Practice Matters
The Virtual Dietitian
By Stanley Lapidos, MS, Amanda Holliday, MS, RD, LD, and Arlene Sanoy, MA, RD, LD
Vol. 6 No. 1 p. 17

Dietitians, like most healthcare professionals, are accustomed to working on an interpersonal basis in almost everything they do—consultations, counseling patients, participating in team meetings and patient rounds, and teaching group education sessions. Face-to-face interaction and communications are essential to patient care in hospitals, nursing homes, rehabilitation clinics, and other healthcare facilities. Patients in these settings receive care from coordinated teams of physicians, nurses, social workers, dietitians, therapists, and others appropriate for the management and treatment of their medical conditions.

Recent studies and reports by organizations such as the Institute of Medicine and the RAND Corporation paint a different picture for primary care. In primary care, services are often difficult to coordinate. Communication between physicians, patients, and other providers is often lacking, and many patients, particularly those with chronic disease, fail to receive treatment from other health providers who are vital to maintaining and improving patient health and rehabilitation.1,2 The reasons for these deficits are understandable. Primary care physicians—the majority of whom work in solo or small group practices—are constrained by financial, insurance, and other restrictions, which can make it difficult to hire or contract with dietitians, social workers, or others with whom they can collaborate.3

Overextended physicians often fail to identify nutritional deficits in their patients, engage in little patient education about the role of diet in disease, and seldom discuss cases with dietitians. Unless alternate ways of organizing and providing primary care are developed, the impact of this isolation and lack of collaboration on patient care will grow as the population ages and the prevalence of chronic disease continues to increase.

Fortunately, dietitians and other chronic disease specialists are often available close to these physicians, working independently or under the auspices of a hospital or community agency. Despite this proximity, however, few physicians have identified and developed a network of such resources for chronic disease management. Therefore, essential health resources continue to be underutilized or poorly coordinated.

Virtual Teams
Advances in technology over the last two decades have dramatically altered the way people function and communicate, impacting the nature of work and social interaction. The Internet, e-mail, and telephone and video conferencing, as well as other communications devices, have erased the distances and barriers between people, often enabling them to work together “virtually” on shared tasks and projects.4 The use of virtual teams in the industrial and corporate worlds has been shown to bring people “together” from disparate locations to engage in common tasks and goals, creating economies in time and money, facilitating more efficient communication between team members using multiple modes of communication, and helping foster an increased sense of purposefulness and direction for team participants.

The Virtual Dietitian and Other Clinicians in Primary Care
If virtual teams are so successful in other industries, could they also be used in healthcare? Could they be effective in providing multidisciplinary team care for millions of patients in outpatient, community-based settings? This question challenged researchers and clinicians at Rush University Medical Center in Chicago to devise the concept of virtual teams in primary care. Using knowledge and insights gained from more than seven years of experience in training and supervising teams through the Rush Geriatric Interdisciplinary Team Training Program, they began looking at alternatives to the traditional “in-person” approach to teamwork. They examined ways in which team members could collaborate without having face-to-face team meetings, including the application of communications technology to address this challenge. Such teams could manage complex patient care issues “virtually,” thus overcoming some of the barriers to the formulation of primary care teams.

Through the financial support of the John A. Hartford Foundation, Rush investigators launched the Virtual Integrated Practice (VIP) Project. In the VIP model, dietitians, physicians, pharmacists, and social workers, though geographically separated, collaborate “virtually” using various communication tools to manage patients with chronic disease. These virtual healthcare teams give complex patients with chronic diseases access to the coordinated care of specialists in multiple disciplines, just as they would have in institutional settings. VIP team members seldom, if ever, meet in person. Instead, they communicate by phone, fax, or e-mail to discuss treatment goals for specific patients, determine best courses of action, track patient progress after referrals, and share other information to keep them updated between patient visits.

How Does VIP Work?
The following case illustrates how one primary care practice is using VIP to improve and better coordinate care for patients.

Mrs. E is a 67-year-old African American woman who was referred to the outpatient nutrition clinic by her internist at the community health center, located 20 minutes south of the hospital. When the physician noted Mrs. E’s rising cholesterol and increased weight, he recommended that she consult the dietitian. Mrs. E agreed to the consultation, and the physician then filled out a referral that he and the dietitian had developed together. This referral gave the dietitian all of the clinical information necessary for an evaluation—diagnoses, medical history, current medications, lab results, and the specific goals for the consultation. This information was then faxed to the hospital’s outpatient nutrition clinic and was received by the clinic’s secretary. The secretary then scheduled Mrs. E for a clinic visit with the designated geriatric dietitian.

Mrs. E initially came to the nutrition clinic with the attitude that she was “too old to lose weight” and didn’t think weight mattered at her age. She was very unmotivated and somewhat disappointed that her doctor had referred her to a nutrition clinic since she believed nutrition changes were hopeless.

Mrs. E had a history of hypercholesterolemia, hypertension, obesity, and anemia. She had recently started taking triamterene in addition to aspirin, calcium, and vitamin D supplementation. She was 5’6”, weighed 207 pounds, and had a Body Mass Index of 33. After taking a diet history, Mrs. E was found to be eating a diet with excessive amounts of fat, calories, and portion sizes. She consumed few fruits and vegetables and enjoyed eating out with friends. She was counseled for one hour on the importance of weight maintenance throughout life and dietary and exercise changes. Large print handouts were explained and food lists were given on how to lower cholesterol and lose weight. The dietitian and Mrs. E agreed on achievable goals, and she was instructed to keep a food record and return to the clinic in three weeks for follow-up. As they had decided previously, the dietitian faxed a short report back to the internist listing the patient’s goals and the follow-up plan.

Mrs. E returned in three weeks for a follow-up and had successfully lost 5 pounds. More nutrition goals were added, and she began to follow up with the dietitian monthly. After three months, Mrs. E had lost a total of 10 pounds and felt much better. She had added exercise to her lifestyle and was eating more fruits and vegetables. Her diet records indicated that she was now eating three meals per day with one evening snack and had significantly decreased the fat and cholesterol intake in her diet.

The dietitian periodically faxed short progress notes to Mrs. E’s physician. When he learned that she had successfully lost 10 pounds, he called Mrs. E to congratulate her. At his next visit with her, the physician used the notes from the dietitian to reemphasize Mrs. E’s nutrition goals. After that visit, the physician faxed his progress notes, along with those of a social worker, to the dietitian to provide better coordinated care.

On occasion, the patient’s case is discussed via telephone with both the physician and social worker. When Mrs. E expressed frustration with the excessive urination caused by the triamterene, the dietitian called the physician to let him know that adherence might be an issue. This allowed the internist to anticipate problems even before Mrs. E had brought them up to him and proactively address them with her.

Despite her initial reluctance, Mrs. E realizes how much more complete her medical care is as a result of the VIP Program. She recognizes that the dietitian is working closely with her physician to improve her health.

How Is VIP Working So Far?
Dietitians have been the most extensively used of the three healthcare consultants represented on the virtual teams. Primary care practices in the VIP project at Rush are using their “virtual dietitian” in a variety of ways. The largest practice participating in VIP has had more than 50 patients with an average age of 80 referred to their dietitian with an average of three follow-up visits per patient. This has led to reported results of consistent weight loss following consultations. Many patients have reported positive affirmation from their physician’s communication with their dietitian regarding how they are managing their care.

Another practice using VIP has automatically been referring its diabetic patients to their VIP dietitian through an “alert” letter sent to patients whose hemoglobin A1c levels are above normal. The letter recommends that the patient contact the VIP dietitian to make an appointment, and these contacts are monitored by the practice’s office manager.

Two other practice sites using the VIP process have developed procedures for automatically referring patients with diabetic control issues to their virtual team dietitian and are using standardized, discipline-specific forms to execute referrals and document patient status and progress. One of the VIP dietitians has also conducted group education visits for patients.

Why Participate in a Virtual Team?
There are a number of reasons why dietitians would benefit from participating in a virtual team. It geographically extends the scope of their practice, provides increased physician and other interdisciplinary contact, and creates additional practice income. Increased communication between patient and dietitian and between dietitian and physician has been shown to lead to better patient compliance and adherence to healthier nutritional behaviors.

For physicians, it broadens the reach of their practice by giving them a referral network of other professionals who can provide the appropriate service or treatment to their patients. It can also save them time by not having to deal with patient care problems that can be better addressed by other clinicians on their virtual team.

Martin Gorbien, MD, one of the physicians participating in VIP, in lauding the value of the virtual dietitian’s relationship to his practice has commented: “It is a luxury to have a dietitian on our virtual team. One of the main reasons for success is that the referral is to a known professional who understands geriatrics rather than making the referral to a department. We can communicate in advance of the consultation, which makes the interaction efficient and more satisfying. We already know that the dietitian on our team knows how to approach older adults and grasps all that is special about this distinct population.”

Other disciplines can benefit as well. Social workers can expand their practice through increased referrals from physicians and bill for Medicare-eligible services. Pharmacists participating in VIP can use their medication management and therapeutic skills for patients, as well as increasing business to the pharmacy.

VIP represents a unique approach for dietitians to adapt their professional roles and clinical skills to a constantly evolving landscape of healthcare delivery. It transforms the traditional definition of the patient care workplace, allowing them to work from almost anywhere to address patient needs. While the VIP is not suited to every ambulatory or outpatient practice setting, it does offer one practical and opportunistic way for integrating dietetic services where they otherwise would not be offered. VIP may yet represent only the beginning of new processes of care, affording opportunities for dietitians to be well-positioned to meet the patient care challenges of today and the future.

— Stanley Lapidos, MS, is the project manager for the Virtual Integrated Practice Project in the department of preventive medicine at Rush University Medical Center and coordinator of the Rush Geriatric Interdisciplinary Team Training Program, Rush Institute for Healthy Aging. Amanda Holliday, MS, RD, LD, and Arlene Sanoy, MA, RD, LD, are dietitians in the department of clinical nutrition, Rush University Medical Center, and they participate in the Virtual Integrated Practice Program.

References
1. Institute of Medicine, Committee on nutrition services for Medicare beneficiaries. Nutrition services in ambulatory care settings. In: The Role of Nutrition in Maintaining Health in the Nation’s Elderly. 2000. (pp. 213-223). Washington, D.C.: National Academy Press.
2. McGlynn E, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 348(26):2635-2645.
3. Kupersmith NC, Wheeler MD. Communication between family physicians and registered dietitians in the outpatient setting. J Am Diet Assoc. 2000;102(12):1756-1763.
4. Duarte DL, Snyder NT. Mastering Virtual Teams. 2nd ed. 2000; San Francisco: Jossey-Bass.