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; 3:159-171 (1997). 2. S Pedersen, U. Holand. Telemedicine Journal;1:47-52 (1995). 3. EA Franken et al. CARS ‘98; Elsevier, New York:478-483 (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.

6. 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

10. 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

11. 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

14. 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

15. 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

16. 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

17. Total Case TAT Results t = 8.051, df = 498, p = 0.0001

18. SF TAT Components CR RV VB FR Mean* 5.79 49.56 0.2964.25 SD 14.78 134.79 1.0860.39 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

19. 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-SpecialtyUMC* In-PersonATP 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 < 0.001 * UMC = University Medical Center, University of Arizona Health Sciences Center

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

22. 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

24. 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.