Telemedicine Evaluation
Victoria Garshnek, Ph.D., Project Manager, PRPO
1. Background -- Since the 1960s, there have been numerous attempts to advance telecommunications technology to augment health care delivery. Yet, despite the simplicity and apparent logic of the concept and three decades of experience, we are unable to show that telemedicine improves access, reduces cost, or affects the quality of health care. There are few well- designed studies and generalizing the findings to the military health care system and patient populations may not be valid. Consequently, there is clearly a need for well designed research in this area. The current evaluation research program consists of four projects that address the following domains: Clinical Outcomes; Patient/Provider Satisfaction; Organizational Impact; and Cost/Effectiveness. The protocol employs a randomized design to compare patient and process outcomes of two methods of consultation (telemedicine and usual care). The sample population for this study is active duty and retired military and their dependents requiring consultation from a primary care (Hickam) to a tertiary care (Tripler) facility and their health care providers. The study uses store and forward technology in a Web-based paradigm.
2. Organization Management:
L. Harrison Hassell, COL, MC, USA* -- Principal Project Director
Victoria Garshnek, Ph.D.** -- Project Manager
Investigators:
Clinical Outcomes
L. Harrison Hassell, COL, MC, USA* (PI); Victoria Garshnek, Ph.D.** (Co-I); George Underwood, M.D.** (Co-I), Mark Nadeau, LTC, MC, USAF***(Co-I), Theresa V. Jones** (Consult Manager)
Patient/Provider Satisfaction
Sharon DeRuvo, LTC, AN, USA+ (PI); Elizabeth Hill, LTC, AN, USA** (Co-I)
Organizational Impact
Robert Doktor, Ph.D.++ (PI); David C. Bangert, Ph.D. ++ (Consultant)
Cost/Effectiveness: Eric L. Mais, Ph.D. ++ (PI)*AMEDD Center and School, Fort Sam Houston, TX
**Tripler Regional Medical Center, HI
***Hickam Air Force Base, HI
+Landstuhl Regional Medical Center, Germany
++University of Hawaii, College of Business Administration, HI
3. Mission Statement -- Before telemedicine consultations are used as a substitute for usual care in which the patient and consultant meet in a clinical encounter, we must demonstrate through objective and measurable outcomes the equivalency of both methods of consultation in providing health care.
4. Goals and Objectives
A. Objectives -- The objective of the overall project is to provide a scientific evaluation of outcomes resulting from insertion of telemedicine into a primary care clinic that routinely refers patients to a tertiary medical care center. Objectives of the four individual research domains are: 1) to investigate if telemedicine consultation between medical treatment facilities: (a) impacts the clinical outcome of patients compared to usual care; (b) affects patient and provider satisfaction compared to usual care and (c) reduces cost in relation to benefits compared to usual care; 2) to evaluate the human impact on providers of performing consultations using advanced telecommunications technology; and 3) to investigate the organizational changes that occur when telemedicine is implemented in a medical treatment facility.
B. Goals -- The major goal of the AKAMAI evaluation effort is to provide health care policy-makers with scientific information to assist them in the decision to augment DoD medical treatment facilities in the Pacific Basin with telemedicine technology.
5. Current Status
A. Primary Accomplishments
Project #1: Clinical Outcomes: Significant progress has been made in establishing an infrastructure for transmission of consult data. A Web-based paradigm will be used. The Medical Information Data Archiving System (MIDAS) has been developed for 12 specialty areas. Training and tools (MedQuest) have been provided to enable modification/update of screens and creation of new ones. Specialists from Dermatology and Orthopedics have reviewed screens in their areas. A "patient trajectory analysis" has been explored as the major analysis tool. Once the infrastructure is operational, an Experiment Verification Test (EVT) will test procedures, systems, and coordination. After refinement, data collection/analysis will commence.
Project #2: Patient/Provider Satisfaction: Once the systems for telemedicine consultation are operational for at least 2 to 3 months, focus groups evaluating patient and provider satisfaction will be conducted. Arrangements are currently underway to conduct the preliminary focus groups.
Project #3: Organizational Impact: An inventory has been identified which measures cognitive perceptions of the caregivers job characteristics. The medical decision making process has been identified as the variable to be measured and qualitative research methodology of ethnography has been adopted as the operative tool. An inventory assessing organizational learning has been chosen as the measuring instrument. Currently, the team is finalizing evaluation instruments and preparing procedures to test these instruments during the EVT phase.
Project #4: Cost-Effectiveness: Currently, refinement of an initial cost/benefit model is underway based on a high-level process flow diagram for the telemedicine consults. The cost/benefit model will continue refinement through the EVT phase. Procedures for the EVT are currently being written.
6. Strategic Direction -- This project will pilot evaluation methodology in Dermatology and Orthopedics. Successful completion will enable additional specialties to be brought on-line and thus expand the scope, value, and application of the basic study methodology.
7. Business Associations
A. Corporate Partnerships -- ISS - Project Manager (Dr. Victoria Garshnek), Consult
Manager (Theresa V. Jones); Picker Institute (consultant services).
B. Government/University Partnerships -- University of Hawaii (Dr. Robert Doktor, Dr. David Bangert, Dr. Eric Mais, one UH graduate student).