VA Telemedicine: An Analysis of Cost and Time Savings

THE IMPACT OF VIDEO VISITS ON MEASURES OF CLINICAL EFFICIENCY AND REIMBURSEMENT

Introduction

Telehealth is gaining more attention in multiple specialties, including urology. Video visits in particular have shown high satisfaction and cost-saving for patients. However, there has been little investigation into how video visits compare to traditional clinic visits on measures of clinical efficiency and reimbursement.

Methods

Our dataset included 250 video visits of established patients at Michigan Medicine Department of Urology and 250 in-person clinic visits with the same providers completed between July 2016 and July 2017. Information on visit completion and cancellation rates; cycle time (time from check in to check out); reimbursement; and patient out-of-pocket expenses was collected using the electronic medical record and billing data.

Results

Completion rates were similar between video and clinic visits (58% versus 61%, respectively; p=0.24). Average cycle time for video visits was significantly shorter compared to clinic visits (24 min vs 80 min, respectively; p<0.01). Neither average commercial payer reimbursement (p=0.21) nor average out-of-pocket expense (p=0.22) was statistically different between video and traditional visits. More video visits than clinic visits were billed as level 3 encounters (85% and 63%, respectively, p=0.002).

Conclusions

Our study demonstrates that video visits have the potential to reduce the time patients spend on follow-up care without negatively impacting reimbursement rates. However, these visits could reduce average billing levels. These findings suggest that the incorporation of video visits into practice may be more efficient for patients but may also reduce billing levels.

Understanding the cost savings of video visits in outpatient surgical clinics

BACKGROUND

Expansion of telehealth is a high-priority strategic initiative for many health systems. Surgical clinics' implementation of video visits has been identified as a way to improve patient and provider experience. However, whether using video visits can reduce the cost of an outpatient visit is unknown.

METHODS

Prospective case study using time-driven activity-based costing at two outpatient surgical clinics at an academic institution. We conducted stakeholder interviews and in-person observations to map outpatient clinic flow and measure resource utilization of four key steps: check-in, vitals collection and rooming, clinician encounter, and check-out. Finally, we calculated the resource cost for each step using representative salary information to calculate total visit cost.

RESULTS

Video visits did not systematically reduce the amount of time clinicians spent with patients. Mean [standard deviation (SD)] visit costs were as follows: traditional clinic visits, $26.84 ($10.13); physician-led video visits, $27.26 ($9.69); and physician assistant-led video visits, $9.86 ($2.76). There was no significant difference in the total cost associated with physician-led traditional clinic visits and video visits (P=0.89). However, physician assistant-led video visits were significantly lower cost than physician-led video visits (P<0.001).

CONCLUSIONS

Using physician-led video visits does not reduce the cost of outpatient surgical visits when compared to traditional clinic visits. However, the use of less expensive clinician resources for video visits (e.g., physician-assistants) may yield cost savings for clinics.

Perceptions of Telehospitalist Services to Address Staffing Needs in Rural and Low Complexity Hospitals in the Veterans Health Administration

PURPOSE

Rural hospitals are disproportionally affected by physician shortages and struggle to staff inpatient services. Telemedicine presents an opportunity to address staffing problems and bring the advantages of hospital medicine to rural areas.

METHODS

In this study we surveyed administrators from 34 rural and low complexity hospitals in the Veterans Health Administration (VHA) to evaluate staffing needs and perceptions of a potential telehospitalist service.

FINDINGS

Of the 25 respondent facilities (74% response rate), 96% reported vacancies that resulted in staffing difficulties within the last 3 years and 84% relied on intermittent providers to staff their inpatient services in the last year. Almost two-thirds of respondents thought that a telehospitalist service could help address their staffing needs and 72% were interested in participating in a pilot program.

CONCLUSIONS

The results of this study corroborate staffing challenges in rural hospitals within VHA and support the use of alternative staffing models like a telehospitalist service to address intermittent and long-term staffing needs.

Barriers to Use of Telepsychiatry: Clinicians as Gatekeepers

Telepsychiatry is effective and has generated hope and promise for improved access and enhanced quality of care with reasonable cost containment. Clinicians and organizations are informed about clinical, technological, and administrative telepsychiatric barriers via guidelines, but there are many practical patient and clinician factors that have slowed implementation and undermined sustainability. Literature describing barriers to use of telepsychiatry was reviewed. PubMed search terms with date limits from January 1, 1959, to April 25, 2019, included telepsychiatry, telemedicine, telemental health, videoconferencing, video based, Internet, synchronous, real-time, two-way, limitations, restrictions, barriers, obstacles, challenges, issues, implementation, utilization, adoption, perspectives, perceptions, attitudes, beliefs, willingness, acceptability, feasibility, culture/cultural, outcomes, satisfaction, quality, effectiveness, and efficacy. Articles were selected for inclusion on the basis of relevance. Barriers are described from both patient and clinicians' perspectives. Patients and clinicians are largely satisfied with telepsychiatry, but concerns about establishing rapport, privacy, safety, and technology limitations have slowed acceptance of telepsychiatry. Clinicians are also concerned about reimbursement/financial, legal/regulatory, licensure/credentialing, and education/learning issues. These issues point to system and policy concerns, which, in combination with other administrative concerns, raise questions about system design/workflow, efficiency of clinical care, and changing organizational culture. Although telepsychiatry service is convenient for patients, the many barriers from clinicians' perspectives are concerning, because they serve as gatekeepers for implementation and sustainability of telepsychiatry services. This suggests that solutions to overcome barriers must start by addressing the concerns of clinicians and enhancing clinical workflow.

Exploring the Impact of a Telehealth Care System on Organizational Capabilities and Organizational Performance from a Resource-Based Perspective

This study explored the effects of information technology (IT) resources-in conjunction with IT infrastructure and organizational resources-on organizational capabilities and performance. The study further analyzed the mediating effect of organizational capabilities on the relationship between IT resources and organizational performance. A cross-sectional research design was adopted, and questionnaire copies were administered to senior care supervisors of Taiwanese day care centers, care institutions, and hospitals. In total, 328 valid questionnaire responses were obtained. The study results are summarized as follows: (1) A direct effect analysis revealed that IT infrastructure significantly affected service performance and financial performance; organizational resources significantly affected service performance but did not significantly affect financial performance. (2) A mediation model analysis indicated that organizational capabilities exerted a mediating effect on the relationship between IT resources and organizational performance. These results can serve as a reference for medical care organizations in developing strategies for reviewing internal IT resources, integrating internal and external capabilities, creating a competitive advantage, and boosting their performance.

Moving toward community based telehealth services using mhealth for hypertensive patients

BACKGROUND

Although self-care can control and prevent complications in hypertensive patients, self-care adherence is relatively low among these patients. Community-based telehealth services through mhealth can be an effective solution.

OBJECTIVE

This study aimed to evaluate the effect and acceptance of an mhealth application as a community-based telehealth intervention on self-care behavior adherence.

METHOD

This clinical trial included sixty hypertensive patients and their matched controls from two heart clinics affiliated to Shiraz University of Medical Sciences (SUMS). Self-care behaviors were assessed using Hill-Bone questionnaire before and after the intervention. Acceptability was evaluated in the intervention group at the end of the study period. The data were analyzed via SPSS 18 software using descriptive and inferential statistics.

RESULT

The results showed a significant difference between the intervention and control groups regarding the mean score of self-care behaviors (4.13 ± 0.23 versus 3.18 ± 0.27, p < .001). Additionally, a significant difference was observed between the two groups concerning the mean scores of the two subscales of self-care behaviors, including "medication taking" and "proper diet". However, no significant difference was observed between the two groups regarding the mean score of "appointment keeping" (p = .075). Overall, the intervention group participants were satisfied (4.27 ± 0.34) with this approach for managing hypertension.

CONCLUSION

Community-based telehealth services through mhealth had the potential to improve self-care behaviors in hypertensive patients and seemed to be accepted by the patients in the intervention group.

National Expansion of Sleep Telemedicine for Veterans: The TeleSleep Program

STUDY OBJECTIVES

(1) Review the prevalence and comorbidity of sleep disorders among United States military personnel and veterans. (2) Describe the status of sleep care services at Veterans Health Administration (VHA) facilities. (3) Characterize the demand for sleep care among veterans and the availability of sleep care across the VHA. (4) Describe the VA TeleSleep Program that was developed to address this demand.

METHODS

PubMed and Medline databases (National Center for Biotechnology Information, United States National Library of Medicine) were searched for terms related to sleep disorders and sleep care in United States military and veteran populations. Information related to the status of sleep care services at VHA facilities was provided by clinical staff members at each location. Additional data were obtained from the VA Corporate Data Warehouse.

RESULTS

Among United States military personnel, medical encounters for insomnia increased 372% between 2005-2014; encounters for obstructive sleep apnea (OSA) increased 517% during the same period. The age-adjusted prevalence of sleep disorder diagnoses among veterans increased nearly 6-fold between 2000-2010; the prevalence of OSA more than doubled in this population from 2005-2014.

CONCLUSIONS

Most VA sleep programs are understaffed for their workload and have lengthy wait times for appointments. The VA Office of Rural Health determined that the dilemma of limited VHA sleep health care availability and accessibility might be solved, at least in part, by implementing a comprehensive telehealth program in VA medical facilities. The VA TeleSleep Program is an expansion of telemedicine services to address this need, especially for veterans in rural or remote regions.

CITATION

Sarmiento KF, Folmer RL, Stepnowsky CJ, Whooley MA, Boudreau EA, Kuna ST, Atwood CW, Smith CJ, Yarbrough WC. National expansion of sleep telemedicine for veterans: the telesleep program. J Clin Sleep Med. 2019;15(9):1355-1364.

Cognitive assessment using face-to-face and videoconferencing methods

BACKGROUND

Early and regular assessment is needed to identify cognitive impairment in older adults. The use of telehealth or telecognitive assessment is widely applied in some aspects of health services, but it is unclear if cognitive assessments conducted in this way are reliable.

AIM

To examine whether using a handheld device to complete a cognitive assessment in adults can provide reliable scores, whether participants would be satisfied to complete a cognitive assessment by videoconference and if they would prefer face-to-face or telehealth assessment, and what challenges might be associated with telecognitive assessment using a handheld device compared with using face-to-face methods.

METHOD

Participants ( n =27) were given a series of cognitive assessments face to face and using a handheld device. Results were examined for reliability, logistical and technical challenges, and participants were questioned about which they preferred.

RESULTS

Cognitive assessments made with the handheld device were effective and reliable, and produced results that were comparable to those made with face-to-face assessments. However, more participants preferred face-to-face assessments than handheld device assessments. Several technical limitations were also noted during the assessments made using the handheld devices.

CONCLUSION

Although scores made using the handheld device were reliable, preliminary evidence suggests there are some tangible barriers to integrating telehealth into all settings for all patients.

Engaging telehealth to drive value-based urology

PURPOSE OF REVIEW

Telehealth, or the remote delivery of healthcare services using telecommunications technology, has the potential to revolutionize the delivery of healthcare and contribute to ongoing efforts to provide high-value care.

RECENT FINDINGS

We discuss several categories of telehealth that have been applied to healthcare. Several of these approaches, in particular video visits and teleconsultations, have promising early data demonstrating the significant benefits of telehealth technology with respect to the quality of care, access, cost savings, and patient experience. Nonetheless, considerable knowledge gaps still exist regarding how and for which patients and diseases telehealth modalities should be applied. Finally, we discuss the barriers to widespread adoption at the institutional, state, and federal levels.

SUMMARY

Maximizing the value of healthcare is an important goal for hospitals, physicians, and policymakers. Telehealth leverages advances in technology and the widespread availability of telecommunications devices to make healthcare communication more available, more convenient, and more efficient for patients and providers. With appropriate policies and incentives, telehealth initiatives can improve the value of urologic care and smooth the transition to a value-based healthcare system.

Telepsychiatry: A New Treatment Venue for Pediatric Depression

The benefits and acceptability of using telepsychiatry to provide psychiatric treatment to youth in their homes, schools, primary care provider offices, juvenile correction centers, and residential facilities are well established. Telepsychiatry removes geographic barriers between patients and providers and improves the access to and ease of receiving quality care. Effective telepsychiatrists use strategic room staging, enhanced nonverbal communication, and technical experience to ensure sessions provide an authentic treatment experience and strong provider-patient alliances are forged. When the telepsychiatry venue is used properly, sessions feel authentic and pediatric treatment outcomes meet and sometimes exceed those of sessions conducted in traditional venues.

A Dynamic MooM Dataset Processing Under TelMED Protocol Design for QoS Improvisation of Telemedicine Environment

Telemedicine research improves the connectivity of remote patients and doctors. Researchers are focused on data optimization and processing over a predefined channel of communication under a depictive low QoS. In this paper a consolidated representation of telemedicine infrastructure of modern topological arrangement is represented and validated. The infrastructure is aided with Multiple Objective Optimized Medical dataset (MooM) processing and a channel optimizing TelMED protocol designed exclusively for remote medicine dataset transmission and processing. The proposed infrastructure provides an application oriented approach towards Electronics health records (EHR) creation and updating over edge computation. The focus of this article is to achieve higher order of Quality of Service (QoS) and Quality of Data (QoD) compared to typical communication channels algorithms for processing of medical data sample. Typically the proposed technique results are achieved to discuss in MooM dataset processing and TelMED channel optimization sessions and a resulting improvement is discussed with a comparison of each MooM dataset in reverse processing towards server end of diagnosis and a consolidated QoS is retrieved for proposed infrastructure.

Telemedicine for Allergy Services to Rural Communities

Telemedicine (TM) involves the use of technology to provide medical services to patients who live at a distance. It can be used asynchronously for interpretation of test results (spirometry, skin tests imaging studies), and for communication of information when the simultaneous presence of provider and patient is unnecessary. Synchronous encounters can either be unscheduled and initiated on demand by patients or be facilitated substitutes for in-person visits. The latter results in asthma outcomes that are as good as those for in-person visits while reducing the cost and inconvenience of travel from rural communities to urban centers. Facilitated visits can be done in the ambulatory and emergency department settings, and they can be used for inpatient consults when allergy specialists are not readily available. Both patients and providers experience high degrees of satisfaction with this type of visit. In addition, virtual visits performed using TM are cost-effective. TM offers a solution to the shortage of specialty care that is present in rural communities.

Factors Determining Patients' Choice Between Mobile Health and Telemedicine: Predictive Analytics Assessment

BACKGROUND

The solution to the growing problem of rural residents lacking health care access may be found in the use of telemedicine and mobile health (mHealth). Using mHealth or telemedicine allows patients from rural or remote areas to have better access to health care.

OBJECTIVE

The objective of this study was to understand factors influencing the choice of communication medium for receiving care, through the analysis of mHealth versus telemedicine encounters with a virtual urgent clinic.

METHODS

We conducted a postdeployment evaluation of a new virtual health care service, Virtual Urgent Clinic, which uses mHealth and telemedicine modalities to provide patient care. We used a multinomial logistic model to test the significance and predictive power of a set of features in determining patients' preferred method of telecare encounters-a nominal outcome variable of two levels (mHealth and telemedicine).

RESULTS

Postdeployment, 1403 encounters were recorded, of which 1228 (87.53%) were completed with mHealth and 175 (12.47%) were telemedicine encounters. Patients' sex (P=.004) and setting (P<.001) were the most predictive determinants of their preferred method of telecare delivery, with significantly small P values of less than .01. Pearson chi-square test returned a strong indication of dependency between chief concern and encounter mediums, with an extremely small P<.001. Of the 169 mHealth patients who responded to the survey, 154 (91.1%) were satisfied by their encounter, compared with 31 of 35 (89%) telemedicine patients.

CONCLUSIONS

We studied factors influencing patients' choice of communication medium, either mHealth or telemedicine, for a virtual care clinic. Sex and geographic location, as well as their chief concern, were strong predictors of patients' choice of communication medium for their urgent care needs. This study suggests providing the option of mHealth or telemedicine to patients, and suggesting which medium would be a better fit for the patient based on their characteristics.

Outpatient Telemedicine Program in Vascular Surgery Reduces Patient Travel Time, Cost, and Environmental Pollutant Emissions

BACKGROUND

We analyze the impact of outpatient telemedicine services on the travel burden of vascular surgery patients with regard to distance, time, and cost, as well as the emission of environmental pollutants.

METHODS

Retrospective analysis was used to compare the patient travel expenditure and environmental impact associated with telemedicine encounters versus hypothetical in-person traditional consultations for all outpatient virtual care encounters with vascular surgery patients from October 2015 to October 2017. The primary outcomes measured were travel distance saved, travel time saved, travel costs saved, reduction in fuel consumption, and reduction in environmental pollutant emission.

RESULTS

Over a two-year period, 146 outpatient telemedicine encounters were conducted among 87 unique patients (61 females, 26 males; mean age, 60 ± 13 years). The average one-way distance saved by the utilization of telemedicine services was 15.6 ± 6.3 miles, with an average roundtrip savings of 31.2 miles. The average one-way travel time saved was 19.5 ± 9.2 minutes, with an average roundtrip savings of 39 minutes. By using telemedicine services, these vascular surgery patients saved an average of $4.26 in gas and parking costs at each telemedicine encounter. The total reduction in passenger vehicle emission of environmental pollutants, including carbon dioxide, carbon monoxide, nitric oxides, and volatile organic compounds was 1632 kg, 42,867 g, 3160 g, and 4715 g, respectively, with a total of 194 gallons of gas saved from driving.

CONCLUSIONS

Utilization of telemedicine services reduces the travel distance, time, and costs for vascular surgery patients. Outpatient telemedicine programs may also provide environmental benefit through the reduction of greenhouse gas and pollutant emissions.

Telemedicine Training in Undergraduate Medical Education: Mixed-Methods Review

BACKGROUND

Telemedicine has grown exponentially in the United States over the past few decades, and contemporary trends in the health care environment are serving to fuel this growth into the future. Therefore, medical schools are learning to incorporate telemedicine competencies into the undergraduate medical education of future physicians so that they can more effectively leverage telemedicine technologies for improving the quality of care, increasing patient access, and reducing health care expense. This review articulates the efforts of allopathic-degree-granting medical schools in the United States to characterize and systematize the learnings that have been generated thus far in the domain of telemedicine training in undergraduate medical education.

OBJECTIVE

The aim of this review was to collect and outline the current experiences and learnings that have been generated as medical schools have sought to implement telemedicine capacity-building into undergraduate medical education.

METHODS

We performed a mixed-methods review, starting with a literature review via Scopus, tracking with Excel, and an email outreach effort utilizing telemedicine curriculum data gathered by the Liaison Committee on Medical Education. This outreach included 70 institutions and yielded 7 interviews, 4 peer-reviewed research papers, 6 online documents, and 3 completed survey responses.

RESULTS

There is an emerging, rich international body of learning being generated in the field of telemedicine training in undergraduate medical education. The integration of telemedicine-based lessons, ethics case-studies, clinical rotations, and even teleassessments are being found to offer great value for medical schools and their students. Most medical students find such training to be a valuable component of their preclinical and clinical education for a variety of reasons, which include fostering greater familiarity with telemedicine and increased comfort with applying telemedical approaches in their future careers.

CONCLUSIONS

These competencies are increasingly important in tackling the challenges facing health care in the 21st century, and further implementation of telemedicine curricula into undergraduate medical education is highly merited.

A decision tree-based classifier for E-visit service provision

This study proposes a decision tree-based e-visit classification approach (DTEVCA) to determine clinic visits qualified as e-visits using clinics' medical records and patients' demographic data. This study assumes that health care insurance will subsidise e-visit service costs, in which case, identifying patients who benefit most from e-visit service is essential. Using a large data set from Taiwan's National Health Insurance, this study verifies the efficiency and validity of the DTEVCA. Results indicate that this approach can accurately classify in-office clinic visits that could switch to e-visit services. The straightforward rules of this decision tree also give insurance agencies a clear guideline to understand the circumstances of using e-visits and predict the effects of implementing e-visits in Taiwan. Result of this study can help countries improve the policy formulation process for physicians' use, or for academic research. The DTEVCA can update classification rules using new data to correct biases and ensure the stability of the e-visit system. In addition, the concept of this approach is feasible not only for e-visit service but also for other 'new services' such as new products or new policies.

Key Factors Affecting the Adoption of Telemedicine by Ambulatory Clinics: Insights from a Statewide Survey

Background: Despite demonstrated benefits and improved demand for telemedicine, adoption rates by U.S. ambulatory clinics remain low. There is a critical need to identify why telemedicine adoption rates remain low among ambulatory providers. Introduction: The aim of this study is to evaluate key predictors of telemedicine adoption by ambulatory clinics and assess salient differences between adopters and nonadopters. Three categories of predictors namely clinic characteristics, health information technology (HIT)-related factor, and organizational variables were examined. Materials and Methods: The study used data from a survey of 1,285 clinics in Minnesota (MN) that was collected by Minnesota Department of Health (MDH) in 2016. Exploratory statistical analyses as well as binary logistic regression analyses were carried out using SPSS software. Results: Fifty-five percent of ambulatory clinics in Minnesota had adopted telemedicine. Real-time consultations were adopted in over 26% clinics, remote patient monitoring in 15% clinics, and store-and-forward consultations in about 7% clinics. Originating site teleconsulting was prevalent in 27% clinics, whereas primary care and specialist services through teleconsulting were adopted by 23% clinics. Logistic regression revealed health system-owned clinics, rural clinics, and primary care ones to exhibit higher levels of telemedicine adoption. Clinics with paperless electronic health record (EHR) systems, health information exchange (HIE)-enablement, and better technological infrastructure had higher odds of telemedicine adoption. Furthermore, clinics that had redesigned their workflows also exhibited higher odds of telemedicine adoption. Clinics that faced high costs of telemedicine equipment, lack of demand had lower adoption levels. Clinics that faced high costs for hosting and staffing were more likely to adopt store-and-forward telemedicine and real-time patient monitoring rather than other high-end telemedicine services. Clinics that reported inadequate coverage or reimbursement were more likely to adopt a restrictive set of telemedicine services. Discussion: Telemedicine is not yet very prevalent among Minnesota ambulatory clinics. Over 45% of the clinics do not offer any telemedicine services. The barriers to adoption vary widely and pertain to HIT as well as organizational factors. Conclusion: With increased demand for telemedicine services, policy changes aimed at improving the reimbursement models, digital infrastructure for telemedicine, HIE capabilities, organizational efforts to move toward paperless EHR systems, and redesigning workflows can facilitate in accelerating telemedicine adoption.

Integration of telehealth services in the healthcare system: with emphasis on the experience of patients living with HIV

The US Health Resources and Services Administration defines telehealth as the use of electronic information and telecommunications technologies to support long-distance clinical healthcare, patient and professional health-related education, public health and health administration. Many studies have supported the use of telehealth to increase convenience to patients, improve patient satisfaction, diminish healthcare disparities, and reduce cost that will ultimately lead to improvement in clinical outcomes and quality of care. However, guaranteeing confidentiality, educating patients and providers, and obtaining insurance reimbursement are some of the challenges that face the implementation of telehealth program. The use of telehealth has been investigated in acute infections, such as endocarditis and chronic infections as in hepatitis C, and HIV. The purpose of this review is to focus on the use of telehealth services for people living with HIV (PLWH). For PLWH, telehealth could be particularly useful by connecting specialty providers to an underserved population and addressing many of the factors identified as barriers to HIV care. To date, the literature supports the use of telehealth for the management of chronic diseases including HIV. Most of the studies showed a high acceptability and positive experience with telehealth services among PLWH. However, fewer studies have evaluated telemedicine for chronic direct care of PLWH. Well-designed studies are needed to show that the implementation of telehealth could improve the HIV care continuum. In addition, future research should focus on identifying the group of patients that could benefit the most from such intervention.

Impact of Telemedicine in Pediatric Postoperative Care

Background: A shortage of pediatricians and long wait times in the hospitals render more efficient follow-up visits increasingly important. Virtual visits between physician and patient offer a solution to this problem. Increased awareness, improved technology, and efficient scheduling methods will contribute to the quality and adoption of telemedicine programs. Introduction: The aim of this study was to analyze the impact of pediatric telemedicine on wait times and visit durations, as compared with in-person visits. A secondary goal was to assess the efficiency of different scheduling methods for virtual visits. Materials and Methods: The study included >800 postoperative virtual visits from urology, cardiovascular surgery, and ophthalmology, comprising data on wait times, visit duration, and postvisit satisfaction collected through SBR Health and Redcap. In-person visit data were collected on 14 patients in urology, and satisfaction scores were obtained through Press Ganey for urology and ophthalmology. Results: Patients reported very high satisfaction with virtual visits and benefitted from reduced wait times, while receiving care of comparable duration and quality. Longer blocks of time scheduled exclusively for virtual visits correlated with shorter wait times. Discussion: Supplementing health care with telemedicine is a viable way to provide patient-centered care. Implemented effectively, a telemedicine program can contribute greatly to the value a hospital provides to its patients. Conclusions: Virtual visits provide an efficient way to conduct postoperative visits, reducing wait times and increasing physician efficiency while retaining high satisfaction and quality of care.

Comparison of virtual visit versus traditional clinic for management of varicose veins

Introduction

The objective of this study is to compare the clinical outcomes of patients with varicose veins managed in the telemedicine clinic and traditional clinic.

Methods

Retrospective analysis of all vein procedures in the institutional Vascular Quality Initiative Varicose Vein Registry (VQI VVR) was performed from January 2015 to August 2017. Patients were divided into two groups: Telemedicine versus Traditional Clinic. Comparison data included patient demographics, past medical history, clinical outcomes, patient-reported outcomes and postoperative complications. Statistical testing included chi-square test for categorical variables and student t-test for continuous variables using the SPSS statistical software.

Results

A total of 1034 varicose vein procedures were performed during the 31-month study period. There were 75 virtual encounters in the Telemedicine Clinic (Group A) and 959 face-to-face encounters in the Traditional Clinic (Group B). Most of the demographics characteristics were clinically similar in both groups. Comparing Group A and Group B, there were no differences in age, sex, race and body mass index. Early 3-month follow up was 100% in Group A and 90.7% in Group B. Both groups had low complication rates of haematoma (1.3% vs 0.3%, p = 0.884), paraesthesia (1.3% vs 0.6%, p = 0.767) and recanalisation (1.3% vs 4.0%, p = 0.383) during the early follow up period.

Discussion

Synchronous virtual visits for patient care are feasible for the management of chronic venous disease. Patients with varicose veins who choose to undergo telemedicine evaluations have similar pre-operative demographics, clinical classification and patient outcomes.

Vet Connect: A Quality Improvement Program to Provide Telehealth Subspecialty Care for Veterans Residing in VA-Contracted Community Nursing Homes

Veterans residing in Veterans Health Administration (VA) contracted Community Nursing Homes (CNHs) receive primary care from the CNH they reside in, but often travel to Veterans Affairs Medical Centers (VAMCs) for specialty care services. The Vet Connect project is a quality improvement project aiming to implement video technology to support access to specialty care. Methods: Eight Denver VAMC specialty care providers and three project nurses underwent telehealth training and obtained appropriate equipment. To identify in-person visits eligible for substitution of video visits, project nurses review charts of CNH Veterans, consult directly with Veterans, and obtain recommendations from staff. Project nurses serve as tele-presenters within the CNHs, while VA specialists provide care from the VAMC. After each visit, team nurses coordinate care with and deliver specialty care recommendations to CNH staff. Results: We assessed clinical, business, and technical domains of the Vet Connect project, and utilized process mapping to identify barriers and facilitators to implementation. Clinically, starting on 26 June 2017 through 1 June 2018, N = 203 video visits have been conducted with 11 different CNHs in three subspecialties: geriatrics, palliative care, and mental health. These visits generated 49 referrals for 37 Veterans. Fiscally, cost analyses indicate that per visit, the health care system saves an estimated $310. Technologically, the success rate was 83%. Process mapping helped identify facilitators and barriers to implementation of the telehealth program, including cultivating buy-in from key stakeholders (i.e., medical and mental health providers, telehealth staff, and CNH staff), communication allowing for ongoing program adaptation, and building relationships. Conclusion: Subspecialty care delivery to nursing homes using video visit technology in the Vet Connect program is feasible using centralized organization to coordinate complex clinical, business and technical processes. Vet Connect has proved sustainable and has potential to expand within and outside of the VA.

Tips for Seeing Patients via Telemedicine

PURPOSE OF REVIEW

Telemedicine is a technology that permits patients to be seen at a distance. This review describes different types of telemedicine, why they might be useful for a practice, what equipment is needed, and how to select and schedule patients.

RECENT FINDINGS

The use of synchronous telemedicine is increasing rapidly and has surpassed 50% of ambulatory encounters in some instances. Management of patients is particularly germane for an allergy practice since it is an outpatient specialty with patients who live in widely distributed locations with limited access to allergists. With utilization of digital exam equipment, in vitro tests for diagnosis, and spirometry at the patient location, there are few clear advantages of seeing patients in-person over virtual visits. Telemedicine is here today. As its use increases, it is critical that allergy specialists embrace this new technology.

An economic cost analysis of an expanding, multi-state behavioural telehealth intervention

Introduction

In this paper the economic costs associated with a growing, multi-state telepsychiatry intervention serving rural American Indian/Alaska Native populations were compared to costs of travelling to provide/receive in-person treatment.

Methods

Telepsychiatry costs were calculated using administrative, information-technology, equipment and technology components, and were compared to travel cost models. Both a patient travel and a psychiatrist travel model were estimated utilising ArcGIS software and unit costs gathered from literature and government sources. Cost structure and sensitivity analysis was also calculated by varying modeling parameters and assumptions.

Results and Discussion

It is estimated that per-session costs were $93.90, $183.34, and $268.23 for telemedicine, provider-travel, and patient-travel, respectively. Restricting the analysis to satellite locations with a larger number of visits reduced telemedicine per-patient encounter costs (50 or more visits: $83.52; 100 or more visits: $80.41; and 150 or more visits: $76.25). The estimated cost efficiencies of telemedicine were more evident for highly rural communities. Finally, we found that a multi-state centre was cheaper than each state operating independently.

Conclusions

Consistent with previous research, this study provides additional evidence of the economic efficiency associated with telemedicine interventions for rural American Indian/Alaska Native populations. Our results suggest that there are economies of scale in providing behavioural telemedicine and that bigger, multi-state telemedicine centres have lower overall costs compared to smaller, state-level centres. Additionally, results suggest that telemedicine structures with a higher number of per-satellite patient encounters have lower costs, and telemedicine centres delivering care to highly rural populations produce greater economic benefits.

Teleneurology and mobile technologies: the future of neurological care

Neurological disorders are the leading cause of global disability. However, for most people around the world, current neurological care is poor. In low-income countries, most individuals lack access to proper neurological care, and in high-income countries, distance and disability limit access. With the global proliferation of smartphones, teleneurology - the use of technology to provide neurological care and education remotely - has the potential to improve and increase access to care for billions of people. Telestroke has already fulfilled this promise, but teleneurology applications for chronic conditions are still in their infancy. Similarly, few studies have explored the capabilities of mobile technologies such as smartphones and wearable sensors, which can guide care by providing objective, frequent, real-world assessments of patients. In low-income settings, teleneurology can increase the capacity of local care systems through professional development, diagnostic support and consultative services. In high-income settings, teleneurology is likely to promote the expansion and migration of neurological care away from institutions, incorporate systems of asynchronous communication (such as e-mail), integrate clinicians with diverse skill sets and reach new populations. Inertia, outdated policies and social barriers - especially the digital divide - will slow this progress at considerable cost. However, a future increasingly will be possible in which neurological care can be accessed by anyone, anywhere. Here, we examine the emerging evidence regarding the benefits of teleneurology for chronic conditions, its role and risks in low-income countries and the promise of mobile technologies to measure disease status and deliver care. We conclude by discussing the future trends, barriers and timing for the adoption of teleneurology.

Patient and Health System Experience With Implementation of an Enterprise-Wide Telehealth Scheduled Video Visit Program: Mixed-Methods Study

BACKGROUND

Real-time video visits are increasingly used to provide care in a number of settings because they increase access and convenience of care, yet there are few reports of health system experiences.

OBJECTIVE

The objective of this study is to report health system and patient experiences with implementation of a telehealth scheduled video visit program across a health system.

METHODS

This is a mixed methods study including (1) a retrospective descriptive report of implementation of a telehealth scheduled visit program at one large urban academic-affiliated health system and (2) a survey of patients who participated in scheduled telehealth visits. Health system and patient-reported survey measures were aligned with the National Quality Forum telehealth measure reporting domains of access, experience, and effectiveness of care.

RESULTS

This study describes implementation of a scheduled synchronous video visit program over an 18-month period. A total of 3018 scheduled video visits were completed across multiple clinical departments. Patient experiences were captured in surveys of 764 patients who participated in telehealth visits. Among survey respondents, 91.6% (728/795) reported satisfaction with the scheduled visits and 82.7% (628/759) reported perceived quality similar to an in-person visit. A total of 86.0% (652/758) responded that use of the scheduled video visit made it easier to get care. Nearly half (46.7%, 346/740) of patients estimated saving 1 to 3 hours and 40.8% (302/740) reported saving more than 3 hours of time. The net promoter score, a measure of patient satisfaction, was very high at 52.

CONCLUSIONS

A large urban multihospital health system implemented an enterprise-wide scheduled telehealth video visit program across a range of clinical specialties with a positive patient experience. Patients found use of scheduled video visits made it easier to get care and the majority perceived time saved, suggesting that use of telehealth for scheduled visits can improve potential access to care across a range of clinical scenarios with favorable patient experiences.

Evaluating barriers to adopting telemedicine worldwide: A systematic review

Introduction and objective Studies on telemedicine have shown success in reducing the geographical and time obstacles incurred in the receipt of care in traditional modalities with the same or greater effectiveness; however, there are several barriers that need to be addressed in order for telemedicine technology to spread. The aim of this review is to evaluate barriers to adopting telemedicine worldwide through the analysis of published work. Methods The authors conducted a systematic literature review by extracting the data from the Cumulative Index of Nursing and Allied Health Literature (CINAHL) and PubMed (MEDLINE) research databases. The reviewers in this study analysed 30 articles (nine from CINAHL and 21 from Medline) and identified barriers found in the literature. This review followed the checklist from Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009. The reviewers organized the results into one table and five figures that depict the data in different ways, organized by: barrier, country-specific barriers, organization-specific barriers, patient-specific barriers, and medical-staff and programmer-specific barriers. Results The reviewers identified 33 barriers with a frequency of 100 occurrences through the 30 articles. The study identified the issues with technically challenged staff (11%), followed by resistance to change (8%), cost (8%), reimbursement (5%), age of patient (5%), and level of education of patient (5%). All other barriers occurred at or less than 4% of the time. Discussion and conclusions Telemedicine is not yet ubiquitous, and barriers vary widely. The top barriers are technology-specific and could be overcome through training, change-management techniques, and alternating delivery by telemedicine and personal patient-to-provider interaction. The results of this study identify several barriers that could be eliminated by focused policy. Future work should evaluate policy to identify which one to lever to maximize the results.

Attitudes Toward e-Health: The Otolaryngologists' Point of View

INTRODUCTION

Online communication and the number of e-health applications have noticeably increased. However, little is known about the otolaryngologists' use behavior and their attitudes toward the potential of e-health. The aims of the study were to evaluate the documentation, information, and communication technologies used by otolaryngologists and to get a better understanding of their attitudes toward the potential of e-health for cross-sectoral patient care.

METHODS

A survey was developed and tested by otolaryngologists, healthcare-information technology experts, and health services researchers. A total of 334 otolaryngologists in private practice were asked to participate in this cross-sectional study. In total, 234 of them took part in the study, and 157 returned completed questionnaires. Statistical analysis was performed by using crosstabs, including chi-square tests, and multivariate logistic regressions. Results and Materials: Digital technologies are widely used by otolaryngologists (e.g., 89.6% use an electronic health record). However, the majority of intersectoral communication is still based on analogue techniques (e.g., fax use in 63.7%). From the otolaryngologists' perspectives, the potential of e-health for intersectoral care is mostly in appointment scheduling, further referrals to hospitals, and automated appointment reminders. The physicians' attitudes toward e-health are associated with their Internet use behavior in daily life (odds ratio = 4.30, confidence interval 1.11-16.64, p = 0.035) but not with their demographics.

DISCUSSION

The otolaryngologists are well prepared and have an overall positive attitude toward e-health for deeper use in cross-sectoral care. Therefore, e-health in otolaryngology needs more attention and resources for further studies, especially with a focus on quality and safety of care.

Pre-surgery evaluations by telephone decrease travel and cost for families of children with cerebral palsy

Introduction:

Children with cerebral palsy need highly specialized care. This can be very burdensome for families, particularly in large rural states, due to the need for long-distance travel to appointments. In this study, children undergoing the selective percutaneous myofascial lengthening surgery utilized a telephone-based telemedicine evaluation to assess for surgical eligibility. The goal was to avoid a separate preoperative clinic visit weeks before the surgery. If possible, eligibility was determined by telephone, and then, the patient could be scheduled for a clinic visit and possible surgery the next day, saving the family a trip. The purposes of the study were to calculate estimated reductions in miles traveled, in travel expenses, and in carbon emissions and to determine whether the telephone assessment was accurate and effective in determining eligibility for surgery.

Methods:

From 2010 to 2012, 279 patients were retrospectively reviewed, and of those, 161 mailed four-page questionnaire and anteroposterior pelvis X-ray followed by a telephone conference. Geographic information system methods were used to geocode patients by location. Savings in mileage and travel costs were calculated. From 2014 to 2015, 195 patients were additionally studied to determine accuracy and effectiveness.

Results:

The telephone prescreening method saved 106,070 miles in transportation over 3 years, a 38% reduction with US$55,326 in savings. Each family saved an average of 658 (standard deviation = 340) miles of travel and US$343.64 (standard deviation = US$178) in travel expenses. For each increase of 10 miles in distance from the health center, the odds of a patient utilizing telephone screening increased by 10% (odds ratio: 1.101, 95% confidence interval: 1.073–1.129, p < 0.001). After the telephone prescreening, 86% were determined to be likely candidates for the procedure. For 14%, a clinic visit only was scheduled, and they were not scheduled for surgery.

Conclusion:

Families seeking specialized surgical care for their disabled children particularly benefited from this approach.

Space, time and demographic change

Purpose

The purpose of this paper is to explore the potential value of applying spatial science and technology to the issue of care integration across what are the often fragmented domains of health and social care provision. The issue of focus for this purpose is population ageing because it challenges existing information and practice silos. Better integration, the author proposes, needs to adopt a geographic approach to deal with the challenges that population ageing present to health and social care as they currently function in many countries.

Design/methodology/approach

The approach utilised here explores the role that could be played by enhancing spatial perspectives in care integration. Spatial and temporal strategies need to be coordinated to produce systems of integrated care that are needed to meet the needs of growing numbers of older people.

Findings

The author’s premise is that, with some rare exceptions, geographies of care are needed to address important shifts in demography such as population ageing and their epidemiological consequences. The rising intersection between the ageing and disability concepts illustrates how the fluid nature of health and social care client groups will challenge existing systems and their presuppositions. Health and medical geography offer a theoretical and practical response to some of these emerging problems.

Research limitations/implications

This is a brief conceptual piece in favour of integrating geographic concepts and methods in the context of changing demography and the social, economic and service implications of such changes. It is limited in scope and a more detailed explanation would be required for a proof of concept.

Practical implications

Practically we know that all human services vary across space as do both healthcare and related social services and supports. Issues of quality and safety are numerous in these policy domains generally, with aged care evidencing a growing number of problems and challenges. Being able to inquire on significant challenges in health and social care through a spatial lens has the potential to provide another, highly practical, kind of evidence in this field of work. This lens is, the author contends, very poorly integrated into either health or social care at present. However, doing so would have a variety of useful outcomes for monitoring and intervening on real problems in care integration. An example could be “frequent flyers” in emergency departments as has been done in Camden, New Jersey through patient mapping.

Social implications

The author’s position in this paper is that the challenges we face in providing integrated care to ageing and increasingly disabled (including both physical and cognitive impairments) populations will only grow in the face of variable governmental responses and increasingly complex funding and service provider arrangements. Without a geographical perspective and the concepts and tools of spatial science the author does not see an adequate response emerging. The shift to community-based care for many groups, including the aged, means that location will become more important rather than less so. This is a societal concern of major proportions and the very concept of integrated care requires of us a geographical perspective.

Originality/value

This is a short but, the author believes, conceptually rich piece with a variety of potential practical implications for health and social care service provision. Issues of equity, quality, safety and even basic access can only grow as population ageing progresses and various forms of chronic disease and disability continue to grow. Knowing where the most affected people and their social and service connections are located will support better integration. And better integration may resolve some of the financial and related resource problems that are already evident but which can only continue to increase. In this context, the author suggests that the integrated care of the future needs to be geographically informed to be effective.

The Past Is Prologue: The Future of Sleep Medicine

ABSTRACT

The field of sleep medicine has gone through tremendous growth and development over a short period of time, culminating in recognition of the field as an independent medical subspecialty by the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS). However, the fellowship training requirement that is now mandatory for sleep medicine board certification eligibility has had the unintended consequence of restricting the influx of young physicians to the field. In response to the potential workforce shortage confronting the field of sleep medicine, the American Academy of Sleep Medicine (AASM) board of directors has developed a comprehensive plan to strengthen the field by growing sleep fellowship programs, exploring novel sleep medicine training opportunities, creating and fostering the sleep team (with special emphasis on engagement of primary care providers), embracing the role of consumer sleep technologies, and expanding the reach of sleep specialists through telemedicine. The AASM plans summarized in this special article represent efforts to confront serious workforce challenges and turn them into opportunities that will improve the health of both our patients and our field.

Next Generation House Call

Just as online shopping is supplanting visits to the mall, and distance learning is part of the new wave in higher education, so is health care coming to a computer or mobile device near you. In the next few years, telehealth will increasingly become part of psychiatric and neurological care. Still to overcome is an unwieldy health care system that will need to adapt to practices that have the potential to lower costs and improve care.

Cost-benefit analysis of telehealth in pre-hospital care

Objective There has been very little use of telehealth in pre-hospital emergency medical services (EMS), yet the potential exists for this technology to transform the current delivery model. In this study, we explore the costs and benefits of one large telehealth EMS initiative. Methods Using a case-control study design and both micro- and gross-costing data from the Houston Fire Department EMS electronic patient care record system, we conducted a cost-benefit analysis (CBA) comparing costs with potential savings associated with patients treated through a telehealth-enabled intervention. The intervention consisted of telehealth-based consultation between the 911 patient and an EMS physician, to evaluate and triage the necessity for patient transport to a hospital emergency department (ED). Patients with non-urgent, primary care-related conditions were then scheduled and transported by alternative means to an affiliated primary care clinic. We measured CBA as both total cost savings and cost per ED visit averted, in US Dollars ($USD). Results In total, 5570 patients were treated over the first full 12 months with a telehealth-enabled care model. We found a 6.7% absolute reduction in potentially medically unnecessary ED visits, and a 44-minute reduction in total ambulance back-in-service times. The average cost for a telehealth patient was $167, which was a statistically significantly $103 less than the control group ( p < .0001). The programme produced a $928,000 annual cost savings from the societal perspective, or $2468 cost savings per ED visit averted (benefit). Conclusion Patient care enabled by telehealth in a pre-hospital environment, is a more cost effective alternative compared to the traditional EMS 'treat and transport to ED' model.

Economic evaluation of home-based telebehavioural health care compared to in-person treatment delivery for depression

Introduction

Home-based telebehavioural healthcare improves access to mental health care for patients restricted by travel burden. However, there is limited evidence assessing the economic value of home-based telebehavioural health care compared to in-person care. We sought to compare the economic impact of home-based telebehavioural health care and in-person care for depression among current and former US service members.

Methods

We performed trial-based cost-minimisation and cost-utility analyses to assess the economic impact of home-based telebehavioural health care versus in-person behavioural care for depression. Our analyses focused on the payer perspective (Department of Defense and Department of Veterans Affairs) at three months. We also performed a scenario analysis where all patients possessed video-conferencing technology that was approved by these agencies. The cost-utility analysis evaluated the impact of different depression categories on the incremental cost-effectiveness ratio. One-way and probabilistic sensitivity analyses were performed to test the robustness of the model assumptions.

Results

In the base case analysis the total direct cost of home-based telebehavioural health care was higher than in-person care (US$71,974 versus US$20,322). Assuming that patients possessed government-approved video-conferencing technology, home-based telebehavioural health care was less costly compared to in-person care (US$19,177 versus US$20,322). In one-way sensitivity analyses, the proportion of patients possessing personal computers was a major driver of direct costs. In the cost-utility analysis, home-based telebehavioural health care was dominant when patients possessed video-conferencing technology. Results from probabilistic sensitivity analyses did not differ substantially from base case results.

Discussion

Home-based telebehavioural health care is dependent on the cost of supplying video-conferencing technology to patients but offers the opportunity to increase access to care. Health-care policies centred on implementation of home-based telebehavioural health care should ensure that these technologies are able to be successfully deployed on patients’ existing technology.