Effect of Telemedicine on Patients

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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

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The manuscript for this study was published in
the Journal of Telemedicine and Telecare 2006
12 39-43.
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Objectives

• Explain the study purpose, methods, and
  instruments
• Describe results for characteristics of the
  teleconsultations and for changes in the
  patients diagnosis and treatment plan
• Identify the study conclusions and limitations
• Describe the implications for clinical practice
  and future research

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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

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

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Introduction

• Changes in the patients 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.

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The Rural Hospital Program Interactive Video
Network

University of Arkansas for Medical Sciences
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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

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Telemedicine Technology Polycom View Stations,
ELMO-400 Document Cameras, T-1 Telephone Lines
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Purpose of the Study

• Examined the effect of telemedicine on changes in
  the patients diagnosis and treatment plan in the
  UAMS Rural Hospital Telehealth Project.
• Changes in the patients 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.

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Methods

• Post-use survey of consultants in the UAMS Rural
  Hospital Telehealth Project
• N 412 consultations
• Data collection March, 1998-June, 2002

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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

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Instruments

• Consultant Demographics 15 items,
  characteristics of teleconsultantspractice,
  training, patient referrals, use of telemed.
• Session Information Evaluation 21 items,
  characteristics of teleconsultationsclinic
  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

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Data Analysis

• Statistical Package for the Social Sciences
  (SPSS), Version 11
• Statistical Procedures Frequency percentages
  for study variables

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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

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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
•  

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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

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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

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Results Characteristics of the Teleconsultations

• Variable n_____
• Number of patients seen
• using telemedicine
• gt 30 patients 104
• lt 30 patients 184
• First consultation 112
• Patient referred for further care
• Yes 171
• No 107

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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 patients community 29
• Via telemedicine 112

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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

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Results Changes in the Patients 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.
•  

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Results Changes in the Patients 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

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Results Changes in the Patients 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.

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Results Changes in the Patients 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

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Conclusions

• These results show that telemedicine had an
  effect on changing the patients diagnosis and
  treatment plan.
• Although changes in the patients diagnosis and
  treatment plan are not direct measures of
  quality, these results imply that the patients
  diagnosis and treatment plan were improved.

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Conclusions

• The majority of consultants had not received
  training in telemedicine, which could reduce the
  consultants confidence in establishing a
  diagnosis and treatment plan by telemedicine.
• These factors might have reduced the likelihood
  of making a change.

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Limitations

• Limitations of the study design restrict the
  generalizability of the findings.
• Non-respondents for variables regarding the
  teleconsultations and the patients diagnosis and
  treatment plan

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Implications for Clinical Practice

• The present study provided evidence for the
  benefits of telemedicine in changing the
  patients 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.

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Implications for Clinical Practice

• The changes that occurred in the patients
  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.

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Implications for Nursing Practice

• Educate patients and healthcare providers
  Benefits of telemedicine in improving the
  patients 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

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Implications for Future Research

• Decrease non-responses for variables regarding
  the teleconsultations and the patients 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

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Implications for Future Research

• Use an experimental design to compare
  teleconsultations and face-to-face primary
  medical care on the patients 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