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"Effect of Telemedicine on Patients' Diagnosis and Treatment,"

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  • Additional authors include: Dr. Ann Bynum, Director, UAMS Rural Hospital Program; Associate Director, Program Development, Arkansas AHEC Program Dr. Charles Cranford, Executive Director, UAMS Arkansas AHEC Program; Vice Chancellor, Regional Programs Dr. Joseph Banken, Assistant Professor; Evaluation Liaison for the Antenatal & Neonatal Guidelines Education and Learning System (ANGELS), UAMS, Department of Obstetrics and Gynecology
  • Reference for Bullet #2: Dept. of Health and Human Services (DHHS), Health Resources and Services Administration (HRSA), 1997, Federal Register.
  • For Reference or Discussion: More studies of evidence for the clinical effectiveness of telemedicine are needed to justify the widespread implementation of telemedicine and third-party reimbursement for these services. Twelve previous studies have been performed to assess the effect of telemedicine on changes in the patient’s diagnosis and treatment plan.
  • The data for this study were gathered from evaluations of a Telemedicine Project that was funded by the Office for the Advancement of Telehealth. The study was conducted by the UAMS Rural Hospital Program The mission of this program is to strengthen hospitals throughout the state by sharing resources available at the University Medical School. My Role as Research Associate at the UAMS Rural Hospital Program : Consultation, develop research design for study Identify variables for the study, based on review of program evaluation instruments and discussion with team of health professionals involved in planning of program/study Prepare study data set Perform the data analysis; consultation with statistician at Univ. of AR Interpret the data analysis Report the study findings Presentations—International, national, state Manuscripts for publication
  • This is a map of the interactive video sites in Arkansas. There are 53 sites in the medical network and compressed video technology in or within 30 miles of every hospital in the state. The target area for the UAMS Telehealth Project includes the East Arkansas Delta, with the following counties: Phillips, St. Francis, Monroe, Crittenden, Desha, Lee, and Chicot Counties. The rural population in this area includes more than 131,000 residents, of whom about 50% were from ethnic minorities; Some of the poorest counties in Arkansas; MUAs and HPSAs Barriers for access to healthcare : lack of providers, insurance, education, transportation, travel costs—need to travel long distances for medical care in other communities; lack of motor vehicles and phones Cultural barriers :Feelings of intimidation, distress and anxiety by idea of traveling to, and dealing with health professionals in large urban areas—prefer comfort of familiar surroundings for healthcare services and family support in their own community. These rural residents may not have the psychological, physical, or financial resources to travel to urban healthcare settings.
  • For Reference or Discussion : The grant funding provides payment for medical consultations for people without insurance. Patient billing for the consult session was made as for any other clinic billing. If the patient’s insurance was denied, the grant funds were used up to $60.00 for the consult. The hospitals pay for the telephone line charges. Plans for payment of telemedicine services when grant funding ends: Medicaid reimbursement Patient compliance with telemedicine appointments and follow-up appointments is very good. Follow-up time for treatment after the telemedicine consultations is adequate and acceptable—Treatment that is recommended by the consultant is readily implemented by the primary care physician. Home telemedicine programs (Not yet developed in UAMS Rural Hospital Telehealth Project): Patients lease the telemedicine equipment or rent the equipment for the telemedicine consultations.
  • The patients participated in the Telehealth Project at the distant, primary healthcare site (clinic exam room) that was equipped with the interactive compressed video technology. The distant sites included hospitals, Community Health Centers, rural health clinics, and AHEC clinics. With the telemedicine technology, patients and primary care providers at the distant healthcare sites could see and hear the consultant and interact with the consultant, who was mainly at the UAMS main campus (other consultant sites included Arkansas Children’s Hospital, Little Rock; Crittenden Hospital, and Helena Med. Center). The consultants included physicians, dieticians, pharmacists, allied health professionals, e.g. physical therapists and dieticians; RNs, nurse practitioners, and clinical nurse specialists. The consultant can perform the patient assessment with inspection and examination over interactive video using an electronic stethoscope and a camera that can be attached to an otoscope, ophthalmoscope, and dermascope.
  • This slide shows a health educator in the Telehealth Project during a telehealth education session, using the interactive video equipment. Photos of patients’ telemedicine consults cannot be used due to confidentiality issues.
  • Significance: The results can be used to improve the telemedicine procedures used in the Telehealth Project.
  • For Reference or Discussion: Sample: Only grant-funded sites Provider-to-provider consults (n = 99) and telepharmacy education study consults (n = 49) were excluded--represented a different type of service. 5 Consultant sites, frequencies ranged from 1-374 (UAMS) 11 Distant primary care sites, frequencies ranged from 3-132 (Clarendon) (See SPSS Frequencies enclosed) Primary care provider’s initial diagnosis and treatment plan were assessed in a pre-use telemedicine survey.
  • For Reference/Discussion : Patients were referred to the Project when physicians in the target counties were unable to provide services that were needed. Coordinator forwarded the pt. hx. , phys. assessm. to consultant prior to the consult Compressed video technology delivers video images that have been processed to remove redundant information, thereby reducing the amount of bandwidth required to transmit them. Typically, the patient would arrive at the distant, primary care site about 30 minutes prior to the consult. Pt. assessment: inspection and phys. examination over interactive video using electronic stethoscope, camera with otoscope, ophthalmoscope, dermascope. The project site facilitator would coordinate the session at the distant site. Telemed. Protocols, Guidelines for consult: Equipment use, referrals, scheduling, appointments, required information and evaluation forms Consultants completed the post-session evaluation and session information form prior to leaving the consult session. After the session, the consultant reviewed the patient data with the referring provider and made recommendations regarding diagnosis and treatment.
  • For Reference or Discussion : The post-session evaluation instrument was developed using items from previous telehealth evaluation instruments.[Reid, A Telemedicine Primer. Understanding the Issues , 1996.] The response scale for the two items regarding the established diagnosis included a yes-no and not applicable response; and the established treatment plan item consisted of a yes-no response. The two items for change in the patient’s diagnosis and treatment plan had a response scale with a yes-no and not applicable response, not aware of a prior diagnosis or treatment plan, and no prior diagnosis or treatment plan.    
  • For Reference or Discussion : The 63 respondents for cases where there was a prior diagnosis and a change was applicable included: n = 17, Yes, change in diagnosis (17/63 = 27%) n = 46, No, change in diagnosis See following table for these results
  • For Reference or Discussion: The 123 respondents for cases where there was a prior treatment plan and a change was applicable included: n = 82, Yes, change in treatment plan (82/123 = 67%). n = 41, No, change in treatment plan See following table for these results
  • Implications for future research include studies that… Additional future research is recommended to… Thank you for your attention. I can now address any Questions or Discussion.

"Effect of Telemedicine on Patients' Diagnosis and Treatment," "Effect of Telemedicine on Patients' Diagnosis and Treatment," Presentation Transcript

  • Effect of Telemedicine on Patients’ Diagnosis and Treatment *Ann B. Bynum, EdD, Rural Hospital Program, Arkansas Area Health Education Center (AHEC) Program; *Charles O. Cranford, DDS, MPA, Regional Programs, Arkansas AHEC Program; *Cathy A. Irwin, PhD, RN, Rural Hospital Program; *Joseph A. Banken, MA, PhD, HSPP, Antenatal & Neonatal Guidelines Education and Learning System (ANGELS), Department of Obstetrics and Gynecology *University of Arkansas for Medical Sciences (UAMS), Little Rock, AR
  • The manuscript for this study was published in the Journal of Telemedicine and Telecare 2006; 12 : 39-43.
  • Objectives
    • Explain the study purpose, methods, and instruments
    • Describe results for characteristics of the teleconsultations and for changes in the patient’s diagnosis and treatment plan
    • Identify the study conclusions and limitations
    • Describe the implications for clinical practice and future research
  • Introduction
    • The quality of the diagnosis and management of patients in remote areas may be improved by using telemedicine.
    • Telemedicine: Use of telecommunications and information technologies for the clinical care of patients and patient counseling
  • Introduction
    • Telemedicine is a promising method for managing the demand for secondary and tertiary health care and disease management within the primary-care delivery system in the patient’s local community.
    • Delays in the diagnosis and management of patients in remote and rural areas may increase their morbidity and mortality.
  • Introduction
    • Changes in the patient’s diagnosis and treatment plan, as a result of the teleconsultation, can avoid:
      • morbidity, costly treatment
      • inappropriate treatment
      • patient transfers
      • traveling costs to see a specialist.
  • The Rural Hospital Program Interactive Video Network University of Arkansas for Medical Sciences
  •  
  • The UAMS Rural Hospital Telehealth Project
    • Developed in 1995
    • Delivers specialty telemedicine consultations to patients at distant sites
    • Serves a poor, underserved, rural population in the East Arkansas Delta
    • Project Objective: Increase rural residents’ access to specialty medical services across the life-span using telemedicine technology
    • Funded by the Office for the Advancement of Telehealth, HRSA, DHHS
  • Telemedicine Technology: Polycom View Stations, ELMO-400 Document Cameras, T-1 Telephone Lines
  •  
  • Purpose of the Study
    • Examined the effect of telemedicine on changes in the patient’s diagnosis and treatment plan in the UAMS Rural Hospital Telehealth Project.
    • Changes in the patient’s diagnosis and treatment plan were based on the initial diagnosis and treatment plan, which were established by the primary care provider before the telemedicine session took place.
  • Methods
    • Post-use survey of consultants in the UAMS Rural Hospital Telehealth Project
    • N = 412 consultations
    • Data collection: March, 1998-June, 2002
  • Procedures
    • Primary care providers from distant, healthcare sites in the East Arkansas Delta requested the telemedicine consults through the project coordinator.
    • Consult sessions, 30 min: Patient interviews, physical examinations
    • The primary care provider or site facilitator presented the patient to the consultant.
    • Follow-up care and instructions for the patient
    • Patient privacy in clinic room
    • Telemedicine protocols for each specialty
    • Interactive compressed video technology
  • Instruments
    • Consultant Demographics: 15 items, characteristics of teleconsultants—practice, training, patient referrals, use of telemed.
    • Session Information Evaluation: 21 items, characteristics of teleconsultations—clinic site, patient status, staffing, equipment
    • Post-Session Evaluation: 9 items, established diagnosis, change in diagnosis, established treatment plan, change in treatment as a result of the teleconsultation
  • Data Analysis
    • Statistical Package for the Social Sciences (SPSS), Version 11
    • Statistical Procedures: Frequency percentages for study variables
  • Results: Characteristics of the Teleconsultations
    • N = 412 consultations
    • 47 consultants who conducted 2-82 consultations each
    • 62% of consultants had not received training in telemedicine
    • Reason for consultants using the telemedicine system: Desire to improve patient access to care (95%)
    • Teleconsultations mainly for new patients (45%)
    • 75% Outpatients
  • Results: Characteristics of the Teleconsultations
    • Variable n_____
    • Primary practice setting
    • Academic medical center 326
    • Hospital 68
    • Outpatient clinic 102
    • Private office 17
    • Date telemedicine practice
    • began within this system
    • 1995-1998 260
    • 1999-2001 140
    •  
  • Results: Characteristics of the Teleconsultations
    • Variable n_____
    • Consultant specialty
    • Nutrition and dietetics 112
    • Psychiatry/psychology 94
    • Dermatology 72
    • Pharmacy 48
    • Neurology 13
    • Pulmonary 11
    • Other 18 specialties 62
  • Results: Characteristics of the Teleconsultations
    • Variable n_____
    • Consultant discipline
    • MD 151
    • PhD 88
    • PhD, registered dietician 83
    • PharmD 48
    • Health-related professions 33
    • RN, nurse practitioner, clinical
    • nurse specialist 7
  • Results: Characteristics of the Teleconsultations
    • Variable n_____
    • Number of patients seen
    • using telemedicine
    • > 30 patients 104
    • < 30 patients 184
    • First consultation 112
    • Patient referred for further care
    • Yes 171
    • No 107
  • Results: Characteristics of the Teleconsultations
    • Variable n__
    • Patient referred to
    • Hospital ER 13
    • Participating primary provider 24
    • Another consulting specialist 11
    • Consulting specialist in
    • telemedicine session 105
    • Referral care
    • In-person in another community 31
    • In-person in patient’s community 29
    • Via telemedicine 112
  • Results: Characteristics of the Teleconsultations
    • Variable n__
    • Problems with equipment or
    • transmission
    • Problems with audio 6
    • Problems with video 9
    • Problems with peripherals 6
    • No problems 298
  • Results: Changes in the Patient’s Diagnosis
    • The teleconsultants established a diagnosis in 74 consultations.
      • This was 26% of the 286 respondents.
    • Of the 63 respondents for cases where there was a prior diagnosis and a change was applicable, 17 (27%) consultants reported that there was a change in the patient's diagnosis.
    •  
  • Results: Changes in the Patient’s Diagnosis
    • Variable n__
    • Established diagnosis
    • Yes 74
    • No 212
    • Change in diagnosis
    • Yes 17
    • No 46
    • Not aware of a prior diagnosis 10
    • No prior diagnosis 9
    • Not applicable 73
  • Results: Changes in the Patient’s Treatment Plan
    • The consultants established a patient treatment plan in 139 consultations.
      • This was 52% of the 268 respondents.
    • Of the 123 respondents for cases where there was a prior treatment plan and a change was applicable, 82 (67%) consultants reported a change in the treatment plan.
  • Results: Changes in the Patient’s Treatment Plan
    • Variable n__
    • Established treatment plan
    • Yes 139
    • No 129
    • Change in treatment plan
    • Yes 82
    • No 41
    • Not aware of prior treatment
    • plan 19
    • No prior treatment plan 19
    • Not applicable 51
  • Conclusions
    • These results show that telemedicine had an effect on changing the patient’s diagnosis and treatment plan.
    • Although changes in the patient’s diagnosis and treatment plan are not direct measures of quality, these results imply that the patient’s diagnosis and treatment plan were improved.
  • Conclusions
    • The majority of consultants had not received training in telemedicine, which could reduce the consultant’s confidence in establishing a diagnosis and treatment plan by telemedicine.
    • These factors might have reduced the likelihood of making a change.
  • Limitations
    • Limitations of the study design restrict the generalizability of the findings.
    • Non-respondents for variables regarding the teleconsultations and the patient’s diagnosis and treatment plan
  • Implications for Clinical Practice
    • The present study provided evidence for the benefits of telemedicine in changing the patient’s diagnosis and treatment plan for a poor, underserved, rural population in the East Arkansas Delta.
    • Telemedicine promoted access to medical specialists for these patients in their local community.
  • Implications for Clinical Practice
    • The changes that occurred in the patient’s diagnosis and treatment plan as a result of the telemedicine session may have avoided delays in the proper diagnosis and treatment of these patients in rural Arkansas.
    • The results can be used to improve the telemedicine procedures used in the Telehealth Project.
  • Implications for Nursing Practice
    • Educate patients and healthcare providers: Benefits of telemedicine in improving the patient’s diagnosis and treatment plan for poor, underserved, rural populations in Arkansas
    • Promote patient referrals for telemedicine
    • Use telemedicine to provide nursing consultations and to address the nursing shortages
    • Promote nursing education regarding the use of telemedicine technology for the clinical care of patients and patient counseling
  • Implications for Future Research
    • Decrease non-responses for variables regarding the teleconsultations and the patient’s diagnosis and treatment plan
    • Instructions for consultants regarding completion of all instrument items for the teleconsultation variables, patient diagnosis and treatment plan variables
    • Training for site facilitators on these methods of instrument distribution
  • Implications for Future Research
    • Use an experimental design to compare teleconsultations and face-to-face primary medical care on the patient’s diagnosis and treatment plan
    • Assess the effect of telemedicine on the number of patients’ hospitalizations, patient transfers to tertiary healthcare facilities, delays in patients’ treatment, and patient referral patterns, especially in rural communities and among different ethnic groups