Telehealth offers continuity of care for ESKD during COVID-19 pandemic
Since the arrival of SARS-CoV-2 on U.S. shores, patients who receive dialysis for end-stage kidney disease have been at heightened risk. The first reported patient to die of COVID-19 was a 50-year-old man who received hemodialysis treatment at a Seattle-area dialysis facility.
As the outbreak spread, it quickly became clear that patients with ESKD were among the most vulnerable to experience severe COVID-19. They are often elderly and burdened by chronic diseases that increase the risk of morbidity and mortality, such as hypertension, heart disease and diabetes. Further, treating ESKD (whether in a dialysis facility or by home-based therapy) requires frequent interaction with health care providers and facilities, either for the treatment itself, or for necessary medical monitoring, evaluation and training.
While many Americans can implement effective social distancing practices to reduce their personal risk of infection, patients with ESKD do not fully share that luxury. Most receive three in-center hemodialysis treatment sessions per week, each lasting 3 to 5 hours and requiring contact with technicians and nurses at each session with additional medical, dietary and social work consultation at other sessions. Patients who dialyze at home, while experiencing greater flexibility in their treatment schedule, still attend monthly blood draws and clinic appointments with their interdisciplinary care team.
Telehealth is an intervention that has been implemented infrequently in dialysis care in the past yet offers additional risk reduction and potentially other benefits for patients, staff and provider partners. At a pivotal moment in ESKD care, Fresenius Medical Care North America (FMCNA) was able to implement telehealth nationwide across our 2,700-plus in-center and home dialysis facilities amid the COVID-19 pandemic.
Telehealth restrictions loosen
Any discussion of telehealth and dialysis is rooted in the context of payer policies. Although some patients with ESKD requiring dialysis have commercial insurance, most are covered by Medicare. Before COVID-19 became a public health emergency, the ability of providers to bill Medicare for telehealth services was limited to specific home dialysis visits and certain rural in-center patients. Professional billing for ESKD monthly capitated payments (MCP) required face-to-face visits per CMS rules. Further, CMS specifically required “hands-on” examination of the vascular access site for those patients receiving hemodialysis.
In early March, CMS issued several blanket waivers intended to expand the use of telehealth in health care amid the pandemic, but the waivers left uncertainty in the kidney care industry about coverage of telehealth for the MCP. On March 27, Congress passed the Coronavirus Aid, Relief and Economic Security (CARES) Act and on March 30, CMS issued an interim final rule clarifying that all physician and practitioner activities associated with the ESKD MCP could be provided by telehealth and the requirement for hands-on examination of the vascular access site could be waived during the public health emergency.
Long before CMS took the actions described above, members of the dialysis care industry began planning and implementing a variety of interventions designed to reduce SARS-CoV-2 exposure risk for patients, staff and provider partners. For example, in late January, we issued an advisory to our Fresenius Kidney Care centers directing facilities to order additional masks and conduct table-top exercises for pandemic preparation. We then began screening all patients to our facilities in February and requiring masks on all patients and care team members by mid-March.
As a focal point of our preparation, we also activated emergency planning to launch an expanded national telehealth program. First, we had to identify key requirements for an integrated COVID-19 telehealth system. These included the following:
- secure, encrypted communication;
- ability of the FMCNA cyber defense center to monitor for threats;
- ability to deactivate user recordings;
- ability to deactivate chat;
- ability to deactivate end-user file storage and collaboration; and
- HIPAA compliance.
Secondly, we had to pair these core capabilities with our short- and long-term objectives, including the following:
- speeding implementation and adoption;
- simplifying training;
- reducing burden for clinic staff and provider partners;
- standardizing IT user support procedures;
- minimizing variation in care practices;
- creating a smooth end-user experience; and
- scaling rapidly.
Leveraging this framework, we were able to select one telehealth system that checked off all the boxes.
The telehealth system we selected for our COVID-19 program was a commercial, unified communication and collaboration platform that combines chat functionality, audio-video meetings (including creation, scheduling and delivery), file storage (including collaboration on files) and application integration. It also allowed deactivation of some of these features that were not directly relevant to telehealth.
We then initiated a concerted interdisciplinary effort to deploy our telehealth program. The general contours of the program were identified for in-center and home therapy implementation separately to meet the unique needs of each modality (see Table). Intense efforts were undertaken across our company to prepare for a March 20, national go-live of the telehealth program across Fresenius Kidney Care centers.
We developed and published new policies and procedures on our COVID-19 response intranet, which were approved by our legal team to ensure alignment with evolving CMS guidance. We enhanced clinical documentation systems and workflows, conducted end-user training sessions for clinic employees and provider partners, and created a dedicated support hotline for staff and responders while enhancing existing hotlines.
We then assessed clinic hardware and distributed tablets to centers that we learned had insufficient inventory, as our IT team performed multiple test runs. Finally, we made plans to analyze the data collection resulting from the program.
Right on schedule, the first telehealth visits under the new system were delivered.
Adoption and outcomes
In the first 4 weeks (March 20 to April 20), 79,596 telehealth visits were documented in the electronic patient record. These visits included 73,356 in-center visits and 6,240 home therapy visits. By the end of May, that number had increased to more than 275,000 telehealth visits logged in electronic health records.
The metric selected for adoption was a telehealth visit as documented in our electronic patient record system. The electronic record system requires the visit be explicitly marked as being conducted by telehealth using drop-down and similarly structured controls in relevant visit documentation forms.
Although our IT systems record initiation and termination of telehealth sessions and allow us to count sessions, we chose not to use the number of such sessions in our reporting. We realized this may result in an inaccurate count because any given session might have been associated with multiple telehealth visits. We also observed highly divergent patterns where certain centers seemed to be opening one session for the entire day, whereas others were opening multiple sessions per day.
Lessons, future directions
As we look back on the “early” phases of this unprecedented public health emergency, we carry with us a number of significant lessons that will shape how we deliver life-sustaining care today and in the weeks, months and years ahead.
- Engage early and involve clinical and operational teams in program design, training and rollout.
- Patients, providers and staff support will lean on support lines. Make sure these exist.
- Providers are generally positive about their telehealth experiences (at least in a public health emergency context with a view toward reduction of infection risk).
- Provider visibility and leadership within dialysis facilities is important for staff morale and encouragement and is perhaps even more important during a public health emergency.
- A substantial percentage of providers still prefer face-to-face in-center rounds.
- Some patients and some visits are not appropriate for telehealth. The professional judgement of providers in patient selection for this style of rounding is critical.
- Patients are generally supportive of telehealth initiatives. Few refuse to participate.
- Some home therapy patients lack the hardware or internet access to participate in telehealth visits.
- Custom sleeves that wrap devices for infection control result in better patient and staff experiences (and are often comparable in price to Ziplocked bags).
- The most commonly expressed patient concerns related to telehealth in the dialysis context are the privacy and confidentiality of patient data. Selection of telehealth software with strong security, privacy and confidentiality controls, as well as employee training to respond to questions, can help overcome these concerns for many patients.
In-center telehealth increases the work burden on clinic employees because of the need for session scheduling and required device disinfection between each patient encounter. Some nursing staff noted the rounds that previously took 30 minutes to support can take up to 2 hours to support when telehealth is offered, underscoring the importance of appropriate staffing.
Next steps for telehealth
In the future, after this public health emergency dissipates, we intend to maintain telehealth as an available option for appropriately selected patients and visit types. Our experience indicates telehealth offers many benefits for patients related to more flexible access to provider services, potentially decreased transportation burden, improved continuity of care and convenience. We hope to work with CMS and other organizations to determine reasonable guidelines and approaches to ensure continued provider reimbursement for telehealth services.
- For more information:
- Ahmad Sharif, MD, is the chief medical information officer at FMCNA and can be reached at firstname.lastname@example.org.
- Robert Kossmann, MD, is the chief medical officer at FMCNA and can be reached at email@example.com.
- Timothy McNamara, MD, is the director of clinical health information technology at FMCNA and can be reached at timothy. firstname.lastname@example.org.