Assessing Case Turn Around Times in a UniversityBased Telemedicine Program

1
Assessing Case Turn Around Times in a
University-Based Telemedicine Program

• Elizabeth Krupinski, PhD,
• Mary Dolliver, Phyllis Webster,
• Kreg Lulloff, Ronald Weinstein, MD
• Presented at
• The American Telemedicine Association Conference
• April 18-21, 1999
• Salt Lake City, UT

2
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.
3
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.

4
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
  3159-171 (1997).
• 
  2. S Pedersen, U. Holand. Telemedicine
  Journal147-52 (1995).
• 
  3. EA Franken et al. CARS 98 Elsevier, New
  York478-483 (1998).

5
The ATP Network I

• The Arizona Rural Telemedicine Network (ARTN) is
  a private Asynchronous Transfer Mode (ATM)
  network built on T1 circuits leased from
  commercial carriers.

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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 MedVision

7
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

8
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

9
Required Forms

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

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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

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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

12
Scheduled ATP Clinics
13
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

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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

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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

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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 2nd highest volume of cases is
  most common RT specialty
• Cases have been processed in 39 sub-specialties

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Total Case TAT Results
t 8.051, df 498, p 0.0001
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SF TAT Components

• CR RV VB FR
• Mean 5.79 49.56 0.29 64.25
• SD 14.78 134.79
  1.08 60.39
• Min 0.08 0.33
  0.08 0.08
• Max 87.00 1560.00 24.00
  648.00
• N 432.00 432.00 190.00
  429
• 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

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RT TAT Components
CR RV VB FR Mean 2.22
193.21 0.80
75.91 SD 9.18 253.60
0.01 71.41 Min 0.08
0.17 0.08
1.00 Max 144.00 2367.00 0.08
600.00 N 315.00 315.00
314.00 315.00
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
20
Appointment Availability

• Sub-Specialty UMC In-Person ATP Teleconsult
• Cardiology 1 month 0.97 days
• Dermatology 1 month 1.26 days
• Neurology 25 days 9.29 days
• Ob/Gyn 1 month 4.92 days
• Orthopedics 1 month 7.33 days
• Peds Cardiol 8 days 6.63 days
• Peds Endocrin 22 days 1.19 days
• Peds Psych 24 days 1 month
• Psychiatry 24 days 6.04 days
• Rheumatology 1 month 9.25 days
• t 4.86, df
  9, p
• UMC University Medical
  Center, University of Arizona Health Sciences
  Center

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Discussion

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

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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 in-person
  appointments at University Medical Center

23
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

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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

25
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 sub-specialist.