 |
|
Profile of Users of Real-Time Interactive Teleconference Clinical Consultations
Susan Gustke, MD;
David C. Balch, MA;
Lance O. Rogers, MA;
Vivian L. West, RN, MBA
Arch Fam Med. 2000;9:1036-1040.
ABSTRACT
| |
Background Real-time interactive teleconference clinical consultations are envisioned for increasing accessibility to medical care by patients whose demographics restrict care. There are no published studies, however, describing referrals and the referring practitioners, patients, and specialists participating in these consultations.
Objective To assess characteristics of participants of interactive teleconference clinical consultations.
Design Descriptive study, February 1, 1996, through April 30, 1999.
Setting Eastern North Carolina: Brody School of Medicine at East Carolina University and 7 rural hospitals and clinics in its telemedicine network.
Subjects Rural practitioners requesting consultations (n = 76), consulting physicians (n = 40), and patients completing evaluations following consultations (n = 495).
Main Outcome Measures Demographic and descriptive variables for referring providers, patients, and consulting physicians relative to the population in the region and to patients and physicians at the East Carolina University School of Medicine clinics.
Results The largest number of referrals (65.2%) were made to obtain a second opinion or recommend a management plan in dermatology (33.5%), allergy (21.0%), or cardiology (17.8%). Significant patient characteristics were race (56.8% minorities), age (19.6%  10 years old and 26.0%  59.0 years old), sex (59% females), and insurance status (10.7% no insurance, 33.7% Medicaid, 15.4% Medicare). In addition, 38.0% had household incomes below the poverty level. Only 5.2% of the patients would have been treated by the referral practitioner, making travel necessary for consultation. Demographic characteristics of the practitioners were not statistically different.
Conclusions Participants of interactive teleconference clinical consultations are patients whose access to medical care might otherwise be limited. Use of telemedicine by practitioners is not related to age or sex.
INTRODUCTION
FOR MORE than 40 years, telecommunications technology has facilitated the development of techniques to overcome the barriers of time and distance in diagnosis.1-4 Telecommunications technology was initially used to provide access to medical care for patients in remote areas. Interest in its use in North America has expanded, and telecommunications technology is now being used to provide health care to rural and urban patients.1, 5-8 Significant differences exist between rural and urban residents, however, in their use of traditional health care services.9-11 Studies have shown that rural residents, particularly the elderly and minority populations, experience fewer outpatient visits than urban residents, with about one third fewer services received from medical specialists.12-15 Physician availability or accessibility is generally thought to be the underlying factor in this inequality.5, 15-16 There is a general belief that the rural health care resource shortage can be improved by using telecommunications technologies to bring physicians and specialists to residents of these rural communities.17
To provide consultations, 2 types of communications technology are used: interactive audio/visual clinical conferencing (a videoconference between patient and provider, or provider to provider), or store-and-forward technology (transmission of static images, full-motion video clips, audio files, or medical records stored as digital files and forwarded for retrieval by the consulting practitioner).18 To assist with patient examination, a consulting physician participating in interactive teleconference clinical consultations (ITCCs) can use remote peripheral devices such as an otoscope, stethoscope, ophthalmoscope, endoscope, or dermascope (a handheld camera for enhancing visual capabilities during dermatology consultations), and electronically transmitted medical records.
While the benefits of telemedicine have been widely espoused, there are few recent studies about the effects of ITCCs on the accessibility of medical care, and none that describe who actually uses ITCCs. Assumptions have been made that programs designed to meet the needs of underserved rural areas are providing services to patients who would not otherwise receive these services. Is the technology used more frequently for those whose age or economic status might restrict access to care? What are the primary reasons for telemedicine referrals? In which specialties are the most consultations being performed? Have younger physicians, who might have had greater exposure to computers and information technology, become the primary users of this technology? To address these questions, we conducted a study to evaluate the referral physicians, patients, and specialists using The Telemedicine Center at the Brody School of Medicine at East Carolina University (ECU) in Greenville, NC.
METHODS
Greenville is an urban community situated in the middle of a large, rural area in eastern North Carolina. The Telemedicine Center at ECU is a hub and spoke model inside a 14 714 sq mi (38 256 km2) referral area. This model is a centralized dedicated network. The hub is the Brody School of Medicine at ECU and specialists available for teleconsultations. The spokes are 12 outreach rural hospitals and clinics and 1 maximum-security prison, all with teleconferencing capabilities. Physicians in the rural sites provide care to patients residing in 29 surrounding counties (hereafter referred to as "the region"). Consultations with specialists at ECU occur using both ITCC and store-and-forward technology. Figure 1 depicts the ECU hub and sites in the region that contributed cases to this study, the population of the counties where there is a spoke site, and the telecommunications technology used for the real-time consults.
|
|
|
|
The hub at East Carolina University, Greenville, NC, and spoke sites (county population noted in parentheses) in the region that contributed cases to the study, and the telecommunications technology used for the real-time consults. T1 indicates point-to-point high-speed telephone line; ISDN, dial-up telephone line.
|
|
|
SAMPLE AND MEASUREMENT TOOL
In 1994, ECU became 1 of 5 participants in the Health Care Financing Administration's Telemedicine Payment Evaluation Project. The Telemedicine Research Center (Portland, Ore), working in conjunction with the Center for Health Policy Research at the University of Colorado, Denver, and ECU, designed the evaluation tool used in this study. The measurement tool includes information about the referring practitioner and need for consultation, patient demographics and travel, and the telemedicine session and consulting physician.
The ECU Telemedicine Center began to collect information about real-time ITCCs conducted with the 7 outreach rural sites depicted in Figure 1 on February 1, 1996. Between then and April 30, 1999, 1643 real-time ITCCs were conducted by specialists from ECU. Of these, 904 were consultations to the prison and 739 were consultations to the outreach sites. Consultations to the outreach sites included emergency consultations, physician-to-physician consultations, and ITCCs between patient and physician with a nurse presenter. Of the ITCCs between patient and physician, 495 evaluations were completed as part of the Telemedicine Payment Evaluation Project and the Health Resources and Services Administration Rural Telemedicine Grant Project, originally administered by the Office of Rural Health Policy, and currently administered by the Office for the Advancement of Telemedicine. From these 495 evaluations, data about the referring physicians, patients, and specialists were used to determine the profile of users of ITCCs. Comparisons were made with data about the practitioners and patients in the outreach areas being served,19-20 and with physicians and patients at the Brody School of Medicine clinics.21-22
STATISTICAL ANALYSIS
Analysis included descriptive statistics on 8 patient variables: age, sex, race, education, household income, primary insurance, employment, and family size. Using  2 testing, ITCC patient age, sex, race, and insurance status were compared with the population in the region and with patients seen in the ECU clinics. Descriptive statistics were used for referral practitioner and specialist data, and 2 testing was performed on age and sex comparing referral practitioners with practitioners in the region and consultants with physicians on staff at the ECU School of Medicine.
RESULTS
REFERRAL PRACTITIONERS
Seventy-six practitioners referred patients for clinical consultations. Of these, 9 are nurse practitioners (4%) or physician assistants (8%), 15 are specialists (20%), and 52 are primary care physicians (68%). Ages ranged from 29 to 90 years, with a median age of 45 years. No significant differences were noted for age or sex of the referring practitioners compared with practitioners in the region.
The majority of the referrals, 65.2%, were made to obtain a second opinion or recommendations for management; 15.9% were made to establish a diagnosis. If ITCC had not been an option, 84.1% of the time the patient would have been referred to a specialist in another community; the referring practitioner would have managed the patient without a referral to another physician 5.2% of the time.
PATIENTS
Table 1 presents the patient profiles of ITCC and ECU clinic patients. Compared with patients seen in the ECU specialty clinics in 1998, ITCC patient age, race, and insurance status are all highly significant (P <.001). More ITCC patients are aged 10 years or younger (19.6% ITCC, 11.3% clinic) and aged 59 years or older (26.0% ITCC, 21.5% clinic). There is a higher percentage of minority patients (56.4% African American and Hispanic) who received ITCCs than those who visited the ECU outpatient clinic (34.7%) or lived in the region (34.8%). The ITCC patients are also more likely than clinic patients to be receiving Medicaid (33.7% ITCC, 4.8% clinic) or to have no insurance (10.7% ITCC, 2.9% clinic).
|
|
|
|
Table 1. Patient Profile Comparing Telemedicine Patients and Clinic Patients
|
|
|
The proportion of female patients being seen with ITCCs (59%) is comparable (P = .65) to those visiting the clinic (58%), but significantly more females (P = .002) are seen through telemedicine compared with the population in the region. The percentage of unemployed ITCC patients is higher than that of the clinic patients (12.5% vs 6.5%) or the population in the region (6.0%). Thirty-eight percent of ITCC patients also have incomes below the poverty level based on income and family size, compared with 14.1% in the region; this information is not available for clinic patients.
CONSULTING PHYSICIANS
Neither age nor sex accounts for which consulting physicians are users of ITCC. The majority (85%; 34 of 40) are 40 to 60 years of age. Median age of consultants is 49 years; median age of physicians at the Brody School of Medicine at ECU is 47 years and of US physicians is 44 years. Comparable to staff at the Brody School of Medicine (86.4% are men, 13.6% are women), 87.8% of the telemedicine consultations were conducted by men, 12.2 % by women. The most frequent consultations are in dermatology (33.5%), allergy (21.0%), and cardiology (17.8%) (Table 2).
|
|
|
|
Table 2. Number of Referrals for Specialty Consultations
|
|
|
COMMENT
Several conclusions can be made from this study, the largest to date on ITCC participants. The majority of consultations are for second opinions or assistance in establishing management plans for dermatology, allergy, or cardiology patients in rural eastern North Carolina. Neither practitioner age nor sex are factors affecting referrals of patients for ITCCs; the practitioners are similar to the profile of all US practitioners in age and sex. Consultants participating in ITCCs are older than the median age for US physicians, but consistent with the composition of physicians on staff at the ECU medical school.
2 Testing using clinic and regional data shows that age, race, and insurance status are relevant for ITCC referrals. A large proportion of patients who use telemedicine are either 18 years and younger or 59 years and older. More than half the patients are minorities, significantly higher than the population in the region or patients visiting the clinic. The economic status of the ITCC patients is also below that of the population in the region. Thirty-eight percent of ITCC patients who reported income are below the poverty level, and 44.4% have no insurance or receive Medicaid, significantly more than clinic patients. A significant number of females are also seen by telemedicine, compared with the region.
Most relevant, however, is that the referring practitioners reported that few of the patients' needs could have been met in their offices (only 5.2% would have been treated by the practitioner making the referral). Transportation costs, inaccessibility of transportation services, and the inability or unwillingness to pay any additional expenses for services have been shown to present economic barriers to individuals with low incomes, preventing them from accessing recommended services.14, 23-24 The patients who would have been referred to the ECU clinic may not have been willing or able to travel to another geographic area for care. The no-show rate (ie, rate of patients who neither kept nor canceled scheduled appointments) for telemedicine was 7%.
Real-time ITCCs for patients in rural eastern North Carolina appear to improve access to health care for patients whose age and economic situation might otherwise restrict access. This descriptive study did not assess the effect of telemedicine on patient health outcomes. Additional studies are needed to examine how patients' health status correlates with telemedicine consultations.
AUTHOR INFORMATION
Accepted for publication July 10, 2000.
Project funding was provided by the Health Care Financing Administration and Health Resources and Services Administration's Rural Telemedicine Grant Project, originally administered by the Office of Rural Health Policy, currently administered by the Office for the Advancement of Telehealth.
Gloria Jones, Telemedicine Program Coordinator at the Center for Health Sciences Communication at Brody School of Medicine at East Carolina University was instrumental in the design, implementation, and coordination of the telemedicine data collection.
Reprints: Susan Gustke, MD, Eastern Area Health Education Center/Internal Medicine, School of Medicine, East Carolina University, Greenville, NC 27836 (e-mail: gustkes{at}mail.ecu.edu).
From Eastern Area Health Education Center/Internal Medicine School of Medicine (Dr Gustke) and Center for Health Sciences Communication (Messrs Balch and Rogers and Ms West), Brody School of Medicine at East Carolina University, Greenville, NC; and University of North Carolina, Chapel Hill, NC (Ms West).
REFERENCES
| |
1. Picot J. Telemedicine and telehealth in Canada. Telemed J. 1998;4:199-205.
ISI
| PUBMED
2. Wright D. Telemedicine and developing countries. December 1997:1-155. Available at: http://www.itu.int/itudoc/itu-d/rtdc96/023e.html. Accessed October 22, 1998 [Web site no longer maintains this document; accessibility unable to be verified September 1, 2000].
3. Perednia DA, Allen A. Telemedicine technology and clinical applications. JAMA. 1995;273:483-488.
FREE FULL TEXT
4. Balas EA, Jaffrey F, Kuperman GJ, et al. Electronic communication with patients: evaluation of distance medicine technology. JAMA. 1997;278:152-159.
FREE FULL TEXT
5. Slovis TL, Guzzardo-Dobson PR. The clinical usefulness of teleradiology of neonates. Pediatr Radiol. 1991;21:333-335.
FULL TEXT
|
ISI
| PUBMED
6. Favrot M, Frappaz D, Saltel P, et al. Breaking the isolation: telecommunication in the service of schooling of sick children. Pediatrie. 1993;48:151-157.
PUBMED
7. Mekhjian H, Turner JW, Gailiun M, McCain TA. Patient satisfaction with telemedicine in a prison environment. J Telemed Telecare. 1999;5:55-61.
ISI
| PUBMED
8. Thrall JH, Boland G. Telemedicine in practice. Semin Nucl Med. 1998;28:145-157.
FULL TEXT
|
ISI
| PUBMED
9. Coward R, McLaughlin DK, Duncan RP, Bull CN. Residential difference in the use of formal services prior to entering a nursing home. Gerontologist. 1994;34:44-49.
ABSTRACT
10. Nelson G. Social services to the urban and rural aged: the experience of area agencies on aging. Gerontologist. 1980;20:200-207.
ISI
| PUBMED
11. Mueller KJ, Patil KD, Boilesen ED. Racial and urban-rural variations in health care utilization and insurance. Health Serv Res. 1998;33:597-610.
ISI
| PUBMED
12. Dor A, Holahan J. Urban/rural differences in Medicare physician expenditures. Inquiry. 1990;27:307-318.
ISI
| PUBMED
13. American Academy of Family Physicians, Physician Payment Review Commission. Monitoring Access of Medicare Beneficiaries. Kansas City, Kan: American Academy of Family Physicians; 1992. Report No. 92-95.
14. McManus MA, Newacheck PW, Weader RA. Metropolitan and nonmetropolitan adolescents. J Rural Health. 1990;6:39-51.
PUBMED
15. Dansky KH, Brannon D, Shea DG, Vasey J, Dirani R. Profiles of hospital, physician, and home health service use by older persons in rural areas. Gerontologist. 1998;38:320-330.
ABSTRACT
16. Himes C, Rutrough T. Differences in the use of health services by metropolitan and nonmetropolitan elderly. J Rural Health. 1994;10:80-88.
PUBMED
17. Western Governors' Association and National Association of State Telecommunications Directors. Health-care on-ramps. April 1998. Available at: http://www.westgov.org/wga/publicat/roadrpt.htm. Accessed October 29, 1998.
18. Strode SW, Gustke S, Allen A. Technical and clinical progress in telemedicine. JAMA. 1999;281:1066-1068.
FREE FULL TEXT
19. Eastern North Carolina Health Care Atlas: A Resource for Healthier Communities. Greenville, NC: Center for Health Services Research and Development, East Carolina University; 1997. Section II.
20. Health Professions Data System [database]. Active and practicing professionals in 29 NC counties as of October 1998. Chapel Hill, NC: Cecil G Sheps Center for Health Services Research; July 28, 1999.
21. Office of Administration Internal memorandum. Greenville, NC: East Carolina University School of Medicine. August 25, 1995.
22. Clinical Management Information Systems [database]. University Medical Association Group Practice: 1998 Outpatient Clinic. Greenville, NC: East Carolina University School of Medicine; July 27, 1999.
23. Minear M, Crose R. Identifying barriers to services for low-income frail elders. J Gerontol Soc Work. 1996;26:57-64.
24. Congress, General Accounting Office. Health Care Access: Opportunities to target programs and improve accountability. Washington, DC, September 1997. Report T-HEHS-97-204. Available at: http://www.gao.gov/. Accessed April 23, 1999.
RELATED ARTICLE
Authors' Comment
Vivian West and Susan Gustke
Arch Fam Med. 2000;9(10):1040.
FULL TEXT
|
