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Eric Wallace, MD, nephrologist and medical director of telehealth, University of Alabama at Birmingham (UAB). His clinical areas of interest include home dialysis, rare genetic kidney disease such as Fabry disease, and telemedicine. He fell in love with medicine at a young age, following his physician father as he visited patients in the hospital or completed weekend rounds.
After earning his medical degree at UAB, he underwent further specialty training in nephrology at Vanderbilt. I love nephrology because it is very cerebral, has infections, has the physiology of the kidney, and a has patient population that I love to work with, specifically because of how much continuity I can provide. I see patients when they have chronic kidney disease, when they're on dialysis, and after they get transplanted. I’m able to have the same kind of continuity that my dad had with his patients, and so it's always been about caring for people. I think that's the passion.
The role of telehealth in chronic kidney disease management
Dr. Wallace started seeing patients with rare genetic kidney disease, many of whom were traveling for hours to see him. To one of my patients, I said, "Hey, what if we did this over telehealth?" That patient was really excited because this particular patient was having to travel two and three hours back and forth to see me once a month. He realized that he could have a massive impact – not only on his patients, but on patients everywhere – if he focused on developing telehealth technology.
I realized that my patients cared much more about telehealth, that it would probably make a far bigger impact in their lives. I started working toward that goal, which is how could I make my patients' lives better? Not necessarily provide any better care, because I wanted to do exactly what I did in person remotely, but how could I make their lives better by providing telehealth? And that's taken me really down the journey of my career at this point.
Every interaction that a patient has with a healthcare system is part of the disease itself. Now it may not be the most unpleasant part about the disease, but it's time away from loved ones, it's time away from family. And if we could just impact that a little bit, we have improved the disease because we are not, we are not making it as intrusive to the patient's life.
Developing and implementing telehealth solutions at UAB
As Dr. Wallace started this initiative, he started by asking a simple question: “What resources do we have?” The first barrier was that some of his patients were elderly, socioeconomically disadvantaged, and lived in rural areas. Many of them did not have access to fast internet and smartphones. He partnered with county health departments in Alabama to set up telehealth equipment and let patients log in to see their provider from there.
There was no reimbursement for telehealth in Alabama at the time, so Dr. Wallace found grant money to support this pilot project with his patients. I'll never forget the first patient who did it. She was 82 at the time, and she participated in telehealth, and we have an amazing video of her doing it and her impressions. She was very, very rural and could not have done telehealth in her home. The look on her face showed me that I was doing the right thing.
The intersection of point-of-care and telemedicine
Point-of-care testing is testing that, for instance, the patient could potentially do in their house. One of the biggest questions of telehealth is, how can we transition a lot more care into the patient's home? Patients need are devices to record vitals, but point-of-care lab tests is the next frontier. It's not nearly comprehensive enough today, but I think as technology improves, point-of-care testing will improve. And the better that becomes, the more patients can do at home.
Such technology can be brought into the home with an unlimited budget but keeping costs down must be part of the equation as well. Dr. Wallace advocates keeping the return on investment in mind as a way to evaluate potential telehealth-friendly tests and diagnostics.
I think in order to do this in a cost-effective way, we're going to have to make some decisions: What tests do we really need to be done in a home? What tests do we really need for the patient to come in? At-home COVID-19 testing is a good next step, but according to Dr. Wallace, there is much more potential:
What if when I placed an order in my electronic medical record, there was a little gadget that sent an order to Amazon Health, Amazon delivered the test within two days, and then I got the results back in my EMR? Those are the types of things we can be working toward.
What does telemedicine look like now?
Today, 30 to 32 percent of UAB’s ambulatory visits are telehealth. Since about mid-July, we've been steady at about 30 to 32 percent. I think that telehealth can be about 30 percent of all visits. It’s a perfect amount for the technology that we have, because we're relying on patients' technology. We have relatively few easy-to-use diagnostics in the home, but about 30 percent of visits, I think, can be and should continue to be telehealth.
Will telehealth reimbursement remain in place after COVID-19 abates? There’s a bill in Congress that's trying to make this permanent, but if Medicare makes this permanent, then you need private insurance companies to make it permanent as well. So, everybody thinks this is going to be permanent, but it's very hard to make plans when nothing's written in stone. Nobody wants to create clinic templates for two years out when we don't know what next month is going to bring.
What are the top aspects to consider as telehealth looks to the future?
The public health emergency declaration for COVID-19 is set to expire in April 2021, raising many questions about what the future reimbursement picture will look like. I really do think that we're going to get some permanency, and then we can start planning. I think more and more will be done in home effectively as we bring down the cost of diagnostics. I don't see huge amounts of people buying tele stethoscopes and things like that. Right now, it's very cumbersome.
Efficiency will continue to drive telehealth adoption. You have to say, "What am I really gaining from an efficiency standpoint?" And the other thing about buying really expensive diagnostics for the home is that the more technology you put in the home, the broader these disparities are going to get – especially if the patient is responsible for buying them. We must make sure that we are as cognizant as possible with telehealth: doing telehealth in the home does increase disparities. We need to make sure the disparities don’t get worse.
Finally, for Dr. Wallace, telehealth has particular utility for physicians who treat rare diseases. As a nephrologist who does rare disease, what I see moving forward is that nephrologists who focus on rare disease, or any doc who focuses on rare disease, will be able to really regionalize care. We talk about telehealth for everything now, but my involvement with telehealth started because of its ability to deliver super subspecialized care across a region. Telehealth could make regional centers of excellence possible for a wider range of rare diseases, bringing patients to experts regardless of geography.
A great start
Because of models, because of reimbursement, because of every single hurdle, we as an industry never met the patient halfway. COVID-19 really forced us to do that. But I think there's more out there. There's more out there that the patients can tell us. I was willing to slog through the barriers because I believed in it. I sat there and said, "I don't care how many barriers they throw at me. My patients are the ones that are going to hold me accountable, and I'm going to do this for them.” And as a result, we had all of those things in place to scale when it was really needed.
I have this pipe dream, and the pipe dream is that we can actually deliver care to everybody at a reasonable cost, on the patient's terms. We just took the first step toward achieving it, and I'm proud that UAB was one of the first to do it, at least in the dialysis population.