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Melanie Cole (Host):  The University of Alabama at Birmingham is using Telehealth to treat kidney transplant patients who would otherwise travel hundreds of miles for a regular checkup. Welcome to UAB Med Cast. Today, we’re discussing the UAB Transplant’s Telehealth initiative. I’m Melanie Cole and joining me is Dr. Clifton Kew. He’s a Professor of Medicine and Surgery in the Division of Nephrology and the Medical Director of the Kidney and Pancreas Transplant Program at UAB Medicine. Dr. Kew, it’s an absolute pleasure to have you join us today. Let’s start with a little working definition of Telehealth for the future for patients, providers. It’s happening all over the country. Tell us a little bit about the evolution and what you’re doing there at UAB?

Clifton Kew, MD (Guest):  So, what we’re doing at UAB is we’re trying to bring the medicine to the patient. And Telehealth is one of the initiatives that allow us to do that. Now traditionally, we have several – well we are coming up with several outreach clinics where a physical provider drives to an outlying area and see patients. And I’ve done an outreach clinic in the Mobile area which is around 250 miles from UAB. I spent eight hours in the car to see four hours’ worth of patients. So, it’s not very efficient from our point of view but it’s a big help to the patients that live in the Mobile area, the panhandle of Florida and southern Mississippi. And patients have always said thank you for coming down because I don’t have to spend the eight hours in the car to come see you.

So, Telehealth eliminates that – it’s actually the best for both provider and patient because they go to a specified site, they see a doctor over the internet and pretty much you can almost do a complete physical exam. They have a wireless stethoscope where a nurse or other designee will place the stethoscope on the patient’s chest, and I am able to hear what’s going on in the patient 200 miles away. So, it brings the medicine to the patient and I have yet to have somebody tell me that they weren’t happy. The only complaint I got was one of the patients said she couldn’t give me a hug at the end of the visit.

Host:  That really is amazing. And how lovely is that. So, give us some other examples. So, besides patient monitoring but on demand, critical care with transplant patients especially Dr. Kew, sometimes there’s emergent situations or questions that they have. They’re worried about rejection. How do some of those things work and I’d also like you to tell us where there any barriers to starting this initiative?

Dr. Kew:  I’ll start with the last question first. So, most of the barriers were administrative. And it was trying to get on the same encrypted communication suite with the outlying sites. So, the Alabama Department of Public Health has designated their Health Department. So, there’s one Health Department in every county in Alabama. And they have designated each one of these Health Departments has its own Telehealth cart. So, it was a matter of getting UAB on their communications program so that was one barrier. Another barrier was that some of these health departments are in such rural areas, that they didn’t even have broadband internet, which is a requirement for Telehealth. So, that was another barrier. Fortunately, the number of available Telehealth sites has grown. So, we now have access to more areas as broadband is getting out and the state government actually has a dedicated task force for encouraging some of the telecommunications companies to lay cable so broadband can get to these more rural areas.

Most of the focus of the Telehealth for transplant is what we’ve termed as immunosuppression monitoring. And the reason that we’ve focused on that is that we don’t need real time blood results or lab results to determine if there’s a problem. So, we would ask the patient to get their lab work a week before the visit and then they would come and we would review the labs and identify problems, identify doses of medications that needed to be changed, update our medical records and oh you had a heart attack six months ago, okay, we’ll put that in the record so when you come back sick then we know that that happened to you.

The next phase would be doing these so-called sick clinics where somebody would come in with a kidney dysfunction and we could actually do some actual diagnostics or at least the first step to diagnostics before having them come to Birmingham to have testing done that only can be done up in Birmingham such as a kidney biopsy.

Right now, we’re focusing on the people that say why do I have to come all the way to Birmingham just for you to tell me my kidney is okay. That’s what we’re focusing on. We feel that we can still contribute to a patient’s health by looking at their levels and their labs and their cell counts. We can look for toxicities. We can look for people that are getting too much. We can look for people that are getting too little and we can stomp out some simple problems.

But ultimately, the plan is to get more sick patient type visits and some of these sites for example, one of our sites is the North Baldwin Infirmary that we do have some sites available to us that are outside the Alabama Department of Public Health so the North Baldwin Infirmary, that’s a hospital. So, if somebody comes in with a chest cold, I can get a chest x-ray. Somebody comes in with a swollen leg. I can get an ultrasound to check for a DVT. Somebody comes in with a high creatinine, I could potentially get an ultrasound of the transplant in order to make sure there’s no urinary obstruction. So, those kinds of things are a little bit difficult at the public health and what we’ve done in those cases, we just say, you just need to come up and see us in Birmingham so we can take care of the problem.

As far as inpatient goes; we have not embarked on that. That would be ideal. We have lots of people that come to emergency rooms in underserved areas. I know my general nephrology counterparts have done some of those. So, that is potentially on the radar but that’s going to be down the road a bit.

Host:  Well thank you for that answer. And as long as we’re talking about how Telemedicine is transforming your decision making scenario, and the functionality that it provides from that clinical perspective; are you seeing Dr. Kew, that it’s changing the care paradigm to the home, decreasing hospitalizations, readmissions, just really the stress on everybody?

Dr. Kew:  I think it’s less of a stress on the patient. I think once they get used to seeing a doctor over the internet, it’s much less intimidating to them. I see people for follow up of test results so, for example, a patient comes, has a kidney biopsy up in Birmingham, they go home, rather than driving all the way up a week later to get the results; I see them via Telehealth, and I’ll say okay here’s what we need to do with the results. Let me go change your medicine, let me arrange for further treatment which doesn’t necessarily have to be done at UAB. Sometimes we can send them blood tubes in the mail to check for various things and follow up. These virtual visits can really, in that scenario, prevent patients from coming back unnecessarily.

I think it’s a bit early to see what impact it has on readmissions. I’m a firm believer that if you have more eyes on patients, then there’s less of a chance that something is going to slip through the cracks. So, my expectation is is that it will. And not only that, getting readmitted to the hospital, I mean our goal is to keep people off dialysis. And I think if we can see patients more frequently, more conveniently, we can delay that. So, I think that’s really where the benefit is going to be. It’s going to be in keeping people off dialysis, keeping them with a bit better quality of life and also going back on dialysis is expensive. And if we can keep the transplant lasting longer, it’s not just good for the patient; but it’s good for the healthcare system in general.

Host:  Well you got to right where my next question was going. What about cost effectiveness and insurance implications. Telemedicine is this being embraced by the insurance companies and I would imagine why wouldn’t they?

Dr. Kew:  The answer is yes. The information that I know, Blue Cross, Blue Shield of Alabama has embraced it. They will pay for it because I think they understand that if you give access to patients to provider then you might avoid some of these downstream costs that could be avoided. Medicare has embraced it primarily in underserved areas. It may be that a patient has to drive 30 minutes to go to a place where we can see them via Telehealth but still, if you have the choice of driving 30 minutes versus two and a half hours; I don’t think the patients have to think that long at what they want to do. Medicaid of Alabama, they also reimburse so the three major payors in our state are paying for this service. And so, I think they realize that if you are able to get specialty care to places that don’t have specialists; there’s a cost savings and I think that if you have higher level of care available earlier on in the process; that you would avoid problems down the road.

Host:  Well that certainly is true and thank you. As we wrap up, and we’re talking about how this would improve the patient journey and the way they receive care, for even related conditions as you mentioned heart attack earlier. What do you see as the endless possibilities of Telehealth for the future of care and especially Dr. Kew for transplant patients? Wrap it up for us with a summary of the UAB Medicine Transplant Initiative.

Dr. Kew:  So, right now, we’re focusing on immunosuppression surveillance, just is your kidney working fine, yes, no, if it is, great, let’s make sure you are on the right medicine, let’s make sure our records are updated. We’ll see you next time. If not, if there is a problem, well then you need to have further workup. So, that’s phase one. Phase two is looking at patients that are not doing 100% well and trying to stomp out some issues and prevent some trips back to the transplant center in Birmingham and deal with it more on a local basis. Phase three and we didn’t even talk about this, I transplant evaluation which would be our third initiative.

So, for example, you have somebody that may have difficulty getting to Birmingham, but they are interested in well can I get a transplant? What are my donor options? Am I going to be limited to getting a kidney off of the waiting list? Do I have an option for a living donor? What are some of my health conditions that would not allow me to get a transplant? Plus all the educational components that our coordinator staff do. That can be done – you could have a Teleconference with a group of potential transplant recipients to teach them what’s going on with the transplant process and find people that say heh, you know, I didn’t know that somebody who was not a blood relative could donate a kidney to me.

Those are things that we can do. And then lastly is the inpatient version which I think that’s probably the furthest down the road, but I think the post-transplant, the care after transplant is number one. We are already doing it. We’re trying to figure out what a pretransplant experience would be like because patients do have to have the ability to get to the transplant center ultimately because they have to come here for surgery. So, we can never eliminate the need to come to Birmingham but what we can do is we can minimize it and for patients that are kind of on the fence, may have a health problem that may exclude them from getting a transplant; they can talk to a physician, they can get some answers to what they need to do to make themselves a transplant candidate.

So, I think there are advantages all around for transplant medicine especially in our state because we do have a population that doesn’t have a lot of resources which is something that we deal with on a daily basis seemingly, in our clinic.

Host:  Wow, it’s such a fascinating topic. What a time to be in your field Dr. Kew. Thank you so much for telling us about the UAB Transplant Telehealth Initiative. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. And that concludes this episode of UAB Med Cast. For more information on resources available at UAB Medicine, please visit our website at www.uabmedicine.org/physician. And please remember to subscribe, rate and review this podcast and all the other UAB podcasts. This is Melanie Cole.