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Laryngoscope Ohio State Study

June 11, 2021

Developing a Synchronous Otolaryngology Telemedicine Clinic:
Prospective Study to Assess Fidelity and Diagnostic Concordance

Nolan B. Seim, MD ; Ramez H. W. Philips, BS ; Laura A. Matrka, MD; Brittany Locklear, MS, RRT;
Mark Inman, MBA; Aaron C. Moberly, MD ; Garth F. Essig Jr., MD

Objective: To evaluate diagnostic concordance of a synchronous telemedicine otolaryngology clinic with use of currently available technology.
Study Design: Prospective.

Methods: Patients in a rural otolaryngology clinic were enrolled in a pilot telemedicine clinic. To assess system fidelity, an on-site and remote (consulting) otolaryngologist conducted simultaneous patient evaluations using streaming telecommunication technology for all aspects of the clinical encounter, including high-definition examination and endoscopic images. Both physicians and patients were blinded and diagnoses recorded. Post-encounter physician surveys and an original patient-centered TeleENT Satisfaction Questionnaire (TESQ) were used to assess overall satisfaction.

Results: Twenty-one patients were enrolled consecutively. Visual technology was found acceptable in all cases, and audio technology was acceptable in 20 of 21 encounters. Patient satisfaction was 96%, and patients felt comfortable using a telemedicine system in the future. Encounters were not significantly longer than traditional encounters. Physician diagnostic agreement was found in 95% of cases, and the consulting physician indicated that all encounters provided sufficient history, examination, and high-quality images to generate an accurate diagnosis, order additional workup, and/or make an appropriate referral.

Conclusion: A synchronous otolaryngology telemedicine clinic is comparable to a standard clinic in terms of diagnostic concordance and patient satisfaction when using streaming technology and high-definition images. Using telemedical technology may be a viable way to increase otolaryngology access in remote or underserved areas. With system validity now established, future studies will assess the feasibility of using trained on-site physician extenders (nurse practitioners or physician assistants) to conduct in-person patient encounters with remote otolaryngologist support.

Key Words: Telemedicine, real-time, synchronous, patient satisfaction, diagnostic concordance.

Level of Evidence: 2c.

Laryngoscope, 128:1068–1074, 2018

INTRODUCTION

Telemedicine is the practice of using telecommunication technology to provide remote-access medical care, typically to an underserved region. Its use has been well established in many fields of medicine including radiology, cardiology, dermatology, and psychiatry, but its role for use in academic surgical subspecialties is yet to be fully explored. As technology improves, costs decrease, and more efficient protocols are established, the use of telemedicine will continue to expand in all areas of medicine. Otolaryngologists represent a relatively small subset of surgical specialists, mostly located in urban areas and largely underrepresented in the rural community setting. Additionally, a primary component of the patient evaluation in otolaryngology depends on images that can be digitized (e.g., high-resolution computed tomography, endoscopic imaging), which are well suited for remote viewing using current technology. This clearly creates an ideal opportunity for further investigation into telemedicine technology as a potential resource to otolaryngologists.

Currently, telemedicine is used to deliver healthcare over a physical distance and has a role in numerous encounter types. As expected, the associated technology has significantly evolved over the last two decades, with streaming high-definition image-sharing capabilities, higher connection speeds, and more readily available equipment that is affordable. Successful telemedicine programs in otolaryngology previously have been described in the clinical setting, with older technology and on a relatively limited basis compared to other fields. Many programs successfully have employed asynchronous or store-and-forward platforms, for which there is no real-time interaction with the patient by the telemedicine physician. In contrast, real-time evaluation has been used, but mainly in a teleconference-like format that excludes the ability to perform any type of detailed physical exam. With recent technological advances, real-time, streamed images have improved quality, speed, and efficiency, creating an opportunity to expand applications for otolaryngologists. The synchronous telemedicine format has several benefits over store-and-forward approaches, including maintaining the physician–patient interaction and relationship with a face-to-face encounter, improved history taking, the ability to direct the examiner during physical examination, and an opportunity to counsel the patient immediately regarding diagnosis. Thus, a real-time interaction, combined with high-definition examination images, and an effective interface between on-site and remote locations provide all the critical components for an otolaryngologist’s evaluation and diagnosis.

Despite numerous technical differences, previously reported telemedicine systems have resulted in increased patient volume, decreased wait times, and improved patient experience, as well as an effective cost–benefit ratio. However, previously published applications of telemedicine to otolaryngology primarily have been limited to unique situations, such as the aftermath of Hurricane Katrina—or to situations that require remote access to care across great physical distances, such as in Alaska and Australia. A telemedicine application that has received less attention but arguably would impact a much larger volume of patients is the rural or underserved patient populations. These patients often are faced with limited access to otolaryngologic care or may routinely be required to travel long distances for an otolaryngology consultation. To address this need, we have developed a synchronous (real-time) general otolaryngology telemedicine clinic, with the long-term goal of expanding care to rural Ohio communities. In this study, we aim to evaluate the diagnostic concordance achievable using a pilot telemedicine otolaryngology clinic by comparing the ability of an on-site and remote otolaryngologist to diagnose and treat patients. This would serve as the first step to developing a telemedicine otolaryngology system in which a well-trained physician extender (nurse practitioner or physician assistant) would serve as the on-site clinician, and a remote otolaryngologist would serve as the consulting physician. Prior to implementing that setup, it was important to assess the fidelity of the telemedicine equipment and setup to provide sufficient information for an on-site and remote otolaryngologist to provide concordant diagnoses. Moreover, we investigated encounter satisfaction for both patients and providers during our experimental pilot telemedicine clinic.

MATERIALS AND METHODS

Telemedicine Protocol

After institutional review board approval, a synchronous telemedicine pilot clinic was created using an already established community otolaryngology clinic in a rural hospital setting  (Fig. 1). Faculty otolaryngologists at The Ohio State University Wexner Medical Center historically have staffed this rural clinic and continued to do so during this pilot project. All telemedical equipment, including otoscopes and endoscopes, were Storz products (Karl Storz Endoscopy-America, Inc., El Segundo, California, U.S.A.), and software was leased through Quintree (Quintree Medical LLC, Detroit, Michigan, U.S.A.). The Quintree system (Quintree Medical LLC) adheres to Heath Insurance Portability and Accountability Act recommendations with regard to security, best practices, and protected health information controls. Quintree (Quintree Medical LLC) provides data encryption at rest as well as encryption of all traffic. All access is user-authenticated and logged within an audit trail. The manufacturer recommends a minimum connection speed of 4.0 Mbit/second for high-quality video streaming, which was used for this pilot program in conjunction with an already present fiber optic connection.

Download the full Laryngoscope Ohio State School of Medicine study (PDF).