key: cord-0790555-8trnpf4b
authors: Lew, Susie Q.; Wallace, Eric L.; Srivatana, Vesh; Warady, Bradley A.; Watnick, Suzanne; Hood, Jayson; White, David L.; Aggarwal, Vikram; Wilkie, Caroline; Naljayan, Mihran V.; Gellens, Mary; Perl, Jeffrey; Schreiber, Martin J.
title: Telehealth for Home Dialysis in COVID-19 and Beyond: A Perspective From the American Society of Nephrology COVID-19 Home Dialysis Subcommittee
date: 2020-09-28
journal: Am J Kidney Dis
DOI: 10.1053/j.ajkd.2020.09.005
sha: 3b75d9d541fd3a8fb895cc259017f637c820d7f5
doc_id: 790555
cord_uid: 8trnpf4b

The COVID-19 pandemic, technological advancements, regulatory waivers, and user acceptance converged to boost telehealth activities during the public health emergency. Providers were able to deliver and bill for services across state lines for new and established patients via HIPAA and non-HIPAA compliant platforms with home as the originating site and without geographic restrictions. Platforms were developed or purchased to perform videoconferencing. The interdisciplinary dialysis team adapted to perform virtual visits. Dialysis providers, clinicians, nurses and patients describe their telehealth experiences and challenges they encountered, exposing healthcare disparities in areas such as access to care, bandwidth connectivity, devices to perform telehealth, and socioeconomic and language barriers. Future directions in telehealth utilization, quality measures and research in telehealth usage need to be explored. Telehealth during the public health emergency has changed the practice of healthcare, with the post COVID-19 world unlikely to resemble the pre-COVID-19 era. The future impact of telehealth in patient care remains to be seen, especially in the context of the Advancing American Kidney Health Initiative.

The coronavirus Disease 2019 (COVID- 19) pandemic, new technologies, regulatory changes, and increased patient acceptance have led to acceleration evolution of telehealth in patient care settings. Telehealth delivers virtual patient care, addresses patient's medical concerns, and identifies issues which warrant in-person visits, while at the same time fostering social distancing in an effort to decrease healthcare worker and patient COVID-19

transmission. [1, 2] Telehealth has benefits for clinicians, the interdisciplinary team (IDT), and patients. Due to the complexity of patients on dialysis, telehealth may complement but not totally replace the in-person visit, [3] [4] [5] and provide better oversight of care with remote monitoring. [6] [7] [8] It is not surprising then that patients receiving peritoneal dialysis (PD) have responded positively to telehealth. [9] [10] [11] [12] [13] [14] [15] Telehealth and home dialysis both foster greater home-based care, less travel time, fewer trips to the clinic, and leverage the principles of patient and care partner autonomy and self-care. Telehealth may also help facilitate patient education about home dialysis modalities, and self-care. Telehealth has been used to manage patients with chronic kidney disease (CKD) and demonstrated equal outcomes in CKD care by either in-person or virtual visits. [16, 17] Although the opportunities for the application of technology to the betterment of the lives and care of our patients exist, implementation of these strategies continues to remain challenging. Here, members of the American Society of Nephrology COVID-19 Home Dialysis Committee review regulatory changes, use-cases, implementation, and provider and patient perspectives on telehealth for home dialysis during the COVID-19 public health emergency.

J o u r n a l P r e -p r o o f In the US, the 2018 Bipartisan Budget Act extended telehealth access to home dialysis patients using home as the originating site beginning in 2019. [18] In a survey of 30 PD patients conducted in August 2018 none knew of the statute allowing them to opt for telehealth from their home. [19] Since 2019, nephrology and telehealth journals have informed their readers about telehealth options for home dialysis patients and how to operationalize them with little effect. [15, 20, 21] However, interest and need for telehealth services during the COVID-19 pandemic has increased significantly resulting in the rapid removal of pre-pandemic telehealth barriers. [22] In addition to removing the geographic restrictions, and allowing for the home to serve as the originating site, the main regulatory changes pertinent to home dialysis patients were the following: 

Nephrology practices and dialysis providers have adopted telehealth platforms to deliver care for patients on dialysis. They may design platforms internally or purchase commercial J o u r n a l P r e -p r o o f products. Platforms can vary significantly in terms of cost, scalability, and technical support. Telehealth platforms range from videoconferencing alone to platforms that allow for self-scheduling, payment collection, and physician notifications, and videoconferencing.

Both providers and patients value ease of use when comparing videoconferencing platforms. Some videoconferencing platforms can only invite patients via text message, while others can only email invitations.

Finally, one must consider security. Security encompasses both encryption standards and cyber security risk. HIPAA compliance requires data encryption, a Business Associates Agreement (BAA) with the provider of the telecommunications, and the patient must be in a private physical environment. An IT security specialist should evaluate cybersecurity and risks to network integrity to minimize potential susceptibilities of healthcare networks to viruses or cyber-attacks.

The clinician performing a telehealth encounter may require several systems to operate simultaneously. The clinician may therefore need simultaneous access to a HIPAA-compliant video platform with a high-quality camera, concurrent audio, and secure communications; and an electronic health record (EHR) to check laboratory results, write a note contemporaneously, and prescribe medications electronically.

On the other hand, the patient only requires one device. It must have a camera that can synchronize with the team's platform at the predetermined appointment time. Although patients mainly use their cell/smart phone as the primary device, options for tablets, and computers (laptop and desktop with webcam) should be considered and the device remains highly dependent on the specific platform. [9] The staff may have to help the patient install the software J o u r n a l P r e -p r o o f application, provide instruction, test the linkage, and hold a practice session. Some patients may not have access to adequate hardware or access to technology, and this should be addressed to ensure equitable care for patients.

A visit will proceed more efficiently if in advance of the session, the team (usually the nurse) assembles and updates the medication list, dialysis prescription, vital signs, laboratory results, and collects remote data from PD or hemodialysis (HD) flow sheets. In this regard, the use of remote patient monitoring (RPM) may be particularly useful. RPM employs digital technologies to acquire home health data; transmitting the information to healthcare providers. [6, 8, 10, 24, 25] Existing home dialysis RPM platforms allow direct transmission of 1) biometric information (i.e. blood pressure, blood glucose, temperature, weight) to providers and 2) home HD and automated PD treatment parameters (i.e. treatment completion, duration, interruptions, alarms, ultrafiltration). [26, 27] RPM obviates the need for paper dialysis treatment logs and provides information in key domains of dialysis access, blood pressure, target weight, and ultrafiltration management while identifying treatment adherence challenges and in some cases allowing remote changes to the prescription.

While the virtual visit lacks the traditional physical examination a virtual "no touch" physical examination remains a possible alternative ( Table 1 ). The absence of a satisfactory electronic stethoscope limits the appreciation of cardiac, pulmonary, and abdominal sounds. In a home hemodialysis (HHD) patient, one can't appreciate the bruit in the arterio-venous (AV) access. Nevertheless, the ''no touch exam'' still allows the clinician to evaluate volume status and dialysis access (catheter exit site or AV access). Volume status may be estimated by using weight, blood pressure, and ultrafiltration rate in addition to observable physical exam findings J o u r n a l P r e -p r o o f such as pedal edema. The exit site can be evaluated via electronic photograph or real-time observation.

Other members of the IDT can perform assessments or counseling with the patient apart from the monthly visit. Studies have shown that dietitians using telemedicine platforms can successfully perform coaching programs for dietary counseling in CKD patients as well as diabetes management. [28, 29] A regular virtual check-in with the social worker can permit discussions around emotional distress, caregiver burnout, and medical resource acquisition and management. These interdisciplinary visits performed virtually have been successfully performed in CKD programs and can be extended into PD programs. [30] A clinical presenter may assist the patient with the telehealth visit. Family members (parents for minors, spouse, or sibling), caregivers, friends, or nurses can gather vital signs, assist in the physical examination, help interpret and carry out changes in care plans or orders, and be an interpreter if a language barrier exists.

As parties become facile with repeated practice and telehealth encounters, it may be possible to invite other health professionals in consultation. This act can increase patient access to care, and reduce time to care, transportation time and cost. These visits may include a virtual pre-operative surgical assessment prior to PD catheter placement or a post-operative visit to evaluate wound healing. A PD nurse can also use telehealth to troubleshoot a PD catheter with the nephrologist or surgeon remotely. Likewise, fellows in nephrology training programs can be included in the care of these patients by using videoconferencing. This can simultaneously address both training for the fellow in both PD and telehealth techniques.

The impact of such broad utilization of telemedicine for home-dialysis care on safe and effective care, infections, hospitalizations, technique failure, and patient-reported outcomes J o u r n a l P r e -p r o o f remains to be determined. Data collected during the COVID-19 pandemic may help inform the best use of telehealth among patients receiving dialysis. Stable home dialysis patients may be one group that could easily benefit from the regular use of telehealth. However, unstable patients who experience difficulty with travel plans may also benefit from telehealth as the alternative is not to be seen at all. The collective input from patients, nephrologists, and the IDT should determine a preferred approach to plan the follow-up visit. A pre-visit review of patient-maintained dialysis logs, remotely monitored data-metrics, laboratory trends, and a screening phone call for patient-reported symptoms by a nurse, along with specific decisionsupport tools, can help in triaging patients (Box 1).

Approximately 45% of dialysis units are unable to provide home dialysis more so in rural areas where access to a nearby home dialysis unit may be less. [31] Whereas urban communities are intuitively thought to have greater access to home dialysis, local traffic patterns may impact travel time as much as distance does in rural communities. In either case, telehealth presents a solution to accessing home dialysis facilities while safely isolating at home during COVID-19.

Nevertheless, challenges remain in the implementation and widespread use of telehealth ( Figure 1 ). Limited patient access to capable devices continues to be a known barrier. Because of this, patients may opt to use telehealth with a friend or family member assisting if they do not have a compatible device themselves. Changes which address regulatory barriers are needed for providers to assist patients by providing connectivity devices without "inducement" concerns. [32] J o u r n a l P r e -p r o o f

The regulatory waivers provided during COVID-19 demonstrate proof of concept that solutions and compromises can be found with the end goal of better care for home dialysis patients. However, even provision of devices themselves may not be enough. Many patients do not have access to broadband internet speeds capable of videoconferencing; in turn, disparities will worsen should audio only options be removed once the state of emergency has been lifted.

Unfortunately, socioeconomic and language barriers persist. African-Americans and Hispanics have been underrepresented in home dialysis nationwide and are underrepresented in video uptake in telehealth.

[33] A recent report on the use of telemedicine for chronic disease management during the COVID-19 pandemic in the primary care setting has already reported a significant decrease in the number of visits by patients over age 65, non-native English speakers, Medicare/Medicaid-insured patients, or patients who self-identified as a racial/ethnic minority. [34] Overcoming access to devices and broadband internet is only the first step in addressing these challenges. Existing telemedicine platforms are unlikely to consider digital technology literacy, health literacy, age, or English language proficiency in their design. [34] Moreover, most nephrologists and dialysis providers do not have existing systems in place to provide training to patients on how to use these tools. There exists an opportunity for telehealth technology itself to provide solutions to ensure equitable access to care. As an example, interpreter services provided within telehealth visits could help bridge both language and cultural barriers to care.

Increasing access to telehealth as above will require a concerted effort from government, regulators, payers, dialysis organizations, and nephrologists. As we move towards value-based care models, removing barriers to telehealth will intuitively help to increase minority While many aspects of a visit include skills that are currently used in successful home dialysis programs, the nurse has taken on the responsibility for the technical aspect of telemedicine.

Home dialysis nurse retention is a growing issue in the US, a development which could adversely impact home growth. These telehealth related care enhancements may provide home dialysis nursing a viable alternative career destination in the post pandemic, social distanced healthcare environment. Telehealth may overcome the challenges of creating workplaces that engage and retain nurses by incorporating flexible nurse schedules; enhancing communications with patients and colleagues; and developing collaborative relationships across the IDT. These strategic initiatives have been implemented in workplaces that have high staff engagement and retention, [36, 37] and can now be experienced in the home dialysis setting. The success of these remote dialysis facilities relies on trained nurses to meet the care demands of this new and changing home dialysis experience.

Patients have had different responses to telehealth. Many of the challenges could be mitigated and improved upon by having patients be involved in both the design of the technology J o u r n a l P r e -p r o o f but also in crafting the patient experience for a telehealth visit. One author, CW, appreciates telehealth and reports, "I use FaceTime to interact with the doctor and nurse at a specified time.

My concerns are addressed. I don't have to travel to the dialysis unit or miss a prolonged period of time from work." Not all patients participated in telehealth due to lack of internet service or device.

Telehealth has also proven to be an extremely valuable resource for the pediatric dialysis The COVID-19 pandemic has stimulated an emphasis on telehealth and highlighted many of the benefits for pediatric dialysis patients and their families in terms of visit related travel time, cost and absence from school and work. The ability to visit with the IDT from home can also be comforting for the young child who may associate the hospital clinic with painful J o u r n a l P r e -p r o o f procedures. At the same time, ongoing challenges to be addressed include 1) the need for accurate biometric measurements such as height and weight, as growth represents a key pediatric specific outcome parameter, and 2) the lack of privacy that may exist for a desired parentless portion of the clinic visit, particularly salient to the adolescent preparing for transfer to adult care or for a mandated, routine suicide screen.

The future landscape for advancing telehealth usage in home dialysis depends on integrating technology with an efficient home program workflow, leveraging platforms that are user friendly, improving efficiency, and ensuring patient outcomes that surpass or are equal to in person visits. Developing a balance between virtual and in person visits for high co-morbidity patients will be critical. Change management initiatives should help the transition from traditional encounters to virtual care, especially as provider practices exit the COVID-19

pandemic.

It remains unclear as to what regulations will return when the public health emergency ends. Box 2 includes considerations that must be accounted for in any long-term planning for ongoing telehealth coverage and expansion.

Using technology and telemedicine to educate patients will be important in a connected world while trying to decrease face-to-face interactions. Future areas of study include virtual education about CKD and dialysis modalities, virtual transplantation evaluations, and virtual training for patients and caregivers as new starts to dialysis or retraining after a prolonged hospitalization.

Measuring and conducting research on the delivered quality of care and patient outcomes, comparing telehealth and standard care along with patient and healthcare provider J o u r n a l P r e -p r o o f satisfaction (PROMS) with telehealth will be important determinants of whether the virtual practice continues to grow post COVID-19. A large scale study from Canada may soon provide some answers (https://clinicaltrials.gov/ct2/show/NCT02670512).

If telehealth usage can be captured during the COVID-19 pandemic using Medicare claims data, analysis of measured quality of care metrics for patients such as hospitalization, readmission, emergency department visits, and transplantation wait list rates may be important to help establish the role of telemedicine as part of routine care.

COVID-19 has pushed telehealth to the forefront of all aspects of healthcare out of necessity to protect providers and patients while maintaining adequate care. Insurance coverage changes aided in this transformation by allowing for a reasonable, sustainable, and efficient way to implement telehealth. It is reasonable to think that telehealth has reached its peak utilization during the pandemic and a subsequent decline may ensue when COVID-19 waivers are lifted.

However, an alternative future for telehealth could be the rapid development of supportive technologies that increase the number of patients that can be effectively cared for in their home. Examples of such technologies include home based point of care labs based on finger sticks and home based diagnostics that reach to the accuracy and ease of use as the Star Trek Tricorder. It is clear, however, that even in its current state, telehealth has changed the way we practice healthcare forever, and there will be no returning to a healthcare system devoid of it. As such, we must continue to make it better; we must continue to make it easier; and we must continue to make it available to anyone and everyone in need of care by addressing internet infrastructure, technology literacy, and socioeconomic determinants of health. 

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High-risk factors that might trigger an in-person visit instead of a telemedicine visit Recent events • PD or HHD related infections within the last 1 month • Hospitalization or emergency room visit within the last 1 month • New home-dialysis starts within the last 1 month Patient factors • Inability to administer ESA at home • Does not have appropriate technology for telemedicine visit • New symptoms or medical issues needing attention, eg

Pre-visit nurse, social worker, dietitian or nephrologist assessment • Concerns regarding adherence to the appropriate technique or prescribed prescription (i.e. identified on remote patient monitoring)

Uncontrolled moderate-severe hypertension or significant hypotension • Patient-reported fluid imbalance not responding to prescription change or diuretics • Patient-reported new/worsening symptoms • Patients reporting social isolation, severe depression or anxiety

• An alternative to monthly laboratory work for stable patients • Home must remain as the originating and distant sites • Allow health professional licensure across state lines • Allow health professionals to bill for services across State lines • Develop various media formats to educate patients and providers on telehealth • Formal adoption of telehealth as a preferred practice for stable home dialysis patients • Dissemination of

Acknowledgement: We thank all the patients who shared their experiences and thoughts about telehealth. Many thanks to Kerry Leigh, BSN, RN, Project Specialist at the American Society of Nephrology for her administrative support.Peer Review: Received July 9, 2020. Evaluated by 2 external peer reviewers, with direct editorial input from an Associate Editor and a Deputy Editor. Accepted in revised form September 10, 2020.

The authors constitute the American Society of Nephrology (ASN) COVID- 19 J o u r n a l P r e -p r o o f