In-center hemodialysis unit patient experience with telehealth

To the Editor

Centers for Medicare and Medicaid Services (CMS) issued a series of telehealth waivers in 2020 that lifted geographic restrictions and expanded originating sites to include the home and dialysis units.¹ For the first time, all nephrology practitioners in the United States could conduct in-center hemodialysis patient visits through telehealth. We evaluated patient experiences with the use of telehealth by their nephrologist in hemodialysis.

Hemodialysis patients from 2 units located in the District of Columbia completed a survey in July/August 2021 regarding the use of telehealth with their nephrologists during the COVID-19 pandemic. Telehealth was conducted while patients were receiving treatment in the dialysis unit, and the clinicians were in their home, office, or hospital. The nephrologist determined whether a telehealth visit occurred. During telehealth visits, renal dietitians facilitated videoconferencing by bringing to the chair-side a laptop or tablet installed with a Health Insurance Portability and Accountability Act (HIPAA) compliant video platform. According to the telepresenters, each session approximated 10 min, with a range of 5–60 min.

The survey, with a response rate of 75%, reported 94 patients using telehealth while 54 patients did not. A p value of <0.05 was used to identify differences between patients who did and did not report receiving dialysis care via telehealth. Patient demographic characteristics, time on dialysis, education level, primary language, and risk factors of COVID-19 exposure and/or infection did not differ by the receipt of care via telehealth (Table S1).

Using a Likert scale ranging from 1 to 10 (10 = extremely satisfied), patients reported an average telehealth satisfaction score of 8.0, with 42% of patients indicating the highest satisfaction rating and 74% indicating a score of 7 or higher (Figure 1). More than 90% of patients reported spending enough time with their physician during their virtual visits and most patients did not report concerns regarding internet security (85%), privacy (85%), or technical issues (92%). Patients (65%) reported that the lack of a physical examination did not hamper the clinician’s ability to treat them. The reported desire to use telehealth in the future (73%) for monthly, weekly, and impromptu visits also suggested satisfaction with telehealth (Table 1).

FIGURE 1.

Ratings of satisfaction with telehealth. Likert scale: where 1 = extremely unsatisfied, 5 = neutral, and 10 = extremely satisfied.

TABLE 1.

Survey results from patients who participated in telehealth in the hemodialysis unit (n = 94)

	N (%)
Demographic
Female	43 (46)
Age mean ± SD	56.5 ± 13.5
Ethnicity
African American	79 (84.0)
Asian	4 (4.3)
Caucasian	1 (1.1)
Hispanic	8 (8.5)
Other	2 (2.1)
Educational level
Elementary school	6 (6.4)
Some or completed	55 (58.5)
High school
Some or completed	27 (28.7)
College
Advanced education	6 (6.4)
Primary language
English	84 (89.4)
Spanish	5 (5.3)
Other	5 (5.3)
Years on dialysis
<1	19 (20.6)
1 to <5	41 (44.6)
5 to <10	18 (19.6)
10 or greater	14 (15.2)
COVID-19-related issue
Diagnosed with COVID-19 during the pandemic	16 (17.0)
Concerned with catching COVID-19 in the dialysis unit	36 (39.6)
Had been a Person Under Investigation	15 (16.7)
Was hospitalized (for any reason)	43 (45.7)
Telehealth attitudes
Clinician still saw the patient in-person at least once a month when using telehealth during the pandemic	78 (83)
Patient had enough time with the clinician during telehealth to address issues and answer medical questions	85 (90.4)
Patient felt that the lack of a hands-on physical examination hampered clinician’s ability to treat them	33 (35.5)
Patient had concerns with technology privacy when using videoconferencing	14 (14.9)
Patient had concerns about privacy issues when using telehealth in the dialysis unit	14 (15.1)
Patient experienced technological issues with telehealth that interfered with their care	7 (7.6)
Patient use of earphone when using telehealth	9 (8.6)
Future use of telehealth
Would like to use telehealth in the dialysis unit after the pandemic	69 (73.4)
For the monthly comprehensive visit	56 (71.8)
For the weekly visit	49 (64.5)
For an impromptu visit	57 (73.1)

Note: Missing data occurred because the individual responder did not enter a response. Telepresenters did not report any patient encountering visual or auditory challenges when assisting with videoconferencing.

Findings from this survey suggest that patients were generally satisfied with the novel ability to conduct telehealth in the dialysis unit, and that they felt they spent enough time during the virtual visit with the clinician. Although patients previously reported positive experiences with telemonitoring in the home dialysis setting,² various aspects of telehealth that are unique to the hemodialysis unit may have contributed to patient satisfaction in our study.

In other areas of medicine, technological challenges limit patient and provider experiences of telehealth.^3-5 In contrast, among our cohort, only 8% of patients surveyed reported concerns with telehealth technology. Dialysis units have internet access, portable electronic devices, access to secure HIPAA-compliant platform to conduct telehealth, and dialysis staff members to facilitate virtual visits. Dialysis facility support may make the process easier for patients compared to those who conduct telehealth from home.

Most patients did not report concerns with security or privacy when conducting virtual visits in the dialysis unit, despite the general absence of privacy screens or other barriers. This may be related to the fact that hemodialysis patients are already accustomed to routine interactions with their physicians in the dialysis unit, and have trust in the facility and its staff.

About 35% of patients reported concerns that the lack of a physical examination hampered their doctor’s ability to care for them, highlighting an area for improvement. For example, dialysis providers could purchase a USB stethoscope to enable auscultation during telehealth visits and dialysis staff can be trained as telepresenters to extend the virtual clinicians’ capabilities to examine the patient.

The future role of telehealth in the dialysis unit post-pandemic has not been defined. Telehealth could be used to conduct routine or impromptu visits to help avert the need for emergency care. Additionally, telehealth could be used to address CMS’s endorsement of value-based care⁶ by facilitating education on treatment options and care coordination through consultation with other specialties or disciplines. Allowing hemodialysis patients to use the dialysis unit as an originating site for telehealth may mitigate the widening social determinants of health gap for those without access to the internet and devices.⁷

Limitations of the study include the small number of patients surveyed (most of whom received at least one inperson visit per month), potential sampling bias, and the absence of information on patient outcomes and costs of performing telehealth. Patient recall bias may exist given the delay between the use of telehealth services and survey administration (~4 months).

In summary, telehealth using the dialysis unit as the originating site is feasible. Most patients had a positive attitude towards telehealth, expressing satisfaction and willingness to continue its use post-pandemic.