Nutritional counseling in the digital age: Improving access, saving time

Substantial innovations in digital technology impact almost every aspect of daily life, from business to social interactions to health care. Telemedicine offers an unprecedented level of access and connectedness, allowing patients from rural or underserved areas to receive appropriate treatment. Within gastroenterology, one essential component of care is the development of and adherence to an appropriate diet for a patient’s condition. The availability of mobile apps and personalized nutritional counseling online have increased patients’ ability to track their diets and remotely access a high standard of specialized care.

“Many gastroenterology patients require some type of specialty dietitian or nutritional advice,” Ryan Stidham, MD, assistant professor of medicine at the Inflammatory Bowel Disease Program at the University of Michigan Medical School, told Healio Gastroenterology and Liver Disease. “Various electronic means are able to provide not just access, but access to expertise, so the patient can find the right dietitian for the exact problem they have.”

Stidham spoke with Healio Gastroenterology and Liver Disease about the various ways in which telemedicine and digital technologies have transformed nutritional counseling in gastroenterology.

Healio: Is there a lack of specialized dietitians, particularly in gastroenterology?

Stidham: Because there’s such an obvious connection between diet and GI, a lot of dietitians come in with a fair bit of understanding of GI conditions. Having said that, at an academic center, for example, you’ll have dietitians who can handle a particular gastrointestinal condition. It may be gastroparesis; it may be structuring or obstructing Crohn’s disease; it may be elemental diets.

Nationally, a lot of credentialed RDNs will know about a FODMAP diet or how to restrict gluten from diets, but the trouble comes when you have competing conditions. Say there is a patient who has celiac, but also is a diabetic, how do you handle that? Or if you have a patient who is overweight but has structuring Crohn’s disease. How do you add low-calorie vegetables into that patient’s diet when they cause obstruction?

That’s where I think you find that there are these pockets of experience and excellence, but they’re often restricted to academic centers, or, in some cases, they are geographically restricted. So, these technologies that essentially remove geography, time and space are really valuable.

Healio: Do you provide telemedicine in your practice?

Stidham: I do a great deal of telemedicine where I replace our clinic visits with virtual visits; that’s a routine part of my care now. We are, as an extension, doing the same thing with our dietitians here at the University of Michigan. These geographic and access issues that we discussed are no longer a barrier for that type of care. It turns out that 70% of our patients have sufficient internet access, mobile devices, and are comfortable with doing these things. We’ve looked at that in various surveys.

There are other access issues to consider, too. I think the ones that are obvious are situations where you don’t have to drive somewhere if you live in Montana or you’re on some cattle ranch. You can still basically do a video conference with someone experienced.

Healio: What are some other access issues to consider?

Stidham: Even if you remove those geographic barriers, that nutritionist or that specialist still only has so many hours in the day. Where I think telemedicine can really improve access is in what’s called asynchronous telemedicine. Asynchronous telemedicine encompasses all the care you do that can be converted into an app or a patient response where the provider and the patient are not in the same time and space.

For example, if a patient has inflammatory bowel disease, and we meet and talk over the computer via video conference. We get everything straightened out, but my next availability is in 4 to 5 months. What do we do in between? There are many levels to this, but essentially, I am having my patients fill out questionnaires on a regular basis, asking the same questions I would ask in that visit. The patients are entering their responses, and I review them when I have time. I can flag a patient who — based on their responses — seems to not be doing well. I can say, “Lets pull them in. I don’t think we can wait until the next appointment.” As opposed to having a visit to just collect that information. I don’t have to do that now.

This makes my time available to more people. That asynchronous approach will be the future of how we use these electronic strategies to improve access; by offloading things that don’t have to be done in real time.

Healio: How would asynchronous telemedicine apply to nutritional counseling?

Stidham: Traditionally, a dietitian’s consultation would involve meeting the dietitian for the first time and talk about what problem you are there to solve. You’d tell the dietitian what you’re eating, your food access and the economics of your diet, and what happens when you eat specific foods. The dietitian puts the plan together, and the patient executes it. Then they come back 2 to 4 weeks later and report how it went. The dietitian then makes adjustments and that cycle continues.

So, what if all that in-between, all of the follow-up on how the patient is doing and executing the diet plan, what if that didn’t have to be done in person anymore? What if you’re basically having the patient report on that through some sort of electronic means? That way, the dietitian now isn’t spending the patient’s time and their own time collecting that information. You can eliminate a lot of those in-between visits and have more of a summary visit months later. In that vacuum that’s been created, you can see more people. That’s how you’re really improving access. We can keep hiring more dietitians, more doctors and more PAs and NPs, but at some point, the system has capacity. We need to leverage the tools we have to make ourselves available to more people without withdrawing any care that people need to fix their problems.

Healio: Is asynchronous care expected to become widespread?

Stidham: Right now, synchronous telemedicine — which includes things like video conferences or anything where the provider and patient are communicating in real time — is covered in many states, and eventually, it will be completely covered by payers and insurers. You would think Medicare and Medicaid would cover these services, but they actually don’t cover them unless there is a health care shortage, or the patient is in a rural area. The government wants to cover these services globally, but I think they need to go through their legislative process to make those changes.

Asynchronous care is not currently covered, but I think that will be something that will come, something that needs to come. It will make sense to payers, so they’ll want to reimburse those services.

Healio: What has been your experience with coverage for telemedicine?

Stidham: I do a lot of my return visits — maybe 10% of them — by video now, and I did a pilot for nearly a year. I was the only doctor doing this, because the insurance companies couldn’t get back to us, and their response to our queries about whether they would pay for telemedicine services was “I don’t know.” We just started doing it and then contacting payers afterwards, and they said, “We’re happy to pay for the service; you’re rendering very similar care, great care. We don’t want to pay for hospitalizations, ER visits and MRIs, but for outpatient visits. We don’t care.” That’s our realm as physicians.

Healio: How does it work for nutritional counseling?

Stidham: For the dietitians’ realm, we found in the state of Michigan that we get similar coverage for video visits compared to in-office visits. What we find still varies is that, in the case of either a virtual or in-office visit, different carriers and insurance companies vary in terms of what types of patients they’ll cover for dietary advice. If a patient has diabetes, if they have an ostomy, or are obese, these are generally all covered. For inflammatory bowel disease or celiac disease, there is some variation.

Having said that, I would point out that in the dietitian world, patients tend to be much more comfortable with paying, or may even expect to pay for some of these services out of pocket, to not have them covered. That makes the video visits much simpler. You can charge maybe $45 or $50 for a return visit — that’s a comfortable amount for many patients. They often see the convenience part of the video conference, where they don’t have to come to the office. There may be value in that. – by Jennifer Byrne

For more information:

Ryan Stidham, MD, can be reached at 1500 E. Medical Center Dr., Ann Arbor, MI 48109; email: ryanstid@med.umich.edu.

Disclosure: Stidham reports no relevant disclosures.

Substantial innovations in digital technology impact almost every aspect of daily life, from business to social interactions to health care. Telemedicine offers an unprecedented level of access and connectedness, allowing patients from rural or underserved areas to receive appropriate treatment. Within gastroenterology, one essential component of care is the development of and adherence to an appropriate diet for a patient’s condition. The availability of mobile apps and personalized nutritional counseling online have increased patients’ ability to track their diets and remotely access a high standard of specialized care.

“Many gastroenterology patients require some type of specialty dietitian or nutritional advice,” Ryan Stidham, MD, assistant professor of medicine at the Inflammatory Bowel Disease Program at the University of Michigan Medical School, told Healio Gastroenterology and Liver Disease. “Various electronic means are able to provide not just access, but access to expertise, so the patient can find the right dietitian for the exact problem they have.”

Stidham spoke with Healio Gastroenterology and Liver Disease about the various ways in which telemedicine and digital technologies have transformed nutritional counseling in gastroenterology.

Healio: Is there a lack of specialized dietitians, particularly in gastroenterology?

Stidham: Because there’s such an obvious connection between diet and GI, a lot of dietitians come in with a fair bit of understanding of GI conditions. Having said that, at an academic center, for example, you’ll have dietitians who can handle a particular gastrointestinal condition. It may be gastroparesis; it may be structuring or obstructing Crohn’s disease; it may be elemental diets.

Nationally, a lot of credentialed RDNs will know about a FODMAP diet or how to restrict gluten from diets, but the trouble comes when you have competing conditions. Say there is a patient who has celiac, but also is a diabetic, how do you handle that? Or if you have a patient who is overweight but has structuring Crohn’s disease. How do you add low-calorie vegetables into that patient’s diet when they cause obstruction?

That’s where I think you find that there are these pockets of experience and excellence, but they’re often restricted to academic centers, or, in some cases, they are geographically restricted. So, these technologies that essentially remove geography, time and space are really valuable.

Healio: Do you provide telemedicine in your practice?

Stidham: I do a great deal of telemedicine where I replace our clinic visits with virtual visits; that’s a routine part of my care now. We are, as an extension, doing the same thing with our dietitians here at the University of Michigan. These geographic and access issues that we discussed are no longer a barrier for that type of care. It turns out that 70% of our patients have sufficient internet access, mobile devices, and are comfortable with doing these things. We’ve looked at that in various surveys.

There are other access issues to consider, too. I think the ones that are obvious are situations where you don’t have to drive somewhere if you live in Montana or you’re on some cattle ranch. You can still basically do a video conference with someone experienced.

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Healio: What are some other access issues to consider?

Stidham: Even if you remove those geographic barriers, that nutritionist or that specialist still only has so many hours in the day. Where I think telemedicine can really improve access is in what’s called asynchronous telemedicine. Asynchronous telemedicine encompasses all the care you do that can be converted into an app or a patient response where the provider and the patient are not in the same time and space.

For example, if a patient has inflammatory bowel disease, and we meet and talk over the computer via video conference. We get everything straightened out, but my next availability is in 4 to 5 months. What do we do in between? There are many levels to this, but essentially, I am having my patients fill out questionnaires on a regular basis, asking the same questions I would ask in that visit. The patients are entering their responses, and I review them when I have time. I can flag a patient who — based on their responses — seems to not be doing well. I can say, “Lets pull them in. I don’t think we can wait until the next appointment.” As opposed to having a visit to just collect that information. I don’t have to do that now.

This makes my time available to more people. That asynchronous approach will be the future of how we use these electronic strategies to improve access; by offloading things that don’t have to be done in real time.

Healio: How would asynchronous telemedicine apply to nutritional counseling?

Stidham: Traditionally, a dietitian’s consultation would involve meeting the dietitian for the first time and talk about what problem you are there to solve. You’d tell the dietitian what you’re eating, your food access and the economics of your diet, and what happens when you eat specific foods. The dietitian puts the plan together, and the patient executes it. Then they come back 2 to 4 weeks later and report how it went. The dietitian then makes adjustments and that cycle continues.

So, what if all that in-between, all of the follow-up on how the patient is doing and executing the diet plan, what if that didn’t have to be done in person anymore? What if you’re basically having the patient report on that through some sort of electronic means? That way, the dietitian now isn’t spending the patient’s time and their own time collecting that information. You can eliminate a lot of those in-between visits and have more of a summary visit months later. In that vacuum that’s been created, you can see more people. That’s how you’re really improving access. We can keep hiring more dietitians, more doctors and more PAs and NPs, but at some point, the system has capacity. We need to leverage the tools we have to make ourselves available to more people without withdrawing any care that people need to fix their problems.

PAGE BREAK

Healio: Is asynchronous care expected to become widespread?

Stidham: Right now, synchronous telemedicine — which includes things like video conferences or anything where the provider and patient are communicating in real time — is covered in many states, and eventually, it will be completely covered by payers and insurers. You would think Medicare and Medicaid would cover these services, but they actually don’t cover them unless there is a health care shortage, or the patient is in a rural area. The government wants to cover these services globally, but I think they need to go through their legislative process to make those changes.

Asynchronous care is not currently covered, but I think that will be something that will come, something that needs to come. It will make sense to payers, so they’ll want to reimburse those services.

Healio: What has been your experience with coverage for telemedicine?

Stidham: I do a lot of my return visits — maybe 10% of them — by video now, and I did a pilot for nearly a year. I was the only doctor doing this, because the insurance companies couldn’t get back to us, and their response to our queries about whether they would pay for telemedicine services was “I don’t know.” We just started doing it and then contacting payers afterwards, and they said, “We’re happy to pay for the service; you’re rendering very similar care, great care. We don’t want to pay for hospitalizations, ER visits and MRIs, but for outpatient visits. We don’t care.” That’s our realm as physicians.

Healio: How does it work for nutritional counseling?

Stidham: For the dietitians’ realm, we found in the state of Michigan that we get similar coverage for video visits compared to in-office visits. What we find still varies is that, in the case of either a virtual or in-office visit, different carriers and insurance companies vary in terms of what types of patients they’ll cover for dietary advice. If a patient has diabetes, if they have an ostomy, or are obese, these are generally all covered. For inflammatory bowel disease or celiac disease, there is some variation.

Having said that, I would point out that in the dietitian world, patients tend to be much more comfortable with paying, or may even expect to pay for some of these services out of pocket, to not have them covered. That makes the video visits much simpler. You can charge maybe $45 or $50 for a return visit — that’s a comfortable amount for many patients. They often see the convenience part of the video conference, where they don’t have to come to the office. There may be value in that. – by Jennifer Byrne

For more information:

Ryan Stidham, MD, can be reached at 1500 E. Medical Center Dr., Ann Arbor, MI 48109; email: ryanstid@med.umich.edu.

Disclosure: Stidham reports no relevant disclosures.