Pulmonary telemedicine—A model to access the subspecialist services in underserved rural areas
Introduction
According to U.S. census data, approximately 21% of the U.S. population lives in rural or medically undeserved localities [1]. Physician shortage, poor access to care, and rural–urban disparities in availability of subspecialty care are important issues that require the attention of health care providers and health policy makers. A comprehensive study by the Committee on Manpower for the Pulmonary and Critical Care Societies projected a worsening pulmonary and critical physician shortage in the face of increasing demand for pulmonary subspecialty services [2].
The Veterans Health Administration (VHA), the largest provider of health care in the U.S., is faced with the challenge of providing primary and subspecialty care to a large and physically dispersed population of veterans. In order to deliver health care to both urban and rural veteran populations, the VHA has made a priority the implementation of telemedicine technologies that can extend specialty services to patients in underserved rural sites.
Telemedicine has been extensively used in clinical specialties such as radiology [3], [4], psychiatry [5], [6], and dermatology [7], [8]. Prior reports in the pulmonary and telemedicine literature have detailed the use of videoconference telemedicine for in-home support and management of chronic obstructive pulmonary disease (COPD) patients [9], for in-home care of acute exacerbations of COPD [10], and to support primary care providers’ management of children with asthma [11]. Wireless and telemetry-based telemedicine technology has been used for performing remote sleep studies [12] and for in-home monitoring of continuous positive airway pressure (CPAP) adherence [13]. In addition, telemedicine has been used to provide pulmonary rehabilitation services; the American Association of Cardiovascular and Pulmonary Rehabilitation has published a position statement on this issue [14]. However, few studies have evaluated the use of telemedicine for providing physician–patient pulmonary consultations for a diverse range of outpatient pulmonary problems.
The goals of the present study are (1) to evaluate the use of telemedicine technology to provide consultative outpatient care for a broad range of pulmonary conditions; and (2) to evaluate the effect of a telemedicine program in terms of (a) access to care (including reduction in both travel for patients and waiting time for appointments), (b) clinical decision making (medical interview and physical exam, medical work-up required, and outcome of telemedicine consultation), and (c) patient disposition (need for follow-up care and need for in-person evaluation).
Section snippets
Telemedicine network
The Milwaukee Veteran Affairs Medical Center’s (VAMC) telemedicine network is a hub and spoke network with pulmonary physician providers located in Milwaukee (hub site) and patients located at Iron Mountain VA, MI and Appleton, WI VAMC clinics (spoke sites). The present data are limited to patients referred for telepulmonary consultations from the Iron Mountain site.
Study setting and patient population
The Milwaukee VAMC, a tertiary care facility, primarily provides services for veterans residing in southeast Wisconsin. The Iron
Results
Between January 1998 and December 2004, 314 patients received pulmonary telemedicine consultations, accounting for 684 clinical encounters. Telemedicine technology was extremely reliable, and only one patient was rescheduled due to telemedicine system failure during the study period. The patient population consisted of predominantly male veterans (99%) of Caucasian race (78%). The mean patient age was 68 years (range 36–89 years). Consequently, a majority of patients (78%) had one or more
Discussion
Telemedicine technology has been considered an alternative for improving availability of subspecialty services for underserved areas. In this study, we describe the feasibility of providing pulmonary consultative care using videoconference telemedicine. In addition, we discuss the effect of a telemedicine program on the process of consultative care delivery in terms of (1) access to care, (2) clinical decision making, and (3) patient disposition.
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