Effect of Telemedicine on Patients’ Diagnosis and Treatment *Ann B. Bynum, EdD, Rural Hospital...

Effect of Telemedicine on Effect of Telemedicine on Patients’ Diagnosis and Patients’ Diagnosis and

TreatmentTreatment*Ann B. Bynum, EdD, Rural Hospital Program, *Ann B. Bynum, EdD, Rural Hospital Program,

Arkansas Area Health Education Center (AHEC) Arkansas Area Health Education Center (AHEC) Program; *Charles O. Cranford, DDS, MPA, Program; *Charles O. Cranford, DDS, MPA,

Regional Programs, Arkansas AHEC Program; Regional Programs, Arkansas AHEC Program; *Cathy A. Irwin, PhD, RN, Rural Hospital Program; *Cathy A. Irwin, PhD, RN, Rural Hospital Program; *Joseph A. Banken, MA, PhD, HSPP, Antenatal & *Joseph A. Banken, MA, PhD, HSPP, Antenatal &

Neonatal Guidelines Education and Learning Neonatal Guidelines Education and Learning System (ANGELS), Department of Obstetrics and System (ANGELS), Department of Obstetrics and

GynecologyGynecology

*University of Arkansas for Medical Sciences *University of Arkansas for Medical Sciences

(UAMS), Little Rock, AR(UAMS), Little Rock, AR

The manuscript for this study The manuscript for this study was published in the was published in the Journal Journal of Telemedicine and Telecare of Telemedicine and Telecare 2006; 2006; 1212: 39-43.: 39-43.

ObjectivesObjectives

Explain the study purpose, methods, and Explain the study purpose, methods, and instrumentsinstruments

Describe results for characteristics of the Describe results for characteristics of the teleconsultations and for changes in the teleconsultations and for changes in the patient’s diagnosis and treatment planpatient’s diagnosis and treatment plan

Identify the study conclusions and Identify the study conclusions and limitationslimitations

Describe the implications for clinical Describe the implications for clinical practice and future researchpractice and future research

IntroductionIntroduction

The quality of the diagnosis and The quality of the diagnosis and management of patients in remote management of patients in remote areas may be improved by using areas may be improved by using telemedicine. telemedicine.

Telemedicine: Use of Telemedicine: Use of telecommunications and information telecommunications and information technologies for the clinical care of technologies for the clinical care of patients and patient counselingpatients and patient counseling

IntroductionIntroductionTelemedicine is a promising method for Telemedicine is a promising method for managing the demand for secondary and managing the demand for secondary and tertiary health care and disease tertiary health care and disease management within the primary-care management within the primary-care delivery system in the patient’s local delivery system in the patient’s local community. community.

Delays in the diagnosis and management Delays in the diagnosis and management of patients in remote and rural areas may of patients in remote and rural areas may increase their morbidity and mortality.increase their morbidity and mortality.

IntroductionIntroduction

Changes in the patient’s Changes in the patient’s diagnosis and treatment plan, as diagnosis and treatment plan, as a result of the teleconsultation, a result of the teleconsultation, can avoid:can avoid:

morbidity, costly treatmentmorbidity, costly treatmentinappropriate treatmentinappropriate treatmentpatient transfers patient transfers traveling costs to see a specialist. traveling costs to see a specialist.

The Rural Hospital Program The Rural Hospital Program Interactive Video NetworkInteractive Video Network

University of Arkansas for University of Arkansas for Medical SciencesMedical Sciences

The UAMS Rural Hospital The UAMS Rural Hospital Telehealth ProjectTelehealth Project

• Developed in 1995Developed in 1995• Delivers specialty telemedicine Delivers specialty telemedicine

consultations to patients at distant sitesconsultations to patients at distant sites• Serves a poor, underserved, rural Serves a poor, underserved, rural

population in the East Arkansas Deltapopulation in the East Arkansas Delta• Project Objective: Increase rural residents’ Project Objective: Increase rural residents’

access to specialty medical services access to specialty medical services across the life-span using telemedicine across the life-span using telemedicine technologytechnology

• Funded by the Office for the Advancement Funded by the Office for the Advancement of Telehealth, HRSA, DHHSof Telehealth, HRSA, DHHS

Telemedicine Technology: Polycom Telemedicine Technology: Polycom View Stations, ELMO-400 View Stations, ELMO-400 Document Cameras, T-1 Telephone Document Cameras, T-1 Telephone LinesLines

Purpose of the StudyPurpose of the Study

Examined the effect of telemedicine on Examined the effect of telemedicine on changes in the patient’s diagnosis and changes in the patient’s diagnosis and treatment plan in the UAMS Rural Hospital treatment plan in the UAMS Rural Hospital Telehealth Project. Telehealth Project.

Changes in the patient’s diagnosis and Changes in the patient’s diagnosis and treatment plan were based on the initial treatment plan were based on the initial diagnosis and treatment plan, which were diagnosis and treatment plan, which were established by the primary care provider established by the primary care provider before the telemedicine session took place.before the telemedicine session took place.

MethodsMethods

Post-use survey of consultants in Post-use survey of consultants in the UAMS Rural Hospital the UAMS Rural Hospital Telehealth Project Telehealth Project

N = 412 consultationsN = 412 consultations

Data collection: March, 1998-Data collection: March, 1998-June, 2002June, 2002

ProceduresProcedures Primary care providers from distant, healthcare Primary care providers from distant, healthcare

sites in the East Arkansas Delta requested the sites in the East Arkansas Delta requested the telemedicine consults through the project telemedicine consults through the project coordinator. coordinator.

Consult sessions, 30 min: Patient interviews, Consult sessions, 30 min: Patient interviews, physical examinationsphysical examinations

The primary care provider or site facilitator The primary care provider or site facilitator presented the patient to the consultant. presented the patient to the consultant.

Follow-up care and instructions for the patientFollow-up care and instructions for the patient Patient privacy in clinic room Patient privacy in clinic room Telemedicine protocols for each specialtyTelemedicine protocols for each specialty Interactive compressed video technologyInteractive compressed video technology

InstrumentsInstrumentsConsultant Demographics: 15 items, characteristics Consultant Demographics: 15 items, characteristics of teleconsultants—practice, training, patient of teleconsultants—practice, training, patient referrals, use of telemed.referrals, use of telemed.

Session Information Evaluation: 21 items, Session Information Evaluation: 21 items, characteristics of teleconsultations—clinic site, characteristics of teleconsultations—clinic site, patient status, staffing, equipment patient status, staffing, equipment

Post-Session Evaluation: 9 items, established Post-Session Evaluation: 9 items, established diagnosis, change in diagnosis, established diagnosis, change in diagnosis, established treatment plan, change in treatment as a result of treatment plan, change in treatment as a result of the teleconsultationthe teleconsultation

Data AnalysisData Analysis

Statistical Package for the Social Statistical Package for the Social Sciences (SPSS), Version 11 Sciences (SPSS), Version 11

Statistical Procedures: Statistical Procedures: Frequency percentages for study Frequency percentages for study variablesvariables

Results: Characteristics of the Results: Characteristics of the TeleconsultationsTeleconsultations

N = 412 consultationsN = 412 consultations47 consultants who conducted 2-82 47 consultants who conducted 2-82 consultations eachconsultations each62% of consultants had not received training 62% of consultants had not received training in telemedicinein telemedicineReason for consultants using the Reason for consultants using the telemedicine system: Desire to improve telemedicine system: Desire to improve patient access to care (95%)patient access to care (95%)Teleconsultations mainly for new patients Teleconsultations mainly for new patients (45%)(45%)75% Outpatients75% Outpatients


VariableVariable n_____ n_____ Primary practice settingPrimary practice setting

Academic medical centerAcademic medical center 326326HospitalHospital 68 68Outpatient clinicOutpatient clinic 102102Private officePrivate office 17 17

Date telemedicine practice Date telemedicine practice began within this systembegan within this system 1995-19981995-1998 260260 1999-20011999-2001 140140


VariableVariable n_____n_____

Consultant specialtyConsultant specialty Nutrition and dieteticsNutrition and dietetics 112112 Psychiatry/psychologyPsychiatry/psychology 94 94 DermatologyDermatology 72 72 PharmacyPharmacy 48 48 NeurologyNeurology 13 13 PulmonaryPulmonary 11 11 Other 18 specialtiesOther 18 specialties 62 62


VariableVariable n_____n_____

Consultant disciplineConsultant discipline MDMD 151151 PhDPhD 88 88 PhD, registered dieticianPhD, registered dietician 83 83 PharmDPharmD 48 48 Health-related professionsHealth-related professions 33 33 RN, nurse practitioner, clinicalRN, nurse practitioner, clinical nurse specialistnurse specialist 7 7


VariableVariable n_____ n_____Number of patients seen Number of patients seen using telemedicineusing telemedicine > 30 patients> 30 patients 104104 < < 30 patients30 patients 184184 First consultationFirst consultation 112112

Patient referred for further carePatient referred for further care YesYes 171171 NoNo 107107


VariableVariable n__ n__Patient referred toPatient referred to Hospital ERHospital ER 13 13 Participating primary providerParticipating primary provider 24 24 Another consulting specialistAnother consulting specialist 11 11 Consulting specialist in Consulting specialist in telemedicine sessiontelemedicine session 105105

Referral careReferral care In-person in another communityIn-person in another community 31 31 In-person in patient’s communityIn-person in patient’s community 29 29 Via telemedicineVia telemedicine 112112


VariableVariable n__ n__

Problems with equipment or Problems with equipment or

transmissiontransmission

Problems with audioProblems with audio 6 6

Problems with videoProblems with video 9 9

Problems with peripheralsProblems with peripherals 6 6

No problemsNo problems 298298

Results: Changes in the Patient’s Results: Changes in the Patient’s DiagnosisDiagnosis

The teleconsultants established a The teleconsultants established a diagnosis in 74 consultations. diagnosis in 74 consultations.

This was 26% of the 286 respondents.This was 26% of the 286 respondents.

Of the 63 respondents for cases where Of the 63 respondents for cases where there was a prior diagnosis and a there was a prior diagnosis and a change was applicable, 17 (27%) change was applicable, 17 (27%) consultants reported that there was a consultants reported that there was a change in the patient's diagnosis.change in the patient's diagnosis.

Results: Changes in the Patient’s Results: Changes in the Patient’s DiagnosisDiagnosis

VariableVariable n__ n__Established diagnosisEstablished diagnosis YesYes 74 74 NoNo 212212

Change in diagnosisChange in diagnosis YesYes 17 17 NoNo 46 46 Not aware of a prior diagnosisNot aware of a prior diagnosis 10 10 No prior diagnosisNo prior diagnosis 9 9 Not applicableNot applicable 73 73

Results: Changes in the Patient’s Results: Changes in the Patient’s Treatment PlanTreatment Plan

The consultants established a patient The consultants established a patient treatment plan in 139 consultations.treatment plan in 139 consultations.

This was 52% of the 268 respondents. This was 52% of the 268 respondents.

Of the 123 respondents for cases Of the 123 respondents for cases where there was a prior treatment where there was a prior treatment plan and a change was applicable, plan and a change was applicable, 82 (67%) consultants reported a 82 (67%) consultants reported a change in the treatment plan.change in the treatment plan.

Results: Changes in the Patient’s Results: Changes in the Patient’s Treatment PlanTreatment Plan

VariableVariable n__ n__Established treatment planEstablished treatment plan YesYes 139139 NoNo 129129

Change in treatment planChange in treatment plan YesYes 82 82 NoNo 41 41 Not aware of prior treatmentNot aware of prior treatment planplan 19 19 No prior treatment planNo prior treatment plan 19 19 Not applicableNot applicable 51 51

ConclusionsConclusionsThese results show that telemedicine These results show that telemedicine had an effect on changing the patient’s had an effect on changing the patient’s diagnosis and treatment plan. diagnosis and treatment plan.

Although changes in the patient’s Although changes in the patient’s diagnosis and treatment plan are not diagnosis and treatment plan are not direct measures of quality, these results direct measures of quality, these results imply that the patient’s diagnosis and imply that the patient’s diagnosis and treatment plan were improved.treatment plan were improved.

ConclusionsConclusions

The majority of consultants had not The majority of consultants had not received training in telemedicine, received training in telemedicine, which could reduce the consultant’s which could reduce the consultant’s confidence in establishing a diagnosis confidence in establishing a diagnosis and treatment plan by telemedicine. and treatment plan by telemedicine.

These factors might have reduced the These factors might have reduced the likelihood of making a change. likelihood of making a change.

LimitationsLimitations

Limitations of the study design Limitations of the study design restrict the generalizability of the restrict the generalizability of the findings.findings.

Non-respondents for variables Non-respondents for variables regarding the teleconsultations regarding the teleconsultations and the patient’s diagnosis and and the patient’s diagnosis and treatment plantreatment plan

Implications for Clinical PracticeImplications for Clinical PracticeThe present study provided evidence The present study provided evidence for the benefits of telemedicine in for the benefits of telemedicine in changing the patient’s diagnosis and changing the patient’s diagnosis and treatment plan for a poor, treatment plan for a poor, underserved, rural population in the underserved, rural population in the East Arkansas Delta. East Arkansas Delta.

Telemedicine promoted access to Telemedicine promoted access to medical specialists for these patients medical specialists for these patients in their local community.in their local community.

Implications for Clinical PracticeImplications for Clinical PracticeThe changes that occurred in the The changes that occurred in the patient’s diagnosis and treatment plan patient’s diagnosis and treatment plan as a result of the telemedicine session as a result of the telemedicine session may have avoided delays in the proper may have avoided delays in the proper diagnosis and treatment of these diagnosis and treatment of these patients in rural Arkansas. patients in rural Arkansas.

The results can be used to improve The results can be used to improve the telemedicine procedures used in the telemedicine procedures used in the Telehealth Project.the Telehealth Project.

Implications for Nursing PracticeImplications for Nursing PracticeEducate patients and healthcare providers: Educate patients and healthcare providers: Benefits of telemedicine in improving the Benefits of telemedicine in improving the patient’s diagnosis and treatment plan for patient’s diagnosis and treatment plan for poor, underserved, rural populations in poor, underserved, rural populations in ArkansasArkansasPromote patient referrals for telemedicine Promote patient referrals for telemedicine Use telemedicine to provide nursing Use telemedicine to provide nursing consultations and to address the nursing consultations and to address the nursing shortagesshortages

Promote nursing education regarding the use Promote nursing education regarding the use of telemedicine technology for the clinical care of telemedicine technology for the clinical care of patients and patient counselingof patients and patient counseling

Implications for Future Implications for Future ResearchResearch

Decrease non-responses for variables Decrease non-responses for variables regarding the teleconsultations and the regarding the teleconsultations and the patient’s diagnosis and treatment planpatient’s diagnosis and treatment plan

Instructions for consultants regarding Instructions for consultants regarding completion of all instrument items for the completion of all instrument items for the teleconsultation variables, patient teleconsultation variables, patient diagnosis and treatment plan variablesdiagnosis and treatment plan variables

Training for site facilitators on these Training for site facilitators on these methods of instrument distributionmethods of instrument distribution

Implications for Future Implications for Future ResearchResearch

Use an experimental design to compare Use an experimental design to compare teleconsultations and face-to-face primary teleconsultations and face-to-face primary medical care on the patient’s diagnosis and medical care on the patient’s diagnosis and treatment plan treatment plan

Assess the effect of telemedicine on the Assess the effect of telemedicine on the number of patients’ hospitalizations, patient number of patients’ hospitalizations, patient transfers to tertiary healthcare facilities, transfers to tertiary healthcare facilities, delays in patients’ treatment, and patient delays in patients’ treatment, and patient referral patterns, especially in rural referral patterns, especially in rural communities and among different ethnic communities and among different ethnic groupsgroups

Effect of Telemedicine on Patients’ Diagnosis and Treatment *Ann B. Bynum, EdD, Rural Hospital...

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