An economic evaluation of an advanced video conferencing system for cardiac multidisciplinary team meetings.

INTRODUCTION: Current UK and international guidelines advocate the need for multidisciplinary team (MDT) discussion of selected patients undergoing either percutaneous or surgical cardiac procedures to decide the optimal treatment strategy. To date, it is unknown if using videoconference facilities is cost-effective. Therefore, we performed a cost analysis of using a high-speed internet video conferencing system compared with conventional face-to-face MDT meetings. METHODS: Costs of running a conventional MDT meeting vs a video conferencing MDT were modelled and compared over a 2-year period. Participants were also surveyed on the overall effectiveness of conducting remote MDTs. RESULTS: The set-up and maintenance cost of the video conferencing system over 2 years was £30 400. The staff costs of running the face-to-face MDT were £95 970 and the video conferencing MDT was £23 992.50. The total travel costs of the conventional face-to-face MDTs were £10 555.34. In total, the cost of the conventional face-to-face MDT was £106 525.34 and the video conferencing MDT was £54 392.50 representing a cost saving of 48.9%. Participants rated the effectiveness of conducing a remote MDT and the ease of technology use as very good. CONCLUSIONS: Video conferencing systems provide a highly cost-effective method of facilitating MDT meetings between cardiologists and cardiac surgeons at remote centres.

Videoconference clinics improve efficiency of inflammatory bowel disease care in a remote and rural setting.

INTRODUCTION: Patients with inflammatory bowel disease (IBD) require long-term secondary care with periodic specialist follow-up. This can be especially challenging for patients living in remote areas. One possible solution is the implementation of videoconference (VC) clinics as a distance-management tool. Here we assessed the use of VC clinics for IBD in terms of patient safety and economic benefit for patients with IBD living in rural areas in the Scottish Highlands and Islands. METHODS: Eighty-eight patients participating in the IBD specialist nurses VC clinic administered via Raigmore Hospital, Inverness, Scotland, UK, between January 2016 and June 2017 were included in this study. A total of 229 appointments were assessed. RESULTS: We found the use of a VC clinic to be safe and effective as only 0.9% of appointments required urgent medical assessment and 92% of the VC clinic appointments resulted in further VC clinic follow-up. A total travelling distance of 72,245.3 km and a total travelling time of 71,688 minutes were saved in this patient cohort. It was shown that an average of US$36.61 of potential travelling cost could be saved per appointment. DISCUSSION: VC clinics represent a patient-centred participatory model of care for IBD patients living in remote areas with enormous time- and cost-saving potential while being safe and effective. Further investigations into patient satisfaction and the combination with other telemedicine tools such as telephone conferencing and mobile phone applications are needed to evaluate the full potential of the concept.

Use of Reimbursed Psychology Videoconference Services in Australia: An Investigation Using Administrative Data.

BACKGROUND: In November 2017, the Australian government approved reimbursement for psychology consultations conducted by videoconference under the Better Access initiative to address inequitable access of mental health services across regions in Australia. OBJECTIVE: This project uses publically available activity data from the Medicare Benefits Scheme to quantify the uptake of videoconference for psychology resulting from the initiative change. METHODS: Data were extracted from the Medicare Benefits Schedule item reports using the item codes for standard consultations and the new item codes for videoconference consultations. Activity data from 2 years before and the first year of the change to the Better Access initiative were compared to examine the uptake of videoconference for psychology. Data were stratified by allied health profession, sex, age and state jurisdiction. RESULTS: In the 1-year period after the introduction of reimbursed videoconference consultations, approximately 5.7 million in-person consultations and 4141 videoconference consultations were funded by Medicare in Australia. Videoconference consultations comprised 0.07% of the total consultations performed in that 1-year period and showed an increased trajectory. The results can guide future research into evaluating the clinical outcomes of patients via both in-person and videoconference delivery modes. CONCLUSIONS: Videoconference mental health services were used in the first year that they were available, although they only accounted for a small percentage of all mental health consultations provided by allied health professionals. This finding lays the foundation for future work which could examine the effectiveness of the scheme in reducing inequity and investigating the economic benefits of the expanded initiative to the government and society.

Adjusted cost analysis of video televisits for the care of people with amyotrophic lateral sclerosis.

INTRODUCTION: We previously reported our amyotrophic lateral sclerosis (ALS) video televisit experience. Here we report on video televisit versus in-clinic costs, adjusting for perceived medical usefulness (MU). METHODS: We take the patient-perspective and a focused institutional-perspective. Costs are adjusted for patient/caregiver and physician perceptions of visit MU. The base-case reflects our outpatient ALS practice. RESULTS: In the base-case, from the patient perspective, in-clinic visits cost $1,116 and video televisits cost $89 ($119 after MU-adjustment). From the institutional perspective, clinic visits cost $799, and video televisits cost $354 ($472 after MU-adjustment). Adjusted cost-savings per televisit are $997 (patient) and $327 (institution). Sensitivity analyses on 5 variables accounted for uncertainty in base-case assumptions. CONCLUSIONS: Video televisits provide marked adjusted cost-savings for patients and institutions. Adjusted costs are sensitive to perceived MU of video televisits. Future research should explore the ability of video televisits to reduce healthcare resource usage. Muscle Nerve 60: 147-154, 2019.

Cost-Effectiveness of Telemedicine in Remote Orthopedic Consultations: Randomized Controlled Trial.

BACKGROUND: Telemedicine consultations using real-time videoconferencing has the potential to improve access and quality of care, avoid patient travels, and reduce health care costs. OBJECTIVE: The aim of this study was to examine the cost-effectiveness of an orthopedic videoconferencing service between the University Hospital of North Norway and a regional medical center in a remote community located 148 km away. METHODS: An economic evaluation based on a randomized controlled trial of 389 patients (559 consultations) referred to the hospital for an orthopedic outpatient consultation was conducted. The intervention group (199 patients) was randomized to receive video-assisted remote orthopedic consultations (302 consultations), while the control group (190 patients) received standard care in outpatient consultation at the hospital (257 consultations). A societal perspective was adopted for calculating costs. Health outcomes were measured as quality-adjusted life years (QALYs) gained. Resource use and health outcomes were collected alongside the trial at baseline and at 12 months follow-up using questionnaires, patient charts, and consultation records. These were valued using externally collected data on unit costs and QALY weights. An extended sensitivity analysis was conducted to address the robustness of the results. RESULTS: This study showed that using videoconferencing for orthopedic consultations in the remote clinic costs less than standard outpatient consultations at the specialist hospital, as long as the total number of patient consultations exceeds 151 per year. For a total workload of 300 consultations per year, the annual cost savings amounted to €18,616. If costs were calculated from a health sector perspective, rather than a societal perspective, the number of consultations needed to break even was 183. CONCLUSIONS: This study showed that providing video-assisted orthopedic consultations to a remote clinic in Northern Norway, rather than having patients travel to the specialist hospital for consultations, is cost-effective from both a societal and health sector perspective. This conclusion holds as long as the activity exceeds 151 and 183 patient consultations per year, respectively. TRIAL REGISTRATION: ClinicalTrials.gov NCT00616837; https://clinicaltrials.gov/ct2/show/NCT00616837 (Archived by WebCite at http://www.webcitation.org/762dZPoKX).

Webside Manner: A Key to High-Quality Primary Care Telemedicine for All.

Evaluation of telemedicine, including videoconferencing, specifically focused on primary care, has demonstrated quality as good as in-person care, reduced cost, elimination of socioeconomic disparities in access, and high levels of patient satisfaction. Distinctly different care models are currently marketed by provider organizations as telemedicine. Inclusion (or not) of videoconferencing capacity constitutes a distinguishing feature that is likely to impact effectiveness, but provider organizations, regulatory agencies, and payers have largely overlooked this distinction. Reassurance reducing patient and family anxiety has long been recognized as essential to both patient satisfaction and value of the medical profession. Interaction that reduces anxiety requires empathic communication. Interpersonal communication involves more than words; also key are intonation of voice, facial expression, body language, and capacity to accurately "read" emotions in others and to respond effectively. Telemedicine with videoconferencing has been shown to redress disparities in access while providing high-quality care that is well accepted by both patients and providers. Technical and practical barriers to inclusion of videoconferencing in telemedicine are minimal. Real-time video interaction, enabling "webside manner," should be the default communication mode as telemedicine is increasingly accepted by patients, clinicians, and provider organizations as a tool to ensure high-quality primary care for all.

Economic evaluation of home-based telebehavioural health care compared to in-person treatment delivery for depression.

Introduction Home-based telebehavioural healthcare improves access to mental health care for patients restricted by travel burden. However, there is limited evidence assessing the economic value of home-based telebehavioural health care compared to in-person care. We sought to compare the economic impact of home-based telebehavioural health care and in-person care for depression among current and former US service members. Methods We performed trial-based cost-minimisation and cost-utility analyses to assess the economic impact of home-based telebehavioural health care versus in-person behavioural care for depression. Our analyses focused on the payer perspective (Department of Defense and Department of Veterans Affairs) at three months. We also performed a scenario analysis where all patients possessed video-conferencing technology that was approved by these agencies. The cost-utility analysis evaluated the impact of different depression categories on the incremental cost-effectiveness ratio. One-way and probabilistic sensitivity analyses were performed to test the robustness of the model assumptions. Results In the base case analysis the total direct cost of home-based telebehavioural health care was higher than in-person care (US$71,974 versus US$20,322). Assuming that patients possessed government-approved video-conferencing technology, home-based telebehavioural health care was less costly compared to in-person care (US$19,177 versus US$20,322). In one-way sensitivity analyses, the proportion of patients possessing personal computers was a major driver of direct costs. In the cost-utility analysis, home-based telebehavioural health care was dominant when patients possessed video-conferencing technology. Results from probabilistic sensitivity analyses did not differ substantially from base case results. Discussion Home-based telebehavioural health care is dependent on the cost of supplying video-conferencing technology to patients but offers the opportunity to increase access to care. Health-care policies centred on implementation of home-based telebehavioural health care should ensure that these technologies are able to be successfully deployed on patients' existing technology.

American College of Allergy, Asthma & Immunology Position Paper on the Use of Telemedicine for Allergists.

The integration of telecommunications and information systems in health care first began 4 decades ago with 500 patient consultations performed via interactive television. The use of telemedicine services and technology to deliver health care at a distance is increasing exponentially. Concomitant with this rapid expansion is the exciting ability to provide enhancements in quality and safety of care. Telemedicine enables increased access to care, improvement in health outcomes, reduction in medical costs, better resource use, expanded educational opportunities, and enhanced collaboration between patients and physicians. These potential benefits should be weighed against the risks and challenges of using telemedicine. The American College of Allergy, Asthma, and Immunology advocates for incorporation of meaningful and sustained use of telemedicine in allergy and immunology practice. This article serves to offer policy and position statements of the use of telemedicine pertinent to the allergy and immunology subspecialty.

Practical Issues in Delivery of Clinician-to-Patient Telemental Health in an Academic Medical Center.

BACKGROUND: In the age of online communication, psychiatric care can now be provided via videoconferencing technologies. While virtual visits as a part of telepsychiatry and telemental health provide a highly efficient and beneficial modality of care, the implementation of virtual visits requires attention to quality and safety issues. As practitioners continue to utilize this technology, issues of clinician licensing, treatment outcomes of virtual visits versus in-person visits, and cost offset require ongoing study. METHODS: This review provides an overview of the topics of technology, legal and regulatory issues, clinical issues, and cost savings as they relate to practicing psychiatry and psychology via virtual visits in an academic medical center. We review the telepsychiatry/telemental health effectiveness literature from 2013 to the present. Our literature searches used the following terms: telemental health effective, telepsychiatry effective, telepsychiatry efficacy, and telemental health efficacy. These searches produced 58 articles, reduced to 16 when including only articles that address effectiveness of clinician-to-patient services. RESULTS: The technological, legal, and regulatory issues vary from state to state and over time. The emerging research addressing diverse populations and disorders provides strong evidence for the effectiveness of telepsychiatry. Cost savings are difficult to precisely determine and depend on the scope of the cost and benefit measured. CONCLUSION: Establishing a telepsychiatry program requires a comprehensive approach with up-to-date legal and technological considerations.

Legal Mapping Analysis of State Telehealth Reimbursement Policies.

BACKGROUND: There exists rapid growth and inconsistency in the telehealth policy environment, which makes it difficult to quantitatively evaluate the impact of telehealth reimbursement and other policies without the availability of a legal mapping database. INTRODUCTION: We describe the creation of a legal mapping database of state-level policies related to telehealth reimbursement of healthcare services. Trends and characteristics of these policies are presented. MATERIALS AND METHODS: Information provided by the Center for Connected Health Policy was used to identify statewide laws and regulations regarding telehealth reimbursement. Other information was retrieved by using: (1) LexisNexis database, (2) Westlaw database, and (3) retrieval from legislative Web sites, historical documents, and contacting state officials. We examined policies for live video, store-and-forward, and remote patient monitoring (RPM). RESULTS: In the United States, there are 24 states with policies regarding reimbursement for live video transmission. Fourteen states have store-and-forward policies, and six states have RPM-related policies. Mississippi is the only state that requires reimbursement for all three types of telehealth transmission modes. Most states (47 states) have Medicaid policies regarding live video transmission, followed by 37 states for store-and-forward and 20 states for RPM. Only 13 states require that live video will be reimbursed "consistent with" or at the "same rate" as in-person services in their Medicaid program. DISCUSSION: There are no widely accepted telehealth reimbursement policies across states. They contain diverse restrictions and requirements that present complexities in policy evaluation and in determining policy effectiveness across states.

Overcoming the tyranny of distance: An audit of process and outcomes from a pilot telehealth spinal assessment clinic.

Introduction There is consistent evidence to indicate people living in rural and remote regions have limited access to healthcare and poorer health outcomes. One way to address this inequity is through innovative models of care such as telehealth. The aim of this pilot trial was to determine the feasibility, appropriateness and access to a telehealth clinic. In this pilot trial, the telehealth clinic outcomes are compared with the outreach clinic. Both models of care are commonly utilised means of providing healthcare to meet the needs of people living in rural and remote regions. Methods A prospective audit was conducted on a Spinal Assessment Clinic Telehealth pilot trial for patients with spinal disorders requiring non-urgent surgical consultation. Data were recorded from all consultations managed using videoconferencing technology between the Royal Adelaide Hospital and Port Augusta Community Health Service, South Australia between September 2013 and January 2014. Outcomes included analysis of process, service activity, clinical actions, safety and costs. Data were compared to a previous spinal assessment outreach clinic in the same area between August and December 2012. Results There were 25 consultations with 22 patients over the five-month telehealth pilot trial. Spinal disorders were predominantly of the lumbar region (88%); the majority of initial consultations (64%) were discharged to the general practitioner. There were three requests for further imaging, five for minor interventions and three for other specialist/surgical consultation. Patient follow-up post telehealth pilot trial revealed no adverse outcomes. The total cost of AUD$11,187 demonstrated a 23% reduction in favour of the spinal assessment telehealth pilot trial, with the greatest savings in travel costs. Discussion The telehealth model of care demonstrated the efficient management of patients with spinal disorders in rural regions requiring non-urgent surgical consultation at low costs with no adverse outcomes reported.

A low-cost, tablet-based option for prehospital neurologic assessment: The iTREAT Study.

OBJECTIVES: In this 2-center study, we assessed the technical feasibility and reliability of a low cost, tablet-based mobile telestroke option for ambulance transport and hypothesized that the NIH Stroke Scale (NIHSS) could be performed with similar reliability between remote and bedside examinations. METHODS: We piloted our mobile telemedicine system in 2 geographic regions, central Virginia and the San Francisco Bay Area, utilizing commercial cellular networks for videoconferencing transmission. Standardized patients portrayed scripted stroke scenarios during ambulance transport and were evaluated by independent raters comparing bedside to remote mobile telestroke assessments. We used a mixed-effects regression model to determine intraclass correlation of the NIHSS between bedside and remote examinations (95% confidence interval). RESULTS: We conducted 27 ambulance runs at both sites and successfully completed the NIHSS for all prehospital assessments without prohibitive technical interruption. The mean difference between bedside (face-to-face) and remote (video) NIHSS scores was 0.25 (1.00 to -0.50). Overall, correlation of the NIHSS between bedside and mobile telestroke assessments was 0.96 (0.92-0.98). In the mixed-effects regression model, there were no statistically significant differences accounting for method of evaluation or differences between sites. CONCLUSIONS: Utilizing a low-cost, tablet-based platform and commercial cellular networks, we can reliably perform prehospital neurologic assessments in both rural and urban settings. Further research is needed to establish the reliability and validity of prehospital mobile telestroke assessment in live patients presenting with acute neurologic symptoms.

A Prospective Pilot Study of the Use of Telemedicine During Pediatric Transport: A High-Quality, Low-Cost Alternative to Conventional Telemedicine Systems.

OBJECTIVE: Few trials address the use of telemedicine during pediatric transport. We believe that video conferencing has equivalent quality, connectivity, and ease of operation, can be done economically, and will improve evaluation. METHODS: Prospective randomized pilot study was used to examine video versus cellular communication between the medical command officer (MCO) and pediatric transport team (TT) for children with moderate to severe illness undergoing interhospital transport. Twenty-five patients were randomized to cellular communication, and 25 patients were randomized to video. The MCO completed a Likert scale to evaluate connection, quality, and ease of operation. Call durations were recorded. A Likert scale to evaluate the communication mode on patient care was completed. RESULTS: Connection and audio quality were equivalent and there were no dropped calls. Average call duration in the phone group was 186 versus 139 seconds in the video group (P = 0.055). The MCO survey results were the following: 100% found video intuitive, 92% felt that disposition based on phone report was difficult, 80% felt that video provided better understanding of patient condition, 70% felt that video assisted disposition, and 80% believe that video should be used for transport. The iPad system offers a significant savings when compared with conventional telemedicine. CONCLUSIONS: Video conferencing seems as easy to complete as phone with equivalent quality and connectivity. Duration of video was equivalent to phone conferencing. Surveyed MCOs believed that video conferencing improved assessment and disposition. The iPad-based conferencing provided significant savings when compared with conventional cart-based or robotic units. Further evaluation of video conferencing during interhospital transport is warranted.