2017 HSC Section 2 - Practice Management

B ESWICK ET AL .

tronically by the head and neck surgeon at PAVA for patients to be evaluated at their home site before traveling to PAVA for operative care. After a treatment plan was finalized, operative intervention and immediate inpatient postoperative care were provided at PAVA. The patient traveled to the local tertiary site (PAVA) the day before sur- gery for an examination by the operative team. In all cases, reconstructive options up to and including microvascular free tissue transfer were available as necessary on the day of surgery. Routine outpatient follow-up care was provided at the remote site with additional telemedicine postoperative visits as necessary. Patients who did not require operative intervention were treated in their home area and/or referred to appropriate specialists. Study design and outcome measurements Clinical, pathological, and operative data were collected from the electronic medical record and retrospectively analyzed. Main outcome measures were the time from referral to initial consultation and subsequently to surgery, as well as travel time spared, travel cost saved, and car- bon dioxide emissions avoided because of telemedicine visits. The time from referral to consultation reflects the time from when a referring VHA physician referred the patient to the head and neck surgery department at PAVA to the time the patient was evaluated by telemedicine by the PAVA department. Parameters related to the patient’s treatment timeline were calculated, including the time from the referral request to the time of telemedicine consultation and the time from telemedicine consultation to intervention. Travel time was based on average driving or flying time from remote locations to PAVA. Cost of travel and proce- dures were based on the federal government’s reimburse- ment rate for travel 14 and calculations by the VHA finance department when determining the cost of the fee based on specific procedures. Carbon dioxide emissions were calculated from the Environmental Protection Agency’s formula and were based on road travel in a car or light truck by each patient. 15 A comparison group of Fresno, CA, patients who were evaluated in-person at PAVA for head and neck cancer was used to compare telemedicine visits to in-person visits. This comparison group, who traveled to PAVA for in-person eval- uation, is distinct from the Fresno, CA, patients who were evaluated remotely via telemedicine and is subsequently referred to as the in-person Fresno group. For this comparison, no Albuquerque, NM, patients were included because of the fact that evaluation and treatment of these patients at PAVA began with the advent of a telemedicine program. RESULTS Fifteen patients were evaluated using this telemedicine protocol from August 2013 to March 2015. An additional 6 patients were followed with 24 telemedicine visits for postoperative care and cancer surveillance for a total of 21 patients. Thirty-nine telemedicine visits were performed in total. Among the 15 patients who underwent the full proto- col, mean age of patients was 64 years (range, 28–95 years) and all patients were men. All 15 patients who were offered a telehealth consultation instead of an in-person

head and neck cancer. In this pilot study, we sought to explore the feasibility of utilizing a real-time audiovisual teleconference to remotely evaluate patients with head and neck cancer and formulate a treatment plan, replacing the traditional preoperative in-person visit that determines surgical treatment planning. Use of this teleconferencing technology has expanded to provide postoperative follow- up and surveillance visits as well. Specifically, we sought to evaluate if this model improves existing access to opera- tive care and if it was associated with any time or financial savings. Secondarily, we sought to compare the wait times of patients evaluated with the telemedicine consultation to a cohort of patients evaluated with traditional in-person visits. MATERIALS AND METHODS This project was reviewed by both the Stanford University Institutional Review Board and the Research Administration at the Palo Alto Veterans Affairs (PAVA) Health Care System and was determined to be a quality improvement project. All patients gave informed consent to participate in a telemedicine encounter. Patients PAVA frequently provides tertiary head and neck onco- logic care for veterans in the Northern California and the southwestern United States, including the New Mexico region. VHA patients requiring care at a tertiary otolaryn- gology facility (PAVA) who were diagnosed at 2 remote VHA sites (New Mexico Veterans Affairs Health Care System, Albuquerque, NM, and Central California Veterans Affairs Health Care System, Fresno, CA) were evaluated remotely via the telemedicine consultation protocol. VHA physicians practicing in Fresno, CA, and Albuquerque, NM, referred the patients. Remote patients were defined as those who reside > 150 miles from Palo Alto, CA. Patients with referrals to PAVA for head and neck cancer treatment were eligible to participate in the protocol. Protocol Eligible patients were offered the option of a telemedicine consultation when the referral was received by PAVA. All patients were also offered a standard in-person consultation. The telemedicine protocol included 3 components: (1) tissue diagnosis and imaging acquisition at a remote site; (2) review of clinical, pathological, and imaging data at the local, tertiary treatment site (PAVA), including discus- sion of the patient at the Stanford Department of Otolaryn- gology multidisciplinary head and neck tumor board; and (3) a preoperative, audiovisual teleconference to finalize the treatment plan and counsel the patient. This encounter was a real-time, 30-minute, teleconference that occurred via an encrypted line. The telemedicine consult was per- formed with the patient, nurse, and speech pathologist present at the patient’s home site, providing the ability for real-time nasopharyngoscopy, and a head and neck surgeon (D.B.S.) at PAVA. For surgical patients, medical services that were needed to provide preoperative clearance (primary care, cardiology, and pulmonology) were determined during the telemedicine visit. Referrals to the necessary service(s) were placed elec-

HEAD & NECK—DOI 10.1002/HED JUNE 2016

90