Clinical and Health Affairs
Telemedicine Applications in Occupational Medicine
By Prathibha Varkey, M.D., M.P.H., Philip T. Hagen, M.D., William Wimsett, and William Buchta, M.D., M.P.H.
Abstract
Telemedicine combines telecommunication technology and medicine to increase access to health care services for patients living in remote areas and enhance the efficiency of delivering that care. This article describes the results of a Mayo Clinic pilot study on the use of telemedicine in an occupational medicine clinic for Mayo Clinic employees and their dependents. The study involved 21 patients who came for initial evaluations for work-related problems or injuries, follow-up visits, visits for acute problems such as low-back pain, and periodic health evaluations. It found that patients and providers were comfortable with the technology after a short training session and satisfied with the outcomes of the visits. More rigorous research evaluating the applications of telemedicine in occupational health care is needed.
Using telecommunication technology to deliver medical care is one way to make health care services more accessible to patients living in remote areas. It also makes it more efficient to provide care, as physicians do not have to travel to see patients, evaluate certain health conditions, and share results of laboratory tests and X-ray images. Insurance companies and other third-party payers believe that telemedicine can save the health care industry up to $200 million a year.1 Since January 1999, the Health Care Financing Administration has been reimbursing physicians for eligible telemedicine services provided to Medicare patients in areas with a shortage of physicians, including Minnesota.1,2 In addition, private health insurance companies, managed care organizations, and state programs are also reimbursing eligible telemedicine services in certain states.2
The effectiveness of telemedicine in primary care, pediatrics, radiology, and psychiatry and in urban and rural hospitals, ambulatory care facilities, and correctional facilities has been well-established.2 For example, in a recent study from North Carolina, where transportation of prisoners to outside health care facilities averages $700 a trip, telemedicine significantly decreased the cost of providing care.2
In addition to improving efficiency of care, telemedicine also can improve clinical outcomes. Liesenfeld et al. found that telemedical care reduces hypoglycemic episodes and improves glycemic control in both children and adolescents with type 1 diabetes.3 Similarly, telemedicine was found to decrease the weight of patients with type 2 diabetes by 4% on average during a 3-month period; those patients also saw their HbA1c levels drop by 16%. A nurse case manager monitored blood pressure and glucose levels as well as weight, exercise, and nutrition goals once a week using telemedicine under the direction of a primary care physician. The physician visited with the patients once a month via telemedicine.4
We are not aware of published literature on the use of telemedicine in occupational medicine. In July of 2005, we conducted a pilot study at Mayo Clinic in Rochester to determine the feasibility of using telemedicine in a work site–based occupational medicine clinic. As part of this study, we evaluated the visual and audio capabilities of the telemedicine system, the physician’s and patient’s comfort with the process, their satisfaction with telemedicine, and the ability to use the existing desktop electronic medical record (EMR) during telemedicine visits.
Methodology
The study, which was approved by the Institutional Review Board, involved 21 patients who presented to Mayo’s Employee Occupational Health Service. Patients ranged in age from 27 to 80 years and included 13 women and 8 men; all patients were Mayo Clinic employees or their dependents.
Two telemedicine units were set up in exam rooms in different areas of the occupational medicine clinic. Those exam rooms were inside Mayo Clinic’s electronic firewall. Each unit consisted of a base and remote video-conferencing system and monitoring software, and was connected to the computer running Mayo’s EMR to allow the use and display of information such as laboratory test results and radiologic images. Clinicians were given 15 minutes of hands-on instruction on how to use the units prior to the start of the study.
After getting informed consent from the patient, a nurse oriented the patient to the telemedicine equipment and assisted them as needed during the visit. Immediately after the telemedicine visit, the patient received standard face-to-face care from the physician for the same clinical condition. Clinicians were asked to identify any potentially unsafe results such as symptoms or signs that were missed or misunderstood as a result of the telemedicine interaction. Both the physician and the patient completed a survey after the visit concerning their satisfaction with the visit, comfort with the telemedicine technology, and willingness to use it for future visits.
Technology
Telemedicine uses a videoconference system with cameras and television screens or computer monitors and other medical peripherals such as a blood pressure cuff or an otoscope. The video connection uses Internet protocol connections over Mayo Clinic’s secure internal data network. A Tandberg 1500 MXP videoconferencing system was used for the study. It has a 17-inch wide screen that can double as a PC monitor and offers wireless capability and embedded security. Advanced capabilities such as the ability to share an electronic medical record and images as well as the ability to connect to more than one videoconference system are also possible with this system.5
Results
We tested the use of telemedicine during a variety of clinic visits including initial evaluations of work-related problems or injuries, follow-up visits, visits for acute problems such as low-back pain, and periodic health evaluations.
These visits offered a number of clinical scenarios, including a visit in which a nurse assisted the patient and created a preliminary note about the patient’s complaint; limited physical examinations in which the patient reported the results of self-measured pulse and blood pressure readings and the physician did a visual assessment of gait, range-of-motion, and skin lesions; a visit by a patient whose second language is English; an encounter with a patient who was hard of hearing and assisted by his spouse; a review of laboratory and radiology results with a patient; and sensitive discussions relating to relationships and depression.
We found that providers quickly became comfortable with the teleconferencing system. Physicians’ average scores on the surveys related to their comfort with the equipment increased by 71.4% over the course of the 21 visits. Patients were comfortable with the system as well; 90.5% agreed that they could use it without assistance. In 77.2% of the visits, patients indicated that telemedicine was neither a barrier to interacting with their physician nor to their relationship with their physician.
Technically, the units functioned well during the majority of visits. Units occasionally had to be shut down and restarted because of technical problems. Patients and physicians agreed or strongly agreed that they were able to see and hear each other clearly during all visits. In 19% (4 of 21) of the visits, patients expressed a need for assistance with the equipment. One problem they noticed was that there was an up-to-2-second delay, which caused patients and clinicians to occasionally speak while the other was speaking; and there was also an echo-like effect when someone was paged on the overhead paging system, a consequence of having both physician and patient in the same building.
Clinicians reported no situations in which patient safety was compromised. They commented that telemedicine was fun to use in 71.4% (15 of 21) of visits, similar to face-to-face visits in 81% (17 of 21) of cases, a potential time saver in 86% (18 of 21) of visits, and capable of improving convenience and efficiency in 86% (18 of 21) of visits. They said the picture and sound quality were adequate for taking a patient history and doing a physical examination, including inspection of skin lesions. However, they indicated that they did need a document imaging device, which was not part of the original system, in order to look at a diabetes or blood pressure log. None of the patients or physicians expressed a need for physical contact. Patients indicated that they were willing to consider paying for 24-hour access to a physician from an upgraded unit in 76% (16 of 21) of visits but were willing to pay to have a unit at home in only 24% (5 of 21) of visits.
Discussion
This pilot study demonstrates the feasibility of using telemedicine in an occupational medicine clinic for evaluation and treatment of acute illnesses as well as for follow-up visits. Telemedicine has the potential to provide real-time access to occupational medicine specialists whose services otherwise may not be available at the work site. It also allows physicians to share diagnostic information, such as laboratory results, images, other providers’ reports from an EMR, and opinions with patients and/or other primary providers without the need for travel. Other potential uses in occupational medicine include evaluation of skin lesions, occupational therapy evaluations, and tele-education for residents or physician extenders at relatively remote sites.6 Telemedicine also could allow occupational physicians to better communicate with a patient’s supervisor in the presence of the patient in order to explain work restrictions or review reasonable accommodations.
Despite concerns about the impersonal nature of telemedicine, our study and others revealed that patients and physicians reported high levels of satisfaction with telemedicine services.7 Similarly, in a recent Mayo Clinic– Jacksonville study of nursing home patients, 61% of participating patients said the system had a positive effect on their relationship with their physician and 94% indicated that the system did not have a negative effect on their relationship with their health care provider.1
For telemedicine to be widely used in an occupational medicine setting or any other setting, several issues will need to be addressed. These include whether physicians will need multiple medical licenses—both in the state where they practice and in the state where the patient is being “seen,” reimbursement for consultations, the security of medical information being transferred over the network, and coordination of physician schedules for telemedicine activities.
Looking to the Future
Our pilot study shows there is a significant potential role for telemedicine in a work site–based occupational medicine clinic. Physicians, nurses, and patients appear capable of using the technology with minimal training, and they are interested in doing so. Existing telemedicine technology allows access to and seamless sharing of information housed in an EMR. Portions of the physical examination can be performed adequately and sensitive discussions carried out in a manner that’s safe and acceptable to patients. Future studies will need to examine the cost- effectiveness of telemedicine in a remote work site location to determine whether the benefits outweigh the expense. MM
Prathibha Varkey is an assistant professor of preventive medicine and internal medicine, Philip Hagen and William Buchta are assistant professors of preventive medicine, and William Wimsett is unit manager of video technical services at Mayo Clinic.
References 1. Bratton R, Cody C. Telemedicine applications in primary care: a geriatric patient pilot project. Mayo Clin Proc. 2000;75(4): 365-8.
2. Strode S, Gustke S, Allen A. Technical and clinical progress in telemedicine. JAMA. 1999;281(12):1066-8.
3. Liesenfeld BL, Renner R, Neese M, Hepp K. Telemedical care reduces hypoglycemias and improves glycemic control in children and adolescents with type I diabetes. Diabetes Technol Thera. 2000;2(4):561-7.
4. Whitlock WL, Brown A, Moore K, et al. Telemedicine improved diabetic management. Mil Med. 2000;165(8):579-84.
5. Mayo videoconference endpoint technology. Available at: http://www.tandberg.net/. Accessed October 6, 2006.
6. Dreyer N, Dreyer KA, Shaw DK, Wittman, PP. Efficacy of telemedicine in occupational therapy: a pilot study. J Allied Health. 2001;30(1):39-42.
7. Nestbitt T, Hilty D, Kuenneth C, Siefkin A. Development of a telemedicine program: a review of 1,000 videoconferencing consultations. West J Med. 2000;173(3):169-74.
History of Telemedicine at Mayo Clinic
Mayo Clinic has been involved in telemedicine since it opened clinics in Jacksonville, Florida, in 1986 and Scottsdale, Arizona, in 1987. Although both clinics opened with 35 physicians, staff wanted to provide patients with access to the greater resources of the clinic in Rochester, Minnesota.
Creating a real-time satellite-based video and audio link that permitted two-way conferencing between sites became a top priority. The video link would be able to display and transmit film-based radiologic images and physicians would be able to fax each other printed medical records.
In the beginning, this satellite link was used for weekly consultations between patients in Florida or Arizona and physicians in Rochester. As the Jacksonville and Scottsdale clinics added more physicians, the need for regular consults lessened, and today the need for this type of consult is rare.
In the late 1980s, a real-time satellite link was established between Mayo Clinic and the King Hussein Medical Center in Amman, Jordan. However, time zone differences, the need for significant technical resources on both ends of the link, physician schedules, and cost were some of the factors that led to cancellation of this project.
In 1999, Mayo embarked on a telemedicine initiative with two hospitals in the United Arab Emirates (UAE). Real-time consultation was impractical because of a 10-hour time difference; therefore, a store-and-forward system was put in place. With this system, diagnostic images are captured and stored at the UAE sites, along with accompanying data from the patient’s medical record. This information is transmitted overnight to Rochester via a highly encrypted data link. The next day, physicians in Rochester review the images and data and offer a second opinion, which is then transmitted back to the UAE hospitals. This initiative has been successful and continues today.
Since early 2006, the internal medicine outreach office in Rochester has been using videoconference systems to provide follow-up visits for gastroenterology patients in Decorah, Iowa. A Mayo physician travels to the Decorah Clinic for the initial work up. The physician then meets with the patient and a nurse in Decorah by videoconference for follow up. During this visit, the physician can show the electronic medical record to the patient as needed. The videoconference link takes place behind the Mayo Clinic firewall, so complete patient confidentiality is assured.
The internal medicine outreach office hopes to expand the telemedicine initiative to include other specialties including cardiology. Mayo is also exploring the idea of providing telemedicine and distance learning to Native American communities as part of a Memorandum of Understanding signed by Mayo Clinic and the Indian Health Service.