhere,” says Neal Sikka, M.D., associate professor of emergency medicine at the George Washington University School of Medicine and Health Sciences (SMHS) and the co-chief of the innovative practice section. The telemedicine center handles hundreds of cases each year. “We walk people through suturing. I’ve walked these guys through pulling a piece of metal out of someone’s eye,” Sikka says.

Now the telemedicine center is about to start helping a different group of people, much closer to home: people on dialysis. Specifically, GW doctors are collaborating to use telemedicine to reach patients who do peritoneal dialysis by themselves at home. The lessons learned from this project may help patients with all sorts of chronic diseases live better lives and waste less time getting to doctors’ appointments or showing up in the emergency room with complications.

The new project is part of a three-year, $1.9 million grant from the U.S. government’s Center for Medicare and Medicaid Services’ (CMS) Center for Medicare and Medicaid Innovation. The grants support projects that try out innovative ways to save money and improve patient outcomes, and might serve as models for the rest of the country. The program was created as part of the Affordable Care Act of 2010.

On the whole, people on dialysis are very sick and their care is very expensive. They have a lot of emergency room visits for problems related to kidney failure, such as electrolyte imbalance and shortness of breath, in addition to other health problems, like heart disease. People with end-stage renal disease make up about one percent of the Medicare population, but they consume six percent of the Medicare budget.

Patients on hemodialysis, the more common form of care, go to a dialysis center three times a week and spend four hours hooked up to a machine that cleans their blood. With two to three days between treatments, they can have large changes in their condition between visits — which means a lot of potential ambulance rides and emergency room visits.

Peritoneal dialysis patients, on the other hand, are generally better off. Rather than going to a dialysis center every other day, peritoneal dialysis patients draw excess fluids and toxins out of their bodies at home. Of the 300,000 Americans on dialysis, about 80,000 choose peritoneal dialysis.

Almost anyone who needs dialysis can choose to do peritoneal dialysis. Rather than having to get to a dialysis center three times a week, they can take care of themselves at home and go about their activities with the fluid in their bellies. “I think almost everybody is an ideal patient,” says Susie Lew, M.D., a nephrologist and professor of medicine, who, along with Sikka, serves as a primary investigator on the project. “It’s just that they have to want to do it.” Lew encourages an unusually large number of her patients to try peritoneal dialysis at home. They get two weeks of training, and then they’re on their own.

A peritoneal dialysis patient has a port installed in the wall of their belly. To clean the blood, the patient takes the sterile cap off of the port and attaches a bag of fluid. The fluid drains into the peritoneal space, where it sits, drawing water and waste products out of the blood vessels. Then the patient drains the fluid. The patient can either do this four times a day or use a machine that does the exchanges during sleep.

Eventually telemedicine could play a big role in lowering health care costs. Following up with patients by phone or video after they’re sent home from surgery could save a lot of time and money, answering their questions about wound care or figuring out whether they’re having normal symptoms or something a doctor should check on.

Even with the training, however, peritoneal dialysis patients still show up in the emergency room more than most people. They can experience electrolyte problems similar to hemodialysis patients and, like them, peritoneal dialysis patients often have other health problems. They are also prone to infections either internally or at the site of the port.

The project is aimed at helping patients take better care of themselves at home. “How can we make sure that our patients are doing what they’re supposed to do — and improve outcomes?” Lew says. The idea is to give patients a new way to get quick help and for nurses and doctors to be able to keep a closer eye on how they’re doing.

Peritoneal dialysis is a natural place to try using telemedicine with patients, because they’re already doing telemedicine in its most basic form. Patients are encouraged to call the peritoneal dialysis nurse whenever they have a problem or a question. “The phone is still one of the easiest ways to provide a service,” Sikka says. “You can do so much over the phone.”

But the project is adding newer technologies as well. Video calling, for example, which has gone from a space-age fantasy to something that’s routinely available for showing off Baby’s latest trick to the grandparents. Most of Lew’s peritoneal dialysis patients already have computers, and those who don’t have webcams will receive them through the program. Patients without computers will be given some way to connect — most likely in the form of a tablet or a netbook computer. When patients call in, they can talk to a dialysis nurse on the phone, or if there’s something that would be better looked at, a rash or a suspected infection for instance, they can switch to video. If the nurse needs a doctor’s opinion, the telemedicine communications center can patch the video call through to a nephrology fellow or to Lew.

Patients will also get a suite of new monitoring tools: a weight scale, a glucometer, and a blood pressure cuff, all with Bluetooth technology that securely transmits the data to the telemedicine communications center. The idea isn’t to keep a Big-Brother-ish eye on every patient; the patient will have to initiate video calls, and they’ll be left alone most of the time. But someone reporting consistently high blood pressure or  large weight gain, suggesting they aren’t removing enough fluid, might get a call from a nurse. Dangerously high blood pressure will trigger a more immediate call.

“Hopefully we’ll be able to monitor their blood pressure readings daily and detect readings outside of the desired range. Therefore we hope to decrease emergency room visits and hospitalizations, because we’ll be able to take care of their medical issues earlier and as outpatients,” Lew says.

The study will start in January with 50 patients in Washington, D.C. Later, they plan to expand to Baltimore, Md. and to Winchester, Va., which will add patients who live in more rural areas. Telemedicine may be particularly useful in rural areas, where a patient might live an hour or more from the nearest doctor. If the doctor could look at the patient from afar and diagnose a mysterious rash as poison ivy, a lot of travel time could be saved. Travel can be challenging for urban and suburban patients, too. There’s no free parking at the dialysis center where Lew sees patients. It’s easily accessible using public transportation, but that can be a challenge for very sick or disabled patients. Transportation can be expensive, too as can lost work time.

Dialysis is a particularly good place to try out this kind of intervention because dialysis care already operates on a bundled model. Physicians like Lew don’t get paid for every visit; they get paid a fee per month, so there are incentives to spot more affordable ways of caring for patients than having them make an appointment to visit the dialysis center. Many states also now require third-party payers to reimburse for video telemedicine as they would reimburse for an office visit.

Manya Magnus, Ph.D., M.P.H., is deputy director of the Center for HIV/AIDS, Epidemiologic, Biostatistics, and Public Health Laboratory Research at GW. An epidemiologist, she’s a co-investigator and evaluator on the project and will work with the team in assessing it. She will survey patients and members of the health care team to find out how satisfied they are with the setup. She also will monitor patients’ health outcomes — whether the telemedicine intervention does indeed result in fewer infections and fewer hospitalizations, and whether having wirelessly collected vital signs improves patient outcomes. “I personally think that telemedicine offers just an incredible strength, in terms of individual empowerment of people’s care, decrease of complications, and improving adherence to treatment,” Magnus says. “I think it’s fantastic.”

This technology could also help other patients, and not just patients on hemodialysis, Sikka says. “Dementia, Alzheimer’s disease — all sorts of other chronic diseases that currently require fairly frequent visits to the doctor that we’d like to be able to manage with fewer visits.” Those patients often need another person to come with them, which makes care even more expensive.

Sikka is also talking with doctors in otolaryngology, neurosurgery, and other specialties about ways they can use telemedicine to expand their reach without having to be physically present. “It’s the doctor’s brain that needs to be there, but not the person,” he says. “We call it a cognitive consult.” A person having a stroke, for example, needs to have clot-busting drugs within three hours. But the drugs have serious side effects, so you don’t want to give them if the person is actually just having a migraine. A neurologist can help make that determination without being in the room.

Eventually, Sikka says, telemedicine could play a big role in lowering health care costs. Following up with patients by phone or video after they’re sent home from surgery could save a lot of time and money, answering their questions about wound care or figuring out whether they’re having normal symptoms or something a doctor should check on. It would be cheaper, for example, to spend a few hundred dollars on home monitoring equipment than thousands on readmitting a patient to the hospital. “If the health care system can come up with reimbursement models that incentivize patients, doctors, and hospitals to invest in really simple tools, we can probably improve a lot of health care and save costs,” Sikka says. “The problem is, you’ve got to just figure out how to put it all together.” With this project, the team is trying to make progress on that problem.

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