Background/Purpose: Access to rheumatologic consultation is limited by available expertise due to inadequate manpower and maldistribution of resources. Rural New England is particularly challenging because of sparse population, prolonged transportation times, and weather conditions that make travel difficult or impossible. Nearly every medical specialty and subspecialty is underrepresented (and often completely absent) in the northern 2/3 of New Hampshire, and this population’s poorer health status and outcomes from disease and injury illustrate the ‘rural penalty’. Dartmouth-Hitchcock Medical Center (DHMC), a Level 1 quaternary academic medical center located in the Upper Connecticut River Valley, is the only referral center for New Hampshire and parts of Vermont, Maine, and Eastern Upper New York State. Weeks Medical Center–Lancaster is a Rural Health Clinic associated with Weeks Medical Center, a 25 bed rural critical access hospital located in northern New Hampshire approximately 2 ½ hours by car north of DHMC. To provide rheumatologic access; we initiated a Tele-Rheumatology pilot clinic between a physician at DHMC and a trained nurse at Weeks Medical Center.

Methods: A two way live synchronous video conference was set up connecting a conference room at DHMC and an exam room at Weeks. Patients were scheduled at both institutions and referral notes and documentation were faxed to DHMC prior to the visit. Patients were seen at Weeks with a nurse who had shadowed the rheumatologist at DHMC and was instructed on joint examinations prior to the encounter. Vital signs, medications, and a problem list were communicated from the nurse at Weeks to the nurse at DHMC. Patients were interviewed and physical examination was achieved with assistance of the trained nurse at Weeks. The encounter was documented at DHMC and electronically communicated to the referring physician. Management included medications electronically prescribed to patient’s pharmacy, laboratory testing and ancillary services at Weeks. All patients are given the option to be seen at DHMC; however, since none of the patients needed to be seenat DHMC follow-up was arranged at the time of the encounter as a return telemedicine appointment. Issues that needed to be resolved before initiation included a contract between the hospitals, credentialing, billing procedures (both facilities billed, Weeks-facility charges and nurse visit, DHMC-professional fee), coding issues, and distribution of responsibilities. Most of these were facilitated by a face-to-face meeting.

Results: Patient, physician, and staff satisfaction was high. We have plans to extend this regionally to more than two dozen rural sites in the region.

Conclusion: As a substitute for outreach clinics telemedicine appears to be more cost effective and efficient limiting valuable specialist time that would otherwise be spent in travel, learning new computer systems and familiarizing themselves with procedures and protocols of different hospitals. It is possible to extend this service to homebound patients through portable units staffed by visiting nurses. Additionally, it would be possible to extend this to utilize instructional videos, web links to treatment information, or multiway conferencing.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/tele-rheumatology-the-future-is-now/