With the click of a live-streaming app on his computer, UAB nephrologist Eric Wallace, M.D., has opened a new era in health care for Alabama. Last year, he began using telehealth—a technology providing two-way, real-time interactive communication between the patient and physician—to replace comprehensive, in-person visits for home dialysis patients.
This innovation is believed to be the first of its kind in the United States. And it has the potential to bridge historic gaps in health care and education in Alabama.
For Ellen McGowen and Mary Epp, telehealth also means far fewer hassles in receiving the care they need. McGowen, 63, lives in Sheffield, Alabama—115 miles from Wallace’s office at UAB. Epp, 84, lives in Selma—88 miles away. Thanks to the secure technology, both women have received “face-to-face” specialized nephrology care from Wallace in Birmingham simply by visiting their county health clinics.
“The convenience is unmatched, and I don’t feel that I am sacrificing my care in any way,” McGowen says. “I get to drive just down the street from my home, be in a private clinic room with a nurse, and interact with a physician who is highly trained and specialized in dealing with my disease. And I don’t have to spend four hours or more making a round trip to Birmingham.”
“Because I did not have to leave Selma, my husband was able to go to work the day of my appointment,” Epp says. “It was a wonderful experience. I felt like I was almost there using that technology.”
Specialty Care Statewide
Wallace’s tele-nephrology visits are part of a pilot study by the UAB School of Medicine and the Alabama Department of Public Health (ADPH), supported by Baxter Healthcare Corporation. Patients in the study can access Wallace through telehealth carts distributed by ADPH to 25 county health department sites. UAB Health System CEO Will Ferniany, Ph.D., says the results will demonstrate telehealth’s potential impact.
“UAB and the ADPH are two of the state’s largest health-care providers, working together for one common goal—to improve the health of Alabama residents,” Ferniany says. “The examples of what telehealth can achieve for Alabamians are limitless.”
“If I can provide a fully comprehensive telehealth visit for a home dialysis patient—which is one of the most complicated visits to do because it requires a full physical exam along with lab work, education, and paperwork—then I can do this for any patient and virtually any disease,” Wallace says. “The subspecialty care that may be available only in a setting like UAB can extend to every corner of Alabama, increasing quality of care across the state.”
Reaching Rural Patients
Many Alabamians in rural areas desperately need access to physicians of all specialties. Wallace estimates that at least 25 percent of his patients have to drive more than an hour for care. In the Black Belt, where the prevalence of cardiovascular disease, cancer, and diabetes is significantly higher than in urban areas of the state, some residents have to travel two hours or more just to access routine care. Specialized care can be intermittent or completely unavailable.
Wallace’s success through the pilot study's second year is building momentum to expand telehealth’s reach. “We're excited about the possibilities,” says Bart Kelly, UAB’s executive director of telehealth.
“If we can provide specialty care in rural communities, then it will help enable community physicians to care for their patients locally,” Kelly says. “If we’re working with rural hospitals, then it helps to keep patients there, which helps those hospitals financially as well. It could help reduce readmissions or complications and strengthen UAB’s relations with community providers.”
“The fewer physicians there are to provide specialized care and the greater the geographic distance, the greater imperative we have to use telehealth to eliminate barriers to care,” Wallace says. He also treats Fabry disease, a painful genetic disorder that can cause kidney and heart problems, and says that patients with such rare diseases—typically treated only in university settings—could benefit from the technology. He also sees advantages in connecting specialists with pediatric patients across the state, and with patients who have limited mobility, including those in nursing homes and those with significant disabilities. “In addition to facilitating care, telehealth can improve our patients’ quality of life,” Wallace says.
So now, “the question about telehealth,” Ferniany says, “is how we organize it so it can be successful.”
“We’ve learned from other states that telehealth can become a fragmented system without thoughtful organization and collaboration, which can make it difficult for everyone, especially patients,” Kelly says. “States are successful when it is a coordinated effort.” In Mississippi, for example, which averages about 6,000 telehealth visits per month, patients can access the system through county health departments and facilities including some hospitals, schools, and primary-care centers.
“We will move quickly, but at an appropriate pace to foster collaboration and develop a sustainable system,” Kelly says. “We must strategically create the right infrastructure and plan for the rollout where care is delivered.”
UAB is working with local and state officials, policymakers, information-technology experts, and industry leaders from around the country to develop a roadmap and timelines. On campus, the schools of Medicine and Nursing have already engaged with Children’s of Alabama and the University of South Alabama on telehealth initiatives. Kelly says other areas of UAB likely will get involved.
“The applications will touch on almost every service UAB provides,” says Kelly, who has heard from a variety of clinicians interested in using it to treat and teach patients. “There are opportunities in multiple departments, like psychology, and other schools, like optometry and public health. Stroke and emergency medicine also are possible. I’m sure there are applications we haven’t thought of yet.”
To investigate all options, Kelly is establishing a telehealth provider advisory committee. He also will work alongside Wallace, recently named UAB’s medical director for telehealth, to foster growth.
Momentum for Growth
One early obstacle to expansion is reimbursement from insurance companies. Alabama does not have laws like Georgia, Mississippi, Tennessee, and half the states across the country requiring coverage for telehealth-provided services. In those states, providers typically are reimbursed at the same rate whether they see the patient by screen or in person.
However, in late 2015, Blue Cross/Blue Shield of Alabama began to reimburse for telehealth visits for five specific conditions—cardiologic and dermatologic conditions, infectious disease, behavioral health, and neurologic diseases, including stroke. Nephrology was added as a sixth area of coverage in 2016 after UAB announced the success of Wallace’s pilot study.
Wallace hopes that momentum continues to build for telehealth’s growth in Alabama. With its expansion, he foresees gains in quality of life, health literacy, and overall quality of care for a large portion of the population.
“Making lives better is our mission as health-care professionals,” he says. “And Alabama is our home. So let’s use what we know to make it the best home possible.”
We’ve come a long way from the iconic black bag. Here are instruments Wallace uses to examine his dialysis patients from afar.
• Bluetooth-enabled stethoscope (pictured above): Both Wallace and the nurse working with the patient have the same stethoscope, which are linked through an encrypted Internet connection. “I hear on my end whatever the person on the other end does, with amazing clarity,” Wallace says. “I listen to heart, lungs, and abdominal sounds with it.”
• Examination camera: The handheld device, operated by the nurse at the remote location, is super high definition, which should make it a good option for tele-dermatology, Wallace says.
• Other tele-tools: The telehealth carts include electronic otoscopes and ophthalmoscopes, making remote visits for ear, nose, and throat and optometry care possible, Wallace says.
“Telehealth also includes capabilities for real-time remote monitoring for things like blood sugars and blood pressures,” he adds. “But this actually is a challenge, because the amount of data could quickly become overwhelming. We have to learn what data will improve care and decrease costs so that we apply telehealth tools in the most effective manner.”