Proposed framework for advancing telemedicine in liver disease: The case for more research and policy changes
Telemedicine can serve two main goals in liver disease: improve access to specialty care, and improve care between visits. For the first goal, the technology is straightforward and limited research is required; the main barriers are regulatory and reimbursement. As an example, one of the authors (M.L.V.) uses telemedicine to perform liver transplant evaluations in Las Vegas, N.V., a state without a liver transplant program. Patients are seen initially by a nurse practitioner who resides in Las Vegas, and those patients needing transplant evaluation are scheduled for a video visit with the attending physician who is physically in California. This works well and patients love it; however, the business model is dependent on the downstream financial incentive of transplantation. In addition, various regulatory requirements must be satisfied such as monthly in-person visits. For the second goal, a number of exciting possibilities exist such as remote monitoring and patient disease management, but more research is needed.
Research
According to the Pew Research Center, 95% of American adults own a cellphone and 77% own a smartphone. These devices passively gather an extraordinary amount of data that could be harnessed to identify early warning signs of complications (remote monitoring). Another potentially fruitful area of research is patient disease management. This includes using technology (e.g., reminder texts) to effect behavior change such as with medication adherence, lifestyle modification, education, or peer mentoring. As an example, the coauthor (M.S.) is leading a study to promote physical activity among liver transplant recipients by using an online web portal developed by researchers at the University of Pennsylvania (Way to Health), which interfaces with patient cell phones and digital accelerometer devices. Participants receive daily feedback through text messages with their step counts, and small financial incentives are provided for adequate levels of physical activity. Technology also can facilitate the development of disease management platforms, which could improve both access and in-between visit monitoring, especially in remote areas. One of the authors (M.L.V.) currently is leading the development of a remote disease management program with funding from the American Association for the Study of Liver Diseases.
Despite the tremendous promise, traditional research methods in telemedicine may be challenging given the rapid and increasing uptake of health technology among patients and health systems. As such, the classic paradigm of randomized controlled trials to evaluate the success of an intervention or change in care delivery often is not feasible. We believe there is a need to recalibrate the definition of what constitutes a high-quality telemedicine study. For example, pragmatic trials and those designed within an implementation science framework that evaluate feasibility, scalability, and cost, in parallel with traditional clinical outcomes, may be better suited and should be accepted more widely.17
Policy
Even when the technology is available and research shows efficacy, the implementation of telemedicine in clinical practice faces regulatory and reimbursement barriers. The first regulatory question is whether a patient–provider relationship is being established (with the exception of limited provider–provider curbside consultation, the answer usually is yes). If so, the practice then is subject to all the usual regulatory concerns. The provider needs to be licensed at the site of origin (where the patient is located) and hold malpractice coverage for that location, and the video and medical record transmission should be compliant with the Health Insurance Portability and Accountability Act. The next challenge is reimbursement. Medicare only pays for video consultation if the patient lives in a designated rural Health Professional Shortage Area (www.cms.gov), and reimbursement by private payers varies. Even this is dependent on ever-changing state laws. Reimbursement for remote patient monitoring is even more limited (the National Telehealth Policy Research Center publishes a useful handbook: http://www.cchpca.org/sites/default/files/resources/50%20State%20FINAL%20April%202016.pdf). Absent a bipartisan Congressional effort to remedy this situation, the best hope for removing reimbursement barriers lies with payment reform. The Medicare Access and CHIP Reauthorization Act of 2015 mandates that the Centers for Medicare and Medicaid Services shift from fee-for-service to alternative payment models in the coming years. In these alternate payment models, providers are responsible for the overall quality and total cost of care for a population of patients. In this scenario, there may be a financial incentive for telemedicine, especially remote monitoring, to keep patients out of the hospital. Until then, under current payment models, reimbursement is limited and the barriers to widespread implementation are high.
