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Assessing Case Turn Around Times in a University-Based Telemedicine Program Elizabeth Krupinski, Ph. D, Assessing Case Turn Around Times in a University-Based Telemedicine Program Elizabeth Krupinski, Ph. D, Mary Dolliver, Phyllis Webster, Kreg Lulloff, Ronald Weinstein, MD Presented at The American Telemedicine Association Conference April 18 -21, 1999 Salt Lake City, UT

Goal 1) Assess case turn-around times in the Arizona Telemedicine Program. 2) Compare store-forward Goal 1) Assess case turn-around times in the Arizona Telemedicine Program. 2) Compare store-forward with real-time sessions. 3) Compare telemedicine times to in -person clinic visits.

Objective • To discover if there is any particular aspect of the case turn-around Objective • To discover if there is any particular aspect of the case turn-around process that could potentially be improved upon in order to more efficiently deliver patient care via telemedicine.

Rationale • Surveys of patients and other users of telemedicine systems indicate that reduced Rationale • Surveys of patients and other users of telemedicine systems indicate that reduced waiting time and timeliness of a diagnostic report are major advantages of telemedicine. 1. JE Brick, et al. Telemedicine Journal; 3: 159 -171 (1997). 2. S Pedersen, U. Holand. Telemedicine Journal; 1: 47 -52 (1995). 3. EA Franken et al. CARS ‘ 98; Elsevier, New York: 478 -483 (1998).

The ATP Network I • The Arizona Rural Telemedicine Network (ARTN) is a private The ATP Network I • The Arizona Rural Telemedicine Network (ARTN) is a private Asynchronous Transfer Mode (ATM) network built on T 1 circuits leased from commercial carriers.

The ATP Network II • The ARTN supports: – Interactive real-time (RT) video using The ATP Network II • The ARTN supports: – Interactive real-time (RT) video using the Health Care System from Tandberg – General purpose store-forward (SF) applications using Visitran-MD from Med. Vision

The ATP Network III • The University of Arizona Health Sciences Center (AHSC) serves The ATP Network III • The University of Arizona Health Sciences Center (AHSC) serves as the operational center for the ATP & ARTN • The AHSC telemedicine hub clinic is located adjacent to the University Medical Center in a physically connected building

Spoke Workflow • Each spoke site has a Site Coordinator – Prepares patient information Spoke Workflow • Each spoke site has a Site Coordinator – Prepares patient information – Fills out required forms – Provides assistance in RT sessions – Interacts with hub to schedule SF & RT consults

Required Forms • Patient consent • Patient demographics • Patient history forms – Internal Required Forms • Patient consent • Patient demographics • Patient history forms – Internal medicine – Cardiology – Non-internal medicine – Initial psychiatric consult – Follow-up psychiatric consult

Hub Workflow I • 2 Telemedicine Case Coordinators at AHSC hub site in charge Hub Workflow I • 2 Telemedicine Case Coordinators at AHSC hub site in charge of specific remote sites – Receive cases anytime at Visitran-MD workstation – Print out information & establish new patient record – Forward case to Telemedicine Service Medical Director

Hub Workflow II • Medical Director reviews case for telemedicine suitability and SF or Hub Workflow II • Medical Director reviews case for telemedicine suitability and SF or RT appropriateness – Arranges consult with ATP clinician – Has Case Coordinator schedule into RT clinic – Dictates letter to referring clinician with explanation if not suitable for telemedicine

Scheduled ATP Clinics Scheduled ATP Clinics

Transcriptions • Tele-consultant dictates report in the Telemedicine Clinic after consult • Tapes given Transcriptions • Tele-consultant dictates report in the Telemedicine Clinic after consult • Tapes given to in-house telemedicine transcriptionist • Copy faxed to consultant to edit/approve • Changes made, hardcopy printed • Approved (unsigned) report faxed to spoke • Original is signed & put in patient record • Copy of signed report mailed to spoke

Assessment Methods • Case turn-around time (TAT) was assessed by reviewing the patient records Assessment Methods • Case turn-around time (TAT) was assessed by reviewing the patient records at the hub site • Case turn-around time was divided into 5 separate components for analysis

TAT Components 1) Time from when case request was received until consulting clinician contacted TAT Components 1) Time from when case request was received until consulting clinician contacted (CR) 2) Time from contact until case reviewed (RV) 3) Time from review until preliminary verbal report given (live for RT; phone for SF if contact possible) (VB) 4) Time until final report faxed (FR) 5) Total case TAT

General Case Statistics • SF = 56% of cases; RT = 44% of cases General Case Statistics • SF = 56% of cases; RT = 44% of cases • Dermatology has highest volume of cases (39%) & is most common SF specialty • Psychiatry has 2 nd highest volume of cases & is most common RT specialty • Cases have been processed in 39 subspecialties

Total Case TAT Results t = 8. 051, df = 498, p = 0. Total Case TAT Results t = 8. 051, df = 498, p = 0. 0001

SF TAT Components CR Mean* 5. 79 SD 14. 78 Min 0. 08 Max SF TAT Components CR Mean* 5. 79 SD 14. 78 Min 0. 08 Max 87. 00 N 432. 00 RV 49. 56 134. 79 0. 33 1560. 00 432. 00 VB 0. 29 1. 08 0. 08 24. 00 190. 00 * time in hours CR = session requested until consulting clinician contacted RV = time from contact until case reviewed VB = time from review until verbal contact FR = time until final report faxed FR 64. 25 60. 39 0. 08 648. 00 429

RT TAT Components CR Mean* 2. 22 SD 9. 18 Min 0. 08 Max RT TAT Components CR Mean* 2. 22 SD 9. 18 Min 0. 08 Max 144. 00 N 315. 00 RV 193. 21 253. 60 0. 17 2367. 00 315. 00 VB 0. 80 0. 01 0. 08 314. 00 * time in hours CR = session requested until consulting clinician contacted RV = time from contact until case reviewed VB = time from review until verbal contact FR = time until final report faxed FR 75. 91 71. 41 1. 00 600. 00 315. 00

Appointment Availability Sub-Specialty UMC* In-Person Cardiology Dermatology Neurology Ob/Gyn Orthopedics Peds Cardiol Peds Endocrin Appointment Availability Sub-Specialty UMC* In-Person Cardiology Dermatology Neurology Ob/Gyn Orthopedics Peds Cardiol Peds Endocrin Peds Psychiatry Rheumatology > 1 month 25 days > 1 month 8 days 22 days 24 days > 1 month ATP Teleconsult 0. 97 days 1. 26 days 9. 29 days 4. 92 days 7. 33 days 6. 63 days 1. 19 days > 1 month 6. 04 days 9. 25 days t = 4. 86, df = 9, p < 0. 001 * UMC = University Medical Center, University of Arizona Health Sciences Center

Discussion • 82% of ATP cases are scheduled, seen and given a final report Discussion • 82% of ATP cases are scheduled, seen and given a final report in less than 1 week’s time • For in-person visits at UMC it takes an average of 32 days to get an appointment with a sub-specialist

Discussion • ATP was longer only in Peds Psych, due to difficulty in lining Discussion • ATP was longer only in Peds Psych, due to difficulty in lining up a Spanish-speaking psychiatrist for a patient • For most specialties, ATP appointments were scheduled more efficiently than inperson appointments at University Medical Center

Discussion • The major difference between ATP SF and RT cases occurs for the Discussion • The major difference between ATP SF and RT cases occurs for the time from when a consultant is contacted until consultation actually takes place • This is not surprising - RT involves more complex scheduling and there are often cancellations which prolong the time to being seen

Discussion • The advantage of RT over SF is that feedback to the patient Discussion • The advantage of RT over SF is that feedback to the patient and referring clinician is essentially immediate • Unless a phone call is made to the referring physician after a SF consult, feedback is not received until the final report is faxed to the remote site

Discussion • A significant benefit to patients participating in the ATP is quicker access Discussion • A significant benefit to patients participating in the ATP is quicker access to specialized care, especially for those who would have to wait for an in-person visit and travel long distances to come to UMC to see a subspecialist.