Gastroenterologists who can practice telemedicine with transplant hepatology can have a significant impact on patients.
Gastroenterologists who can practice telemedicine with transplant hepatology can have a significant impact on patients who might either have difficulty with in-person appointments or who would benefit from a remote consultation.
In his lecture "Telemedicine Care and the Transplant Hepatologist," now available for CME credit through AudioDigest, Jonathan Fenkel, MD, associate director of the liver transplant program and director of the Jefferson Hepatitis Center at Thomas Jefferson University Hospital, discusses the small population of hepatologists in the United States and how telemedicine can shape liver transplant.
Sizing the hepatology population
Nationally, Dr. Fenkel says, there are only 580 board-certified hepatologists, compared to 16,000 gastroenterologists and more than 30,000 cardiologists. Most hepatologists are located in urban areas or in academic medical center environments. In fact, he says, there are 20 states with fewer than five providers and six states with no hepatologists.
Additionally, there are only 146 transplant hepatology programs nationwide, including pediatric programs. These two factors point to a significant need for hepatologists who can provide remote care.
Throughout hepatology, Dr. Fenkel explains, telemedicine can be a valuable option in several scenarios.
Monitoring patients at home
Patients who live far from a hepatologist can face difficulty coming for an in-person visit. Not only can telemedicine provide the opportunity to meet with these patients, but it can also give the hepatologist the chance to see how the patient lives daily. For example, a telemedicine visit could reveal that a patient is using a teaspoon rather than a tablespoon to take medication. Addressing these concerns and mistakes could potentially help a patient avoid a meeting for transplant.
Keeping track of a patient after a nontransplant hospitalization can also help a provider stay ahead of any issues that might lead down a surgical path. During a telehealth visit, regardless of the patient's location, a hepatologist who can practice telemedicine can examine the patient for any swelling in the legs or abdomen, review the patient's weight log, examine pill bottles to ensure they have filled medications and go over any lab results. If necessary, these check-ins can be used to pinpoint problems for which a patient should be seen in person.
Prior to transplant
Meeting with a patient and their referring physician prior to the transplant can ensure that the process goes as smoothly as possible. A virtual consultation can give a hepatologist the opportunity to discuss the details of the transplant and answer any questions from the patient and their doctor.
In some instances, telemedicine in transplant hepatology is more about the patient than the provider. For many patients, being able to talk with their doctor both before and after the surgery can increase their satisfaction levels. Not only do they have the opportunity to ask any pressing questions, but they can also connect with their doctor and surgeon from the comfort of home.
In addition to monitoring and managing patients pretransplant, doctors can also provide care for patients who have Hepatitis C, Dr. Fenkel says. For example, a program launched at the University of New Mexico called Project ECHO allows providers to create an individualized care plan, identify problems that can negatively impact treatment and alter therapy plans as needed. It's also currently being used by the Department of Veterans Affairs as a way for providers to consult via videoconference about patient cases.
But telemedicine is not appropriate for every clinical situation, Dr. Fenkel explains. Patients who need emergent care should seek medical assistance in the emergency department.
Real-world telemedicine impact
Research published in the December 2019 issue of Clinical Gastroenterology and Hepatology reveals that telemedicine can have a direct impact on the evaluation and referral of patients who are in need of transplant hepatology. According to Binu V. John, MD, of McGuire Veterans Affairs Medical Center in Richmond, Virginia, implementing telemedicine can expedite both patient evaluation and putting patients on the transplant list.
In his study, John and his team analyzed the medical records of 465 patients who had been considered for liver transplants. Of the group, half received telemedicine services. Based on research findings, those patients receiving care from providers who can practice telemedicine saw an 85% reduction in time needed from referral to evaluation and a 74% drop in time to being added to a transplant list. However, the use of telemedicine did not have any impact on time to transplant or pretransplant mortality.
Overall, a 2019 study published in Hepatology Communications notes that telemedicine can be an invaluable tool in transplant hepatology and to the providers who can practice it.
"Telehealth offers unique opportunities to patients and providers," the study's authors write. "Telemedicine is certainly reaching prime time, thus providing world-class care to all our liver patients across geographic and economic barriers. Telehealth should be the logical extension of clinical care for all academic and tertiary medical centers."