Assessing Case Turn-Around Times in a University-Based ...

Assessing Case Turn Around Times in a University-Based

Telemedicine ProgramElizabeth 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

Goal1) 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.

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.

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).

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.

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

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

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

Required Forms• Patient consent• Patient demographics• Patient history forms

– Internal medicine– Cardiology– Non-internal medicine– Initial psychiatric consult– Follow-up psychiatric consult

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

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

Scheduled ATP Clinics

Mon Tues Wed Thurs Fri

AM Rheum Hem/ Onc

Neuro

PM Psych Card Derm

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

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

TAT Components1) 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

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

Total Case TAT Results

05

1015202530354045

Per

cen

t o

f C

ases

< 24Hrs

< 48Hrs

< 72Hrs

< 1Wk

> 1Wk

RT

SF

t = 8.051, df = 498, p = 0.0001

SF TAT Components CR RV VB FR

Mean* 5.79 49.56 0.29 64.25SD 14.78 134.79 1.08 60.39Min 0.08 0.33 0.08

0.08Max 87.00 1560.00 24.00 648.00N 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

RT TAT Components CR RV VB FRMean* 2.22 193.21 0.80 75.91SD 9.18 253.60 0.01 71.41Min 0.08 0.17 0.08 1.00Max 144.00 2367.00 0.08 600.00N 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

Appointment AvailabilitySub-Specialty UMC* In-Person ATP Teleconsult

Cardiology > 1 month 0.97 daysDermatology > 1 month 1.26 daysNeurology 25 days 9.29 daysOb/Gyn > 1 month 4.92 daysOrthopedics > 1 month 7.33 daysPeds Cardiol 8 days 6.63 daysPeds Endocrin 22 days 1.19 daysPeds Psych 24 days > 1 monthPsychiatry 24 days 6.04 daysRheumatology > 1 month 9.25 days

t = 4.86, df = 9, p < 0.001 * UMC = University Medical Center, University of Arizona Health Sciences Center

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

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

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

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

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.