Pandemic Action Plan: Phase 3-Lessons Learned from Implementation. "What Did We Learn?"

The COVID-19 pandemic created critical challenges for hospitals and health care providers. Suddenly clinics were forced to close; elective procedures were delayed; scheduled visits were canceled; emergency rooms were overcrowded; hospital beds, equipment, and personal protective equipment (PPE) were in short supply; and staff were faced with rapidly changing circumstances, care protocols, trauma, and personal risk. To better address challenges of the ongoing COVID-19 pandemic and prepare for future pandemics, the National Telemedicine Technology Assessment Resource Center (TTAC) was asked to develop a Pandemic Response Action Plan that would allow its users to address critical issues with available telemedicine and related technologies. The project was constructed in 3 phases. Phase 1-Develop a Pandemic Response Action Plan and a Pandemic Response Action Plan Policy and Regulatory Summary, which identifies the regulatory challenges as well as policy recommendations. Phase 2-Publish the Action Plan and the Policy and Regulatory Summary. Phase 3-Look at health care providers who used the approaches, tools, and technology in the Pandemic Action Plan and document the results. This document represents Phase 3. This document is Phase 3. In this report we look back at health care providers who used the approaches in the Phase 1 Pandemic Response Action Plan as published in Phase 2. In this document we report on the challenges and results of implementing parts of the Pandemic Action Plan. It records the findings, conclusions, and recommendations resulting from the experience of health care providers and the professional experiences of the team and their organizations in implementing parts or all of the plan. Methods: The same multidisciplinary team that constructed Phase 1 and Phase 2 were engaged to develop this Phase 3 report. The members of the team represent leadership expertise and key stakeholders in health care delivery during a pandemic (administration, infection control, physicians, nurses, public health, contingency planning, disaster response, and information technology) as well as a facilitator. For Phase 3, the group used structured brainstorming to define the findings, issues, and results of their own organizations' digital health response to the pandemic. In addition, eight health care providers (hospitals) identified by the Telemedicine Resource Centers' (TRCs) organizations, who used the Pandemic response Plan (created in Phases 1 and 2), were interviewed. All interviews were conducted by the same facilitator with leaders (CEO, and leaders of the telemedicine programs) in each of the eight programs, using a standard questionnaire created by the team. Current literature references are included in this report to illustrate when findings are known to have broader applicability. Conclusions: The impact of the COVID-19 Pandemic was severe and identified multiple critical challenges and weaknesses. Applying the approaches, tools, and technology outlined in the Pandemic Response Action Plan proved to be effective in addressing critical provider challenges. However, implementing these tools during a crisis was difficult unless the organization had experience with the tools and necessary workflows in advance. Implementing these tools as part of standard workflows and everyday operations increased the capabilities and resilience of these organizations in the provision of care during this and for future pandemics.

The Alaska experience using store-and-forward telemedicine for ENT care in Alaska.

This article discusses the development, evaluation, and growth of telemedicine in Alaska. Store-and-forward telemedicine has been used to deliver ear, nose, and throat (ENT) care to rural Alaska since 2002. It has proved valuable in the treatment of many conditions of the head and neck, and it is particularly well suited for the diagnosis and treatment of ear disease. Usage has grown steadily as telemedicine has become widely accepted. Store-and-forward telemedicine has been shown within the Alaska Native Health System to improve access for care and reduce wait times, as well as decrease travel-associated costs for patients.

Preoperative planning for ear surgery using store-and-forward telemedicine.

OBJECTIVE: To determine if store-and-forward telemedicine can be used to accurately plan ear surgery. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care hospital. SUBJECTS AND METHODS: Charts were reviewed for elective major ear surgeries resulting from telemedicine referrals during a 13-month period. The store-and-forward telemedicine referrals (electronic consultations) included clinical history, digital images, and audiology data. Consultants reviewed each telemedicine case and documented the recommended surgery and estimated operative time. These charts were matched with patients seen in person during a standard evaluation and had identical surgeries recommended. For the telemedicine evaluation and in-person evaluation groups, the recommended surgeries were compared with actual surgeries performed and the estimated time was compared with the actual operative time. RESULTS: Forty-five ear surgeries were recommended by the telemedicine evaluation and were matched with 45 surgeries from the standard evaluation and included tympanoplasty with or without canalplasty, mastoidectomy, stapes surgery, and myringoplasty. Telemedicine and in-person evaluation accurately predicted the surgery 89 percent and 84 percent of the time, respectively. The average difference of "actual time" and "estimated time" for the actual surgical procedures performed was not statistically different between the two groups: 32 minutes for the telemedicine evaluation group and 35 minutes for the in-person evaluation group. CONCLUSION: Store-and-forward telemedicine is as effective as in-person evaluation for planning elective major ear surgery.

The impact of telehealth on wait time for ENT specialty care.

Audiology in rural Alaska has changed dramatically in the past 6 years by integrating store and forward telemedicine into routine practice. The Audiology Department at the Norton Sound Health Corporation in rural Nome Alaska has used store-and-forward telemedicine since 2002. Between 2002 and 2007, over 3,000 direct audiology consultations with the Ear, Nose, and Throat (ENT) Department at the Alaska Native Medical Center in Anchorage were completed. This study is a 16-year retrospective analysis of ENT specialty clinic wait times on all new patient referrals made by the Norton Sound Health Corporation providers before (1992-2001) and after the initiation of telemedicine (2002-2007). Prior to use of telemedicine by audiology and ENT, 47% of new patient referrals would wait 5 months or longer to obtain an in-person ENT appointment; this dropped to 8% of all patients in the first 3 years with telemedicine and then less than 3% of all patients in next 3 years using telemedicine. The average wait time during the first 3 years using telemedicine was 2.9 months, a 31% drop compared with the average wait time of 4.2 months for the preceding years without telemedicine. The wait time then dropped to an average of 2.1 months during the next 3 years of telemedicine, a further drop of 28% compared with the first 3 years of telemedicine usage.

Implementation and evaluation of telehealth tools and technologies.

In June 2009, the National Center for Research Resources (NCRR), National Institutes of Health (NIH), convened a conference of experts to discuss future directions for research in addressing healthcare disparities through the use of telehealth technologies. As part of this conference, a panel was convened to review the status of current efforts to assess, implement, and evaluate telehealth technologies, and to recommend future directions for research. The panel members provided a series of practical recommendations to those who are contemplating establishing a telehealth service, as well as recommendations to the NIH on future funding for telehealth research. The recommendations to the NIH focused on three broad areas of concern: (1) technology assessment, (2) evaluation, and (3) technical assistance, education, and dissemination. The panel members emphasized the need for NIH to support research in areas that have been seriously underfunded in the past, including but not limited to primary care research, multisite collaborative telehealth studies, nonphysician telehealth services, and methodological development to develop a "gold standard" for telehealth studies.

Selecting the right digital camera for telemedicine-choice for 2009.

Digital cameras are fundamental tools for store-and-forward telemedicine (electronic consultation). The choice of a camera may significantly impact this consultative process based on the quality of the images, the ability of users to leverage the cameras' features, and other facets of the camera design. The goal of this research was to provide a substantive framework and clearly defined process for reviewing digital cameras and to demonstrate the results obtained when employing this process to review point-and-shoot digital cameras introduced in 2009. The process included a market review, in-house evaluation of features, image reviews, functional testing, and feature prioritization. Seventy-two cameras were identified new on the market in 2009, and 10 were chosen for in-house evaluation. Four cameras scored very high for mechanical functionality and ease-of-use. The final analysis revealed three cameras that had excellent scores for both color accuracy and photographic detail and these represent excellent options for telemedicine: Canon Powershot SD970 IS, Fujifilm FinePix F200EXR, and Panasonic Lumix DMC-ZS3. Additional features of the Canon Powershot SD970 IS make it the camera of choice for our Alaska program.

Traveling an audiologist to provide otolaryngology care using store-and-forward telemedicine.

This project increased access to otolaryngology services by having an audiologist travel to remote Alaska and communicate with an otolaryngologist using store-and-forward electronic consultation. The audiologist was instructed to effectively image appropriate parts of the otolaryngology exam and create telemedicine cases that included clinical histories, images, audiograms, tympanograms, otoacoustic emission testing and/or other documents. The otolaryngology consultants reviewed new referrals as well as follow up cases and made treatment and triage recommendations. Over a 57 month period, 54 trips were made to 14 villages providing 197 clinic service days. The 1,458 patient encounters resulted in referral for surgery or special diagnostic testing 26%, referral for monitoring 23%, starting of medications 19%, referral to regional ENT clinic 15%, and referral to another specialty 5%. Approximately 27% patients did not need to see the otolaryngologist and were triaged out of the specialty clinic. The total cost to run this project was $141,114. Travel was prevented for 85% encounters, resulting in travel cost avoidance in airfare of $496,420. These services were provided at a significantly lower cost and with fewer burdens to the patients when compared to the standard referral system. An audiologist that travels to remote locations and uses store-and-forward telemedicine can rapidly deliver otolaryngology services. This model is a proven mechanism of efficient healthcare delivery that may be expanded to other specialties.

Selecting a digital camera for telemedicine.

The digital camera is an essential component of store-and-forward telemedicine (electronic consultation). There are numerous makes and models of digital cameras on the market, and selecting a suitable consumer-grade camera can be complicated. Evaluation of digital cameras includes investigating the features and analyzing image quality. Important features include the camera settings, ease of use, macro capabilities, method of image transfer, and power recharging. Consideration needs to be given to image quality, especially as it relates to color (skin tones) and detail. It is important to know the level of the photographer and the intended application. The goal is to match the characteristics of the camera with the telemedicine program requirements. In the end, selecting a digital camera is a combination of qualitative (subjective) and quantitative (objective) analysis. For the telemedicine program in Alaska in 2008, the camera evaluation and decision process resulted in a specific selection based on the criteria developed for our environment.

Telehealth: the promise of new care delivery models.

Telehealth possesses a significant potential to revolutionize healthcare delivery processes by challenging some of the long-held assumptions about healthcare delivery and by creating innovative alternative models. Those assumptions relate to the location-linked nature of healthcare and its episodic nature. Telehealth can challenge the assumption that healthcare is inextricably linked to the provider's location. Numerous models involving such approaches as interactive videoconferencing and store-and-forward technologies already exist. Telehealth also challenges the episodic nature of care. One example is provided by the models evolving from the convergence of three technologies: remote monitoring, electronic health records, and clinical decision support systems. Telehealth-based models of care can also lead to a reduced demand for services and greater efficiencies in the care process. These telehealth-enabled care delivery models have the potential to reduce the costs of care, improve quality, and mitigate provider shortages. However, the achievement of these goals is not straightforward. The current healthcare financing system is not designed to support such new models, and the existing healthcare culture is deeply ingrained within workflow processes and provider attitudes. A great deal of work remains to be done before the benefits of telehealth-based care delivery models are fully realized. Change is inherently risky but we must have the courage to assume the risk in order to create telehealth-driven innovations that lead to better and more cost-effective medical care for all.

Digital images for postsurgical follow-up of tympanostomy tubes in remote Alaska.

OBJECTIVE: To determine if video otoscope still images of the tympanic membrane taken in remote clinics are comparable to an in-person microscopic examination for follow-up care. DESIGN: Comparative concordance, diagnostic reliability. METHODS: Community health aide/practitioners in remote Alaska imaged 70 ears following tympanostomy tube placement. The patients were then examined in person by two otolaryngologists. Images were later reviewed at 8 and 14 weeks. RESULTS: Intraprovider concordance for physical examination findings was: "Tube in," 94 percent -97 percent (kappa = 0.89-0.94); "Tube patent," 94 percent -97 percent (kappa = 0.89-0.94); "Drainage," 90 percent -96 percent (kappa = -0.04-0.38); "Perforation," 90 percent -96 percent (kappa = 0.61-0.82); "Granulation," 97 percent -100 percent (kappa = 0.49-1.0); "Middle ear fluid," 88 percent -96 percent (kappa = 0.28-0.71); "Retracted," 83 percent -91 percent (kappa = 0.26-0.58). These agreement rates are similar to interprovider concordance when two otolaryngologists examine the same patient in person. Intraprovider concordance for diagnoses was 76 percent -80 percent (kappa = 0.64-0.71) and 77 percent -88 percent (kappa = 0.66-0.81) when poor images were excluded. Interprovider diagnostic concordance for the in-person exam was 89 percent (kappa = 0.83). CONCLUSION: Video-otoscopy images of the tympanic membrane are comparable to an in-person examination for assessment and treatment of patients following tympanostomy tubes. Store-and-forward telemedicine is an acceptable method of following patients post tympanostomy tube placement.

Telehealth in Alaska: delivery of health care services from a specialist's perspective.

Integrating store-and-forward telemedicine into the ANMC ENT practice for remotely located patients has improved access for care as well as the quality of care for our patients. The involvement of the ANMC ENT department in the design of the telemedicine system was critical. Yet building the telemedicine service required creative measures to encourage use and careful management of our capacity to receive a growing number of cases. Cost savings due to avoided travel have been readily apparent, based on the high cost of travel in Alaska, The improvement in departmental productivity was an unexpected yet welcome outcome. Much of the current research in telemedicine appropriately focuses on the applicability of this modality to clinical problems. Our four years experience indicates that one of the challenges in the future will be to integrate telemedicine with the existing infrastructure of medicine so that it can more easily become part of mainstream practice.

ECG acquisition using telemedicine in Alaska.

The Alaska Federal Health Care Access Network includes a telecommunications network supporting telemedicine carts and store-and-forward telemedicine software throughout Alaska. Electrocardiograms are being acquired at remote locations and being interpreted at regional and tertiary care facilities as part of routine and acute care. This promising new technology is just beginning to have an impact on cardiovascular patient care.

A comparison of in-person examination and video otoscope imaging for tympanostomy tube follow-up.

The objective of this study was to determine if video otoscope still images (640 x 480 pixel resolution) of the tympanic membrane following surgical placement of tympanostomy tubes are comparable to an in-person microscopic examination. Forty patients having undergone tympanostomy tube placement in both ears were independently examined in-person by two otolaryngologists and imaged using a video otoscope and telemedicine software package. The two physicians later reviewed images at 6 and 12 weeks. Physical examination findings and diagnosis were documented and compared for their concordance using kappa statistics. For both physicians, the intraprovider concordance between the in-person examination and the corresponding image review was high for each of the physical examination findings: Tube In 93-94% (K 0.85-0.87), Tube Patent 86-93% (K 0.74-0.85), Drainage 94-98% (K 0.42-0.66), Perforation 85-98% (K 0.40-0.84), Granulation 95-99% (K -0.01 to 0.00), Middle Ear Fluid 89-91% (K -0.03 to 0.50), and Retracted 89-94% (K 0.13-0.43). These agreement rates are similar to the normal interprovider concordance observed when two physicians independently examined the same patient in-person for physical exam findings: Tube In 96% (K 0.93), Tube Patent 94% (K 0.88), Drainage 96% (K 0.56), Perforation 90% (K 0.60), Granulation 96% (K 0.39), Middle Ear Fluid 88% (K 0.14), and Retracted 91% (K 0.43). For both physicians, the intraprovider diagnostic concordance between the in-person examination and the corresponding image review was high 79-85% (K 0.67-0.76). The interprovider diagnostic concordance for the in-person exam was 88% (K 0.81). The interprovider diagnostic concordance when two physicians independently reviewed all images was 84% (K 0.74), and 89% (K 0.80) when poor images were excluded. This study demonstrates that physician review of video otoscope images is comparable to an in-person microscopic examination. Store-and-forward video otoscopy may be an acceptable method of following patients post-tympanostomy tube placement.