Use of Telemedicine by Registered Dietitians (RDs) to Improve Healthcare for Patients

Written by: McKenna M. Murphy, Student Dietitian

Introduction

                  Telemedicine “healing from a distance” in healthcare professions attempts to deliver health care services and information at a distance through electronic devices to improve access, quality, and cost. Telemedicine ranges from live interactive video for consultations, mHealth or the use of mobile devices for patient self-management, electronic instruments to collect patient data in real-time for provider analysis, and the use of Health Insurance Portability and Accountability Act (HIPPA) compliant portals for providers to share electronic health records (EHR).¹ Most of the research on telemedicine has been done for many health care professions as it has entered mainstream practice. The Academy of Nutrition and Dietetics recognizes telenutrition as a tool for registered dietitians as it is an included topic in their evidence analysis library (EAL); however, it has not been updated since 2012.² Outcome measures in the literature review will include access to RDs, cost-effectiveness, quality of care, and the effects of state licensure laws on telehealth.

Access to Registered Dietitians

                  Rural areas in the U.S. present with the highest rates of food insecurity among the 48 million people suffering nationwide. Research shows that food insecurity is directly linked to diet, weight gain, and chronic disease. This presents a need for RDs to provide food and nutrition education related to accessing a sustainable food supply to combat hunger, obesity, and diabetes.^3-6 However, RDs are unable to offer services to millions of Americans because of limited access via transportation and time.       The use of Telemedicine offers a promising new opportunity for food insecure Americans; especially in rural locations to receive high quality nutrition education without the hassle of traveling to visit a dietitian. According to a study conducted by Homenko⁶, 74 older adults from rural areas of New York intervention program. The goal was to observe meal planning, preparation, shopping behaviors, obesity, and glycemic control in older adults with and without food insecurity to understand if the intervention program would be beneficial to reduce food insecurity and related concerns. Results showed mildly insecure patients had higher BMIs and lower household incomes than food secure patient; however, HbA1c levels and following Dietitian advice when choosing foods did not differ between both groups. Despite no participants being classified as severely food insecure, the study concluded telemedical nutrition support services have the potential to be an important adjunct for rural primary care providers whose patients have poor access to the services of dietitians. Further research needs to be conducted to locate the severely food insecure and analyze correlations with access to internet and electronic devices to understand the limitations that telemedicine still may present with uniting patients and needed nutritional support.  

Cost-Effectiveness

                  Cost of RD services has also been a barrier in connecting patients to needed nutritional support in rural and urban settings. Two studies offered a 12-month weight management program that looked at the cost-effectiveness of telemedicine vs. face-to-face nutrition intervention and found that costs were less expensive for telemedicine services for the RD and patient.^7,8 The 1-year prospective randomized controlled clinical trial resulted in the face-to-face group having a fixed cost of $420 a patient and the telephone counseling group to be $268 a participant. The mail/control group was $42 less expensive than the telephone counseling group at $226 a patient, but average weight regain after intervention was 3.1kg as opposed to face-to-face of 1.7kg and telephone format of 2.1kg.⁷ Results show that a face-to-face intervention may have superior outcomes as opposed to telephone interventions, but weight regain was only an 0.4kg difference; however, price of administration was a substantial $152 difference.⁷ The second study by Rollo showed in-person nutrition intervention costs to be about $560.59/patient and eHealth nutrition intervention costs to be about $389.78/patient. One key addition of Rollo’s study was the examination of establishment costs for dietitians and patients of $90.05 for in-person delivery and $1394.21 for eHealth. This offers one barrier in the use of telemedicine nutrition programs as start-up costs to dietitians are far higher for equipment than for in-person programs. However, if a dietitian is willing to make the investment on average the dietitian will save $42.56 per patient as compared to in-person services. This means a dietitian will only need to see about 31 patients using eHealth technology to offset the establishment costs of telemedical delivery and in the long run make/save more money than if in-person services were utilized.⁸

                  The price of telemedicine nutrition services offers the opportunity to increase access for low-income patients with only mild differences in quality of treatment, but at about half the cost of administration.^6-8 The use of a telephone intervention program may also affect weight regain results as compared to videoconferencing or more personal technological use as seen in Homenko’s research, which had equal results in HbA1c and food choice to face-to-face vs. telemedicine nutrition intervention.^6,7 However, the use of telephone interventions may offer an ideal opportunity for the severely food insecure to gain access to RD intervention nutrition programs that may not have access to a camera for videoconferencing. According to Rollo’s study 83% of Australians have access to the internet with 7.5 million using the internet through their mobile phone.⁸ This leaves 17% of the Australian population in need of internet access, but for a wide section of the population telemedicine offers a promising solution to connect RDs to food insecure populations.

Quality of Care

                  Although Telemedicine offers the opportunity to increase access between RDs and patients by reducing cost and negating distance concerns, the access would be insignificant if services did not generate similar or better intervention results than face-to-face contact with patients.^6-8

                  A 12-month parallel randomized controlled trial looked at 415 patients with uncontrolled type 2 diabetes mellitus in an online disease management system. The primary outcome was HbA1c levels and at 6 months the intervention group had better diabetes control than the usual care group, but at 12 months results from HbA1c scores showed no significant difference between the usual care and intervention group. Tang’s study concluded that usual care and telemedicine intervention resulted in similar quality of care for patient treatment of diabetes.⁹ In comparison, Radcliff’s 1-year prospective randomized controlled clinical trial resulted in a face-to-face weight management group as having a slightly better median weight regain primary outcome of 0.4kg than the telephone weight management group.⁷

                  Tang’s and Radcliff’s studies could have had conflicting results because of the type of nutritional intervention programs implemented, telemedical equipment utilized, and personnel leading the programs. Tang’s study used a more in-depth online disease management program with an interdisciplinary health care team which included nurses and dietitians to gain results compared to Radcliff’s telephone consultations with group leaders who underwent diabetic prevention program training with degrees in nutrition, exercise science, or psychology.Tang incorporated personalized text and video educational information from the health care team, nutrition and exercise logs, wirelessly uploaded home glucometer readings with graphical feedback, insulin records, online instant messaging with a patient’s health care team, and comprehensive patient-specific diabetes summary status reports. Overall Tang’s experiment was far more in-depth and utilized far more avenues for telemedical intervention than Radcliff’s research and may have accounted for similar outcomes compared to face-to-face nutritional interventions. However, Radcliff targeted the food insecure and the use of a telephone model may be more realistic to help patients living in rural areas with limited access to telemedical equipment, so the small difference in quality of care may be insignificant as results still show significant improvement in administration of nutritional interventions compared to controls. More research needs to be done to explore the most practical applications and equipment of telemedicine intervention.^7,9

                  Also, Tang obtained results that participants whose HbA1c improved the most in the intervention group had significantly more glucose readings and uploaded more information compared with patients that did not improve.⁹ It may be that the use of more technology offers more patient and provider engagement to enhance patient motivation and quality of care, but more research needs to be done to understand the motivations for patient involvement in any nutrition intervention program.

 Effects of State Licensure Laws on Telehealth

                  Telemedicine incorporation in all health care practices and professions is continuing to grow as 42% of hospitals in 2012 had adopted telehealth.¹⁰ This would make sense from the past analysis as access to care, reduced cost to practitioner and patient, and similar quality of care has been shown.^1-9 As telemedicine incorporation continues to increase policy makers need to understand the research behind implementation of telemedicine to make optimal decisions for the future of telemedicine in health care practice. This has been shown with the implementation of the Affordable Care Act as home health care monitoring usage has increased to reduce rates of readmission to prevent penalization features of the act from readmissions and increase incentive collection through lack of readmission.¹⁰

                  A study by Adler-Milstein sent surveys to 2,891 hospitals across the U.S. with a 63% response rate to understand several factors that influence adoption of telehealth in hospital settings. Interesting factors found to increase acceptance were teaching hospitals, those already equipped with advanced medical equipment, nonprofit organizations, and hospitals that were in business with larger systems. However, state policy seems to lead to and how hospitals adopt telemedicine more than any other factor and accounts for variations in hospital adoption of telemedicine by state. State policies that promote private payer reimbursement for telehealth increase likelihood of adoption, but policies that require out-of-state providers to have a special license reduces chances of incorporation of telemedicine.¹⁰

                  The Adler-Milstein findings are relevant to the adoption of telenutrition in the United States of America because the current policy for Registered Dietitians in 47 states have statutory provisions regulating the dietetic profession. For example, in Florida, a state with strict RD state licensure laws, an RD could only offer medical nutrition therapy (MNT) and nutritional counseling to patients living in that state or states like California that do not have strict licensure laws for nutrition counseling. This limits access to the RD to treat patients outside of the state of Florida unless the RD payed an annual fee to treat patients in each other individual state that has state licensure laws.¹¹ This decreases the likelihood of an RD treating patients outside of their state which an RD with a strong telemedical practice could easily perform.¹⁰ As the demand for RDs increases with the increase of baby boomers, limitations on RD access to potential patients hurts the consumer and provider.¹¹ Possible solutions could be to create a federal licensure law to allow RDs to practice in all 50 states of the U.S.A. or to get rid of the state licensure law entirely saving the RD an annual fee, but not protecting the RD credentials.

Conclusion

                  Telemedicine offers an alternative to standard in-person nutrition services through administration by RDs and interdisciplinary health care teams. As benefits abound for practitioners and patients through access and cost with similar outcomes it seems apparent that telemedicine is the future of healthcare.^1-9

                  Food insecurity has been shown to be one of the key problems that could be positively impacted with the implementation of nutrition intervention programs that utilize telemedicine instead of in-person services. For the severely food insecure problems may still arise with limited access to internet, but overall use of telemedicine by RDs could reach far more persons in need of nutrition support especially related to diabetes and obesity as opposed to in-person services.^3-7

                  Optimal nutrition intervention programs that are face-to-face or via eHealth services are still being perfected. The use of telemedicine offers opportunities to improve nutritional interventions for all populations because of immediate and accurate results to health care workers by real time appliances like wireless glucose monitors and enhanced communication between providers through EHR applications.^1,9 However, patient activity in a nutrition program seems to be the number one factor for program success and telemedicine implementation seems to neither discourage or motivate program incorporation that appears to be at the mercy of the individual program formats and leaders.^7,9 This should offer RDs comfort that jobs will not be lost to digital devices as participants still need encouragement to engage in nutrition intervention programs for healthier lifestyle outcomes.

                  Adoption of telenutrition tends to be slow because of state licensure laws, increased start-up costs and the learning curve to new systems, but if barriers to telehealth can be overcome the benefits of telehealth outweigh the initial hassle.^8,10

References

1. Kvedar J, Coye MJ, Everett W. Connected health: A review of technologies and strategies to improve patient care with telemedicine and telehealth. Health Aff. 2014;33(2):194-9. https://search.proquest.com/docview/1498231601?accountid=12390.
2. Gradwell EK. TELENUTRITION (TN) (2012). EatRight: Academy of Nutrition and Dietetics- Evidence Analysis Library. https://www.andeal.org/topic.cfm?menu=4706. Published 2012.
3. Holben D. Position of the American Dietetic Association: Food Insecurity in the United States. Journal of the Academy of Nutrition and Dietetics Association. 2010;110(9):1368-1377.
4. Laraia AB. Food insecurity and chronic disease. Adv Nutr. 2013;4(2):203-12. Published 2013 Mar 6. doi:10.3945/an.112.003277.
5. Schroeder K, Smaldone A. Food Insecurity: A Concept Analysis. Nurs Forum. 2015;50(4):274-84.
6. Homenko DR, Morin PC, Eimicke JP, Teresi JA, Weinstock RS. Food Insecurity and Food Choices in Rural Older Adults with Diabetes Receiving Nutrition Education via Telemedicine. Journal of Nutrition Education and Behavior. 2010;42(6):404-409. doi:10.1016/j.jneb.2009.08.001.
7. Radcliff TA, Bobroff LB, Lutes LD, et al. Comparing Costs of Telephone vs Face-to-Face Extended-Care Programs for the Management of Obesity in Rural Settings. Journal of the Academy of Nutrition and Dietetics. 2012;112(9):1363-1373. doi:10.1016/j.jand.2012.05.002.
8. Rollo ME, Burrows T, Vincze LJ, Harvey J, Collins CE, Hutchesson MJ. Cost evaluation of providing evidence-based dietetic services for weight management in adults: In-person versuseHealth delivery. Nutrition & Dietetics. 2017;75(1):35-43. doi:10.1111/1747-0080.12335.
9. Tang PC, Overhage JM, Chan AS, et al. Online disease management of diabetes: Engaging and Motivating Patients Online With Enhanced Resources-Diabetes (EMPOWER-D), a randomized controlled trial. Journal of the American Medical Informatics Association. 2013;20(3):526-534. doi:10.1136/amiajnl-2012-001263.
10. .Adler-Milstein J, Kvedar J, Bates DW. Telehealth Among US Hospitals: Several Factors, Including State Reimbursement And Licensure Policies, Influence Adoption. Health Affairs. 2014;33(2):207-215. doi:10.1377/hlthaff.2013.1054.
11. .Licensure and Professional Regulation of Dietitians. eatrightpro- Academy of Nutrition and Dietetics. https://www.eatrightpro.org/advocacy/licensure/professional-regulation-of-dietitians.