1. Implementing a Rural Telemedicine OSCE for Remote and On-Campus Clerkship Learners Ryan Palmer, Ed.D.; Lisa Dodson, M.D., Frances E Biagioli, M.D. L21A, STFM Medical Student Education Conference, February 1, 2014

2. Disclosure The presenters have no conflicts of interest. Drs. Biagioli and Palmer have received partial federal grand funding: National Cancer Institute (1R25CA158571-01A1). Integrating Patient Centered EHR and HIT Curriculum into BSS Medical Education. PI: Frances Biagioli, MD Consent for publication of student photos on file at OHSU Family Medicine

3. Objectives Participants of this Lecture Discussion will be able to: Define telemedicine. Explain the role of telemedicine in rural healthcare. Describe how to create a TeleOSCE (telemedicine OSCE) using Internet videoconferencing technology (e.g. Adobe Connect, Skype, GoTo Meeting, etc.). Describe the costs of implementing the TeleOSCE. Describe student perspectives of TeleOSCEs. Discuss how to access and integrate these technologies into your own curricula.

4. Background Oregon Rural Scholars Program (ORSP) –HRSA funded and run by Oregon Area Health Education Centers (AHEC) and OHSU Family Medicine. Pilot July 2009. –Select MS3 students, 14 weeks in one rural location (combining Rural, FM and elective) –Curricular equivalent during FM Clinic Lectures, fmCases, exam Student Clinical Rounds (SCR)

7. Background Oregon Rural Scholars Program (ORSP) –Select students spend Rural and FM clerkships in 1 location –Curricular equivalent during FM Clinic Lectures, fm cases, exam SCR Teaching OSCE

8. Telemedicine Definition –Telemedicine is “the remote delivery of healthcare services and clinical information using telecommunications technology. This includes a wide array of clinical services using internet, wireless, satellite and telephone media.” -American Telemedicine Association http://www.americantelemed.org/learn/what-is-telemedicine/faqs http://www.americantelemed.org/learn/what-is-telemedicine/faqs

9. Rationale Real world application

10. Comment on Joe Robertson’s 96k square miles blog:96k square miles blog: William P. Russell February 17th, 2013 at 5:49 pm 96,000 square miles – that’s awesome. We live only 23 miles from Coos Bay but I have not been able to find where the connection to OHSU Telemedicine is located. I have experience hosting WebEx video conferencing; is there any chance that this technology could be used for telemedicine? My wife has been a Type I Diabetic for 56 years and we have driven the 256 miles to OHSU for a consult, but at our age it takes 2 nights in a motel so we can not afford to come often enough. “it takes 2 nights in a motel so we can not afford to come often enough”

11. Rationale “ Specific health concerns of rural populations can be further addressed through increased use of telemedicine consultations. By partnering with providers in rural areas and through the use of innovative technologies, AHCs can help rural providers increase the quality of care.” Gazewood, J. D., Rollins, L. K., & Galazka, S. S. (2006). Beyond the Horizon: The Role of Academic Health Centers in Improving the Health of Rural Communities. Academic Medicine, 81(9), 793–797.

12. Rationale ACGME Competencies –Patient Care –Medical Knowledge –Practice Based Learning and Improvement –Systems Based Practice –Professionalism –Interpersonal Skills and Communication

13. Rationale ACGME Competencies –Patient Care –Medical Knowledge –Practice Based Learning and Improvement –Systems Based Practice –Professionalism –Interpersonal Skills and Communication

14. On-line Implementation 8 ORSP (total) students took telemedicine OSCE in April and September 2013. Emulated in-person FM OSCE (time, feedback) Adobe Connect technology –Setup:

15. Student SP Faculty (feedback) Faculty (operator)

16. Scenario Don Baker, 66 y/o diabetic Lives in Crane, OR., PCP in Burns set up with telemedicine portal. Closest hospital 200 miles. Sore on right toe Previous false alarm, patient resistance Student must –Assess severity of condition –Utilize technology –Work with patient on treatment plan

17. Scenario Don Baker, 74 y/o diabetic Lives in Crane, OR., PCP in Burns set up with telemedicine portal. Closest hospital 200 miles. Sore on right toe Previous false alarm, patient resistance Student must –Assess severity of condition –Utilize technology –Work with patient on treatment plan

18. Crane Burns Bend

19. Scenario Don Baker, 74 y/o diabetic Lives in Crane, OR., PCP in Burns set up with telemedicine portal. Closest hospital 200 miles. Sore on right toe, Rising sugar levels Previous false alarm, patient resistance Student must –Assess severity of condition –Utilize technology –Work with patient on treatment plan

20. Scenario Don Baker, 74 y/o diabetic Lives in Crane, OR., PCP in Burns set up with telemedicine portal. Closest hospital 200 miles. Sore on right toe, Rising sugar levels Previous false alarm, patient resistance Student must –Assess severity of condition –Utilize technology –Work with patient on treatment plan

21. Scenario Don Baker, 74 y/o diabetic Lives in Crane, OR., PCP in Burns set up with telemedicine portal. Closest hospital 200 miles. Sore on right toe, Rising sugar levels Previous false alarm, patient resistance Student must –Assess severity of condition –Utilize technology –Work with patient on treatment plan

22. Learning Objectives Clinical knowledge –Diabetes management Patient-centered use of technology –Intentional “stumbling block” Socio-economic knowledge –Transportation issues –No pharmacy –Poor access to fresh food

25. In-Person Implementation FM Clerkship 2013-14 Student and faculty in-room, SP and operator remote Prompt outside door –Labs and picture emailed vs. uploaded Tech “Stumbling block” can be adjusted Still experimenting

26. Feasibility Study Case Study, n=4 Was project implementation feasible (<$5,000)? Was it acceptable to students? –Interviews

27. Feasibility Cost for this study Extrapolated cost for 100 student institution, least expensive methods TeleOSCE development (14 hours of combined faculty FTE.) $1,039 (fixed start-up cost) $0 (case freely available, contact authors) TeleOSCE implementation- Observer (1 hour for four students ) $100/ hour for clinician faculty FTE ($25 per student) $375 (assuming SP* observer at $15/hour with 4 students/ hour) TeleOSCE implementation- Technical Support (1 hour for four students ) $45/ hour for non- clinical faculty ($11.25 per student) $625 (assuming staff support at 50k/year with 4 students/hour) Adobe® Connect™ phone charges ($.06/minute/user for 2 hour session – 15 minutes for each of 4 students) $28.80 ($7.20 per student) $0 (Using Google Hangouts™) Standardized patient ($15/hour. 1 hour training and 2 hours for OSCE) $45 $15 for SP training (same SP is used to grade and act) Total$1404.80 $1015 per 100 students

28. Acceptability Students found the TeleOSCE to be acceptable. Student experiences with the technology were positive. Students reported the TeleOSCE made them more aware of new practice models. Students did not feel participating in an OSCE online was inferior to participating in person.

29. Student Interviews “Before I thought that telemedicine was mainly for OHSU or for big city physicians to kind of consult with rural physicians, you know like a rural physician would have a patient in their office to like consult with a specialist…but then after this experience it kind of taught me that you can actually do visits with patients in their houses. It’s never crossed my mind before that patients would have the same technology as the physician in the office so that you could do a visit with the patient in their homes by themselves like that….That was new for me.” (Student A) “It (the TeleOSCE) fits pretty well with the theme that we do have a lot of patients who have a hard time getting in to see the doctor… even though this is a rural area, they live even farther out, so I can definitely see myself doing this, you know, later on in my career when I will have to do telemedicine with patients.” (Student B)

30. Closing Thoughts Other technology can be used: Skype, Google Hangouts –Use a telephone option for voice Interprofessional opportunities Remote learners get OSCE experience that also teaches them about rural learning context Case will be available on fmdrl.org

31. Discussion Reedsport, Oregon Photo by Lisa Merriman, MS3, OHSU Rural Clerkship, January 2014 Questions: palmerry@ohsu.edu

32. References Gazewood, J. D., Rollins, L. K., & Galazka, S. S. (2006). Beyond the Horizon: The Role of Academic Health Centers in Improving the Health of Rural Communities. Academic Medicine, 81(9), 793–797. Monegain, B. (2011) EMR, telemedicine saves Texas $1B, Healthcare IT News. Retrieved from http://www.healthcareitnews.com/news/emr- telemedicine-saves-texas-1b Robertson, T., (2012). Telemedicine gives rural doctors immediate access to help. MPR News. Retrieved from http://www.mprnews.org/story/2012/08/22/health/telemedicine-gives-rural- doctors-immediate-access-to-help http://www.mprnews.org/story/2012/08/22/health/telemedicine-gives-rural- doctors-immediate-access-to-help Telemedicine Frequently Asked Questions (FAQs). (2012). American Telemedicine Association. Retrieved January 20, 2014, from http://www.americantelemed.org/learn/what-is- telemedicine/faqs#.UudkPxDTnIU http://www.americantelemed.org/learn/what-is- telemedicine/faqs#.UudkPxDTnIU