The opportunity to treat neurotologic patients when the patient and physician are in separate locations is an important clinical delivery mechanism. The authors developed their applications of neurotologic telemedicine in the aftermath of Hurricane Katrina and found this to be an effective way to deliver clinical care, develop a clinical neurotology practice, and train residents and fellows and to manage a growing neurotologic clinical practice remotely. This article outlines the technical requirements, current uses, clinical applicability, and implementation details of the Our Lady of the Lake – LSU neurotology telemedicine program; administrative issues surrounding telemedicine; and future considerations.
The opportunity to treat neurotologic patients when the patient and physician are in separate locations is an important clinical delivery mechanism. The authors developed their applications of neurotologic telemedicine in the aftermath of Hurricane Katrina and found this to be an effective way to deliver clinical care, develop a clinical neurotology practice, and train residents and fellows and to manage a growing neurotologic clinical practice remotely. This article outlines the technical requirements, current uses, clinical applicability, and implementation details of the Our Lady of the Lake – Louisiana State University (LSU) neurotology telemedicine program; administrative issues surrounding telemedicine; and future considerations. Although the initial program was a necessary step to maintain clinical services and the otolaryngology residency after Hurricane Katrina, the benefits have extended far beyond the initial intent, including identifying a practical technique to extend services to underserved areas and potentially help alleviate the pending shortage of otolaryngologists.
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Neurotology is well suited for delivery through telemedicine, and this delivery method is particularly useful in underserved areas or in times of natural disaster.
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Basic technical requirements for neurotologic telemedicine are a codec, video otoscopy, infrared video eye movement recording, an otoscopist at the patient end, digital access to imaging, technical support at the patient and provider locations, and secure data transmission.
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Legal requirements usually include medical licensure at the patient and provider locations.
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Reimbursement is location-specific, with clear guidelines in rural areas. Reimbursement in other areas requires specific discussions with insurers and government programs.
Telemedicine is a mode of health care delivery in which the physician is able to care for a patient when the patient and physician are not in the same place at the same time. Like other applications of telemedicine, neurotology applications of telemedicine can occur as real-time encounters or as delayed (store-and-forward) interactions. Because neurotology relies heavily on visualization of the ear, imaging studies, physiologic evaluations of balance, and review of electrophysiologic studies, the technical requirements lend themselves to widespread application of telemedicine.
The use of telemedicine as a delivery tool for otology and neurotology has grown beyond a novel theoretical consideration, because telemedicine is now a practical and viable clinical delivery method. This article reviews several aspects, presented in Box 1 .
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Technical requirements and options for telemedicine
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Codec
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Content
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Peripherals
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Connectivity
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Virtual private network (VPN)
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Current applications of otology and neurotology telemedicine
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Otoscopy
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Conferencing
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Vestibular evaluation
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Education
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The diffusion of telemedicine in the United States and internationally
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Clinical applicability of neurotology telemedicine
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Symptoms
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Manpower considerations
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Rural
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Disaster
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Training
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Cochlear implant testing and programming
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Our Lady of the Lake – LSU Neurotology Telemedicine
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Program organization
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Patient satisfaction
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Outcomes
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Administrative issues surrounding telemedicine
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Consent
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Malpractice insurance
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Licensure
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Future consideration
Technical requirements and options for neurotology telemedicine
For store-and-forward neurotology telemedicine, any system that allows recording of images and or videos for later viewing, interpretation, and treatment recommendations is applicable. These types of efforts have been particularly useful in rural outreach where many patients’ ears are examined and recorded by an advance screening team with later transmission of the data to experts at a central location. Furthermore, these systems have been validated and compared with on-site otoscopy documenting the accuracy of the technique for otologic diagnosis. High-quality otoendoscopes and computer software with the ability to record and transmit digital images permit accurate visualization of ear canal and tympanic membrane pathology.
For real-time telemedicine, the needs are more complex. A codec unit is the centerpiece. This unit permits teleconferencing, including not only traditional video and audio but also the ability to connect additional input sources, such as the video endoscope for otoendoscopy, digital stethoscope, fiber optic laryngeal endoscopy, infrared video camera for eye movement recording, and digital transmission of overhead projections of imaging films/paper documents, and real-time computer display of word processing and slide presentation software. Tandberg and Polycom manufacture units with easy compatibility. Figs. 1 and 2 show two of the codec units used by the authors. Price for these devices and peripheral configurations ranges from approximately $10,000 to several hundred thousand dollars for multisite configurations. Factors influencing selection include screen size, space availability, technical expertise available for customization, and the compatibility of the peripheral devices selected.
Beyond the basic equipment, software configuration and negotiating firewalls appropriately are necessary steps to initiate and maintain the functionality of the system. Clinicians planning a real-time telemedicine clinical program must specifically consider the availability of information system resources to troubleshoot and expand the system, because Internet access, security issues, and program updates create a fluid situation requiring multisystem functionality.
Health Insurance Privacy and Portability Act (HIPPA) requirements are specific in the need for confidentiality. Security requirements are a necessary component of the system to maintain patient confidentiality. A VPN is one technique this program has found effective in creating a secure environment for patient communication. Using special username and password access, clinicians near and far can communicate freely about the patient, with access to the session permitted only to personnel with appropriate security access to the codes.
Peripheral inputs include the video endoscope tools described in the store-and-forward section. Endoscopic views of the ear canal and tympanic membrane can be taken real-time to adjust the view or focus on different aspects of the tympanic membrane or mastoid cavity. Additionally, magnified views can be obtained through connecting the office microscope to the codec, thus permitting otomicroscopy as a telemedicine tool. Facial function can be visualized with the high-resolution, remote zoom function of the video conferencing portion of the codec. Nystagmus evaluation is facilitated by infrared goggles and cameras, which permit nonfixation analysis of nystagmus and eye motion recording for positional, spontaneous, and gaze nystagmus. Fig. 3 illustrates use of the Micromedical infrared goggles (Micromedical Technologies, Inc., Chatham, Illinois) during an actual telemedicine session with the author (MA) in Pittsburgh, Pennsylvania while the patient and neurotology fellow were in Baton Rouge, Louisiana during a Hallpike test for positional nystagmus.
The teleconferencing capabilities of the system require that the physician have control of camera position and zoom image of the patient’s location. Similarly, both the patient and physician location need split-screen capabilities so that they can see an inset screen of their image being transmitted to the other party, and see each other. For neurotology, it is particularly useful for the physician to be able to manage multiple screen windows. In addition to visualizing the patient and himself, the physician needs visualization of peripheral inputs, such as the video endoscope and infrared video goggles. For instance, during the Hallpike test, the physician can see the patient being placed in the Hallpike position while watching the infrared video camera transmission of their eye movements.
Additional content transmission during neurotology telemedicine sessions is also helpful for communication. In communicating with deaf and hard-of-hearing patients, one of the authors (MA) will switch to a word processing program using a large font display to close caption the conversation with the hard-of-hearing patient. In this manner, the communication is enhanced and both parties are sure the correct message has been relayed. Similarly, for patient education purposes during on-site patient encounters in neurotology, patient information pamphlets and brochures are often used to show normal and diseased physiology. With the telemedicine unit, physicians are able to switch to a slide presentation program during the visit to efficiently educate patients and their family during the patient visit.
Current applications of otology and neurotology telemedicine
Otoscopy is the most frequent current application of telemedicine in otology and neurotology. During outreach trips to underserved areas, recorded otoendoscope images are transmitted to a central area with more specialized personnel than are available in the remote screening location. The Alaskan Telemedicine Project incorporates otoendoscopy as part of a complex telemedicine unit that is housed in various secondary centers closer to the patients’ rural homes, which in turn transmits the images to a central location where more trained physicians and specialists can review the images and make recommendations.
Special considerations in real-time neurotologic applications of otoendoscopy include ear canal moisture and focused views of different aspects of the tympanic membrane, ear canal, and mastoid cavity. A perforation with moisture can interfere with visualization of the tympanic membrane through fogging the lens. Generous application of antifog material, air puffs, and efficient placement and photography of the pathology can circumvent this limitation. The personnel maneuvering the endoscope need specific training and practice for accurate endoscopy. Particular skill is needed to understand what portion of the anatomy is necessary for visualizing pathology.
Teleconferencing can be considered the core capability of the codec unit, with visualization of peripheral inputs as add-on features. This core capability lends itself to applicant interviews and team conferences, even though the physician is not physically at the same office as the rest of the team.
The vestibular evaluation during a telemedicine session is similar to an on-site examination. The history is taken in a standard fashion using the teleconferencing function. The neurologic examination can include detailed cranial nerve examination, and endoscopic oral, pharyngeal, nasal, and even laryngeal examination. The camera can follow the patient in the examination room during gait, Romberg, and Fukuda step testing. Infrared goggles can evaluate for gaze and positional nystagmus, and even evaluate for fistula, Tullio phenomenon, hyperventilation, and vibration-induced nystagmus.
Similarly, telemedicine evaluations of patients with skull base lesions use the discussed functionalities. However, the patient education components are especially useful in skull base tumor and acoustic neuroma evaluations. Families particularly appreciate the real-time review of images showing the pathology, reviewing the anatomy, and discussing the treatment options. The conversation can be enhanced with brief PowerPoint presentations of computer slides.
Objective tinnitus is a specific symptom that requires auscultation in various head and neck sites for appropriate diagnosis. The digital stethoscope permits recording and transmission of sounds for diagnosis. This tool has been validated by its role in cardiology and remote physician evaluation/management of patients in intensive care units at distant locations.
Multiple Site Education
Resident, medical student, and ancillary staff education is facilitated by the teleconferencing capabilities. Since March 2006, the LSU Otolaryngology Department has had a regular telemedicine weekly lecture series highlighting simultaneous participation by faculty in numerous local, national, and international locations. Current participants in the lecture series include sites at Children’s Hospital, New Orleans, LSU School of Allied Health, Our Lady of the Lake Regional Medical Center, Ohio Osteopathic Residency, Allegheny General Hospital, and Siglo 21 Medical Center in Mexico City. Because the teleconferencing functions use visualization and participation at the sites receiving and transmitting the lectures, the sessions can be truly interactive, with participants asking the presenter questions and the presenter able to quiz the participants on hypothetical cases and their mastery of the assigned reading material.
Diffusion of Telemedicine
Neurotology telemedicine is obviously a small part of telemedicine in modern medicine. Accordingly, taking a step back to understand the process of incorporating this new innovation is important to understand the future role of telemedicine in neurotology.
In the mid 20th century, Everett Rogers championed diffusion of innovation theory, which is still used to study the manner that new ideas spread. Diffusion, as explained by Rogers is, “the process by which an innovation is communicated through certain channels over time among members of social systems.” Rogers defines an innovation as, “an idea, practice, or object perceived as new by an individual or other unit of adoption.” Rogers emphasizes that regardless of whether the adoption decision is planned, both uncertainty and the potential to create a social change are underlying characteristics of an innovation. The adoption of an innovation is a five-step process, which Rogers described as (1) learning about the innovation, (2) developing an attitude or opinion regarding the innovation, (3) deciding to accept or reject the innovation, (4) beginning to execute it, and (5) confirming the decision. The final step refers to the pivotal decisions adopters must make to integrate the innovation into their regular activities.
A review of the five steps of the innovation adoption process shows that in the United States. telemedicine has surpassed the first stage of the process, learning about the innovation. This step represents gathering “how” and “why” knowledge about telemedicine. A simple search engine query for the terms “telemedicine” and “telehealth” shows a high volume of corresponding Web sites ( Fig. 4 ). For example, a search for the term “telemedicine” at yahoo.com returned more than 9,000,000 results.
Anecdotally, the idea of telemedicine has permeated the mainstream media, as evidenced by the new Cisco television commercial with Ellen Page. The commercial highlights the capabilities created by the use of telemedicine in a doctor’s office. In the commercial, Page’s doctor is on vacation in Copenhagen, yet he is still able to connect with the office and see patients.
The second and third stages of the innovation adoption process are inextricably linked. The second stage focuses on the formation of an opinion about telemedicine, whereas the third stage emphasizes the decision to accept or reject telemedicine, a decision highly dependent on the opinion formed. The prevalence of varying editorial articles that provide opinions of the value of telemedicine and its potential financial benefit, coupled with telemedicine’s incorporation into legislative initiatives, show that as a practice, telemedicine is past the opinion-formation phase and has clearly accomplished the third stage, the decision to accept or reject the innovation, as evidenced by the ensuing prevalence of telemedicine programs.
Perhaps this is best examined through the level of government approval that telemedicine receives. Government approval is necessary to regulate procedures and treatment methods; thus, government approval should shed light on the opinion of telemedicine and the decision to adopt or reject. For example, a program called BR Med-Connect at Our Lady of the Lake Regional Medical Center in Baton Rouge, Louisiana is a mobile telemedicine program linking the city’s emergency medical services, such as ambulances, to hospital emergency rooms. The program sends live streaming video images from the ambulances through a Wi-Fi network downtown, which is supplemented by a 3G Evolution-Data Optimized (EV-DO) cellular network outside of downtown. Baton Rouge is the second location in the country to implement this program. Tucson, Arizona in the Western region was the first, highlighting the unpredictable transference of telemedicine programs. Thus, the local government has formulated a decision about telemedicine and made a decision to accept the innovation.
Accomplishment of the fourth phase of the innovation adoption process, execution or the active gathering of information and the implementation (regardless of the scale) of the program, can be easily seen through a state-by-state search for telemedicine programs ( Fig. 5 ). This search shows that each state has at least one telemedicine program operating; however, no single coordinated national telemedicine program exists.
