Abstract
Telemedicine—the use of telecommunications technology to provide remote access to medical diagnosis and patient care—has the potential to change how healthcare is delivered. Many things about the practice of medicine that seem self-evident and which we currently take for granted, such as the practice of evaluating and treating patients in person in the outpatient clinic, could eventually seem like quaint anachronisms.
The use of the Digital Imaging and Communications in Medicine (DICOM) standard in the field of radiology, for example, led to a revolution in radiologic imaging and remote interpretation that has become the standard of care. The light boxes found in every office and classroom throughout the hospital remind us of a time not long ago when clinicians used printed film to look at x-rays and imaging studies.
The field of otolaryngology–head and neck surgery is uniquely suited to the use of telemedicine in clinical practice. Although the cornerstone of many otolaryngic diagnoses remains a careful medical history, we obtain a significant amount of diagnostic data from objective sources, such as tympanograms, audiometry, and telescopic and diagnostic imaging. Many of these sources are easily amenable to remote interpretation, allowing for a telemedical approach to patient diagnosis and treatment. In addition, because many otolaryngologists are found clustered in urban settings, getting access to specialty care in rural areas can be challenging. Telemedicine, therefore, has the potential to fulfill this specific healthcare need and improve access to care.
In our article, “Successful telemedicine programs in otolaryngology,” we discuss several programs that have reported success with using a telemedical approach to patient care in otolaryngology–head and neck surgery. 1 These practices have generated substantial benefits in terms of improved access to care and reductions in cost. Some of the most successful telemedicine programs documented in the literature are in Alaska 2 and Australia, 3 both places where a rural population and challenging geography make the delivery of subspecialty healthcare to remote areas challenging.
Alaska has a land area of 586,000 square miles and a population density of 1.1 persons per square mile, which makes delivering subspecialty healthcare in remote areas difficult. Most of the state of Alaska is designated as a Health Professional Shortage Area, 4 and Alaska has the sixth lowest physician-to-population ratio in the nation. 5 Since 1999, the ENT department at Alaska Native Medical Center (ANMC) in Anchorage has been successfully using a telemedicine program to facilitate the care of patients living in remote areas.
In 2008, Kokesh et al at ANMC described the successful use of video-otoscopy for patient follow-up after tympanostomy tube insertion in remote areas of Alaska. 2 Utilizing community health aides and non-physician health workers who performed video-otoscopy in remote village clinics, they found high concordance rates between an in-person and telemedical encounter, and they concluded that telemedicine is a reliable way to follow patients after tympanostomy tube insertion to ensure that the tubes remain in place and patent.
In 2009, Hofstetter et al of ANMC performed an analysis of ENT specialty clinic wait times for all new patient referrals both before and after the implementation of a telemedicine service. 6 They found that after the introduction of telemedicine consultations, the average clinic wait time dropped 50%—from 3.4 to 1.7 months. The total number of ENT specialty appointments and providers remained the same during the study period, further supporting the idea that the change in wait time was a direct result of the implementation of a telemedical practice.
The telemedicine program in Queensland, Australia, is another example of a successful program used in an otolaryngology practice. Queensland is the second largest state in Australia with a land area of 1.7 million kilometers and an estimated population of four million people. 7 The state subsidizes part of the travel costs for patients to receive otolaryngology services at a hospital in Brisbane, which amounts to a cost of $30 million a year to the state health authorities. 8
In November of 2000, the Royal Children's Hospital in Queensland established a telepediatric service so that patients could be seen via videoconference rather than traveling from remote areas of Queensland to the hospital in Brisbane. 3 They took into consideration the costs of operating a telemedicine service—including the purchase of videoconference equipment to allow for remote nasopharyngolaryngoscopy, salaries for the coordinators and clinical staff, and telecommunications charges—and compared those to the costs involved in a traditional in-person encounter, including the state-subsidized costs for travel and accommodation for patients and their families.
Smith et al found that the total cost of providing a tele-otolaryngology consult service was AU$955,996 while the cost of providing patients with traditional outpatient consultation was AU$1,553,264. 3 Given the fixed costs of AU$640,000 needed to purchase the equipment necessary to start up a telemedicine practice, they calculated that a threshold of 774 patients would need to be seen over 5 years to make a tele-medicine practice cost-effective. In this case, the actual workload was 1,499 consultations, which is well above that threshold. This demonstrates that telemedicine can be a cost-effective way to deliver healthcare when compared to traditional means.
Another interesting use of telemedicine has been reported in the development of a tele-otology service in Louisiana after hurricane Katrina. After Katrina there was no neurotology service available at the Louisiana State University Health Sciences Center in New Orleans, so Arriaga et al devised a neurotology program in which patients were seen in Baton Rouge via telemedicine. 9 A neurotologist was available on-site only 3 days monthly for in-person examinations and for surgery, with the rest of the time spent at a hospital in Pittsburgh. During 12 months of operation, there were 450 telemedicine consultations and 150 operative procedures.
Of particular interest, Arriaga and colleagues held direct discussions with third-party payers to ensure that there were opportunities for reimbursement, and they were able to obtain explicit written approval from private insurers for physician reimbursement using standard management codes. 9 This experience validates the role of telemedicine in preoperative planning, particularly in isolated areas, in areas with limited resources, or in areas without access to otolaryngologic specialty care.
Telemedicine clearly has the potential to transform the way healthcare is delivered. We have seen the promise of telemedicine achieved in other medical specialties, such as radiology and cardiology, and the future appears promising for the field of otolaryngology-head and neck surgery. Telemedicine can help bring healthcare services to historically underserved populations living in remote areas in addition to allowing for significant time and cost savings for everyone involved. The telemedicine programs in place at the ANMC in Anchorage and the Royal Children's Hospital in Queensland have been largely successful in achieving these goals.
Several challenges remain, including issues of insurance reimbursement and issues related to the start-up costs involved in creating a telemedicine practice. Regardless, the future of telemedicine continues to look promising, and we will likely see a larger role for it in the future.