Use of telemedicine for haemodialysis: perceptions of patients and health-care providers,and clinical effects

Abstract

Summary

In Michigan, the use of telemedicine for dialysis patients began in three centres in 2005. A total of 747 clinical consultations was conducted in the following 22 months. Telephone surveys were conducted with 34 patients and four providers. The patients and providers all had positive perceptions of the telemedicine system and the care that was delivered. Most of the clinical measures of the patients met or exceeded the recommendations made by Renal Network 11. In addition to the clinical work, the telemedicine equipment was used for educational events. Twenty-six professional educational events were provided with a total audience of 105 individuals, and 35 administrative meetings were provided with 286 staff members in attendance. The study showed that patients and providers could participate in educational events that might not be available locally. Despite the success of dialysis telemedicine, the Marquette General Health System discontinued its use in 2007 when the Center for Medicare and Medicaid Services re-affirmed that dialysis centres were not approved sites for telemedicine.

Introduction

Haemodialysis patients are particularly vulnerable to challenges associated with accessing specialty health-care services. Patient's lives centre on scheduled treatments three times per week, which require four hours per visit. Since 1999, the Marquette General Health System (MGHS) has been affiliated to three remote dialysis centres which allow patients to receive dialysis services close to home. MGHS nephrologists provide monthly on-site visits to manage the health care of some 50 patients.

In January 2004, the Center for Medicare and Medicaid Services (CMS) revised its haemodialysis standard of care structure for haemodialysis reimbursement. The change required patients to see their nephrologists 3–4 times per month instead of once a month. For patients, this required more frequent travel to Marquette, and for nephrologists it meant an increase in patient visit volume of 3–4 times. As such, the CMS change threatened access to medical care for this vulnerable patient population.

Telemedicine has been used for rural dialysis patients in Australia and Norway.^1–3 A recent meta-analysis indicated that ‘non-comparative studies have demonstrated the value of telehealth in both haemodialysis and peritoneal dialysis, and have suggested benefits in terms of improved access, and cost and travel savings for patients’.⁴ In addition, the use of telemedicine for renal treatment has been the subject of investigations of home- and clinic-based telemedicine programmes for dialysis and it has been suggested that there are substantial benefits in terms of convenience, time and cost in connecting dialysis patients and providers.^5–10

In Michigan, the use of telemedicine for dialysis patients began in February 2005. Telemedicine was used to connect dialysis patients with nephrologists in Marquette, and to reduce patient and provider travel while ensuring compliance with the new CMS standard of care structure. Wireless videoconferencing equipment was placed in the local dialysis clinics and connected to the Marquette General Health System. The telemedicine equipment was mounted on a cart that could be moved around the dialysis clinic so that patients could connect with their nephrologists while receiving dialysis. The wireless videoconferencing units utilized the regional data network.

The aim of the present study was to investigate the clinical effect of the teleconsultations on patients, as well as perceptions of telemedicine of both patients and health-care providers.

Methods

There were three research questions:

What are the patient and provider perceptions of the haemodialysis telemedicine programme?

How does the use of telemedicine affect the clinical outcomes of haemodialysis patients?

Can telemedicine be used for educational and other purposes?

The data from one centre were excluded in several parts of the evaluation because of credentialing and contract issues with the nephrologist, equipment difficulties and a delayed connection to the telemedicine service. To recruit patients for participation, individuals receiving haemodialysis treatment from the other two centres (Western Upper Peninsula Dialysis Center [WUPDC] and Eastern Upper Peninsula Dialysis Center [EUPDC]) were invited to participate in the telemedicine programme and the evaluation of the service.

Telephone surveys were conducted with 34 patients and four providers. Of the 34 patients, 30 received treatment from the WUPDC and four from the EUPDC. The telephone surveys, which took approximately 10 minutes to complete, consisted of 11 open-ended questions, 14 Likert-type scale items and three yes/no questions related to computer and Internet usage. For data analysis, descriptive statistics were employed to understand patient and provider perceptions of the telemedicine programme.

Patient outcomes were measured in terms of anaemia management, haemodialysis adequacy, nutritional status and bone health using archived clinical data. In all clinical measures, patient data were averaged over the first six months of dialysis treatment with telemedicine consultations. For the WUPDC, the evaluation period ranged from October 2005 to March 2006 and for the EUPDC, the evaluation period ranged from April 2005 to September 2005. All averaged clinical data were compared against the Renal Network of the Midwest (Renal Network 11) recommendations for dialysis centres.¹¹

A needs assessment was conducted with all 12 of the rural clinical staff and educational programming was developed to meet their needs. Patient education was provided by videoconferencing. To determine the utilization of the educational events, each event was logged along with the topic and the number of people in attendance.

Results

A total of 747 clinical consultations were conducted from the three local dialysis clinics from February 2005 to the end of 2006.

Patient and provider perceptions

Patients had positive perceptions of the telemedicine service and the care they received (Table 1). However, perceptions were mixed regarding whether patients would rather be seen in person than via telemedicine and whether telemedicine should only be used when a health-care professional could not be physically present.

Table 1

Patient perceptions of telehealth consultations (scored from 0 = strongly disagree to 7 = strongly agree)

	Mean	SD
I found the telehealth service easy to use	6.1	1.2
I think that telehealth is a good way to provide medical care	5.8	1.5
It was easy to communicate with the other person during the telehealth consultation	6.3	1.0
I enjoy telehealth visits	5.7	1.4
I felt comfortable using the telehealth equipment	6.1	1.4
I was able to communicate what was bothering me	6.0	1.5
The health-care provider was able to address what was bothering me	6.1	1.6
The care that I received via the telehealth consultation was as good as an ordinary in-person visit	5.2	1.8
Overall, I am satisfied with the telehealth service that I received	6.2	1.1
I would rather be seen in person than via the telehealth equipment	4.8	2.0
I believe that the telehealth equipment increases my access to health care	5.8	1.3
I felt that telehealth limited my privacy	3.2	2.0
Telehealth should only be used when a health-care professional cannot be physically present	4.7	2.3
More people should have access to telehealth programmes	6.0	1.2

Providers also had positive perceptions of the telemedicine service and the care that they provided (Table 2). However, like the patients, providers also had mixed perceptions of when telemedicine services should be used.

Table 2

Provider perceptions of telehealth consultations (scored from 0 = strongly disagree to 7 = strongly agree)

	Mean	SD
I found the telehealth service easy to use	7.0	0.0
I think that telehealth is a good way to provide medical care	5.5	1.7
It was easy to communicate with the other person during the telehealth consultation	6.0	0.8
I enjoy telehealth visits	5.8	1.0
The patient felt comfortable with the telehealth equipment	5.5	0.6
The patient was able to communicate what was bothering him/her	6.0	0.8
I felt comfortable using the telehealth equipment	7.0	0.0
The care that I provided via the telehealth consultation was as good as a regular in-person visit	5.8	0.5
Overall, I am satisfied with the telehealth service that I provided	6.5	0.6
I would rather see the patient in person than via the telehealth equipment	4.0	2.4
The telehealth equipment increases my access to my patients	7.0	0.0
I felt that telehealth limited my patient's privacy	4.5	1.0
Telehealth should only be used when a health-care professional cannot be physically present	3.0	2.2
More people should have access to telehealth programmes	6.8	0.5

Clinical outcomes

Most of the clinical measures of the patients met or exceeded the recommendations made by Renal Network 11 (Table 3).

Table 3

Comparisons of clinical data to Renal Network 11 recommendations and best practices

	Renal Network 11 recommendation	Renal Network 11 best practices	Six-month average
Haemoglobin	≥80% of patients should have haemoglobin ≥11 g/dL	>85% of patients have haemoglobin ≥11 g/dL	89%*^†
Urea reduction ratio	≥80% of patients should have urea reduction ratio ≥65%	>85% of patients will have urea reduction ratio ≥65%	98%*^†
Albumin	≥80% of patients should have mean serum albumin ≥ lower limit of normal (3.4 g/dL)	>85% of patients have a mean serum albumin ≥ lower limit of normal (3.4 g/dL)	76%
Albumin	≤10% of patients should have mean serum album <0.9 lower limit of normal (3.1 g/dL)	≤10% of patients with a mean serum album <0.9 lower limit of normal (3.1 g/dL)	7%*^†
Phosphorus	≥70% of patients should have mean serum phosphorus ≤5.5 mg/dL	>80% of patients should have mean serum phosphorus ≤5.5 mg/dL	74%*
Phosphorus	<10% of patients should have mean serum phosphorus >8 mg/dL	<5% of patients should have mean serum phosphorus >8 mg/dL	0%*^†
Calcium	≥80% of patients should have mean corrected serum calcium concentration ≤10.2 mg/dL	>85% of patients should have mean corrected serum calcium concentration ≤10.2 mg/dL	91%*^†
Calcium		>75% of patients should have a mean corrected calcium concentration ≤9.5 mg/dL	33%

*Clinical data from investigation met Renal Network 11 recommendations

^†Clinical data from investigation met Renal Network 11 recommendations for best practices

Educational and administrative events

From the date of implementation of the first site (February 2005) to the end of 2006, nine patient educational events were provided with a total of nine audience members. The topics included dietary and nutrition information, herbal supplements and effective tobacco interventions.

During 2005 and 2006, 26 professional educational events were provided with a total audience of 105 individuals. The topics included common emergency department presentations of dialysis patients, diabetes and kidney disease, pain management, mental health issues in the elderly, infection control, foot care, hypotension and congestive heart failure in dialysis patients.

In addition to educational events, the videoconferencing equipment was also used by dialysis unit staff for quarterly staff meetings. During 2005 and 2006, 35 administrative meetings were provided via telemedicine with 286 staff members in attendance.

Discussion

Patients and providers reported mostly positive perceptions of the telemedicine system. Patients no longer had to travel three or four times per month to Marquette. Conversely, specialists no longer needed to visit the rural dialysis clinics so frequently. Patients and providers reported that telemedicine increased access to health-care services and they were generally pleased with the care provided. One of the common fears associated with telemedicine is that the patient–provider relationship will suffer. However, the evidence from the present study suggests that this is not the case.

Using benchmarks developed by Renal Network 11, it was apparent that the care provided to haemodialysis patients by the rural dialysis clinics was satisfactory. There were additional benefits to patients and providers in terms of educational events and administrative networking.

A limitation of the present study is that it only included patients participating in clinical consultations provided via telemedicine. Future work should include patients receiving traditional forms of care to act as a control group.

Despite the success of dialysis telemedicine, the MGHS discontinued its use in 2007 when the CMS re-affirmed that dialysis centres were not approved sites for telemedicine. Nonetheless, the results of the present study indicate that patients and providers have positive perceptions of telemedicine and the care delivered with it. Providing consultations via telemedicine is a feasible technique in haemodialysis and averaged clinical measures met or exceeded the recommendations of the Renal Network 11. Finally, in addition to its clinical uses, telemedicine was employed successfully for educational events for patients and providers, and for administrative support of clinical staff.

Footnotes

Acknowledgements

We thank Susan Makela and the staff of the Upper Peninsula Telehealth Network for their cooperation and assistance. The project was partly funded by the USDA Rural Utilities Services (RUS), Distance Learning and Telemedicine Grant Program.

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(last checked 6 July 2007)