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:

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 1995Developed in 1995 Delivers specialty telemedicine consultations to patients at distant sitesDelivers specialty telemedicine consultations to patients at distant sites Serves a poor, underserved, rural population in the East Arkansas DeltaServes 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 technologyProject 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, DHHSFunded 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, June, 2002

Procedures Primary care providers from distant, healthcare sites in the East Arkansas Delta requested the telemedicine consults through the project coordinator. 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 Consult sessions, 30 min: Patient interviews, physical examinations The primary care provider or site facilitator presented the patient to the consultant. The primary care provider or site facilitator presented the patient to the consultant. Follow-up care and instructions for the patient Follow-up care and instructions for the patient Patient privacy in clinic room Patient privacy in clinic room Telemedicine protocols for each specialty Telemedicine protocols for each specialty Interactive compressed video technology 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 Package for the Social Sciences (SPSS), Version 11 Statistical Procedures: Frequency percentages for study variables 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 center326 Hospital 68 Outpatient clinic102 Private office 17 Date telemedicine practice began within this system

Results: Characteristics of the Teleconsultations Variable n_____ Consultant specialty Nutrition and dietetics112 Nutrition and dietetics112 Psychiatry/psychology 94 Psychiatry/psychology 94 Dermatology 72 Dermatology 72 Pharmacy 48 Pharmacy 48 Neurology 13 Neurology 13 Pulmonary 11 Pulmonary 11 Other 18 specialties 62 Other 18 specialties 62

Results: Characteristics of the Teleconsultations Variable n_____ Consultant discipline MD151 MD151 PhD 88 PhD 88 PhD, registered dietician 83 PhD, registered dietician 83 PharmD 48 PharmD 48 Health-related professions 33 Health-related professions 33 RN, nurse practitioner, clinical RN, nurse practitioner, clinical nurse specialist 7 nurse specialist 7

Results: Characteristics of the Teleconsultations Variable n_____ Number of patients seen using telemedicine > 30 patients104 > 30 patients104 < 30 patients184 < 30 patients184 First consultation112 First consultation112 Patient referred for further care Yes171 Yes171 No107 No107

Results: Characteristics of the Teleconsultations Variable n__ Patient referred to Hospital ER 13 Hospital ER 13 Participating primary provider 24 Participating primary provider 24 Another consulting specialist 11 Another consulting specialist 11 Consulting specialist in Consulting specialist in telemedicine session105 telemedicine session105 Referral care In-person in another community 31 In-person in another community 31 In-person in patient’s community 29 In-person in patient’s community 29 Via telemedicine112 Via telemedicine112

Results: Characteristics of the Teleconsultations Variable n__ Problems with equipment or transmission Problems with audio 6 Problems with audio 6 Problems with video 9 Problems with video 9 Problems with peripherals 6 Problems with peripherals 6 No problems298 No problems298

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 Yes 74 No212 No212 Change in diagnosis Yes 17 Yes 17 No 46 No 46 Not aware of a prior diagnosis 10 Not aware of a prior diagnosis 10 No prior diagnosis 9 No prior diagnosis 9 Not applicable 73 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 Yes139 Yes139 No129 No129 Change in treatment plan Yes 82 Yes 82 No 41 No 41 Not aware of prior treatment Not aware of prior treatment plan 19 plan 19 No prior treatment plan 19 No prior treatment plan 19 Not applicable 51 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