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If you are a current AGA trainee, medical resident, or student member, please renew your membership today to ensure the continuation of your career-enhancing benefits for the upcoming membership year. Prepare for your next chapter with the latest news and breakthroughs in the field, as well as access to educational programs, events and much more.
While renewing, please update your member profile at My AGA for news and resources tailored to your professional interests. The deadline to renew is Aug. 31, 2018.
If you have any questions, please contact AGA Member Relations at [email protected] or 301-941-2651.
If you are a current AGA trainee, medical resident, or student member, please renew your membership today to ensure the continuation of your career-enhancing benefits for the upcoming membership year. Prepare for your next chapter with the latest news and breakthroughs in the field, as well as access to educational programs, events and much more.
While renewing, please update your member profile at My AGA for news and resources tailored to your professional interests. The deadline to renew is Aug. 31, 2018.
If you have any questions, please contact AGA Member Relations at [email protected] or 301-941-2651.
If you are a current AGA trainee, medical resident, or student member, please renew your membership today to ensure the continuation of your career-enhancing benefits for the upcoming membership year. Prepare for your next chapter with the latest news and breakthroughs in the field, as well as access to educational programs, events and much more.
While renewing, please update your member profile at My AGA for news and resources tailored to your professional interests. The deadline to renew is Aug. 31, 2018.
If you have any questions, please contact AGA Member Relations at [email protected] or 301-941-2651.
A successful career starts with taking charge
Successful careers don’t just happen. They are made by individuals who take charge and build their own success. The alternative is burnout.
“Part of burnout is feeling overburdened, overworked, and out of control,” said Barbara Jung, MD, AGAF, professor and chief of gastroenterology and hepatology at the University of Illinois at Chicago, during Strategies for a Successful Career: Wellness, Empowerment, Leadership and Resilience at Digestive Disease Week® (DDW) 2018. “If somebody is staying until 9 or 10 o’clock [at night] to finish notes, I have a discussion with them. It is good to be done at 5 p.m. and go home. It is all about setting your own priorities and not letting the job take over your life.”
Associations have a role to play, too. The ASGE Technology Committee reported in 2010 that up to 89% of GIs suffer musculoskeletal injuries from manipulating scopes. Colonoscopist’s thumb (left thumb tendonitis) and metacarpophalangeal joint strain were the most common injuries.
“Risk factors are part of our work,” said Mehnaz Shafi, MD, AGAF, professor of gastroenterology, hepatology and nutrition at the University of Texas MD Anderson Cancer Center, Houston. “Pinching, pushing, pulling, and awkward positions are part of what we do. This is an injury with consequences.”
Dr. Shafi chairs the AGA Task Force on Ergonomics. The group has recommended changes to endoscopic work stations that minimize injury. The most important changes include mounting monitors on flexible stands to accommodate GIs of all heights, adding straps to the control head to allow the fingers to relax, providing ergonomic training to all GIs and using patient beds that can be raised and lowered to accommodate both tall and short GIs.
“Shaping your career is one of the key principles in preventing burnout,” said Arthur DeCross, MD, AGAF, professor of medicine, gastroenterology and hepatology at the University of Rochester Medical Center, N.Y. “We know that more than half of gastroenterologists self-identify as being burned out. And one of the major contributors to burnout is lack of control over your work environment, your career, your colleagues. Taking control of your career can make a difference.”
Taking control can be particularly important for women. An AGA burnout survey in 2015 found that 51% of male GIs reported burnout versus 62% of female GIs.
One reason is women’s tendency to negotiate poorly on their own behalf, said Marie-Pier Tétreault, PhD, assistant professor of gastroenterology and hepatology at Northwestern University Feinberg School of Medicine, Chicago.
“It’s a matter of attitude,” she explained. “Men tend to believe they can and should make life happen. Women tend to believe that what you see is what you get. Even when women do negotiate, they tend to ask for 15%-30% less than their male colleagues. If you don’t ask, you won’t get.”
Simply taking the lead in negotiations can improve the outcome, she continued. Network with colleagues and mentors to find the appropriate ranges for salaries, benefits, and perks such as parking, spousal job opportunities, facilities and space, teaching expectations, administrative support, and more.
Successful careers don’t just happen. They are made by individuals who take charge and build their own success. The alternative is burnout.
“Part of burnout is feeling overburdened, overworked, and out of control,” said Barbara Jung, MD, AGAF, professor and chief of gastroenterology and hepatology at the University of Illinois at Chicago, during Strategies for a Successful Career: Wellness, Empowerment, Leadership and Resilience at Digestive Disease Week® (DDW) 2018. “If somebody is staying until 9 or 10 o’clock [at night] to finish notes, I have a discussion with them. It is good to be done at 5 p.m. and go home. It is all about setting your own priorities and not letting the job take over your life.”
Associations have a role to play, too. The ASGE Technology Committee reported in 2010 that up to 89% of GIs suffer musculoskeletal injuries from manipulating scopes. Colonoscopist’s thumb (left thumb tendonitis) and metacarpophalangeal joint strain were the most common injuries.
“Risk factors are part of our work,” said Mehnaz Shafi, MD, AGAF, professor of gastroenterology, hepatology and nutrition at the University of Texas MD Anderson Cancer Center, Houston. “Pinching, pushing, pulling, and awkward positions are part of what we do. This is an injury with consequences.”
Dr. Shafi chairs the AGA Task Force on Ergonomics. The group has recommended changes to endoscopic work stations that minimize injury. The most important changes include mounting monitors on flexible stands to accommodate GIs of all heights, adding straps to the control head to allow the fingers to relax, providing ergonomic training to all GIs and using patient beds that can be raised and lowered to accommodate both tall and short GIs.
“Shaping your career is one of the key principles in preventing burnout,” said Arthur DeCross, MD, AGAF, professor of medicine, gastroenterology and hepatology at the University of Rochester Medical Center, N.Y. “We know that more than half of gastroenterologists self-identify as being burned out. And one of the major contributors to burnout is lack of control over your work environment, your career, your colleagues. Taking control of your career can make a difference.”
Taking control can be particularly important for women. An AGA burnout survey in 2015 found that 51% of male GIs reported burnout versus 62% of female GIs.
One reason is women’s tendency to negotiate poorly on their own behalf, said Marie-Pier Tétreault, PhD, assistant professor of gastroenterology and hepatology at Northwestern University Feinberg School of Medicine, Chicago.
“It’s a matter of attitude,” she explained. “Men tend to believe they can and should make life happen. Women tend to believe that what you see is what you get. Even when women do negotiate, they tend to ask for 15%-30% less than their male colleagues. If you don’t ask, you won’t get.”
Simply taking the lead in negotiations can improve the outcome, she continued. Network with colleagues and mentors to find the appropriate ranges for salaries, benefits, and perks such as parking, spousal job opportunities, facilities and space, teaching expectations, administrative support, and more.
Successful careers don’t just happen. They are made by individuals who take charge and build their own success. The alternative is burnout.
“Part of burnout is feeling overburdened, overworked, and out of control,” said Barbara Jung, MD, AGAF, professor and chief of gastroenterology and hepatology at the University of Illinois at Chicago, during Strategies for a Successful Career: Wellness, Empowerment, Leadership and Resilience at Digestive Disease Week® (DDW) 2018. “If somebody is staying until 9 or 10 o’clock [at night] to finish notes, I have a discussion with them. It is good to be done at 5 p.m. and go home. It is all about setting your own priorities and not letting the job take over your life.”
Associations have a role to play, too. The ASGE Technology Committee reported in 2010 that up to 89% of GIs suffer musculoskeletal injuries from manipulating scopes. Colonoscopist’s thumb (left thumb tendonitis) and metacarpophalangeal joint strain were the most common injuries.
“Risk factors are part of our work,” said Mehnaz Shafi, MD, AGAF, professor of gastroenterology, hepatology and nutrition at the University of Texas MD Anderson Cancer Center, Houston. “Pinching, pushing, pulling, and awkward positions are part of what we do. This is an injury with consequences.”
Dr. Shafi chairs the AGA Task Force on Ergonomics. The group has recommended changes to endoscopic work stations that minimize injury. The most important changes include mounting monitors on flexible stands to accommodate GIs of all heights, adding straps to the control head to allow the fingers to relax, providing ergonomic training to all GIs and using patient beds that can be raised and lowered to accommodate both tall and short GIs.
“Shaping your career is one of the key principles in preventing burnout,” said Arthur DeCross, MD, AGAF, professor of medicine, gastroenterology and hepatology at the University of Rochester Medical Center, N.Y. “We know that more than half of gastroenterologists self-identify as being burned out. And one of the major contributors to burnout is lack of control over your work environment, your career, your colleagues. Taking control of your career can make a difference.”
Taking control can be particularly important for women. An AGA burnout survey in 2015 found that 51% of male GIs reported burnout versus 62% of female GIs.
One reason is women’s tendency to negotiate poorly on their own behalf, said Marie-Pier Tétreault, PhD, assistant professor of gastroenterology and hepatology at Northwestern University Feinberg School of Medicine, Chicago.
“It’s a matter of attitude,” she explained. “Men tend to believe they can and should make life happen. Women tend to believe that what you see is what you get. Even when women do negotiate, they tend to ask for 15%-30% less than their male colleagues. If you don’t ask, you won’t get.”
Simply taking the lead in negotiations can improve the outcome, she continued. Network with colleagues and mentors to find the appropriate ranges for salaries, benefits, and perks such as parking, spousal job opportunities, facilities and space, teaching expectations, administrative support, and more.
AGA honors GI Congressional champions Sen. Bill Cassidy and Rep. Mike Thompson
During Digestive Disease Week® (DDW) this year the AGA Political Action Committee (PAC) honored Sen. Bill Cassidy, R-La., and Rep. Mike Thompson, D-Calif., for their support over the years in advancing the science and practice of gastroenterology on Capitol Hill.
Cassidy has been instrumental in passing legislation that reformed the broken sustainable growth rate (SGR) formula and transitioned physicians to more value-based payments in the Medicare Access and Chip Reauthorization Act (MACRA). Cassidy was particularly helpful in creating a pathway for specialty physician–focused payment models and was helpful to AGA in communicating with the Centers for Medicare & Medicaid Services (CMS) about the need for specialty-driven health care models. Cassidy also championed our transparency campaign when the GI codes were being reevaluated and because of his help, CMS reformed the way they announce changes to the fee schedule and now provide notice so that stakeholders are able to participate in the process. Cassidy has also been a strong proponent in providing more transparency across our health care system and helping to provide regulatory relief to physicians, especially in the area of electronic health records.
Thompson has been a champion for GIs and our patients by supporting efforts to increase access to colorectal cancer screenings. He is a cosponsor of Removing Barriers to the Colorectal Cancer Screening Act, legislation that would correct the problem of requiring patients to pay a copay when a screening colonoscopy turns therapeutic. He also played a key role in AGA’s efforts to require CMS to change its fee setting system to one that is more transparent and provides stakeholders such as AGA the opportunity to participate more meaningfully in the process. Thompson signed onto two key letters to CMS calling on the agency to change its system to a more transparent one and to heed stakeholder input into the process. He has also been a strong supporter of meaningful funding increases for the National Institutes of Health.
During Digestive Disease Week® (DDW) this year the AGA Political Action Committee (PAC) honored Sen. Bill Cassidy, R-La., and Rep. Mike Thompson, D-Calif., for their support over the years in advancing the science and practice of gastroenterology on Capitol Hill.
Cassidy has been instrumental in passing legislation that reformed the broken sustainable growth rate (SGR) formula and transitioned physicians to more value-based payments in the Medicare Access and Chip Reauthorization Act (MACRA). Cassidy was particularly helpful in creating a pathway for specialty physician–focused payment models and was helpful to AGA in communicating with the Centers for Medicare & Medicaid Services (CMS) about the need for specialty-driven health care models. Cassidy also championed our transparency campaign when the GI codes were being reevaluated and because of his help, CMS reformed the way they announce changes to the fee schedule and now provide notice so that stakeholders are able to participate in the process. Cassidy has also been a strong proponent in providing more transparency across our health care system and helping to provide regulatory relief to physicians, especially in the area of electronic health records.
Thompson has been a champion for GIs and our patients by supporting efforts to increase access to colorectal cancer screenings. He is a cosponsor of Removing Barriers to the Colorectal Cancer Screening Act, legislation that would correct the problem of requiring patients to pay a copay when a screening colonoscopy turns therapeutic. He also played a key role in AGA’s efforts to require CMS to change its fee setting system to one that is more transparent and provides stakeholders such as AGA the opportunity to participate more meaningfully in the process. Thompson signed onto two key letters to CMS calling on the agency to change its system to a more transparent one and to heed stakeholder input into the process. He has also been a strong supporter of meaningful funding increases for the National Institutes of Health.
During Digestive Disease Week® (DDW) this year the AGA Political Action Committee (PAC) honored Sen. Bill Cassidy, R-La., and Rep. Mike Thompson, D-Calif., for their support over the years in advancing the science and practice of gastroenterology on Capitol Hill.
Cassidy has been instrumental in passing legislation that reformed the broken sustainable growth rate (SGR) formula and transitioned physicians to more value-based payments in the Medicare Access and Chip Reauthorization Act (MACRA). Cassidy was particularly helpful in creating a pathway for specialty physician–focused payment models and was helpful to AGA in communicating with the Centers for Medicare & Medicaid Services (CMS) about the need for specialty-driven health care models. Cassidy also championed our transparency campaign when the GI codes were being reevaluated and because of his help, CMS reformed the way they announce changes to the fee schedule and now provide notice so that stakeholders are able to participate in the process. Cassidy has also been a strong proponent in providing more transparency across our health care system and helping to provide regulatory relief to physicians, especially in the area of electronic health records.
Thompson has been a champion for GIs and our patients by supporting efforts to increase access to colorectal cancer screenings. He is a cosponsor of Removing Barriers to the Colorectal Cancer Screening Act, legislation that would correct the problem of requiring patients to pay a copay when a screening colonoscopy turns therapeutic. He also played a key role in AGA’s efforts to require CMS to change its fee setting system to one that is more transparent and provides stakeholders such as AGA the opportunity to participate more meaningfully in the process. Thompson signed onto two key letters to CMS calling on the agency to change its system to a more transparent one and to heed stakeholder input into the process. He has also been a strong supporter of meaningful funding increases for the National Institutes of Health.
Current and future applications of telemedicine to optimize the delivery of care in chronic liver disease
Telemedicine is defined broadly by the World Health Organization as the delivery of health care services at a distance using electronic means for “the diagnosis of treatment, and prevention of disease and injuries, research and evaluation, education of health care providers”1 to improve health. Although no single accepted definition exists, telehealth often is used as the umbrella term to encompass telemedicine (health care delivery) in addition to other activities such as education, research, health surveillance, and public health promotion.2 These various terms often are used interchangeably throughout the literature, leading to confusion.1,3 For the purpose of this review, we will use the term telemedicine to describe any care delivery model whereby patient care is provided at a distance using information technology such as cellphones, computers, or other electronic devices.
In the United States, the use of telemedicine is increasing. According to a 2017 survey of 184 health care executives conducted by the American Telemedicine Association, 88% believed that they would invest in telehealth in the near future, 98% believed that it offered a competitive advantage, with the caveat that 71% believed that lack of coverage and payments were barriers to implementation. Recent studies have shown that telehealth interventions are effective at improving clinical outcomes and decreasing inpatient utilization, with good patient satisfaction in the areas of mental health and chronic disease management. The Veterans Administration has emerged as an early telehealth adopter in chronic disease settings such as mental health, dermatology, hypertension, heart failure, and, as of 2016, has provided care to nearly 700,000 (12%) veterans since its inception.4-6 Despite the increased uptake, significant infrastructure and legal barriers to telemedicine remain and the literature regarding its utility in clinical practice continues to emerge.
Compared with other chronic diseases (e.g., heart failure, diabetes, mental illness) there is a dearth of literature on the use of telemedicine in liver disease. The first portion of this review synthesizes currently published literature of telemedicine/telehealth interventions to improve health care delivery and health outcomes in chronic liver disease including published peer-reviewed articles, abstracts, and ongoing clinical trials. The second portion discusses a framework for the future development of telemedicine and its integration into clinical practice by citing examples currently used throughout the country as well as ways to overcome implementation barriers.
Use of telemedicine in chronic liver disease: A literature review
We performed a systematic review of telemedicine in chronic liver disease. In consultation with a biomedical librarian, we searched for English-language articles for relevant studies with adult participants from July 1984 to May 2017 in PubMed, OVID Medline, American Association for the Study of Liver Disease, EMBASE, Web of Science, ClinicalTrials.gov, Elsevier/Science Direct, and the Cochrane Library (the search strategy is shown in the Supplementary Material at https://doi.org/10.1016/j.cgh.2017.10.004). The references of original publications and of review articles additionally were screened for potentially relevant studies. Abstracts that later resulted in no publications and studies in which telemedicine was used to deliver care, but was neither an exposure nor outcome, were excluded. Social media studies were not considered telemedicine if no patient care was involved. Studies of purely medical education interventions or those that evaluated the accuracy of technology to aid in diagnosis also were excluded.
Supplementary Table 1 (https://doi.org/10.1016/j.cgh.2017.10.004) shows the 20 published articles of telemedicine studies. Among these, there were 9 prospective trials, 3 retrospective studies, 2 case reports, and 6 small case series. One of the studies was randomized prospectively and 10 were uncontrolled.
Telemedicine in hepatitis C treatment
Telemedicine to aid in procedural/surgical management
A few reports have been published in the use of synchronous video and digital technology to aid in periprocedural management in liver disease. A case report highlighted a successful example of gastroenterologist-led teleproctoring using basic video technology to enable a surgeon to perform sclerotherapy for hemostasis in the setting of a variceal bleed.9 Another case report described the transmission of smart phone images from surgical trainees to an attending physician to make a real-time decision regarding a possibly questionable liver procurement, which took place 545 km away from the university hospital.10 A retrospective case series described the feasibility and successful use of high-resolution digital macroscopic photography and electronic transmission between liver transplant centers in the United Kingdom to increase the utilization of split liver transplantation, a setting in which detailed knowledge of vessel anatomy is needed for advanced surgical planning.11 Similarly, an uncontrolled case series from Greece reported on the feasibility and reliability of macroscopic image transmission to aid in the evaluation of liver grafts for transplantation.12
Telemedicine to support evaluation and management of hepatocellular carcinoma
One recent abstract reported on the use of asynchronous store-and-forward telemedicine for screening and management of hepatocellular carcinoma and evaluated process outcomes of specialty care access for newly diagnosed patients.13 A multifaceted approach included live video teleconferencing and centralized radiology review, which was conducted by a multidisciplinary tumor board at an expert hub site, which provided expert opinion and subsequent care (e.g., locoregional therapy, liver transplant evaluation) to spoke sites. As a result of the initiative, the time to specialty evaluation and receipt of hepatocellular carcinoma therapy decreased by 23 and 25 days, respectively.
Remote monitoring interventions
Proposed framework for advancing telemedicine in liver disease: The case for more research and policy changes
Telemedicine can serve two main goals in liver disease: improve access to specialty care, and improve care between visits. For the first goal, the technology is straightforward and limited research is required; the main barriers are regulatory and reimbursement. As an example, one of the authors (M.L.V.) uses telemedicine to perform liver transplant evaluations in Las Vegas, N.V., a state without a liver transplant program. Patients are seen initially by a nurse practitioner who resides in Las Vegas, and those patients needing transplant evaluation are scheduled for a video visit with the attending physician who is physically in California. This works well and patients love it; however, the business model is dependent on the downstream financial incentive of transplantation. In addition, various regulatory requirements must be satisfied such as monthly in-person visits. For the second goal, a number of exciting possibilities exist such as remote monitoring and patient disease management, but more research is needed.
Research
According to the Pew Research Center, 95% of American adults own a cellphone and 77% own a smartphone. These devices passively gather an extraordinary amount of data that could be harnessed to identify early warning signs of complications (remote monitoring). Another potentially fruitful area of research is patient disease management. This includes using technology (e.g., reminder texts) to effect behavior change such as with medication adherence, lifestyle modification, education, or peer mentoring. As an example, the coauthor (M.S.) is leading a study to promote physical activity among liver transplant recipients by using an online web portal developed by researchers at the University of Pennsylvania (Way to Health), which interfaces with patient cell phones and digital accelerometer devices. Participants receive daily feedback through text messages with their step counts, and small financial incentives are provided for adequate levels of physical activity. Technology also can facilitate the development of disease management platforms, which could improve both access and in-between visit monitoring, especially in remote areas. One of the authors (M.L.V.) currently is leading the development of a remote disease management program with funding from the American Association for the Study of Liver Diseases.
Despite the tremendous promise, traditional research methods in telemedicine may be challenging given the rapid and increasing uptake of health technology among patients and health systems. As such, the classic paradigm of randomized controlled trials to evaluate the success of an intervention or change in care delivery often is not feasible. We believe there is a need to recalibrate the definition of what constitutes a high-quality telemedicine study. For example, pragmatic trials and those designed within an implementation science framework that evaluate feasibility, scalability, and cost, in parallel with traditional clinical outcomes, may be better suited and should be accepted more widely.17
Policy
Even when the technology is available and research shows efficacy, the implementation of telemedicine in clinical practice faces regulatory and reimbursement barriers. The first regulatory question is whether a patient–provider relationship is being established (with the exception of limited provider–provider curbside consultation, the answer usually is yes). If so, the practice then is subject to all the usual regulatory concerns. The provider needs to be licensed at the site of origin (where the patient is located) and hold malpractice coverage for that location, and the video and medical record transmission should be compliant with the Health Insurance Portability and Accountability Act. The next challenge is reimbursement. Medicare only pays for video consultation if the patient lives in a designated rural Health Professional Shortage Area (www.cms.gov), and reimbursement by private payers varies. Even this is dependent on ever-changing state laws. Reimbursement for remote patient monitoring is even more limited (the National Telehealth Policy Research Center publishes a useful handbook: http://www.cchpca.org/sites/default/files/resources/50%20State%20FINAL%20April%202016.pdf). Absent a bipartisan Congressional effort to remedy this situation, the best hope for removing reimbursement barriers lies with payment reform. The Medicare Access and CHIP Reauthorization Act of 2015 mandates that the Centers for Medicare and Medicaid Services shift from fee-for-service to alternative payment models in the coming years. In these alternate payment models, providers are responsible for the overall quality and total cost of care for a population of patients. In this scenario, there may be a financial incentive for telemedicine, especially remote monitoring, to keep patients out of the hospital. Until then, under current payment models, reimbursement is limited and the barriers to widespread implementation are high.
Conclusions
Telemedicine has continued to increase in uptake and shows tremendous promise in expanding access to health care, promoting patient disease management, and facilitating in-between health care visit monitoring. Although the future is bright, more research is needed to determine optimal ways to integrate telemedicine — especially remote monitoring — into routine clinical care. We call on our specialty societies to send a clear political advocacy message that policy changes are needed to overcome regulatory and reimbursement challenges.
Acknowledgments
The authors would like to thank Lauren Jones and Mackenzie McDougal for their assistance with the literature review.
Supplementary materials and methods
The telemedicine interventions PubMed literature search strategy was as follows: ((“liver diseases”[MeSH Terms] OR (“liver”[All Fields] AND “diseases”[All Fields]) OR “liver diseases”[All Fields] OR (“liver”[All Fields] AND “disease”[All Fields]) OR “liver disease”[All Fields] OR liver dysfunction OR liver dysfunctions)) OR “liver transplantation”[MeSH Terms] OR “liver transplantation” [All Fields] AND (((“telemedicine”[MeSH Terms] OR “telemedicine”[All Fields] OR mobile health OR mhealth OR telehealth OR mhealth)) OR (videoconferencing OR videoconference)).
References
1. Kirsh S., Su G.L., Sales A., et al. Access to outpatient specialty care: solutions from an integrated health care system. Am J Med Qual. 2015;30:88-90.
2. Wilson L.S., Maeder A.J. recent directions in telemedicine: review of trends in research and practice. Healthc Inform Res. 2015;21:213-22.
3. Cross R.K., Kane, S. Integration of telemedicine into clinical gastroenterology and hepatology practice. Clin Gastroenterol Hepatol. 2017;15:175-81.
4. Darkins A., Ryan P., Kobb R., et al. Care coordination/home telehealth: the systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions. Telemed J E Health. 2008;14:1118-26.
5. Tuerk P.W., Fortney J., Bosworth H.B., et al. Toward the development of national telehealth services: the role of Veterans Health Administration and future directions for research. Telemed J E Health. 2010;16:115-7.
6. VA Press Release. Available: https://www.va.gov/opa/pressrel/includes/viewPDF.cfm?id=2789. Accessed: July 27, 2017.
7. Arora S., Kalishman S., Thornton K., et al. Expanding access to hepatitis C virus treatment-extension for Community Healthcare Outcomes (ECHO) project: disruptive innovation in specialty care. Hepatology. 2010;52:1124-33.
8. Mitruka K., Thornton K., Cusick S., et al. Expanding primary care capacity to treat hepatitis C virus infection through an evidence-based care model–Arizona and Utah, 2012-2014. MMWR Morb Mortal Wkly Rep. 2014;63:393-8.
9. Ahmed A., Slosberg E., Prasad P., et al. The successful use of telemedicine in acute variceal hemorrhage. J Clin Gastroenterol. 1999;29:212-3.
10. Croome K.P., Shum J., Al-Basheer M.A., et al. The benefit of smart phone usage in liver organ procurement. J Telemed Telecare. 2011;17:158-60.
11. Bhati C.S., Wigmore S.J., Reddy S., et al. Web-based image transmission: a novel approach to aid communication in split liver transplantation. Clin Transplant. 2010;24:98-103.
12. Mammas C.S., Geropoulos S., Saatsakis G., et al. Telepathology as a method to optimize quality in organ transplantation: a feasibility and reliability study of the virtual benching of liver graft. Stud Health Technol Inform. 2013;190:276-8.
13. Egert E.M., et al. A regional multidisciplinary liver tumor board improves access to hepatocellular carcinoma treatment for patients geographically distant from tertiary medical center. Hepatology. 2015;62:469A
14. Thomson M., Volk M., Kim H.M., et al. An automated telephone monitoring system to identify patients with cirrhosis at risk of re-hospitalization. Dig Dis Sci. 2015;60:3563-9.
15. Ertel A.E., Kaiser T.E., Abbott D.E., et al. Use of video-based education and tele-health home monitoring after liver transplantation: results of a novel pilot study. Surgery. 2016;160:869-76.
16. Thygesen G.B., Andersen H., Damsgaard B.S. et al. The effect of nurse performed telemedical video consultations for patients suffering from alcohol-related liver cirrhosis. J Hepatol. 2017;66:S349
17. Proctor E., Silmere H., Raghavan R. et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health. 2011;38:65-76.
Dr. Serper is in the division of gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, and the department of medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia; Dr. Volk is in the division of gastroenterology and Transplantation Institute, Loma Linda University, Loma Linda, Calif. The authors disclose no conflicts.
Telemedicine is defined broadly by the World Health Organization as the delivery of health care services at a distance using electronic means for “the diagnosis of treatment, and prevention of disease and injuries, research and evaluation, education of health care providers”1 to improve health. Although no single accepted definition exists, telehealth often is used as the umbrella term to encompass telemedicine (health care delivery) in addition to other activities such as education, research, health surveillance, and public health promotion.2 These various terms often are used interchangeably throughout the literature, leading to confusion.1,3 For the purpose of this review, we will use the term telemedicine to describe any care delivery model whereby patient care is provided at a distance using information technology such as cellphones, computers, or other electronic devices.
In the United States, the use of telemedicine is increasing. According to a 2017 survey of 184 health care executives conducted by the American Telemedicine Association, 88% believed that they would invest in telehealth in the near future, 98% believed that it offered a competitive advantage, with the caveat that 71% believed that lack of coverage and payments were barriers to implementation. Recent studies have shown that telehealth interventions are effective at improving clinical outcomes and decreasing inpatient utilization, with good patient satisfaction in the areas of mental health and chronic disease management. The Veterans Administration has emerged as an early telehealth adopter in chronic disease settings such as mental health, dermatology, hypertension, heart failure, and, as of 2016, has provided care to nearly 700,000 (12%) veterans since its inception.4-6 Despite the increased uptake, significant infrastructure and legal barriers to telemedicine remain and the literature regarding its utility in clinical practice continues to emerge.
Compared with other chronic diseases (e.g., heart failure, diabetes, mental illness) there is a dearth of literature on the use of telemedicine in liver disease. The first portion of this review synthesizes currently published literature of telemedicine/telehealth interventions to improve health care delivery and health outcomes in chronic liver disease including published peer-reviewed articles, abstracts, and ongoing clinical trials. The second portion discusses a framework for the future development of telemedicine and its integration into clinical practice by citing examples currently used throughout the country as well as ways to overcome implementation barriers.
Use of telemedicine in chronic liver disease: A literature review
We performed a systematic review of telemedicine in chronic liver disease. In consultation with a biomedical librarian, we searched for English-language articles for relevant studies with adult participants from July 1984 to May 2017 in PubMed, OVID Medline, American Association for the Study of Liver Disease, EMBASE, Web of Science, ClinicalTrials.gov, Elsevier/Science Direct, and the Cochrane Library (the search strategy is shown in the Supplementary Material at https://doi.org/10.1016/j.cgh.2017.10.004). The references of original publications and of review articles additionally were screened for potentially relevant studies. Abstracts that later resulted in no publications and studies in which telemedicine was used to deliver care, but was neither an exposure nor outcome, were excluded. Social media studies were not considered telemedicine if no patient care was involved. Studies of purely medical education interventions or those that evaluated the accuracy of technology to aid in diagnosis also were excluded.
Supplementary Table 1 (https://doi.org/10.1016/j.cgh.2017.10.004) shows the 20 published articles of telemedicine studies. Among these, there were 9 prospective trials, 3 retrospective studies, 2 case reports, and 6 small case series. One of the studies was randomized prospectively and 10 were uncontrolled.
Telemedicine in hepatitis C treatment
Telemedicine to aid in procedural/surgical management
A few reports have been published in the use of synchronous video and digital technology to aid in periprocedural management in liver disease. A case report highlighted a successful example of gastroenterologist-led teleproctoring using basic video technology to enable a surgeon to perform sclerotherapy for hemostasis in the setting of a variceal bleed.9 Another case report described the transmission of smart phone images from surgical trainees to an attending physician to make a real-time decision regarding a possibly questionable liver procurement, which took place 545 km away from the university hospital.10 A retrospective case series described the feasibility and successful use of high-resolution digital macroscopic photography and electronic transmission between liver transplant centers in the United Kingdom to increase the utilization of split liver transplantation, a setting in which detailed knowledge of vessel anatomy is needed for advanced surgical planning.11 Similarly, an uncontrolled case series from Greece reported on the feasibility and reliability of macroscopic image transmission to aid in the evaluation of liver grafts for transplantation.12
Telemedicine to support evaluation and management of hepatocellular carcinoma
One recent abstract reported on the use of asynchronous store-and-forward telemedicine for screening and management of hepatocellular carcinoma and evaluated process outcomes of specialty care access for newly diagnosed patients.13 A multifaceted approach included live video teleconferencing and centralized radiology review, which was conducted by a multidisciplinary tumor board at an expert hub site, which provided expert opinion and subsequent care (e.g., locoregional therapy, liver transplant evaluation) to spoke sites. As a result of the initiative, the time to specialty evaluation and receipt of hepatocellular carcinoma therapy decreased by 23 and 25 days, respectively.
Remote monitoring interventions
Proposed framework for advancing telemedicine in liver disease: The case for more research and policy changes
Telemedicine can serve two main goals in liver disease: improve access to specialty care, and improve care between visits. For the first goal, the technology is straightforward and limited research is required; the main barriers are regulatory and reimbursement. As an example, one of the authors (M.L.V.) uses telemedicine to perform liver transplant evaluations in Las Vegas, N.V., a state without a liver transplant program. Patients are seen initially by a nurse practitioner who resides in Las Vegas, and those patients needing transplant evaluation are scheduled for a video visit with the attending physician who is physically in California. This works well and patients love it; however, the business model is dependent on the downstream financial incentive of transplantation. In addition, various regulatory requirements must be satisfied such as monthly in-person visits. For the second goal, a number of exciting possibilities exist such as remote monitoring and patient disease management, but more research is needed.
Research
According to the Pew Research Center, 95% of American adults own a cellphone and 77% own a smartphone. These devices passively gather an extraordinary amount of data that could be harnessed to identify early warning signs of complications (remote monitoring). Another potentially fruitful area of research is patient disease management. This includes using technology (e.g., reminder texts) to effect behavior change such as with medication adherence, lifestyle modification, education, or peer mentoring. As an example, the coauthor (M.S.) is leading a study to promote physical activity among liver transplant recipients by using an online web portal developed by researchers at the University of Pennsylvania (Way to Health), which interfaces with patient cell phones and digital accelerometer devices. Participants receive daily feedback through text messages with their step counts, and small financial incentives are provided for adequate levels of physical activity. Technology also can facilitate the development of disease management platforms, which could improve both access and in-between visit monitoring, especially in remote areas. One of the authors (M.L.V.) currently is leading the development of a remote disease management program with funding from the American Association for the Study of Liver Diseases.
Despite the tremendous promise, traditional research methods in telemedicine may be challenging given the rapid and increasing uptake of health technology among patients and health systems. As such, the classic paradigm of randomized controlled trials to evaluate the success of an intervention or change in care delivery often is not feasible. We believe there is a need to recalibrate the definition of what constitutes a high-quality telemedicine study. For example, pragmatic trials and those designed within an implementation science framework that evaluate feasibility, scalability, and cost, in parallel with traditional clinical outcomes, may be better suited and should be accepted more widely.17
Policy
Even when the technology is available and research shows efficacy, the implementation of telemedicine in clinical practice faces regulatory and reimbursement barriers. The first regulatory question is whether a patient–provider relationship is being established (with the exception of limited provider–provider curbside consultation, the answer usually is yes). If so, the practice then is subject to all the usual regulatory concerns. The provider needs to be licensed at the site of origin (where the patient is located) and hold malpractice coverage for that location, and the video and medical record transmission should be compliant with the Health Insurance Portability and Accountability Act. The next challenge is reimbursement. Medicare only pays for video consultation if the patient lives in a designated rural Health Professional Shortage Area (www.cms.gov), and reimbursement by private payers varies. Even this is dependent on ever-changing state laws. Reimbursement for remote patient monitoring is even more limited (the National Telehealth Policy Research Center publishes a useful handbook: http://www.cchpca.org/sites/default/files/resources/50%20State%20FINAL%20April%202016.pdf). Absent a bipartisan Congressional effort to remedy this situation, the best hope for removing reimbursement barriers lies with payment reform. The Medicare Access and CHIP Reauthorization Act of 2015 mandates that the Centers for Medicare and Medicaid Services shift from fee-for-service to alternative payment models in the coming years. In these alternate payment models, providers are responsible for the overall quality and total cost of care for a population of patients. In this scenario, there may be a financial incentive for telemedicine, especially remote monitoring, to keep patients out of the hospital. Until then, under current payment models, reimbursement is limited and the barriers to widespread implementation are high.
Conclusions
Telemedicine has continued to increase in uptake and shows tremendous promise in expanding access to health care, promoting patient disease management, and facilitating in-between health care visit monitoring. Although the future is bright, more research is needed to determine optimal ways to integrate telemedicine — especially remote monitoring — into routine clinical care. We call on our specialty societies to send a clear political advocacy message that policy changes are needed to overcome regulatory and reimbursement challenges.
Acknowledgments
The authors would like to thank Lauren Jones and Mackenzie McDougal for their assistance with the literature review.
Supplementary materials and methods
The telemedicine interventions PubMed literature search strategy was as follows: ((“liver diseases”[MeSH Terms] OR (“liver”[All Fields] AND “diseases”[All Fields]) OR “liver diseases”[All Fields] OR (“liver”[All Fields] AND “disease”[All Fields]) OR “liver disease”[All Fields] OR liver dysfunction OR liver dysfunctions)) OR “liver transplantation”[MeSH Terms] OR “liver transplantation” [All Fields] AND (((“telemedicine”[MeSH Terms] OR “telemedicine”[All Fields] OR mobile health OR mhealth OR telehealth OR mhealth)) OR (videoconferencing OR videoconference)).
References
1. Kirsh S., Su G.L., Sales A., et al. Access to outpatient specialty care: solutions from an integrated health care system. Am J Med Qual. 2015;30:88-90.
2. Wilson L.S., Maeder A.J. recent directions in telemedicine: review of trends in research and practice. Healthc Inform Res. 2015;21:213-22.
3. Cross R.K., Kane, S. Integration of telemedicine into clinical gastroenterology and hepatology practice. Clin Gastroenterol Hepatol. 2017;15:175-81.
4. Darkins A., Ryan P., Kobb R., et al. Care coordination/home telehealth: the systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions. Telemed J E Health. 2008;14:1118-26.
5. Tuerk P.W., Fortney J., Bosworth H.B., et al. Toward the development of national telehealth services: the role of Veterans Health Administration and future directions for research. Telemed J E Health. 2010;16:115-7.
6. VA Press Release. Available: https://www.va.gov/opa/pressrel/includes/viewPDF.cfm?id=2789. Accessed: July 27, 2017.
7. Arora S., Kalishman S., Thornton K., et al. Expanding access to hepatitis C virus treatment-extension for Community Healthcare Outcomes (ECHO) project: disruptive innovation in specialty care. Hepatology. 2010;52:1124-33.
8. Mitruka K., Thornton K., Cusick S., et al. Expanding primary care capacity to treat hepatitis C virus infection through an evidence-based care model–Arizona and Utah, 2012-2014. MMWR Morb Mortal Wkly Rep. 2014;63:393-8.
9. Ahmed A., Slosberg E., Prasad P., et al. The successful use of telemedicine in acute variceal hemorrhage. J Clin Gastroenterol. 1999;29:212-3.
10. Croome K.P., Shum J., Al-Basheer M.A., et al. The benefit of smart phone usage in liver organ procurement. J Telemed Telecare. 2011;17:158-60.
11. Bhati C.S., Wigmore S.J., Reddy S., et al. Web-based image transmission: a novel approach to aid communication in split liver transplantation. Clin Transplant. 2010;24:98-103.
12. Mammas C.S., Geropoulos S., Saatsakis G., et al. Telepathology as a method to optimize quality in organ transplantation: a feasibility and reliability study of the virtual benching of liver graft. Stud Health Technol Inform. 2013;190:276-8.
13. Egert E.M., et al. A regional multidisciplinary liver tumor board improves access to hepatocellular carcinoma treatment for patients geographically distant from tertiary medical center. Hepatology. 2015;62:469A
14. Thomson M., Volk M., Kim H.M., et al. An automated telephone monitoring system to identify patients with cirrhosis at risk of re-hospitalization. Dig Dis Sci. 2015;60:3563-9.
15. Ertel A.E., Kaiser T.E., Abbott D.E., et al. Use of video-based education and tele-health home monitoring after liver transplantation: results of a novel pilot study. Surgery. 2016;160:869-76.
16. Thygesen G.B., Andersen H., Damsgaard B.S. et al. The effect of nurse performed telemedical video consultations for patients suffering from alcohol-related liver cirrhosis. J Hepatol. 2017;66:S349
17. Proctor E., Silmere H., Raghavan R. et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health. 2011;38:65-76.
Dr. Serper is in the division of gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, and the department of medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia; Dr. Volk is in the division of gastroenterology and Transplantation Institute, Loma Linda University, Loma Linda, Calif. The authors disclose no conflicts.
Telemedicine is defined broadly by the World Health Organization as the delivery of health care services at a distance using electronic means for “the diagnosis of treatment, and prevention of disease and injuries, research and evaluation, education of health care providers”1 to improve health. Although no single accepted definition exists, telehealth often is used as the umbrella term to encompass telemedicine (health care delivery) in addition to other activities such as education, research, health surveillance, and public health promotion.2 These various terms often are used interchangeably throughout the literature, leading to confusion.1,3 For the purpose of this review, we will use the term telemedicine to describe any care delivery model whereby patient care is provided at a distance using information technology such as cellphones, computers, or other electronic devices.
In the United States, the use of telemedicine is increasing. According to a 2017 survey of 184 health care executives conducted by the American Telemedicine Association, 88% believed that they would invest in telehealth in the near future, 98% believed that it offered a competitive advantage, with the caveat that 71% believed that lack of coverage and payments were barriers to implementation. Recent studies have shown that telehealth interventions are effective at improving clinical outcomes and decreasing inpatient utilization, with good patient satisfaction in the areas of mental health and chronic disease management. The Veterans Administration has emerged as an early telehealth adopter in chronic disease settings such as mental health, dermatology, hypertension, heart failure, and, as of 2016, has provided care to nearly 700,000 (12%) veterans since its inception.4-6 Despite the increased uptake, significant infrastructure and legal barriers to telemedicine remain and the literature regarding its utility in clinical practice continues to emerge.
Compared with other chronic diseases (e.g., heart failure, diabetes, mental illness) there is a dearth of literature on the use of telemedicine in liver disease. The first portion of this review synthesizes currently published literature of telemedicine/telehealth interventions to improve health care delivery and health outcomes in chronic liver disease including published peer-reviewed articles, abstracts, and ongoing clinical trials. The second portion discusses a framework for the future development of telemedicine and its integration into clinical practice by citing examples currently used throughout the country as well as ways to overcome implementation barriers.
Use of telemedicine in chronic liver disease: A literature review
We performed a systematic review of telemedicine in chronic liver disease. In consultation with a biomedical librarian, we searched for English-language articles for relevant studies with adult participants from July 1984 to May 2017 in PubMed, OVID Medline, American Association for the Study of Liver Disease, EMBASE, Web of Science, ClinicalTrials.gov, Elsevier/Science Direct, and the Cochrane Library (the search strategy is shown in the Supplementary Material at https://doi.org/10.1016/j.cgh.2017.10.004). The references of original publications and of review articles additionally were screened for potentially relevant studies. Abstracts that later resulted in no publications and studies in which telemedicine was used to deliver care, but was neither an exposure nor outcome, were excluded. Social media studies were not considered telemedicine if no patient care was involved. Studies of purely medical education interventions or those that evaluated the accuracy of technology to aid in diagnosis also were excluded.
Supplementary Table 1 (https://doi.org/10.1016/j.cgh.2017.10.004) shows the 20 published articles of telemedicine studies. Among these, there were 9 prospective trials, 3 retrospective studies, 2 case reports, and 6 small case series. One of the studies was randomized prospectively and 10 were uncontrolled.
Telemedicine in hepatitis C treatment
Telemedicine to aid in procedural/surgical management
A few reports have been published in the use of synchronous video and digital technology to aid in periprocedural management in liver disease. A case report highlighted a successful example of gastroenterologist-led teleproctoring using basic video technology to enable a surgeon to perform sclerotherapy for hemostasis in the setting of a variceal bleed.9 Another case report described the transmission of smart phone images from surgical trainees to an attending physician to make a real-time decision regarding a possibly questionable liver procurement, which took place 545 km away from the university hospital.10 A retrospective case series described the feasibility and successful use of high-resolution digital macroscopic photography and electronic transmission between liver transplant centers in the United Kingdom to increase the utilization of split liver transplantation, a setting in which detailed knowledge of vessel anatomy is needed for advanced surgical planning.11 Similarly, an uncontrolled case series from Greece reported on the feasibility and reliability of macroscopic image transmission to aid in the evaluation of liver grafts for transplantation.12
Telemedicine to support evaluation and management of hepatocellular carcinoma
One recent abstract reported on the use of asynchronous store-and-forward telemedicine for screening and management of hepatocellular carcinoma and evaluated process outcomes of specialty care access for newly diagnosed patients.13 A multifaceted approach included live video teleconferencing and centralized radiology review, which was conducted by a multidisciplinary tumor board at an expert hub site, which provided expert opinion and subsequent care (e.g., locoregional therapy, liver transplant evaluation) to spoke sites. As a result of the initiative, the time to specialty evaluation and receipt of hepatocellular carcinoma therapy decreased by 23 and 25 days, respectively.
Remote monitoring interventions
Proposed framework for advancing telemedicine in liver disease: The case for more research and policy changes
Telemedicine can serve two main goals in liver disease: improve access to specialty care, and improve care between visits. For the first goal, the technology is straightforward and limited research is required; the main barriers are regulatory and reimbursement. As an example, one of the authors (M.L.V.) uses telemedicine to perform liver transplant evaluations in Las Vegas, N.V., a state without a liver transplant program. Patients are seen initially by a nurse practitioner who resides in Las Vegas, and those patients needing transplant evaluation are scheduled for a video visit with the attending physician who is physically in California. This works well and patients love it; however, the business model is dependent on the downstream financial incentive of transplantation. In addition, various regulatory requirements must be satisfied such as monthly in-person visits. For the second goal, a number of exciting possibilities exist such as remote monitoring and patient disease management, but more research is needed.
Research
According to the Pew Research Center, 95% of American adults own a cellphone and 77% own a smartphone. These devices passively gather an extraordinary amount of data that could be harnessed to identify early warning signs of complications (remote monitoring). Another potentially fruitful area of research is patient disease management. This includes using technology (e.g., reminder texts) to effect behavior change such as with medication adherence, lifestyle modification, education, or peer mentoring. As an example, the coauthor (M.S.) is leading a study to promote physical activity among liver transplant recipients by using an online web portal developed by researchers at the University of Pennsylvania (Way to Health), which interfaces with patient cell phones and digital accelerometer devices. Participants receive daily feedback through text messages with their step counts, and small financial incentives are provided for adequate levels of physical activity. Technology also can facilitate the development of disease management platforms, which could improve both access and in-between visit monitoring, especially in remote areas. One of the authors (M.L.V.) currently is leading the development of a remote disease management program with funding from the American Association for the Study of Liver Diseases.
Despite the tremendous promise, traditional research methods in telemedicine may be challenging given the rapid and increasing uptake of health technology among patients and health systems. As such, the classic paradigm of randomized controlled trials to evaluate the success of an intervention or change in care delivery often is not feasible. We believe there is a need to recalibrate the definition of what constitutes a high-quality telemedicine study. For example, pragmatic trials and those designed within an implementation science framework that evaluate feasibility, scalability, and cost, in parallel with traditional clinical outcomes, may be better suited and should be accepted more widely.17
Policy
Even when the technology is available and research shows efficacy, the implementation of telemedicine in clinical practice faces regulatory and reimbursement barriers. The first regulatory question is whether a patient–provider relationship is being established (with the exception of limited provider–provider curbside consultation, the answer usually is yes). If so, the practice then is subject to all the usual regulatory concerns. The provider needs to be licensed at the site of origin (where the patient is located) and hold malpractice coverage for that location, and the video and medical record transmission should be compliant with the Health Insurance Portability and Accountability Act. The next challenge is reimbursement. Medicare only pays for video consultation if the patient lives in a designated rural Health Professional Shortage Area (www.cms.gov), and reimbursement by private payers varies. Even this is dependent on ever-changing state laws. Reimbursement for remote patient monitoring is even more limited (the National Telehealth Policy Research Center publishes a useful handbook: http://www.cchpca.org/sites/default/files/resources/50%20State%20FINAL%20April%202016.pdf). Absent a bipartisan Congressional effort to remedy this situation, the best hope for removing reimbursement barriers lies with payment reform. The Medicare Access and CHIP Reauthorization Act of 2015 mandates that the Centers for Medicare and Medicaid Services shift from fee-for-service to alternative payment models in the coming years. In these alternate payment models, providers are responsible for the overall quality and total cost of care for a population of patients. In this scenario, there may be a financial incentive for telemedicine, especially remote monitoring, to keep patients out of the hospital. Until then, under current payment models, reimbursement is limited and the barriers to widespread implementation are high.
Conclusions
Telemedicine has continued to increase in uptake and shows tremendous promise in expanding access to health care, promoting patient disease management, and facilitating in-between health care visit monitoring. Although the future is bright, more research is needed to determine optimal ways to integrate telemedicine — especially remote monitoring — into routine clinical care. We call on our specialty societies to send a clear political advocacy message that policy changes are needed to overcome regulatory and reimbursement challenges.
Acknowledgments
The authors would like to thank Lauren Jones and Mackenzie McDougal for their assistance with the literature review.
Supplementary materials and methods
The telemedicine interventions PubMed literature search strategy was as follows: ((“liver diseases”[MeSH Terms] OR (“liver”[All Fields] AND “diseases”[All Fields]) OR “liver diseases”[All Fields] OR (“liver”[All Fields] AND “disease”[All Fields]) OR “liver disease”[All Fields] OR liver dysfunction OR liver dysfunctions)) OR “liver transplantation”[MeSH Terms] OR “liver transplantation” [All Fields] AND (((“telemedicine”[MeSH Terms] OR “telemedicine”[All Fields] OR mobile health OR mhealth OR telehealth OR mhealth)) OR (videoconferencing OR videoconference)).
References
1. Kirsh S., Su G.L., Sales A., et al. Access to outpatient specialty care: solutions from an integrated health care system. Am J Med Qual. 2015;30:88-90.
2. Wilson L.S., Maeder A.J. recent directions in telemedicine: review of trends in research and practice. Healthc Inform Res. 2015;21:213-22.
3. Cross R.K., Kane, S. Integration of telemedicine into clinical gastroenterology and hepatology practice. Clin Gastroenterol Hepatol. 2017;15:175-81.
4. Darkins A., Ryan P., Kobb R., et al. Care coordination/home telehealth: the systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions. Telemed J E Health. 2008;14:1118-26.
5. Tuerk P.W., Fortney J., Bosworth H.B., et al. Toward the development of national telehealth services: the role of Veterans Health Administration and future directions for research. Telemed J E Health. 2010;16:115-7.
6. VA Press Release. Available: https://www.va.gov/opa/pressrel/includes/viewPDF.cfm?id=2789. Accessed: July 27, 2017.
7. Arora S., Kalishman S., Thornton K., et al. Expanding access to hepatitis C virus treatment-extension for Community Healthcare Outcomes (ECHO) project: disruptive innovation in specialty care. Hepatology. 2010;52:1124-33.
8. Mitruka K., Thornton K., Cusick S., et al. Expanding primary care capacity to treat hepatitis C virus infection through an evidence-based care model–Arizona and Utah, 2012-2014. MMWR Morb Mortal Wkly Rep. 2014;63:393-8.
9. Ahmed A., Slosberg E., Prasad P., et al. The successful use of telemedicine in acute variceal hemorrhage. J Clin Gastroenterol. 1999;29:212-3.
10. Croome K.P., Shum J., Al-Basheer M.A., et al. The benefit of smart phone usage in liver organ procurement. J Telemed Telecare. 2011;17:158-60.
11. Bhati C.S., Wigmore S.J., Reddy S., et al. Web-based image transmission: a novel approach to aid communication in split liver transplantation. Clin Transplant. 2010;24:98-103.
12. Mammas C.S., Geropoulos S., Saatsakis G., et al. Telepathology as a method to optimize quality in organ transplantation: a feasibility and reliability study of the virtual benching of liver graft. Stud Health Technol Inform. 2013;190:276-8.
13. Egert E.M., et al. A regional multidisciplinary liver tumor board improves access to hepatocellular carcinoma treatment for patients geographically distant from tertiary medical center. Hepatology. 2015;62:469A
14. Thomson M., Volk M., Kim H.M., et al. An automated telephone monitoring system to identify patients with cirrhosis at risk of re-hospitalization. Dig Dis Sci. 2015;60:3563-9.
15. Ertel A.E., Kaiser T.E., Abbott D.E., et al. Use of video-based education and tele-health home monitoring after liver transplantation: results of a novel pilot study. Surgery. 2016;160:869-76.
16. Thygesen G.B., Andersen H., Damsgaard B.S. et al. The effect of nurse performed telemedical video consultations for patients suffering from alcohol-related liver cirrhosis. J Hepatol. 2017;66:S349
17. Proctor E., Silmere H., Raghavan R. et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health. 2011;38:65-76.
Dr. Serper is in the division of gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, and the department of medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia; Dr. Volk is in the division of gastroenterology and Transplantation Institute, Loma Linda University, Loma Linda, Calif. The authors disclose no conflicts.
Introducing the 2018 class of AGA Research Foundation awardees
The American Gastroenterological Association (AGA) and the AGA Research Foundation are pleased to award 41 investigators with more than $2 million in research funding in the 2018 award year.
“We were impressed by the quality of applications received in 2018,” said Robert S. Sandler, MD, MPH, AGAF, chair, AGA Research Foundation. “The AGA Research Foundation is excited to add 41 investigators into the AGA Research Foundation awards family and we look forward to seeing the results of their research. Based on the proposals, we are confident that the newest class of awardees will continue to push gastroenterology and hepatology research forward and contribute to the next big discoveries in our field.”
The AGA Research Foundation Awards Program recruits, retains, and supports the most promising investigators in gastroenterology and hepatology. With AGA Research Foundation funding, recipients have protected time to continue their fundamental research into causes and treatments for digestive disorders. AGA grants have launched the careers of investigators doing important work that translates to new patient care tools for clinicians and better outcomes for patients. To view the list of recipients go to https://www.gastro.org/press-release/introducing-the-2018-class-of-aga-research-foundation-awardees.
The awards program is made possible thanks to generous donors and funders contributing to the AGA Research Foundation. Learn more about the AGA Research Foundation at www.gastro.org/foundation.
The American Gastroenterological Association (AGA) and the AGA Research Foundation are pleased to award 41 investigators with more than $2 million in research funding in the 2018 award year.
“We were impressed by the quality of applications received in 2018,” said Robert S. Sandler, MD, MPH, AGAF, chair, AGA Research Foundation. “The AGA Research Foundation is excited to add 41 investigators into the AGA Research Foundation awards family and we look forward to seeing the results of their research. Based on the proposals, we are confident that the newest class of awardees will continue to push gastroenterology and hepatology research forward and contribute to the next big discoveries in our field.”
The AGA Research Foundation Awards Program recruits, retains, and supports the most promising investigators in gastroenterology and hepatology. With AGA Research Foundation funding, recipients have protected time to continue their fundamental research into causes and treatments for digestive disorders. AGA grants have launched the careers of investigators doing important work that translates to new patient care tools for clinicians and better outcomes for patients. To view the list of recipients go to https://www.gastro.org/press-release/introducing-the-2018-class-of-aga-research-foundation-awardees.
The awards program is made possible thanks to generous donors and funders contributing to the AGA Research Foundation. Learn more about the AGA Research Foundation at www.gastro.org/foundation.
The American Gastroenterological Association (AGA) and the AGA Research Foundation are pleased to award 41 investigators with more than $2 million in research funding in the 2018 award year.
“We were impressed by the quality of applications received in 2018,” said Robert S. Sandler, MD, MPH, AGAF, chair, AGA Research Foundation. “The AGA Research Foundation is excited to add 41 investigators into the AGA Research Foundation awards family and we look forward to seeing the results of their research. Based on the proposals, we are confident that the newest class of awardees will continue to push gastroenterology and hepatology research forward and contribute to the next big discoveries in our field.”
The AGA Research Foundation Awards Program recruits, retains, and supports the most promising investigators in gastroenterology and hepatology. With AGA Research Foundation funding, recipients have protected time to continue their fundamental research into causes and treatments for digestive disorders. AGA grants have launched the careers of investigators doing important work that translates to new patient care tools for clinicians and better outcomes for patients. To view the list of recipients go to https://www.gastro.org/press-release/introducing-the-2018-class-of-aga-research-foundation-awardees.
The awards program is made possible thanks to generous donors and funders contributing to the AGA Research Foundation. Learn more about the AGA Research Foundation at www.gastro.org/foundation.
AGA announces its newest class of Fellows
AGA Fellowship status is an honor awarded to members who demonstrate a personal commitment to the field of gastroenterology, as well as professional achievement in clinical private or academic practice and in basic or clinical research.
The most recent inductees into the AGA Fellows Program were recognized at Digestive Disease Week® (DDW) 2018 and received a digital ribbon in their AGA Community profile. The 2018 class of AGA Fellows includes 112 members, who added the designation “AGAF” in their professional activities.
Join the AGA Fellowship Recognition Panel in congratulating these distinguished members and view the 2018 class of AGA Fellows in the AGA Community forum, community.gastro.org
Learn more about joining this international community of excellence. Applications for the 2019 cohort are now being accepted. Those in clinical private or academic practice and in basic or clinical research who meet the AGAF criteria are invited to apply. Applications are due Aug. 27, 2018. Learn more at gastro.org/fellowship.
AGA Fellowship status is an honor awarded to members who demonstrate a personal commitment to the field of gastroenterology, as well as professional achievement in clinical private or academic practice and in basic or clinical research.
The most recent inductees into the AGA Fellows Program were recognized at Digestive Disease Week® (DDW) 2018 and received a digital ribbon in their AGA Community profile. The 2018 class of AGA Fellows includes 112 members, who added the designation “AGAF” in their professional activities.
Join the AGA Fellowship Recognition Panel in congratulating these distinguished members and view the 2018 class of AGA Fellows in the AGA Community forum, community.gastro.org
Learn more about joining this international community of excellence. Applications for the 2019 cohort are now being accepted. Those in clinical private or academic practice and in basic or clinical research who meet the AGAF criteria are invited to apply. Applications are due Aug. 27, 2018. Learn more at gastro.org/fellowship.
AGA Fellowship status is an honor awarded to members who demonstrate a personal commitment to the field of gastroenterology, as well as professional achievement in clinical private or academic practice and in basic or clinical research.
The most recent inductees into the AGA Fellows Program were recognized at Digestive Disease Week® (DDW) 2018 and received a digital ribbon in their AGA Community profile. The 2018 class of AGA Fellows includes 112 members, who added the designation “AGAF” in their professional activities.
Join the AGA Fellowship Recognition Panel in congratulating these distinguished members and view the 2018 class of AGA Fellows in the AGA Community forum, community.gastro.org
Learn more about joining this international community of excellence. Applications for the 2019 cohort are now being accepted. Those in clinical private or academic practice and in basic or clinical research who meet the AGAF criteria are invited to apply. Applications are due Aug. 27, 2018. Learn more at gastro.org/fellowship.
How does the Quality Payment Program affect you?
AGA asks Congress and CMS to continue to implement the Quality Payment Program (QPP) in a way that maximizes flexibility and success for you and your Medicare patients.
Most gastroenterologists participate in the Merit-Based Incentive Payment System (MIPS), which means how the QPP is implemented impacts the entire GI profession. The QPP replaced the sustainable growth rate (SGR) formula in 2015 when the Medicare Access and CHIP Reauthorization Act (MACRA) was signed into law. The QPP is comprised of two tracks: MIPS and Advanced Alternative Payment Models (Advanced APMs).
CMS has designated 2017 and 2018 as transition years to allow providers to learn about the QPP and to gradually increase their preparedness for MIPS.
Congress also recently acted to provide CMS additional flexibility with respect to QPP and MIPS implementation, including:
• Excluding Medicare Part B drug costs from MIPS payment adjustments.
• Eliminating improvement scoring for the cost performance category for the second through fifth years of MIPS.
• Allowing CMS to weight the cost performance category at less than 30 percent, but not less than 10 percent for the second through fifth years of MIPS.
• Allowing CMS flexibility in setting the performance threshold for MIPS in years two through five to ensure a gradual and incremental transition to the performance threshold set at the mean or median for the sixth year.
QPP implementation is a top priority for AGA to ensure that the value of specialty care is recognized. Learn more on our website www.gastro.org/QPP.
AGA asks Congress and CMS to continue to implement the Quality Payment Program (QPP) in a way that maximizes flexibility and success for you and your Medicare patients.
Most gastroenterologists participate in the Merit-Based Incentive Payment System (MIPS), which means how the QPP is implemented impacts the entire GI profession. The QPP replaced the sustainable growth rate (SGR) formula in 2015 when the Medicare Access and CHIP Reauthorization Act (MACRA) was signed into law. The QPP is comprised of two tracks: MIPS and Advanced Alternative Payment Models (Advanced APMs).
CMS has designated 2017 and 2018 as transition years to allow providers to learn about the QPP and to gradually increase their preparedness for MIPS.
Congress also recently acted to provide CMS additional flexibility with respect to QPP and MIPS implementation, including:
• Excluding Medicare Part B drug costs from MIPS payment adjustments.
• Eliminating improvement scoring for the cost performance category for the second through fifth years of MIPS.
• Allowing CMS to weight the cost performance category at less than 30 percent, but not less than 10 percent for the second through fifth years of MIPS.
• Allowing CMS flexibility in setting the performance threshold for MIPS in years two through five to ensure a gradual and incremental transition to the performance threshold set at the mean or median for the sixth year.
QPP implementation is a top priority for AGA to ensure that the value of specialty care is recognized. Learn more on our website www.gastro.org/QPP.
AGA asks Congress and CMS to continue to implement the Quality Payment Program (QPP) in a way that maximizes flexibility and success for you and your Medicare patients.
Most gastroenterologists participate in the Merit-Based Incentive Payment System (MIPS), which means how the QPP is implemented impacts the entire GI profession. The QPP replaced the sustainable growth rate (SGR) formula in 2015 when the Medicare Access and CHIP Reauthorization Act (MACRA) was signed into law. The QPP is comprised of two tracks: MIPS and Advanced Alternative Payment Models (Advanced APMs).
CMS has designated 2017 and 2018 as transition years to allow providers to learn about the QPP and to gradually increase their preparedness for MIPS.
Congress also recently acted to provide CMS additional flexibility with respect to QPP and MIPS implementation, including:
• Excluding Medicare Part B drug costs from MIPS payment adjustments.
• Eliminating improvement scoring for the cost performance category for the second through fifth years of MIPS.
• Allowing CMS to weight the cost performance category at less than 30 percent, but not less than 10 percent for the second through fifth years of MIPS.
• Allowing CMS flexibility in setting the performance threshold for MIPS in years two through five to ensure a gradual and incremental transition to the performance threshold set at the mean or median for the sixth year.
QPP implementation is a top priority for AGA to ensure that the value of specialty care is recognized. Learn more on our website www.gastro.org/QPP.
AGA opens GI Patient Center to the public
We’re proud to announce the public launch of the AGA GI Patient Center, an online hub for digestive health information developed by specialists, for patients. The GI Patient Center – previously only accessible by AGA member physicians – now directly provides patients with trusted information on a variety of GI conditions and procedures.
Browse the GI Patient Center, which includes information on more than 30 topics, available in both English and Spanish. All AGA patient education was written and reviewed by leading gastroenterologists, and developed with health literacy in mind.
You can print this information for your practice, email patients a link, include a link on your website – whatever is needed to ensure your patients are getting trusted health information about their condition, treatment, or procedure.
To get started, visit patient.gastro.org.
We’re proud to announce the public launch of the AGA GI Patient Center, an online hub for digestive health information developed by specialists, for patients. The GI Patient Center – previously only accessible by AGA member physicians – now directly provides patients with trusted information on a variety of GI conditions and procedures.
Browse the GI Patient Center, which includes information on more than 30 topics, available in both English and Spanish. All AGA patient education was written and reviewed by leading gastroenterologists, and developed with health literacy in mind.
You can print this information for your practice, email patients a link, include a link on your website – whatever is needed to ensure your patients are getting trusted health information about their condition, treatment, or procedure.
To get started, visit patient.gastro.org.
We’re proud to announce the public launch of the AGA GI Patient Center, an online hub for digestive health information developed by specialists, for patients. The GI Patient Center – previously only accessible by AGA member physicians – now directly provides patients with trusted information on a variety of GI conditions and procedures.
Browse the GI Patient Center, which includes information on more than 30 topics, available in both English and Spanish. All AGA patient education was written and reviewed by leading gastroenterologists, and developed with health literacy in mind.
You can print this information for your practice, email patients a link, include a link on your website – whatever is needed to ensure your patients are getting trusted health information about their condition, treatment, or procedure.
To get started, visit patient.gastro.org.
Announcing the 2018 Section Research Mentor Award recipients
The AGA Institute Council Section Research Mentor Award acknowledges AGA members for their achievements as outstanding mentors in a specific area of research. We are pleased to announce the 2018 recipients who will be recognized by each of the 13 AGA Institute Council sections during Digestive Disease Week® (DDW) 2018. Congratulations to these exceptional mentors!
AGA Institute Council 2018 Section Research Mentor Award recipients
Basic & Clinical Intestinal Disorders
Gary D. Wu, MD
Cellular & Molecular Gastroenterology
Charalabos Pothoulakis, MD
Clinical Practice
Amnon Sonnenberg, MD, MSc
Esophageal, Gastric & Duodenal Disorders
Nicholas J. Shaheen, MD, MPH, AGAF
Gastrointestinal Oncology
Randall W. Burt, MD, AGAF
Growth, Development & Child Health
Deborah L. Gumucio, PhD
Imaging, Endoscopy & Advanced Technology
Michael B. Wallace, MD, MPH, AGAF
Immunology, Microbiology & Inflammatory Bowel Diseases
Claudio Fiocchi, MD
Liver & Biliary
Scott L. Friedman, MD
Microbiome & Microbial Diseases in the Gastrointestinal Tract
Jeffrey I. Gordon, MD
Neurogastroenterology & Motility
Richard W. McCallum, MD, AGAF
Obesity, Metabolism & Nutrition
Lee M. Kaplan, MD, PhD, AGAF
Pancreatic Disorders
Suresh T. Chari, MD
The AGA Institute Council Section Research Mentor Award acknowledges AGA members for their achievements as outstanding mentors in a specific area of research. We are pleased to announce the 2018 recipients who will be recognized by each of the 13 AGA Institute Council sections during Digestive Disease Week® (DDW) 2018. Congratulations to these exceptional mentors!
AGA Institute Council 2018 Section Research Mentor Award recipients
Basic & Clinical Intestinal Disorders
Gary D. Wu, MD
Cellular & Molecular Gastroenterology
Charalabos Pothoulakis, MD
Clinical Practice
Amnon Sonnenberg, MD, MSc
Esophageal, Gastric & Duodenal Disorders
Nicholas J. Shaheen, MD, MPH, AGAF
Gastrointestinal Oncology
Randall W. Burt, MD, AGAF
Growth, Development & Child Health
Deborah L. Gumucio, PhD
Imaging, Endoscopy & Advanced Technology
Michael B. Wallace, MD, MPH, AGAF
Immunology, Microbiology & Inflammatory Bowel Diseases
Claudio Fiocchi, MD
Liver & Biliary
Scott L. Friedman, MD
Microbiome & Microbial Diseases in the Gastrointestinal Tract
Jeffrey I. Gordon, MD
Neurogastroenterology & Motility
Richard W. McCallum, MD, AGAF
Obesity, Metabolism & Nutrition
Lee M. Kaplan, MD, PhD, AGAF
Pancreatic Disorders
Suresh T. Chari, MD
The AGA Institute Council Section Research Mentor Award acknowledges AGA members for their achievements as outstanding mentors in a specific area of research. We are pleased to announce the 2018 recipients who will be recognized by each of the 13 AGA Institute Council sections during Digestive Disease Week® (DDW) 2018. Congratulations to these exceptional mentors!
AGA Institute Council 2018 Section Research Mentor Award recipients
Basic & Clinical Intestinal Disorders
Gary D. Wu, MD
Cellular & Molecular Gastroenterology
Charalabos Pothoulakis, MD
Clinical Practice
Amnon Sonnenberg, MD, MSc
Esophageal, Gastric & Duodenal Disorders
Nicholas J. Shaheen, MD, MPH, AGAF
Gastrointestinal Oncology
Randall W. Burt, MD, AGAF
Growth, Development & Child Health
Deborah L. Gumucio, PhD
Imaging, Endoscopy & Advanced Technology
Michael B. Wallace, MD, MPH, AGAF
Immunology, Microbiology & Inflammatory Bowel Diseases
Claudio Fiocchi, MD
Liver & Biliary
Scott L. Friedman, MD
Microbiome & Microbial Diseases in the Gastrointestinal Tract
Jeffrey I. Gordon, MD
Neurogastroenterology & Motility
Richard W. McCallum, MD, AGAF
Obesity, Metabolism & Nutrition
Lee M. Kaplan, MD, PhD, AGAF
Pancreatic Disorders
Suresh T. Chari, MD
Psychotherapy helps patients with chronic digestive disorders
Patients with chronic digestive disorders can better cope with their symptoms and the effects on their daily lives when they receive support from mental health professionals specializing in psychogastroenterology, according to a new AGA Clinical Practice Update, published in the April issue of Gastroenterology (gastrojournal.org). , which will help reduce patient symptom burden and health care resource utilization. These therapies are optimally delivered by mental health professionals specializing in psychogastroenterology, a field dedicated to applying effective psychological techniques to GI problems.
According to best practice advice, to help promote the use of brain-gut psychotherapies in routine GI care, gastroenterologists should:
1. Routinely assess health-related quality of life, symptom-specific anxieties, early life adversity and functional impairment related to a patient’s digestive symptoms.
2. Master patient-friendly language on the following topics: the brain–gut pathway and how this pathway can become dysregulated by any number of factors; the psychosocial risk, perpetuating and maintaining factors of GI diseases; and why the gastroenterologist is referring a patient to a mental health provider.
3. Know the structure and core features of the most effective brain–gut psychotherapies.
4. Establish a direct referral and ongoing communication pathway with one to two qualified mental health providers and assure patients that he or she will remain part of their care team.
5. Familiarize themselves with one or two neuromodulators that can be used to augment behavioral therapies when necessary.
Patients with chronic digestive disorders can better cope with their symptoms and the effects on their daily lives when they receive support from mental health professionals specializing in psychogastroenterology, according to a new AGA Clinical Practice Update, published in the April issue of Gastroenterology (gastrojournal.org). , which will help reduce patient symptom burden and health care resource utilization. These therapies are optimally delivered by mental health professionals specializing in psychogastroenterology, a field dedicated to applying effective psychological techniques to GI problems.
According to best practice advice, to help promote the use of brain-gut psychotherapies in routine GI care, gastroenterologists should:
1. Routinely assess health-related quality of life, symptom-specific anxieties, early life adversity and functional impairment related to a patient’s digestive symptoms.
2. Master patient-friendly language on the following topics: the brain–gut pathway and how this pathway can become dysregulated by any number of factors; the psychosocial risk, perpetuating and maintaining factors of GI diseases; and why the gastroenterologist is referring a patient to a mental health provider.
3. Know the structure and core features of the most effective brain–gut psychotherapies.
4. Establish a direct referral and ongoing communication pathway with one to two qualified mental health providers and assure patients that he or she will remain part of their care team.
5. Familiarize themselves with one or two neuromodulators that can be used to augment behavioral therapies when necessary.
Patients with chronic digestive disorders can better cope with their symptoms and the effects on their daily lives when they receive support from mental health professionals specializing in psychogastroenterology, according to a new AGA Clinical Practice Update, published in the April issue of Gastroenterology (gastrojournal.org). , which will help reduce patient symptom burden and health care resource utilization. These therapies are optimally delivered by mental health professionals specializing in psychogastroenterology, a field dedicated to applying effective psychological techniques to GI problems.
According to best practice advice, to help promote the use of brain-gut psychotherapies in routine GI care, gastroenterologists should:
1. Routinely assess health-related quality of life, symptom-specific anxieties, early life adversity and functional impairment related to a patient’s digestive symptoms.
2. Master patient-friendly language on the following topics: the brain–gut pathway and how this pathway can become dysregulated by any number of factors; the psychosocial risk, perpetuating and maintaining factors of GI diseases; and why the gastroenterologist is referring a patient to a mental health provider.
3. Know the structure and core features of the most effective brain–gut psychotherapies.
4. Establish a direct referral and ongoing communication pathway with one to two qualified mental health providers and assure patients that he or she will remain part of their care team.
5. Familiarize themselves with one or two neuromodulators that can be used to augment behavioral therapies when necessary.