Pulmonary telemedicine—A model to access the subspecialist services in underserved rural areas

Abstract

Background

To describe the use of videoconference telemedicine for providing outpatient pulmonary consultation to a remote, underserved clinic site.

Methods

Analysis of data from the Milwaukee Veteran Affairs Medical Center (VAMC) pulmonary telemedicine clinic. Pulmonary physicians at the Milwaukee VAMC provide outpatient consultations with the use of videoconference technology to patients located at the Iron Mountain VAMC in Iron Mountain, MI (346 km or 215 miles from Milwaukee). Data on demographics, referral patterns, access to care, consultation process, and outcomes are presented.

Results

A total of 314 patients (684 visits) received telemedicine consultations between January 1, 1998 and December 31, 2004. Common reasons for referral were abnormal radiology (38%), chronic obstructive pulmonary disease (COPD) (26%), and dyspnea (13%). Physical exam was performed by the telemedicine registered nurse or respiratory therapists in 90% of visits. Common diagnoses were COPD (29%), benign pulmonary nodule (11%), bronchial asthma (6%), and lung cancer (6%). Telemedicine consultation resulted in a change in management for 41% of patients. Only 8% of patients required an in-person clinic visit at Milwaukee VAMC following a telemedicine visit. Telemedicine saved patients 473,340 km or 294,120 miles of travel over the study period.

Conclusions

The provision of subspecialty services using telemedicine to a remote underserved rural population provides improved patient access to subspecialty care. Physicians are able to rely on medical history and radiology to manage patients across a broad spectrum of complex pulmonary conditions with the assistance of a non-physician health care provider at the remote site.

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).