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Date September18,2018Subject: GeorgiaCouncilonLupusEducationandAwareness

TelemedicinePilotprojectandFeasibilityReportTo AmericanCollegeofRheumatologyFrom: ChristopherReed,Co-Chair

KimSchofield,Co-ChairPurposeToprovideyouwithasummaryofthetelemedicinepilotprogramtodeterminethefeasibilityatelemedicineprograminDoughertyCounty,Georgiaforpersonswithlupus.BackgroundTheAmericanCollegeofRheumatology(ACR)wasfundedbytheCentersforDiseaseControlandPrevention(CDC)toimplementseveralactivitiestoimprovelupuseducation,awarenessandaccesstoearlydiagnosisandtreatmentandawareness.1TheGeorgiaCouncilonLupusEducationandAwareness(GCLEA)2receivedfundingtoplanandimplementatelemedicine3pilotstudyforpersonslivingwithlupusinruralsouthwestGeorgia.4ThestudylinkedprimarycarepractitionersinruralsouthwestGeorgiawithrheumatologyspecialistsatEmoryUniversityHospitalandEmoryUniversitySchool

1TheprojectdescribedwassupportedbyGrantnumber6NU58DP006138-01-02;CFDAnumber93.068,DevelopingandDisseminatingProgramstoBuildSustainableLupusAwareness,Knowledge,SkillsandPartnerships.2 TheGCLEAistheonlystatesponsoredmandatedentitycreatedtoimprovethelivesofGeorgiaresidentswholivewithlupusbyimprovingpubliceducationandawareness,improvingaccesstoresourcesforpatientsandfamilymembers,anddevelopinginformationthatwillinformcurrentandfuturepublichealthefforts.ItishousedintheGeorgiaDepartmentofCommunityHealthandfrequentlypartnerswiththeDPH. 3TheAmericanTelemedicineAssociation(2017)definestelemedicineasthe:“useofmedicalinformationfromonesitetoanotherviaelectroniccommunicationstoimproveapatient’sclinicalhealthstatus.Telemedicineincludesagrowingvarietyofapplicationsandservicesusingtwo-wayvideo,email,smartphones,wirelesstoolsandotherformsoftelecommunicationstechnology.”AmericanTelemedicineAssociation.(2017).Retrievedfromwww.americantelemedicineassociation.com.4 AnalysisandEvaluationoftheGCLEAPilotStudywasconductingbySineadYoung,Ph.D.ofYoungeConsulting,LLC.

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ofMedicine(Emory).SincetheGeorgiaDepartmentofPublicHealth(DPH)hasasystemofsitesthroughoutGeorgiathatcooperatewithtelemedicineconsultationsforavarietyofhealthconditions,GCLEA’sstudyassessedthefrequencywithwhichprimarycarepractitionersinsouthwestGeorgiasawlupuspatientsandtheirperceptionofthevalueoftelemedicineintheirpractice.TheGCLEAalsoconductedanassessmentofattitudes,behaviorsandbeliefsofvariousrheumatologiststhroughoutthestatebeforethepilotconsultationexperience.Onegovernmenthealthclinic,DoughertyCountyHealthClinic(Clinic)whichcurrentlyspecializesinobstetricsandgynecologytelemedicineconsults,agreedtoexpandconsultationstoincludepersonswithlupus.First,theClinictrainedrheumatologistsfromEmoryonthewaysinwhichtelemedicinecanbeusedtodiagnoseandtreatlupus;thelogisticsofexaminations,andfundingmechanismsfortheClinicandrheumatologistsasapartyofthestudy.Next,fivewomenfromsouthwestGeorgia,whowerepreviouslydiagnosedwithlupus,agreedtobeexaminedbytherheumatologistsattheClinicusingthetelemedicineequipment.Datacollectedonthesepatientsbeforeandafterthestudyincludedtheirperceptionoftelemedicinebothbeforeandaftertheconsultation,age,race/ethnicity,insurancestatus,currenttreatmentplanandcurrenttraveltimetoseearheumatologist.Theresultsofthisstudyaresetforthinthefollowingreport.DiscussionIn2016,theGCLEAandLupusFoundationofAmerica,GeorgiaChapter,convenedastatewideworkshopofpublichealthprofessionals,educators,medicalproviders,socialworkers,researchers,andcommunityactivists.5OneofthegoalsoftheworkshopwastocollaborateandcreatetheGeorgiaActionPlan-waystoencourageandfacilitatepublicandprivateactiondesignedtocombatlupus.AkeycomponentofthePlanistoimproveaccesstocareandservicesforpeoplelivingwithlupusbyconnectingpatientsandrheumatologistsusingtelemedicine.6AnenvironmentalscanoftelemedicineinGeorgia,conductedforGCLEAbyHighlandNonprofitConsulting,LLCin2017,indicatesthatthereareeducationgapsamongrheumatologistsandpatientsontheuses,benefits,administration,andlogisticsoftelemedicine.Basedonthefindingofthescan,thebenefitsoftelemedicine,accordingtothescan,isthatittreatspatientswhowouldnototherwisehaveconvenientaccesstoaspecialist,butalsoitcanteachothermedicalprovidersaboutthediagnosisandtreatmentoflupus.

5 FundingwasprovidedbyagrantfromtheCentersforDiseaseControlandPrevention(CDC)andsupervisionwasprovidedbytheNationalAssociationofChronicDiseaseDirectorsandtheLupusInitiative.TheGCLEAhasreceivedthisfundingthreeyearsinarow. 6 TheLupusFoundationofAmerica-GeorgiaChapterestimatesthatthereare55,000Georgianslivingwithlupus.TheGeorgiaSocietyofRheumatologistsandtheAmericanCollegeofRheumatology(ACR)indicatethatthereare109rheumatologistsinpracticeinGeorgiawhoarequalifiedtodiagnoseandtreatlupus.AlargemajorityoftheserheumatologistsarecenteredinmetropolitanAtlanta,particularlyinthenorthernsuburbs.

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Telemedicineequipmentexiststhroughoutamajorityofthestate.TheGeorgiaPartnershipforTelehealth(GPT)7,astatewidenon-profittelehealthnetwork,reportsthatithasprovided130,000patientencountersusing40differentspecialties,asrecentlyas2013,andhasthecapacitytoprovidethesameserviceto106ofGeorgia’s159counties.TheGeorgiaDepartmentofCommunityHealthusestelemedicineequipmenttoprovideservicesinsomeclinicsthroughoutthestateforpatientsonMedicaid.TheClinicusestelemedicinetoprovidemedicalservicestothosewithinfectiousdiseases,womenwithhigh-riskobstetrics,andwomenandchildrenintheWomen,Infants,andChildren’snutritionprogramorWIC.TheDoughertyCountyHealthClinic,aclinicrunbytheGeorgiaDepartmentofPublicHealthinAlbany,DoughertyCounty,Georgia8,usestelemedicineequipmenttoeducatepregnantmothersaboutprenatalhealthandthebirthingprocess.Theyhavetwounits,oneofwhichismobile.Theclinic,alsoknownastheTelemedicineOriginatingSite(OriginatingSite),alsoperformsprenatalpatientexaminationsandconsultationsbycommunicatingviathetelemedicineequipmentwithDr.C.AnnePatterson,anOB/GYNinSandySprings,Georgia.Dr.Patterson,whoisdefinedastheDistantSiteProvider(ProviderSite),canusethetelemedicinestethoscopetolistentothepatient’sabdomen,alaptoptoviewultrasounds,aDermascope9toviewrealtimeimagesoftheepidermis,electrocardiograms,sonograms,andmedicalrecordsinrealtime.Allequipment,withtheexceptionofthetelemedicinestethoscopeandDr.Patterson’slaptop,ishousedandprovidedtotheOriginatingSite.The“PregnancyCenteringModel”,asitiscalledhashadpositiveresultsandtheClinicdepartmentreportsbetterpregnancyoutcomesthanneighboringcounties.Inadditiontothepre-natalprogram,theClinicusestelemedicineequipmenttotreatchildrenwithsicklecellanemia.TheOriginatingSiteusesaTelemedicinePresenter,usuallyaregisterednurseorlicensedpracticalnurse,toassistwiththeexaminationofeachpatient.AllparticipantsintheexaminationaregivenindividualizedaccountnumbersfromGPTwhichholdsacopyofthepatientconsentformandHIPAAforms.AllmedicalrecordsarehousedelectronicallyattheOriginatingSite.TherearenosetcriteriaforwomenandchildrentobetreatedorusethetelemedicineservicesprovidedbytheClinic.Dr.Pattersoniscompensatedusingapatient’s

7 GPToperatesanOpenAccessNetworkthatconnectsoperationalstatewidetelemedicineproviderprogramswithtelemedicinepatientcliniclocations. 8DoughertyCountyhasapopulationof89,502basedonestimated2017US.Censusrecords.It’sdemographicsareasfollows:70.2%BlackorAfricanAmerican,27%White,2.9%HispanicorLatino,.3%AmericanIndian,.9%Asian,and1.3%tworacesormore.Themedianhouseholdincomefrom2012-2016was$33,605.00.Thirtypercent(30%)ofthepopulationlivesbelowthepovertylevel. 9Dermascopesarecomputerizedpolarized-lightvideomicroscopethatuse,insomecases,lenseswith×20to×70factorsofmagnificationtoviewsegmentsofapatient’sepidermis.AntonellaTosti,MD;FernandaTorres,MD;CosimoMisciali,MD;etal.,FollicularRedDots:ANovelDermoscopicPatternObservedinScalpDiscoidLupusErythematosus.ArchDermatol.2009;145(12):1406-1409.doi:10.1001/archdermatol.2009.277;“Thedermoscopehasbeenknowntorevealstructures[ontheepidermis]notvisibletothenakedeye...”KittlerH.,PehambergerH.,WolffK.,BinderM.Diagnosticaccuracyofdermoscopy.TheLancetOncology.2002;3(3):159–165.doi:10.1016/s1470-2045(02)00679-4.

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privateinsurancecarrier10,Medicaid11,PeachCareforKids,oronaslidingscale.TelemedicineOriginatingSites,liketheClinicmaybillafacilityfeetotheinsuranceprovider.12TheClinicanditscountyseat,Albany,GeorgiawerechosenasthepilotsitebecauseDoughertyCountyandthesurrounding39countiesthatmakeupsouthwestGeorgiaaresomeofthepoorestcountiesinGeorgia.Outofthethreerheumatologistsinthisarea,onetakesgovernmentfundedhealthinsuranceandhisofficeisoveranhourawayfromDoughertyCounty.Theothertworheumatologistsinthe39countyareadonottakegovernmentfundedhealthinsurance.Therefore,manypatientsareforcedtoseekcarefromrheumatologisthoursaway,waitmonthstoseelocalrheumatologists,seekcarefromanothertypeofmedicalproviderornocareatall.DiscussionontheTelemedicinePilotStudyMethodAtotaloffivewomenlivingwithlupusvolunteeredtoparticipateintheAugust31,2018,pilotstudyattheOriginatingSite.Volunteers,alldiagnosedwithSystemicLupusErythematosus,wererequiredtocompleteconsentformstoparticipateinthestudyaswellasacknowledgetheirunderstandingoftheirprivacyrightsviatheHealthInsurancePortabilityandAccountabilityAct.Volunteersweregivenapre-pilotsurveyandapostpilotsurvey.Eachvolunteersawoneoftworheumatologists,Dr.S.SamLimofEmoryUniversitySchoolofMedicineandGradyHealthSystemorDr.AlizaLipsonofEmoryUniversitySchoolofMedicinewhowerehouseattwodifferentProviderSites.Drs.LimandLipsoncommunicatedwitheachpatientusingallofthetelemedicineequipmentavailableexceptthetelemedicinestethoscopewhichwasnotavailabletothephysicians.Whilebothdoctorswereabletovieweachexamination,onlyonedoctorconductedtheexaminationandeachpatientwasonlyawarethatonephysicianwasconductingthatexamination.13EachrheumatologistandpatientwereassistedbyNurseValeniaMilling,theTelemedicinePresenterattheDoughertyCountyHealthClinic.Eachexaminationtookonaveragetwenty(20)minutes.Drs.LimandLipsonweregivenpostpilotsurveys.

10Commercialinsurancecarriersaremandatedtocovertelemedicineservicesandreimburseprovidersinthesamewayitwouldin-personmedicaltreatment,pursuanttotheGeorgiaTelemedicineActof2005.O.C.G.A.§§33-24=-6.4,43-34-31.11“GeorgiaMedicaidwillreimburseforlivevideowhentheserviceis“medicallynecessary,theprocedureisindividualized,specific,consistentwithsymptomsorconfirmeddiagnosisofanillnessorinjuryundertreatment,andnotinexcessofthemember’sneeds.”GADept.ofCommunityHealth,GAMedicaidTelemedicineHandbook,p.2,(Oct.2014).(AccessedSeptember2018)).12GADept.ofCommunityHealth,GAMedicaidTelemedicineHandbook,p.48,(Oct.2014)(AccessedSeptember2018). 13 ThetelemedicinehasamechanismallowinguptofourphysicianstobeconnectedwiththepatientfrommultipleProviderSites.Eachphysiciancouldhidetheirparticipationfromviewofthepatient.

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ParticipantDemographicsAtotaloffive(n=5)AfricanAmerican/Blackwomenvolunteers,livingwithLupusparticipatedinthepilotstudyonAugust31,2018.Theparticipantsrangedinagefrom39to67yearsofagewithanaverageageof57yearsold(seeTable1).Themajorityofparticipants(n=3)reportedhavingbeendiagnosedwithSystemicLupus.OneparticipantdidnotreportwhattypeofLupusshewasdiagnosedwithandanotherparticipantreportedhavingDrugInducedLupus.Allfivevolunteersreportedcurrentlyhavinghealthinsurance,havingarheumatologist,andbeingtreatedbytherheumatologistinthelast12months.

Table1

AccesstoMedicalProvidersThreeparticipantsreportedtravelingatleast120milestovisittheirrheumatologist.Twoparticipantsreportedtraveling10milesorundertovisittheirrheumatologist.TwoparticipantsreportedthattheydonotseearheumatologistfortheirLupus.OneparticipantreportedseeinganinternistandtheotherreportedthatshedidnotseeanyoneforherLupus.Twoofthethreeparticipantsreportedhavingheardabouttelemedicinepriortothepilot.Oneofthefiveparticipantsreportedusingtelemedicineinthepast.

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VolunteerPreandPostPilotSurveyResultsWhenasked,“Telemedicineprovidesthesamequalityofcareasaninpersonvisit?”TwoparticipantsStronglyAgreedandtwoparticipantsAgreed.Oneparticipantreported,“Don’tKnow.”Postpilot,threeparticipantsreportedStronglyAgreeingandtwoparticipantsreportedAgreeingthattelemedicineprovidedthesamequalityofcareasaninpersonvisit.Whenparticipantswereasked,“Ifnorheumatologistswereavailableinyourarea,howlikelywouldyouagreetoallowyourhealthcareprovidertouseatelemedicinesystemtotreatyourlupus?”Atpre-test,twoparticipantsreportedbeingverylikelyandatpost-test,threeparticipantsreportedbeingVeryLikely,andoneparticipantreportedbeingLikelytousetelemedicinetotreattheirLupus14(seeTable2).Table2

VolunteerPatientConcernsUsingTelemedicineLackofface-to-facetimewiththerheumatologistwasthemostendorsedconcernofthepre-test.(seeTable3).1516Table3

Pre-TestEndorsements

Post-TestEndorsements

1 FutureoncallaccesstotheRheumatologist

3 1 LackoffacetofacetimewiththeRheumatologist

14 One respondent did not answer all of the post test questions. 15 Two respondents did not answer all of the post test questions. 16 Lack of face time is possibly a result of the age range of the participants and the possible limited experience with online technology and social media. In addition, participants may feel that the absence of physical contact diminishes the examination.

012345

VeryLikely Likely NeitherLikelynorUnlikely

Unlikely VeryUnlikely

LiklihoodofUsingTelemedicinetoTreatLupus

PreTest Post-Test

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1 Comfortwithtechnology

1 Other:NoPhysicalExam.InPersonHandson

OpenEndedResponsesfromPost-TestWhatdidpatientparticipantslikemost? Whatdidpatientparticipantslikeleast?

• Talking • Sheisnotinperson/nothere• Friendly• Ifeelveryconfidentwiththisprogram.• ConcernwithwhatImayneedhelp• Convenience

• Beingabletofaceandtalkwiththerheumatologistasifinanofficesetting(questions/answers)

• Ilikedit

MedicalProviderResponses Inaseparatesurvey,medicalprovidersinsouthwestGeorgiarespondedtoa

surveyabouttreatingLupuspatients.Atotalof(n=25)providersresponded.Themajorityofrespondents(n=11)werenursepractitionersfollowedbyphysicians(n=9),physicianassistants(n=4)and‘other’(n=1).Table4 Table5

Atotalofsixor24%ofhealthcareprovidersreportedusingsomeformoftelemedicine.Whenasked,“Doyouthinktelemedicineprovideseffectivecoordinationofcarewithoutcompromisingqualityorpatientoutcomes?”All(N=24)100%oftheprovidersreported‘yes’(seeTable8).Themajorityofmedicalprovidersreportedseeing10orlessLupuspatientsayear(seeTable7).Whenasked,themajorityofrespondents(n=19)reportedincreasedaccesstophysicians’referralnetworkasan

9

11

4

1

HealthCareProviderSurveyRespondents

Physician NursePractitioner

Physician'sAssistant Other

15

5

PrimaryAreaofPractice

FamilyPractice InternalMedicine

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advantage.BenefitsandchallengesofusingtelemedicinetotreatLupuspatientsarereportedinTable8.

Table6

Table7

Table8

MainAdvantagesofUsingTelemedicinetoTreatLupus?

MainBarrierstoUsingTelemedicinetoTreatLupus?

0

10

20

Yes No

Areyoucurrentlyusinganyformoftelemedicinetotreat

patients?

0 5 10 15 20

Lessthan1011-20 21-30 31-40 41-50

Greaterthan50

0

2

4

6

8

10

12

14

16

18

20

0246810121416

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FutureProjectionsMostprovidersStronglyAgreedthatifapatientpresentedwithsymptomsofLupus,theywouldknowwhentorefers/hetoarheumatologist(seeTable9).ThetoptwoendorsedconcernsforusingtelemedicinewereMedicarecoverstoofewtelemedicineservices(n=10)andWereceivenoreimbursementsforatelemedicinevisit(n=10).ThemajorityofhealthcareprovidersreportedbeingVeryLikelyorSomewhatLikelythattheywouldusetelemedicinetotreatpatientswithLupus(seetable9).TheleastendorsedconcernswereManagedcarecompaniespayinglowerratesfortelemedicinethanin-personcare(n=3)(seeTable10).Themajorityofhealthcareprovidersprojectthatthreeyearsfromnow25%orlessofpatientswillbeusingtelemedicine(seeTable11).

Table9 Table10

Table11

0

5

10

15

StronglyAgree Agree Disagree StronglyDisagree

ConfidenceinReferringtoaRheumatologist

024681012

Managedcarecompaniespayinglowerratesfor

telemedicinethanin-personcare.

Medicarecoverstofewtelemedicine

services.

Wereceivenoreimbursementforatelemedicinevisit.

SignificantConcernsRegardingReimbursementofTelemedicine

129

2

Threeyearsfromnow,whatpercentageofyourpatientswillbe

usingtelemedicineservices?

Lessthan25% 25% 50% 75% greaterthan75%

10

Table12

MedicalProviders’Open-EndedResponses

• Iworkforpublichealth-wewouldrefertotheirPMDandthePMDwouldrefertorheum.Luckily,wehaveaspecialistinThomasville.IworkaweekendamonthintheERinThomasCounty.Weusetelemedicineonstrokealertsandontheinputsidetheyhavebeenusingtelemedtohaveneuroconsultationanditseemstoworkwell.ItwasveryefficientandeffectiveintheER.

RheumatologistsResponses

ElevenrheumatologistsrespondedtoasurveyregardingthetreatmentofLupuspatients.Whenasked,whereisyourpracticeislocated,themajority(90%or10outof11)ofrheumatologistspracticeinmetroAtlanta.PatientTravelTimeandNumberofPatientsTreatedWhenasked,“Whatpercentageofyourpatientstravelmorethananhourtovisityou?”Themajorityresponsesrangedfrom25%to50%(seeFigure1).Themajority(90%or10outof11)ofrheumatologistsreportedencountering50ormorepatientsperyear.Figure1

024681012

Verylikely Somewhatlikely

Somewhatunlikely

Notlikely

Ifavailable,howlikelywouldyouusetelemedicinetotreatlupuspatients?

00.51

1.52

2.53

3.5

lessthan10%

10% 25% 50% 75% greaterthan75%

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FeasibilityofTelemedicineWhenasked,“Doyouthinktelemedicineprovideseffectivecoordinationofcarewithoutcompromisingqualityorpatientoutcomes?”Themajorityofrheumatologists(n=9)reported“yes.”AdvantagesandBarriersWhenasked,“WhatarethemainadvantagestousingtelemedicinetotreatLupuspatients.”Thenumberoneendorsedadvantagelistedwas“Bettercoordinationofcare.”TheadditionalresponsesarelistedinFigure2.Interestingly,whenaskedaboutthemainbarrierstousingtelemedicinewere“Coordinationofcare”and“QualityofCare.”

Figure2

Advantages

TelemedicineConcerns

Figure3

Barriers

Whenasked,“Whatisyourmostsignificantconcernregardingreimbursementoftelemedicineservices.”Themostcommonresponseswere“Wereceivenoreimbursementforatelemedicinevisit”and“Managedcarecompaniespayinglowerratesfortelemedicinethaninpersoncare.”

024681012

012345678

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Figure4

FutureofTelemedicinetoTreatLupusWhenasked,“Threeyearsfromnow,whatpercentageofyourpatientswillusetelemedicinetomanagesomeoralloftheirhealth?”Themajorityofrespondentsreportedlessthan25%(seeFigure5).Therheumatologistswerealsoasked,“Howlikelyareyourpatientstousetelemedicinetotreatlupuspatients?”(SeeFigure6).Themajorityofrheumatologistsreportedbeing“VeryLikely.”Figure5

0 1 2 3 4 5

Managedcarecompaniespayinglowerratesfortelemedicinethanin-person

care.

Medicarecoverstofewtelemedicineservices.

Wereceivenoreimbursementforatelemedicinevisit.

0 1 2 3 4 5 6 7

lessthan25%

25%

50%

75%

greaterthan75%

Other(pleasespecify)

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PatientInsuranceCoverageWhenasked,“WhatpercentageofyourLupuspatientsusegovernmentfundedinsurancesuchasMedicaidorMedicare”ThemajorityofRheumatologistreportedbetween25%to40%(seeFigure7).Figure6

OpenEndedResponses

• Foundphysicalexamdifficultviatele-medicine.• IhaveseveralyearsofexperiencewithtelemedicinethroughGeorgia

TelehealthchampionedbyJohnOxendine• Ithinkitwillgiveaccesstopeopleindireneedandurgentneed.Itshouldnot

replacevisitstothedoctor!• NeedLogisticalData

0 1 2 3 4 5 6

Verylikely

Somewhatlikely

Somewhatunlikely

Notlikely

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5

lessthan10%10% 25% 40% 50% 65% 80%

greaterthan80%

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ConclusionsOverall,thehealthcareproviderssurveyedseemedreceptivetotheuseoftelemedicinetotreattheirLupuspatients.Careandcoordination,inadditiontothequalityofcarewerekeyfactorsthatneedtob

SummationofResponsesfromRheumatologistswhoParticipateinthePilotStudyTheStudywasDrs.LimandLipsonfirstchancetousetelemedicinetoexaminepatientsanddeterminedthatthiswasawellperformedpilotstudythatwhenconductedinarealscenariocanbeaneffectiveoptionandalternativetoservicescurrentlybeingprovidedtoundertreatedlupuspatientswhovisitemergencyroomsandurgentcarecenters.Bothdoctorsfoundthattheabsenceofsomemedicalrecords,labrecords,andtheseofsomeexaminationtoolsmadetheexaminationlessduplicativeofaliveexamination.Dr.Lipsonfoundthetelemedicineexaminationalittlemoredifficultthananin-personexamination.Bothdoctorsdonotbelievethatthetelemedicineexaminationwouldhinderdiagnosisortreatmentoflupus,butDr.Lipsonsuggestedthatsomein-personsvisitswouldlikelybeneededonoccasion.Bothdoctorsthatthelargestconcernwithtelemedicineisthepossibilityoftechnicaldifficultiesandthetransmissionofelectronicmedicalrecords.Dr.Limindicatedthattheuseoftelemedicinetotreatlupuspatientsisahugewin,andbetterthanthealternative.Hebelievesthatsomeofhisconcernscanbeworkedoutthroughimprovementsinoptimization,standardizationofthenurseparticipationandexaminations,training,bettercoordination,andpartnershipswithlocalproviderswhocancoordinatecarethatcannotbeprovidedusingthetelemedicineequipment.

TechnologyConsiderationsTelemedicine(alsoreferredtoas“telehealth”or“e-health”)allowshealthcareprofessionalstoevaluate,diagnoseandtreatpatientsinremotelocationsusingtelecommunicationstechnology.Telemedicineallowspatientsinremotelocationstoaccessmedicalexpertisequickly,efficientlyandwithouttravel.Sincelupusrequireslifetimeattentionofseveralphysicians,telemedicinecanbeimplementedtoimprovehealthservicestolupuspatientsespeciallytheoneswithremoteaccesstohealthpractitioners.GiventhatDPHandFederallyQualifiedHealthCentersinGeorgiahavemadeanefforttoequipremoteclinicswithtelemedicineandtheequipmentcostsforrheumatologistsislimitedtothecostofthestethoscopeandcomputer,thebenefitfaroutreachesthecost.BasedonsomeofGCLEA’sresearch,therearesomeimportantconsiderationstonote,includinguseoftechnologyandspecialequipmentneededtoimplementtelemedicineacrosshealthcarelocations.

Product/ServiceMarketplaceIntheearly2000’s,astudywasconductedbytheGeorgiaLupusRegistryaimingtoexpandtheexistingknowledgesurroundingLupusina“targetedpopulation”( “TheIncidenceandPrevalenceofSystemicLupusErythematosus,2002–2004:The

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GeorgiaLupusRegistry”).From2002-2004,twospecificcountiesinGeorgia,FultonCountyandDeKalbCounty,weretargetedtoconductfurtherresearchonlupus.Withthepopulationsofthecountybeingmajoritywomen,andmajorityAfricanAmericans,thestudyconcludestheincidenceratebeing5.6per100,000people17Thestudyconfirmsthatthecasesamongblackwomenaretriplethecasesamongwhitewomen.Also,thecasesfoundforwomenwereninetimesthecasesfoundformen18SimilarstudieshavebeenconductedinareasofSanFrancisco,California,Manhattan,NewYork,andsoutheastMichigan.19Yet,therehavebeennostudiesconductedintheruralcommunitiesinournation.ThereisashortageofhealthcareprovidersintheruralregionsofGeorgiathathavetheexpertisetotreatpatientswithLupus,contributingtotheneedfortelemedicinefortheunderservedpopulations.

ResearchWhiletheGCLEA’stelemedicinepilotstudyforlupuspatientsisknowntobethefirstofitskind,telemedicinestudieshavebeenconductedonpatientswithothermedicalconditions.Dr.SamuelG.Burgess,etal.conductedastudythatwaspublishedin1997connectingruraldermatologypatientswithdermatologistsusingtelemedicine.20Burgessstudied87patientsovera17-monthperiodandconfirmedthattelemedicineiscost-effectiveandaresourcefuloptionforpatientswhocannoteasilyaccesshealthcarefornecessaryroutinecheck-ups.

Conclusions,RecommendationsandActionStepsTelemedicineisthefuture.TowersWatson.comreportedin2014thattelemedicinecouldpotentiallydelivermorethan$6billionayearinhealthcaresavingtoU.S.companies.21Thereportindicatedthatoutofonethousand(1,000)companiessurveyed,22%wereusingtelemedicinein2016andthatnumberincreasedto37&in2017.BasedonthefindingsfromtheTelemedicinePilotinDoughertyCountyandthesurveyresultsofhealthcareprovidersinsouthwestGeorgiaand

17Lim,S.S.etal,TheIncidenceandPrevalenceofSystemicLupusErythematosus,2002-2004.Arthritis&Rheumatology2014,66:357-368.http://onlinelibrary.wiley.com/doi/10.1002/art.38239/abstractMichiganregistryarticle:Somers,E.C.etal,Population-BasedIncidenceandPrevalenceofSystemicLupusErythematosus.Arthritis&Rheumatology2014,66:369.18Id.19Dall’Era,M.,etal.TheIncidenceandPrevalenceofSystemicLupusErythematosusinSanFranciscoCounty,California:TheCaliforniaLupusSurveillanceProject.,Arthritis&Rheumatology:2017,69(10)1996-2005;Izmirly,PM,etal.TheIncidenceandPrevalenceofSystemicLupusErythematosusinNewYorkCounty(Manhattan)NewYork:TheManhattanLupusSurveillanceProgram.,Arthritis&Rheumatology:2017,69(10):2006-2017;Housey,M.,etal.IncidenceandprevelanceofsystemiclupuserythematosusamongArabandChaldeanAmericansinsoutheasternMichigan:theMichiganLupusEpidemiologyandSurveillanceProgram.AmericanJournalofPublicHealth:2015,105(5):74-9.20iBurgiss,SG,etal.Telemedicinefordermatologycareinruralpatients.TelemedicineJournal.1997,Fall:3(3):227-33.21CurrentTelemedicineTechnologyCouldMeanBigSavings.(2014);https://www.towerswatson.com/EN-US/PRESS/2014/08/CURRENT-TELEMEDICINE-TECHNOLOGY-COULD-MEAN-BIG-SAVINGS

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rheumatologiststhroughoutthestate,theimplementationoftelemedicineisfeasibleandfulfillsagreatneedamongstpatientswithLupuslivinginGeorgia.Therearesomedrawbacks.Certainly,ourrheumatologistswerenotabletosufficientlycomparewhetherornottheneedfortactileexaminationsislimitedbytelemedicineandtheuseofatelemedicinepresenter.Alargerstudywouldneedtobeexecutedtodeterminewhetherthesamequalityofcare,dianogisandtreatmentisgiventoeachpatient.Anotherdrawbacktothecurrentsystemoftelemedicineisthatthecurrentmodellimitstheabilityofrheumatologiststoeducatenursepractitioners,physicianassistants,andphysiciansonhowtodiagnoseandtreatLupus,aninteractionthatwouldcertainlyimprovetheefforttocombatLupus,becausethetelemedicinepresenterisusuallyaregisterednurseornursingassistant.OnedrawbacktoconductingabroadertelemedicinepilotinsouthwestGeorgiaisthefactthatwesimplydonothaveavastunderstandingofwhatpercentageofthepopulationislivingwithlupus.Inordertoeffectivelyimplementtelemedicine,thereareseveralconsiderationsthatneedtobetakenintoaccount:

Þ EducateLupuspatientsabouttheirexpectationsincludingthelimitationsandbenefitsoftelemedicine;

Þ EducateandtrainLupuspatienthealthcareprovidersonhowtousetechnologyandbillingpoliciesandprocedures;

Þ Conductorretrieveaheatmapstudytodeterminewherealargerpilotstudyontheuseoftelemedicinetotreatlupuspatientswouldbemostbeneficial;

Þ Collaborateandbuildarelationshipwiththelocalphysicians,rheumatologistsandcitizenstobuildaleveloftrustinthecommunity;

Þ Expandthepilotprogramtoincludepersonslivingwithlupuswhoarenolongerutilizingcurrentservicesprovidedtolupuspatientsacrossthestate;

Þ ExpandtheLupusRegistrytodeterminediseaseprevalence;Þ Workwithinsurancecompaniestodeterminewhatcostsarecoveredand

howwecanengagecompaniestoinvestinequipment;Þ Reviewprevioustelemedicinepilotstudiestocomparecostsbenefitanalysis

andpatient-physiciansatisfaction.Þ WorkwithentitiessuchasAreaHealthEducationCenters,GeorgiaBoardfor

PhysicianWorkforce,GeorgiaSocietyofRheumatology,andtheAmericanCollegeofRheumatologytopromoterheumatologyasamedicalspecialty,andencouragegreaterusoftelemedicineasaviabletool.