1. Lisa Dodson, M.D. , Frances E Biagioli, M.D.
Using a Telemedicine OSCE to Meet the Future Needs of Diverse Patient Populations
L35A, STFM Annual Spring Conference, May 5, 2014
Ryan Palmer, Ed.D.
Lisa Dodson, M.D. , Frances E Biagioli, M.D.

2. Disclosure The presenter has no conflicts of interest
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
Describe the rationales for telemedicine simulation
Describe the feasibility and acceptability of implementing the TeleOSCE
Discuss how to access and integrate these technologies into your own curricula.
Define telemedicine.
Explain the rising role of telemedicine in meeting the healthcare needs of rural patients.
 Describe how "out of box" Internet based videoconferencing technologies (e.g. Adobe Connect, Skype, Google Hangouts, etc.) can be leveraged to deliver a simulated rural telemedicine OSCE, thus exposing students to future rural practice models.
Describe the results of a feasibility study that examined the cost of implementing the telemedicine OSCE as well as explore the student perspective of having participated in the OSCE.
Discuss how participants can access and integrate these technologies into their own curricula.

4. Oregon Rural Scholars Program (ORSP)
Background
Oregon Rural Scholars Program (ORSP)
Select students spend Rural and FM clerkships in 1 location
Curricular equivalent during FM

6. Definition Telemedicine
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

7. Rationale- Real World Application

8. Rationale- Patient Need
Comment on Joe Robertson’s 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.

10. ACGME Competencies Rationale- Education Patient Care Medical Knowledge
Practice Based Learning and Improvement
Systems Based Practice
Professionalism
Interpersonal Skills and Communication

11. ACGME Competencies Rationale- Education Patient Care Medical Knowledge
Practice Based Learning and Improvement
Systems Based Practice
Professionalism
Interpersonal Skills and Communication

12. Emulated in-person FM OSCE (time, feedback) Adobe Connect technology
Implementation
14 ORSP (total) students took telemedicine OSCE in April and September 2013, April 2014.
Emulated in-person FM OSCE (time, feedback)
Adobe Connect technology
Setup:

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

14. 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
Image from

15. 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
Image from

16. Bend
Burns
Crane

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, Rising sugar levels
Previous false alarm, patient resistance
Student must
Assess severity of condition
Utilize technology
Work with patient on treatment plan
Image from

18. 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
Image from

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
Image from

20. Patient-centered use of technology Socio-economic knowledge
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

23. Was project implementation feasible (<$5,000)?
Feasibility Study
Case Study, n=10
Was project implementation feasible (<$5,000)?
Was it acceptable to students?
Interviews

24. 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 $
$1015 per 100 students

25. 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.

26. 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)

27. Can be adjusted for in person students
Closing Thoughts
Can be adjusted for in person students
Other technology can be used: Skype, Google Hangouts
Residency and CME opportunities
Case available on fmdrl.

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

29. 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
Robertson, T., (2012). Telemedicine gives rural doctors immediate access to help. MPR News. Retrieved from
Telemedicine Frequently Asked Questions (FAQs). (2012). American Telemedicine Association. Retrieved January 20, 2014, from