Telemedicine and IBDresults of an international survey

Charlie W Lees1, Sara Lewin2, Ailsa Hart3, Miguel Regueiro4, Uma Mahadevan2

1. The Edinburgh IBD Unit and IGMM, University of Edinburgh

2. Division of Gastroenterology, University of California, San Francisco

3. IBD Unit, St Mark’s Hospital, London

4. Department of Gastroenterology, Hepatology & Nutrition, Cleveland Clinic

Epidemiology of IBD: “Why are my clinics getting busier?”

• Prevalence of IBD is 0.78%• Age at diagnosis is young adult• Morbidity high but mortality low• Incidence is stable; 5x higher than mortality• The population is getting older, with more co-

morbidities

Figures reproduced from Jones G, et al. Gut 2019; 68: 1953–1960 © (2019) under Creative Commons license CC-BY-4.0.

COVID-19 Timeline

1. https://coronavirus.jhu.edu/data/hubei-timeline. 2. https://www.who.int/news-room/detail/08-04-2020-who-timeline---covid-19. 3. https://www.gov.uk/government/publications/wuhan-novel-coronavirus-background-information/wuhan-novel-coronavirus-epidemiology-virology-and-clinical-features. 4. https://coronavirus.data.gov.uk/?_ga=2.106106883.1059945750.1587645792-2140283630.1587645792. 5. https://services.parliament.uk/bills/2019-21/coronavirus.html

December January February March

31 December 2019World Health Organization (WHO) was informed of a cluster of cases of pneumonia of unknown cause detected in Wuhan City, Hubei Province, China2

29-30 December 2019First few cases reported Wuhan City, Hubei Province, China1

12 January 2020Novel coronavirus identified in samples obtained from cases. This virus is referred to asSARS-CoV-2, and the associated disease as COVID-192,3

30 January 20201st UK case 4

24 January 2020Wuhan put under

‘Lock Down’ 3

21 March 2020UK Shut Down

begins

25 March 2020Coronavirus Act 2020gained Royal Assent5

8 April 2020Wuhan lifted restrictions

on outgoing travel3

April

29 March 2020Shielding instruction given and

IBD risk grid published. Draft guidance also published

6 April ibdregistry tool

goes live

3 AprilGut manuscript revised

6 April Accepted17 AprilOnline

6 April 2020Boris Johnson hospitalised

28 March Gut manuscript

submitted

Maintain IBD team ü Redeployment & sickness are real threatsü One or two consultants to lead serviceü Maintain helplinesü Keep core IBD nursing teamü Move offsite/remote working

Daily flare clinic (consultant & IBD nurse)

Virtualise workingü Daily huddles (via Zoom/Teams)ü Phone & video consultationsü Use of apps & point of care tests (calprotectin)

Suspend all but essential endoscopy activityü Acute severe colitis ü Selected high risk new patients (suspected IBD)

Infusion suiteü Move out to clean site if possibleü Spacing & hand hygiene ü COVID-19 symptom checks and masks

1. BSG expanded consensus advice for the management of IBD during the COVID-19 pandemic. https://www.bsg.org.uk/covid-19-advice/bsg-advice-for-management-of-inflammatory-bowel-diseases-during-the-covid-19-pandemic/. Accessed: April 2020.

COVID-19 and IBD service provision

• Telemedicine Pro’s• Needed: Social Distancing• Social Acceptance: Convenience• Technology exists• Cost with respect to clinic staff &

space

• Telemedicine Con’s• Human touch; in person

assessment• Cheapens the brand?

• Reimbursement • Currently in US Medicare pays

• Security Concerns

• Designed in Google Forms

• Survey was piloted amongst IOIBD members with n=46 responses

• Several questions were removed; a few were modified

• New questionnaire takes max. 5 minutes

• Sent via Twitter, LindedIn and email on 20th April

• Closed Monday 27th April

IOIBD telemedicine and IBD survey

Who responded?N=754

82.4% are gastroenterologists

10.1% are IBD specialist nurses

4.1% are surgeons

What sector do you work in?61.9% public

13.8% private

22.2% public and private

IOIBD telemedicine and IBD surveyAlgeria, 0, 0%

Argentina, 3, 0%Australia, 18, 2%Austria, 1, 0%Belgium, 15, 2%

Brazil, 43, 6%

Bulgaria, 1, 0%

Canada, 23, 3%

Chile, 1, 0%

China, 22, 3%

Colombia, 6, 1%

Costa Rica, 2, 0%

Croatia, 3, 0%

Czech Republic, 3, 0%

Denmark, 25, 3%Egypt, 5, 1%

Estonia, 1, 0%

Faroe Islands, 1, 0%

France, 3, 0%

Germany, 6, 1%

Greece, 21, 3%

Hong Kong, 8, 1%

Hungary, 2, 0%India, 28, 4%

Ireland, 19, 3%Israel, 36,

5%

Italy, 78, 10%

Japan, 7, 1%

Korea, Republic of, 5, 1%

Kuwait, 17, 2%

Lebanon, 16,

2%Lithuania, 1, 0%

Malaysia, 3, 0%

Malta, 1, 0%

Moldova, Republic of, 1, 0%Netherlands, 5, 1%

New Zealand, 28, 4%

Niger, 1, 0%

Nigeria, 1, 0%N

Poland, 1, 0%Portugal, 2, 0%

Romania, 25, 3%

San Marino, 1, 0%Saudi Arabia,

17, 2%

Slovenia, 1, 0%

South Africa, 6, 1%

Spain, 23, 3%

Sweden, 14, 2%

Switzerland, 2, 0% Turkey, 3, 0%

United Arab Emirates, 4, 1%

United Kingdom, 90, 12%

United States, 83, 11%

United Kingdom 90United States 83Italy 78Brazil 43Israel 36India 28New Zealand 28Denmark 25Romania 25Canada 23Spain 23China 22Greece 21Ireland 19Australia 18Kuwait 17Saudi Arabia 17Lebanon 16Belgium 15Sweden 14Norway 12Hong Kong 8Japan 7Colombia 6Germany 6South Africa 6Egypt 5Korea, Republic of 5Netherlands 5United Arab Emirates 4Argentina 3Croatia 3Czech Republic 3France 3Malaysia 3Turkey 3Costa Rica 2Hungary 2Portugal 2Switzerland 2Austria 1Bulgaria 1Chile 1Estonia 1Faroe Islands 1Lithuania 1Malta 1Moldova, Republic of 1Niger 1Nigeria 1Poland 1San Marino 1Slovenia 1

Only a small proportion use an app to monitor patient reported outcomes

0 100 200 300 400 500 600

No, never and I don't really see their value

No, never but this is something I am keen to explore

Yes, in some of my patients

Yes, in the majority of my patients

Do you currently use an app to monitor patient reported outcomes and / or to

communicate with patients?

Most commonly used Apps?WhatsApp and WeChat

Only a small proportion use an app to monitor patient reported outcomes

Laboratory faecal calprotectin testing88.9% had routine access to prior to COVID-19

0 50 100 150 200 250 300 350 400 450

No, never and I have no plans to

No, never but I would love to

Yes, in some of my patients

Yes, in the majority of my patients

Do you currently use a point of care faecal

calprotectin test?

53.3% IBDoc

39.3% Calprosmart

7.4% don’t know

We asked if there had been any change to this service during

the COVID-19 pandemic

52.9% reported no change

34.6% reported a reduction in capacity

12.5% had the service completely suspended

Maintain IBD team ü Redeployment & sickness are real threatsü One or two consultants to lead serviceü Maintain helplinesü Keep core IBD nursing teamü Move offsite/remote working

Daily flare clinic (consultant & IBD nurse)

Virtualise workingü Daily huddles (via Zoom/Teams)ü Phone & video consultationsü Use of apps & point of care tests (calprotectin)

Suspend all but essential endoscopy activityü Acute severe colitis ü Selected high risk new patients (suspected IBD)

Infusion suiteü Move out to clean site if possibleü Spacing & hand hygiene ü COVID-19 symptom checks and masks

How to open up service again• Who?• How?• What?• Where?

Balance need with risk

Build resilience – patients and IBD team

1. BSG expanded consensus advice for the management of IBD during the COVID-19 pandemic. https://www.bsg.org.uk/covid-19-advice/bsg-advice-for-management-of-inflammatory-bowel-diseases-during-the-covid-19-pandemic/. Accessed: April 2020.

COVID-19 and IBD service provision

Telemedicine Setup

Choose a telemedicine platform that:• can provide a secure, private connection• is compliant with local government regulations of telemedicine• can be easily implemented by both patients and provider

Pre-visit Preparation

Prior to a telemedicine visit:• Develop a workflow to identify patients who are appropriate for telemedicine visit • Provide instructions to patient how to access telemedicine platform, including tips for troubleshooting• Clinic staff may opt to perform a “dress rehearsal” with patient to ensure patient • Utilize electronic tools to collect history and data from patient • --- online questionnaire, eHealth, IBDoc, myIBDcoach• Clinic staff can “pre” chart and input clinical information including IBD scores• Find a space that is quiet, private, and without distractions to conduct visit• Determine if telemedicine visit must be performed by provider in a clinic space (rather than from home)

During the visit

• Medical Assistant may “room” the patient and review insurance, demographics, preferred pharmacy and perform medication reconciliation

• Obtain verbal consent to perform video visit• Obtain history and limited physical examination• Complete visit, communicating follow-up plan

Addressing technology challenges

• Can mostly be avoided by pre-visit trial with medical staff and/or providing a tips sheet for troubleshooting ahead of time

• Trial of alternate platform (e.g., FaceTime, WhatsApp)• If all else fails, convert to telephone visit

After the visit• Provide electronic copy of after visit summary• Route prescriptions and laboratory orders electronically. Drive-through pharmacy and delivery options• Instruct staff to contact patient to schedule follow-up care

Documentation• Use similar note template to in-person documentation• Use a physical exam template appropriate for video visit.• Document that patient provided consent the modality used for the visit

Telemedicine Setup

Choose a telemedicine platform that:• can provide a secure, private connection• is compliant with local government regulations of telemedicine• can be easily implemented by both patients and provider

Pre-visit Preparation

Prior to a telemedicine visit:• Develop a workflow to identify patients who are appropriate for telemedicine visit • Provide instructions to patient how to access telemedicine platform, including tips for troubleshooting• Clinic staff may opt to perform a “dress rehearsal” with patient to ensure patient • Utilize electronic tools to collect history and data from patient • --- online questionnaire, eHealth, IBDoc, myIBDcoach• Clinic staff can “pre” chart and input clinical information including IBD scores• Find a space that is quiet, private, and without distractions to conduct visit• Determine if telemedicine visit must be performed by provider in a clinic space (rather than from home)

During the visit

• Medical Assistant may “room” the patient and review insurance, demographics, preferred pharmacy and perform medication reconciliation

• Obtain verbal consent to perform video visit• Obtain history and limited physical examination• Complete visit, communicating follow-up plan

Addressing technology challenges

• Can mostly be avoided by pre-visit trial with medical staff and/or providing a tips sheet for troubleshooting ahead of time

• Trial of alternate platform (e.g., FaceTime, WhatsApp)• If all else fails, convert to telephone visit

After the visit• Provide electronic copy of after visit summary• Route prescriptions and laboratory orders electronically. Drive-through pharmacy and delivery options• Instruct staff to contact patient to schedule follow-up care

Documentation• Use similar note template to in-person documentation• Use a physical exam template appropriate for video visit.• Document that patient provided consent the modality used for the visit

Telemedicine Setup

Choose a telemedicine platform that:• can provide a secure, private connection• is compliant with local government regulations of telemedicine• can be easily implemented by both patients and provider

Pre-visit Preparation

Prior to a telemedicine visit:• Develop a workflow to identify patients who are appropriate for telemedicine visit • Provide instructions to patient how to access telemedicine platform, including tips for troubleshooting• Clinic staff may opt to perform a “dress rehearsal” with patient to ensure patient • Utilize electronic tools to collect history and data from patient • --- online questionnaire, eHealth, IBDoc, myIBDcoach• Clinic staff can “pre” chart and input clinical information including IBD scores• Find a space that is quiet, private, and without distractions to conduct visit• Determine if telemedicine visit must be performed by provider in a clinic space (rather than from home)

During the visit

• Medical Assistant may “room” the patient and review insurance, demographics, preferred pharmacy and perform medication reconciliation

• Obtain verbal consent to perform video visit• Obtain history and limited physical examination• Complete visit, communicating follow-up plan

Addressing technology challenges

• Can mostly be avoided by pre-visit trial with medical staff and/or providing a tips sheet for troubleshooting ahead of time

• Trial of alternate platform (e.g., FaceTime, WhatsApp)• If all else fails, convert to telephone visit

After the visit• Provide electronic copy of after visit summary• Route prescriptions and laboratory orders electronically. Drive-through pharmacy and delivery options• Instruct staff to contact patient to schedule follow-up care

Documentation• Use similar note template to in-person documentation• Use a physical exam template appropriate for video visit.• Document that patient provided consent the modality used for the visit

Telemedicine Setup

Choose a telemedicine platform that:• can provide a secure, private connection• is compliant with local government regulations of telemedicine• can be easily implemented by both patients and provider

Pre-visit Preparation

Prior to a telemedicine visit:• Develop a workflow to identify patients who are appropriate for telemedicine visit • Provide instructions to patient how to access telemedicine platform, including tips for troubleshooting• Clinic staff may opt to perform a “dress rehearsal” with patient to ensure patient • Utilize electronic tools to collect history and data from patient • --- online questionnaire, eHealth, IBDoc, myIBDcoach• Clinic staff can “pre” chart and input clinical information including IBD scores• Find a space that is quiet, private, and without distractions to conduct visit• Determine if telemedicine visit must be performed by provider in a clinic space (rather than from home)

During the visit

• Medical Assistant may “room” the patient and review insurance, demographics, preferred pharmacy and perform medication reconciliation

• Obtain verbal consent to perform video visit• Obtain history and limited physical examination• Complete visit, communicating follow-up plan

Addressing technology challenges

• Can mostly be avoided by pre-visit trial with medical staff and/or providing a tips sheet for troubleshooting ahead of time

• Trial of alternate platform (e.g., FaceTime, WhatsApp)• If all else fails, convert to telephone visit

After the visit• Provide electronic copy of after visit summary• Route prescriptions and laboratory orders electronically. Drive-through pharmacy and delivery options• Instruct staff to contact patient to schedule follow-up care

Documentation• Use similar note template to in-person documentation• Use a physical exam template appropriate for video visit.• Document that patient provided consent the modality used for the visit

Telemedicine Setup

Choose a telemedicine platform that:• can provide a secure, private connection• is compliant with local government regulations of telemedicine• can be easily implemented by both patients and provider

Pre-visit Preparation

Prior to a telemedicine visit:• Develop a workflow to identify patients who are appropriate for telemedicine visit • Provide instructions to patient how to access telemedicine platform, including tips for troubleshooting• Clinic staff may opt to perform a “dress rehearsal” with patient to ensure patient • Utilize electronic tools to collect history and data from patient • --- online questionnaire, eHealth, IBDoc, myIBDcoach• Clinic staff can “pre” chart and input clinical information including IBD scores• Find a space that is quiet, private, and without distractions to conduct visit• Determine if telemedicine visit must be performed by provider in a clinic space (rather than from home)

During the visit

• Medical Assistant may “room” the patient and review insurance, demographics, preferred pharmacy and perform medication reconciliation

• Obtain verbal consent to perform video visit• Obtain history and limited physical examination• Complete visit, communicating follow-up plan

Addressing technology challenges

• Can mostly be avoided by pre-visit trial with medical staff and/or providing a tips sheet for troubleshooting ahead of time

• Trial of alternate platform (e.g., FaceTime, WhatsApp)• If all else fails, convert to telephone visit

After the visit• Provide electronic copy of after visit summary• Route prescriptions and laboratory orders electronically. Drive-through pharmacy and delivery options• Instruct staff to contact patient to schedule follow-up care

Documentation• Use similar note template to in-person documentation• Use a physical exam template appropriate for video visit.• Document that patient provided consent the modality used for the visit

Telemedicine Setup

Choose a telemedicine platform that:• can provide a secure, private connection• is compliant with local government regulations of telemedicine• can be easily implemented by both patients and provider

Pre-visit Preparation

Prior to a telemedicine visit:• Develop a workflow to identify patients who are appropriate for telemedicine visit • Provide instructions to patient how to access telemedicine platform, including tips for troubleshooting• Clinic staff may opt to perform a “dress rehearsal” with patient to ensure patient • Utilize electronic tools to collect history and data from patient • --- online questionnaire, eHealth, IBDoc, myIBDcoach• Clinic staff can “pre” chart and input clinical information including IBD scores• Find a space that is quiet, private, and without distractions to conduct visit• Determine if telemedicine visit must be performed by provider in a clinic space (rather than from home)

During the visit

• Medical Assistant may “room” the patient and review insurance, demographics, preferred pharmacy and perform medication reconciliation

• Obtain verbal consent to perform video visit• Obtain history and limited physical examination• Complete visit, communicating follow-up plan

Addressing technology challenges

• Can mostly be avoided by pre-visit trial with medical staff and/or providing a tips sheet for troubleshooting ahead of time

• Trial of alternate platform (e.g., FaceTime, WhatsApp)• If all else fails, convert to telephone visit

After the visit• Provide electronic copy of after visit summary• Route prescriptions and laboratory orders electronically. Drive-through pharmacy and delivery options• Instruct staff to contact patient to schedule follow-up care

Documentation• Use similar note template to in-person documentation• Use a physical exam template appropriate for video visit.• Document that patient provided consent the modality used for the visit