Phase 2: Outreach
Clinic managers and medical directors of the affiliated CBOC were informed of the planned telemedicine clinic. Also, we identified local champions who could function as point persons and assist in the organization of visits. One member of the team personally visited key sites to discuss needs and opportunities with CBOC personnel during a routine staff meeting. The goal was to introduce the program, the key personnel, to explain criteria for appropriate candidates that may benefit from telemedicine consults, and to agree on a referral pathway. Finally, we emphasized that the consultant would always defer to the referring provider or patient and honor their requests.
Phase 3: Identifying Appropriate Patients
The team planned for and has since used 4 different pathways to identify possible candidates for telemedicine visits. The consult triaging process with telemedicine is an option that is brought up with patients if their travel to the facility exceeds 100 miles. Similarly, the team reviews procedural requests to optimize diagnostic yields and limit patient burden. For example, if endoscopic testing is requested to address chronic abdominal pain or other concerns that had already prompted a similar request with negative results, then the team will ask for feedback and recommend a telemedicine consultation prior to performing the procedure. Telemedicine also is offered for follow-up encounters to veterans seen in the facility for clinical or procedural evaluations if they live ≥ 40 miles away. The 2 other pathways are requests from referring providers or patients that specifically ask for telemedicine visits.
Phase 4: Implementation
Since rolling out the program in November 2016, video visits have been used for more than 150 clinic encounters. Within the first 12 months, 124 patients were seen at least once using telemedicine links. Of 144 visits, 54 (38%) were follow-up visits; the rest constituted initial consultations. Focusing on initial encounters only, veterans specifically asked for a telemedicine visit in 16 cases (17.8%). One-third of these referrals was specifically marked as a telemedicine visit by the primary care provider. In the remaining cases, the triaging personnel brought up the possibility of a telemedicine interaction and requested feedback from the referring provider.
Veterans resided in many different areas within and outside of the facility’s immediate referral area (Figure).
Abnormal bowel patterns, gastroesophageal reflux, and dyspepsia accounted for most concerns (Table 1).
Beyond obtaining contextual data and information about the specific clinical manifestations, the rationale for these encounters was a detailed discussion of the problem and treatment options available. Ablative therapy in Barrett esophagus best exemplifies the potential relevance of such an encounter: Although conceptually appealing to decrease cancer risk, the approach requires a significant commitment typically involving repeated sessions of radiofrequency ablation followed by intense endoscopic surveillance. With travel distances of several hundred miles in these cases, these encounters provide relevant information to patients and the opportunity to make informed decisions without the burden and cost of a long trip.
A shift in telemedicine encounters will likely occur that will increasingly rely on access from home computers or handheld devices. However, the initial phase of this program relied on connections through a CBOC. Coordination between 2 sites adds a level of complexity to ensure availability of space and videoconferencing equipment. To limit the logistic burden and improve cost-effectiveness, the authors did not expect or request the presence of the primary or another independent provider. Instead, the team communicated with a locally designated point person who coordinated the remote encounters and assisted in implementing some of the suggested next steps. Prior site visits and communications with referring providers had established channels of communication to define concerns or highlight findings. The same channels also allowed the team to direct its attention to specific aspects of the physical examination to support or rule out a presumptive diagnosis.
If additional testing was suggested, Telemedicine Services generally ordered the appropriate assessments unless veterans requested relying on local resources better known to personnel at the remote site. The most common diagnostic steps recommended were laboratory tests (n = 21; 14.6%), endoscopic procedures (n = 18; 12.5%), and radiologic studies (n = 17; 11.8%) (Table 2).
Most of the treatment changes focused on medication and dietary management, followed by lifestyle modifications and behavioral or psychological interventions. Some treatments, such as ablation of dysplastic epithelium in patients with Barrett esophagus or pneumatic dilation of achalasia required traveling to the George E. Wahlen VAMC. Nonetheless, the number of trips were limited as the team could assess appropriateness, explain approaches, and evaluate symptomatic outcomes with the initial or subsequent remote encounters. Most of the follow-up involved the primary care providers (n = 62; 43.1%), while repeat remote encounters were suggested in 31 visits (21.5%) and an in-person clinic follow-up in 7 cases (n = 4.9%). In the remaining cases, veterans were asked to contact the team directly or through their primary care provider if additional input was needed.