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.
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Store-and-forward telemedicine is well suited to the specialty of otolaryngology.
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Clinician involvement in selecting medical devices, creating protocols, and improving and modifying software are key to the success of a telemedicine program.
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Referring providers in Alaska believe that the use of telemedicine improves both clinical outcomes and patient satisfaction.
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The combination of high-quality images of the tympanic membrane and tympanometry data allows a diagnosis to be established in most telemedicine cases involving ear disease.
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Consultants using telemedicine should always have the options of recommending a traditional face-to-face encounter when appropriate care cannot be delivered solely through the telemedicine encounter.
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For facial trauma and facial plastics, review of images before seeing the patient has proved invaluable for consulting ear, nose, and throat (ENT) surgeons.
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A telemedicine system must have robust processes for initial and ongoing training, technical and clinical support, and technology assessment.
Historically, Alaska Native and Canadian First Nations populations have been burdened with a high prevalence of otitis media and associated morbidity. The incidence of ambulatory care visits related to otitis media for American Indian and Alaska Native children is twice that for all US infants, and the placement rate for tympanostomy tubes in these children younger than 5 years of age was 20 times higher in Alaska compared with the continental United States. In addition, Alaska has an ongoing shortage of physicians, nurses, and allied health professionals, especially in rural and remote areas. The ratio of physicians to population is less than the national average (2.05 MDs per 1000 population in Alaska vs 2.38 in the United States) and Alaska has the sixth lowest physician/population ratio in the nation. The lack of access to medical specialty care, coupled with the high prevalence of ear disease, created a powerful motivator to develop innovative ways to extend the reach of physicians into rural Alaska.
The ear, nose, and throat (ENT) Department at the Alaska Native Medical Center (ANMC) initiated a telemedicine program in 1999 to help provide comprehensive ENT care. The ENT Department resides within ANMC, a 150-bed, level II trauma center in Anchorage, Alaska, that provides specialty and tertiary care for the 130,000 Native Alaskans throughout the state. Most Alaska Natives live outside Anchorage in small communities and many live in remote villages only accessible by air travel. The ENT Department provides otolaryngology clinics at the Anchorage facility (daily) and at field clinics held at 6 regional hospitals (every 2–6 months). Patients living in rural Alaska need to travel to the regional hospital or Anchorage for the specialty clinic services. The need to service this remote population was the driving force to implement a better alternative for care delivery.
The technology
Store-and-forward telemedicine (electronic consultation) is well suited to augmenting otolaryngology services. Store-and-forward telemedicine is an asynchronous communication that allows the sender to take the necessary time to collect data from the patient and then send the case, which the consulting physician can later read and respond to when time is available. This method is convenient for the sender and receiver, and allows them to best use their clinical time. Store-and-forward telemedicine supports, replaces, or works with existing methods of communication. For example, scanned documents can replace faxes, and can be easier to find than paper faxes. Electronic data capture and keyboard entry removes the need for faxes and scans altogether. A store-and-forward case may remove the need for a telephone call.
Store-and-forward telemedicine (electronic consultation) has advantages compared with videoconferencing telemedicine, including that there is no need to synchronize the referring and consulting providers’ time, no need to schedule a session using a videoconferencing network and bridge, low bandwidth requirements, minimal technical support needs, documentation of multimedia data for future reference, the potential for electronic data integration into electronic health records, and tracking of cases for time studies and administrative purposes.
The ENT Department uses the Alaska Federal Health Care Access Network (AFHCAN) tConsult store-and-forward software developed by the Alaska Native Tribal Health Consortium (ANTHC) as the primary telemedicine communication tool. The department’s physicians provided clinical advisory expertise during the software development process and served as one of the early deployment sites. The tConsult software is touch screen compatible, color coded for easy navigation, requires minimal training, and integrates with multiple biomedical devices such as the video otoscope, digital camera, self-administered screening audiometer, and tympanometer ( Fig. 1 ). The software provides both a client-server model (for easy capture of data in clinics with poor or intermittent connectivity) and a Web-based interface for a patient-centric consultant display. The software supports secure client-to-server and server-to-server connectivity for a wide range of telecommunications infrastructure. There are a variety of software features that accommodate clinical workflow practices: cases can be sent to individuals or groups, consultants can be advertised locally or shared throughout an enterprise, and cases can be managed immediately or tagged for further work at a later time. Clinical guidelines for diagnosis, treatment, and triage can also be integrated into the software.
Cases are generated at remote village clinics or regional hospitals by health care providers using an AFHCAN telemedicine cart that includes tConsult software, biomedical peripherals, wireless network capability, and power management hardware ( Fig. 2 ). In Alaska, most of these telemedicine carts are equipped with an audiometer, digital camera, dental camera, electrocardiogram, scanner, spirometer, stethoscope, tympanometer, video otoscope, and vital sign monitor. The ENT Department recognized the need early in the development process of the AFHCAN program for a high-quality video otoscope to visualize and capture images of the tympanic membrane (TM) and related structures. A comprehensive evaluation was conducted on the available video otoscopes, with the conclusion that the highest quality images could be obtained by using the AMD/Welch Allyn 300S Imaging and Illumination platform. Continued use of this video otoscope led to best practices on image acquisition documented as a user’s manual. In time, it was recognized that some blurry images captured by providers were caused by improper focus, leading to the development of a focus tool used for prefocusing the equipment.
The ENT Department also identified the need for tympanometry to be used in the field to supplement visualization of the TM. A review was conducted to identify an appropriate tympanometer that was easy to use and was reliable in the typical remote clinic setting. This combined audiometer/tympanometer was integrated into the AFHCAN telemedicine cart and has since been a useful tool for ear and hearing assessment. Similar reviews were conducted to choose the most appropriate digital camera for dermatologic and facial imaging.
The ENT Department continues to work closely with the ANTHC Telehealth Department to review and identify the best equipment for store-and-forward telemedicine applications. The need for a systematic, objective, and collaborative approach for selecting appropriate medical peripheral devices cannot be overemphasized because these tools become the eyes and ears for specialist operating at great distances from the patient.
Validation and clinical buy-in
AFHCAN telemedicine carts were placed in all of the ENT Department examination rooms early in the project. Staff were introduced and trained on the telemedicine software and instructed on the use of the digital cameras and video otoscopes. Physicians initially used the equipment mostly for preoperative and postoperative images of the TMs and facial lesions. Later, the equipment was adapted for intranasal and laryngeal imaging. The carts were used as image acquisition stations for clinical documentation and archiving. The system was especially useful for patient education (eg, highlighting TM disorders and explaining the related middle ear problems). The staff quickly became experts on the hardware, software, and imaging techniques. They became comfortable receiving cases from the rural referring providers, could act as a resource for referring providers for matters related to image acquisition and case creation, and, most importantly, began to think creatively about the possible clinical applications of the technology. In retrospect, engaging the consultant providers in this way was a critical step in the development of the ENT telemedicine effort.
Although the benefits of video-otoscopy seemed obvious, there was little evidence to support its use as a means of providing clinical care. An initial study was conducted to determine whether TM images could be reliably used to substitute for in-person ENT care, comparing video-otoscopy with the in-person microscope examination for tympanostomy tube follow-up. Forty patients who had tympanostomy tube placement in both ears were independently examined in person by 2 otolaryngologists and imaged locally by an expert telemedicine trainer/imager using a video otoscope and telemedicine software package. The 2 physicians later reviewed images at 6 and 12 weeks. For both physicians, the intraprovider concordance (agreement) between the in-person examination and the corresponding image review was high for each of the physical examination findings. The otolaryngologists were confident in their diagnosis, and confidence increased when cases with poor images were excluded ( Table 1 ).
| “Please Rate how Confident you are in the Diagnosis/Assessment Using Telemedicine in this Case” | ||||||
|---|---|---|---|---|---|---|
| [Blank] | 1 = Not Confident at all | 2 | 3 = Somewhat Confident | 4 | 5 = Very Confident | |
| Provider AA | 0 | 5 | 7 | 14 | 33 | 21 |
| Provider BB | 1 | 2 | 4 | 10 | 23 | 40 |
| Total | 1 | 7 | 11 | 24 | 56 | 61 |
| (1%) | (4%) | (7%) | (15%) | (35%) | (38%) | |
| “Please Rate how Confident you are in the Diagnosis/Assessment using Telemedicine in this Case” | ||||||
|---|---|---|---|---|---|---|
| [Blank] | 1 = Not Confident at all | 2 | 3 = Somewhat Confident | 4 | 5 = Very Confident | |
| Provider AA | 0 | 1 | 4 | 12 | 33 | 21 |
| Provider BB | 2 | 0 | 2 | 5 | 22 | 40 |
| TOTAL | 2 | 1 | 6 | 17 | 55 | 61 |
| (1%) | (1%) | (4%) | (12%) | (39%) | (43%) | |
In a later study, TM imaging was performed by Community Health Aide/Practitioners (CHAP) on 35 patients in remote Alaska. The patients were then flown to the regional facility where they were examined in person by 2 otolaryngologists. Images were later reviewed at 8 and 14 weeks. Similar to the first study, intraprovider concordance for physical examination findings was high ( Fig. 3 ): tube in, 94% to 97% (κ = 0.89–0.94); tube patent, 94% to 97% (κ = 0.89–0.94); drainage, 90% to 96% (κ = 0.04–0.38); perforation, 90% to 96% (κ = 0.61–0.82); granulation, 97% to 100% (κ = 0.49–1.0); middle ear fluid, 88% to 96% (κ = 0.28–0.71); retracted, 83% to 91% (κ = 0.26–0.58). Although there were differences in the findings for the patients in person and later through images, this intraprovider agreement approximated the level of agreement found between 2 providers both seeing the patient in-person, which is the gold standard.
The overall conclusions drawn from these studies were that (1) the differences between viewing images and viewing TM in person were no different than the differences observed between 2 providers both viewing the patients in person, and (2) the results did not vary when images were taken in ideal conditions by an expert or when the images were taken by local providers in the remote village clinics.
Validation and clinical buy-in
AFHCAN telemedicine carts were placed in all of the ENT Department examination rooms early in the project. Staff were introduced and trained on the telemedicine software and instructed on the use of the digital cameras and video otoscopes. Physicians initially used the equipment mostly for preoperative and postoperative images of the TMs and facial lesions. Later, the equipment was adapted for intranasal and laryngeal imaging. The carts were used as image acquisition stations for clinical documentation and archiving. The system was especially useful for patient education (eg, highlighting TM disorders and explaining the related middle ear problems). The staff quickly became experts on the hardware, software, and imaging techniques. They became comfortable receiving cases from the rural referring providers, could act as a resource for referring providers for matters related to image acquisition and case creation, and, most importantly, began to think creatively about the possible clinical applications of the technology. In retrospect, engaging the consultant providers in this way was a critical step in the development of the ENT telemedicine effort.
Although the benefits of video-otoscopy seemed obvious, there was little evidence to support its use as a means of providing clinical care. An initial study was conducted to determine whether TM images could be reliably used to substitute for in-person ENT care, comparing video-otoscopy with the in-person microscope examination for tympanostomy tube follow-up. Forty patients who had tympanostomy tube placement in both ears were independently examined in person by 2 otolaryngologists and imaged locally by an expert telemedicine trainer/imager using a video otoscope and telemedicine software package. The 2 physicians later reviewed images at 6 and 12 weeks. For both physicians, the intraprovider concordance (agreement) between the in-person examination and the corresponding image review was high for each of the physical examination findings. The otolaryngologists were confident in their diagnosis, and confidence increased when cases with poor images were excluded ( Table 1 ).
