Telemedicine reduces cancellations for care during COVID in large Ohio heath center

November 06, 2020

Telemedicine Reduces Cancellations and No-Shows for Rheumatology Care During COVID in Large Ohio Health System

ATLANTA -- New research presented at ACR Convergence, the American College of Rheumatology's annual meeting, shows that expanded use of telemedicine during the COVID-19 pandemic improved cancellation rates, no-shows and completed medical visits for rheumatology ambulatory clinics in one large Ohio health system (ABSTRACT #1584).

Telemedicine is the practice of medicine at a physical distance using various forms of communication technology. While the doctor, nurse or other healthcare professional works at one site, the patient receives care at another site. Telemedicine may be practiced using webcams, smartphones, secure video messaging platforms or other technology. All modalities used are HIPPA compliant.

When COVID-19 surged worldwide in early 2020, many rheumatology clinics and practices cut back on their in-patient care services to reduce the risk of infection spread among their vulnerable patients, many of whom take immune-suppressing drugs that put them at higher risk for serious infections. Some patients remain wary of going into the clinic for routine care due to COVID, and lack of transportation and other issues had been a nagging barrier to rheumatology care in the past.

Researchers wanted to know if telemedicine could bridge gaps in access to rheumatology care, allowing medical visits with physical distancing and eliminating the need for a time-consuming or costly trip to the clinic. In a new retrospective study, researchers at MetroHealth Medical Center in Cleveland, Ohio compared data on completed clinic visits, no-shows and cancellation rates between their in-person and telemedicine appointments for rheumatology clinics in 2020.

"In the setting of a novel infection with unclear infectious characteristics, patients and hospital systems across the country moved to postpone procedures and cancel face-to-face visits due to the potential risk," says the study's co-author, Reem Alkilany, MD, a rheumatology fellow at MetroHealth. "Many rheumatology patients are already at an increased risk for infection due to immunosuppressive medications and immune system dysfunction related to their diseases. While in-person visits may place patients at risk for contracting the virus, delaying care can increase the risk for disease flares and the potential need for hospitalization. Telemedicine offered a way for rheumatology patients and providers to connect with one another in place of delayed care or even absence of care."

The researchers pulled retrospective data from their electronic health record system for rheumatology outpatient appointments between Jan. 3 and May 31, 2020. Appointments were placed in three categories: canceled, no-show or completed. They divided all the data into two 10-week periods: a pre-COVID phase from Jan. 3 to March 15, and a COVID phase from March16 to May 31. During the pre-COVID phase, there were only in-person clinic visits, while in the COVID phase, the clinic offered telemedicine or in-person visits to their patients.

Telemedicine appointment cancellations were nearly zero in the COVID phase, or one out of 825 telemedicine appointments scheduled, compared to the pre-COVID phase, when 527 out of 1677 appointments, all in person, were cancelled. No-shows also trended downward when telemedicine became an option for care. In the COVID phase of the study, the clinics had 191 no-shows, including 121 in-person and 70 telemedicine. In the pre-COVID phase, when only in-person care was offered, there were 220 no-shows. During the COVID period, MetroHealth Medical Center also had slight increases in visit completions with telemedicine as an option for rheumatology care: 1,038 completed visits, including 754 telemedicine and 284 in-person visits out of 1675 scheduled visits, compared to only 930 completed visits out of 1677 scheduled, all in person, in the phase of the study before COVID.

Based on these findings, MetroHealth's Division of Rheumatology aims for 40% of future follow-up visits to be performed through telemedicine, says Dr. Alkilany. "We see that there are some rheumatology concerns that are more cognitive, or less reliant on procedural intervention or physical exam, that are suited for patient-provider visits via telemedicine, such as titrating gout medication to reach a particular uric acid level," she says. "Visits that require diagnostic or therapeutic procedures, such as joint injection or ultrasound, will always require in-person visits and a physical exam. Although in-person visits cannot always be replaced by phone or video visits, we believe that telemedicine's potential to increase the accessibility and convenience of healthcare makes it an essential component to the future of medicine."
About ACR Convergence

ACR Convergence, the ACR's annual meeting, is where rheumatology meets to collaborate, celebrate, congregate, and learn. Join ACR for an all-encompassing experience designed for the entire rheumatology community. ACR Convergence is not just another meeting - it's where inspiration and opportunity unite to create an unmatched educational experience. For more information about the meeting, visit, or join the conversation on Twitter by following the official hashtag (#ACR20).

About the American College of Rheumatology

The American College of Rheumatology (ACR) is an international medical society representing over 7,700 rheumatologists and rheumatology health professionals with a mission to empower rheumatology professionals to excel in their specialty. In doing so, the ACR offers education, research, advocacy and practice management support to help its members continue their innovative work and provide quality patient care. Rheumatologists are experts in the diagnosis, management and treatment of more than 100 different types of arthritis and rheumatic diseases.


Telemedicine Visits During COVID-19 Improved Clinic Show Rates


The COVID-19 pandemic has tremendously affected the healthcare sector. State of Ohio officials recommended to hold in-person outpatient visits and elective procedures to limit virus spread. Many patients with chronic illnesses had reduced access to healthcare, this prompted the necessity to take active steps to continue delivering healthcare while ensuring safety for both patients and healthcare providers.

The MetroHealth System is an academic, public health care institution that services the population of Cuyahoga County in Cleveland, OH. Within 1 week of the State of Ohio issuing a statewide order limiting gatherings in March 2020, the Rheumatology outpatient clinics implemented telemedicine by video or telephone limiting in person visit sonly when deemed medically necessary. Anecdotally, Rheumatology providers reported improved clinic show rates with telemedicine visits, prompting this quality improvement project.

Our aim is to investigate and compare completed visit, no show, and cancellation rates between in-person and telemedicine appointments to see if telemedicine has a beneficial impact on access to Rheumatology ambulatory clinics


Using Reporting Workbench in our Epic electronic health record, we collected data retrospectively pertaining to rheumatology outpatient appointments at the MetroHealth System between Jan 3-May 31, 2020 - a 20-week period. Appointments were allocated into 3 categories: canceled; no-show; and completed. Data was segmented into in-person versus telemedicine, weekly stratified. figures 1-3.

For analysis, the data was divided into two 10-week periods: period 1, the pre-COVID19 interval (Jan 3-Mar 15, 2020) and period 2, during COVID19 pandemic (Mar16-May 31, 2020). During period 1, the only modality was in-person visits, while during period 2 telemedicine started taking place in addition to in-person visits. Appointment Activity denoted the sum of cancellations, no shows, and completed visits. On-Schedule appointment totals summed no show and completed visits. Rates of cancelations, no shows, and completed visits were compared to Appointment Activity totals as well as On-Schedule totals.


Telemedicine appointment cancellations were nearly zero (1 out of 825 telemedicine appointments offered) in the 10-week During COVID-19 period as compared to the pre-COVID-19 period where 527 appointments were cancelled, all in-person appointments. No shows also trended down in period 2 when there were 191 no shows (121 in-person and 70 telemedicine) versus 220 no shows in period 1 where only in-person visits were offered. This led to a slight increase in completed visits During COVID-19 when 1038 had a completed appointment (754 telemedicine and 284 in-person); whereas, pre-COVID-19 resulted in 930 completed in-person.


Barriers to accessing in-person healthcare because of transportation or other issues has been a challenge that might be conquered by telemedicine. The offering of telemedicine had seemingly favorable impacts on access to Rheumatology ambulatory clinics at our academic, public health system. We encourage examining the incorporation of telemedicine in our routine clinic visits to improve patient's appointment adherence.

American College of Rheumatology

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