The promise of telemedicine: providing curbside consults for chronic care, urgent care, and pain

An 18-month cost analysis study comparing the use of  telemedicine versus in-person consultation for patients with chronic pain found that direct costs were lower in the telemedicine group than the in-person group (median cost $133 vs $433, respectively). In addition, more chronic pain patients reported they were highly satisfied with telemedicine consultations (56%) compared with those who were highly satisfied with in-person consultations (24%).⁹

A rural telemedicine success

A recent study shows the significant impact a rural telemedicine program can have on clinical outcomes. Researchers looked at outcomes of patients with hepatitis C whose providers participated in the UNMH’s Project ECHO™. In ECHO, academic specialists offer long-distance training and support for rural primary care providers. Among hepatitis C patients of these providers, 58% had a sustained viral response as a result of treatment. That was nearly identical to the percentage of sustained viral response in patients seen in person at the academic medical center in Albuquerque.¹⁰ The ECHO study involved 16 community sites and 5 prisons.

Today, the ECHO program encompasses 255 sites, the majority of them in NewMexico. The Universities of Washington and Nevada have adopted the ECHO strategy in rural areas of their states, and the University of Chicago is using it to help underserved urban patients.

Since its beginning in 2002, Project ECHO™ has grown to include separate hepatitis C virtual “clinics” for communities and prisons, as well as clinics for a range of conditions from addiction to asthma, dementia, diabetes, high- risk pregnancy, and palliative care. Because Project ECHO™ also includes a pain management clinic, this program holds some valuable lessons for pain specialists.

ECHO’s chronic pain and headache management clinic includes a neurologist, a psychiatrist and addiction specialist, an internist, a family physician, a physiatrist, an interventional pain specialist, and a clinical psychologist. All members of the team attend most of the video teleconferences.

Weekly pain clinics attract an average of 35 primary care providers, including physicians, nurse practitioners, and physician assistants. While some are located in the Albuquerque area, the majority come from rural parts of New Mexico and Oklahoma, with some coming from army hospitals and locations overseas.

Many providers use videoconferencing equipment, including TV sets, speakers, and a high-speed Internet connection to participate in the clinics from their own offices. Some join the clinics via webcam or telephone. If a practice or community health center wants to use videoconferencing and doesn’t have theequipment, UNMH technicians will travel to their offices and install it.

Videoconferencing gear for a clinic such as Project ECHO™ is expensive, costing $20,000 to $30,000 to set up. Project ECHO™ is able to cover the costs of its services through grants from the state of New Mexico and the Robert Wood Johnson Foundation.

Case-based weekly presentations on pain

Project ECHO™ offers one 2-hour pain clinic per week that provides a mix of didactic and hands-on instruction using case-based learning. In addition, providers can present their own challenging cases and receive guidance from the multidisciplinary specialty team. Providers who plan to participate in a pain clinic fill out questionnaires about their patients beforehand, and everyone who wants to present is given an opportunity to do so. Providers are also encouraged to contact ECHO’s academic specialists between clinics if they have specific questions about a case.

The purpose behind Project ECHO™ is to meet the needs of patients who have difficulty obtaining appointments at the medical center or who may have to travel a long distance to get there. However, the main goal of ECHO’s pain clinic is to educate rural  providers about how to provide comprehensive pain management themselves, to enable a greater degree of confidence and comfort in prescribing pain medications, and to support providers in striking a balance between offering prescription analgesics and other pain therapies.  

Marlene Baska, a PA in Lordsburg, NM, agrees that her participation in ECHO has been very beneficial in treating patients with chronic pain. “The multidisciplinary panel has given me education, suggestions, and guidance on specific cases. It has helped me develop some effective plans of care for my patients. When I see patients with chronic pain, I make them aware of my participation in Project ECHO™ and they’re very appreciative.”

Baska, who works for Hidalgo MedicalServices, a multisite community health center that covers 2 counties, says she has learned to use an integrative approach that combines the appropriate use of opiates with adjunctive medications and referrals to professionals who offer behavioral therapy, massage therapy, acupuncture, physical therapy, occupational therapy, and dietetics.

Measuring outcomes

Measuring outcomes is an important component of the Project ECHO™ design.  Providers participating in the pain clinic are trained to use functional status assessments, including the Brief Pain Inventory and the Pain Outcomes Profile of the American Academy of PainManagement. The provider outcomes data show that as a result of training self-efficacy has grown among participants.