Review of 5.5 Years' Experience Using E-mail-Based Telemedicine to Deliver Orthopedic Care to Remote Communities

Abstract

Introduction: The use of e-mail-based telemedicine has been demonstrated as an effective and low-cost way of delivering healthcare to patients in remote areas who have limited access to medical services. We established a novel teleorthopedic service for a catchment area encompassing 972,000 km² using a commercial off-the-shelf e-mail application. Before the implementation of this program, patients with acute orthopedic injuries were required to travel by air up to 1,900 km for evaluation by an orthopedic surgeon. In the present study, we examined the patient demographics and consultation characteristics and calculated the cost savings associated with patient travel for this teleorthopedic service. Methods: We retrospectively reviewed 1,000 consecutive e-mail-based consults and radiographic images received for new patients with acute orthopedic injuries from January 2008 to June 2013. Seventy-nine consults were excluded due to incomplete documentation, leaving 921 available for analysis. The service records were examined to identify patient demographics, orthopedic diagnosis, the percentage of patients managed locally, and the medical indications for patients requiring transfer. As the travel costs for patients requiring transport to the university hospital center are borne by governmental health agencies, the savings accrued from treating patients in their home communities were also calculated. Results: For the 921 consultations, the mean age of patients was 27 years (range, 3 months–88 years), with 40.7% of all patients being younger than 18 years. The most common diagnoses were ankle fractures (15.2%), clavicle fractures (11.2%), distal radius fractures (11.2%), and fractures of the foot (10.2%). One hundred ninety patients (20.6%) required transfer, whereas 731 patients (79.4%) were treated in their home communities. Of the patients who were transferred, 123 (64.7%) required surgery, 55 (28.9%) required clinical evaluation by an orthopedic surgeon, and 12 (6.4%) required CT or MRI. Cost savings related to return trip travel expenses were calculated to be $5,538,120 Canadian (CAD) for the review period. Summary: Using an e-mail-based teleorthopedic service to manage acutely injured patients in remote communities allowed 79% of patients to be treated locally, with travel-related cost savings of $5,538,120 CAD.

Introduction

Access to specialist healthcare for patients living in remote communities is costly and time consuming. Patients are required to travel to referral centers for consultation unless they have access to specialist outreach clinics or telemedicine alternatives.¹ The use of e-mail-based telemedicine has been demonstrated as an effective and low-cost way of delivering healthcare to patients in remote areas, who have limited access to medical services.^2,3 There has not been a widespread implementation of this type of care model. Economic advantages for providing telemedicine consultations for patients in remote communities include reducing travel time, time off work, and the costs associated with transportation and accommodations to attend face-to-face appointments with specialists.^4
–6

The Quebec provincial government established the Réseau Universitaire Intégré de Santé (RUIS) in 2003, assigning a portion of the provincial territory to each of the four faculties of medicine within Quebec.⁷ The catchment area for the RUIS McGill includes 1.8 million people within a 972,000 km² area spanning seven health regions (Nunavik, the Cree Territory, Nord du Québec, Abitibi-Temiscamingue, Outaouais, Montérégie West, and Montreal West-Central and the West Island of Montreal).^8,9 Due to the remote location of communities in the northern regions of the province, patients need to travel by air up to 1,900 km for evaluation by a specialist.

We established a novel teleorthopedic service for the RUIS McGill territory in January 2008 using a commercial off-the-shelf e-mail application to connect healthcare providers from remote communities with orthopedic consultation services based at the McGill University. The goals of establishing this program were to minimize the cost burden and wait times associated with unnecessary transport to Montreal and provide better access to orthopedic consultation services, all while patients are treated closer to their home communities. Before implementing this service, patients with acute orthopedic injuries not easily treated or diagnosed were required to travel to a tertiary referral center for a face-to-face evaluation with an orthopedic surgeon. E-mail-based consultations were integrated as part of the daily morning report/fracture conference and reviewed and managed by the orthopedic trauma service in a timely manner. Any patients requiring transport for advanced imaging, face-to-face evaluation, or surgery were referred on to the orthopedic clinic coordinators for scheduling.

The primary aim of this study was to calculate the potential cost savings related to travel expenses for patients who were managed using the teleorthopedic service. Secondary outcomes included identifying patient demographics, injury patterns, consultation outcomes, and the rate and reason for transfer to our tertiary referral center.

Methods

We retrospectively reviewed 1,000 consecutive e-mail-based consults and radiographic images received for new patients with acute isolated orthopedic injuries from six remote villages (Puvirnituq, Inukjuak, Salluit, Ivujivik, Kuujjuaq, and Chisasibi) within the RUIS McGill catchment area. These consults were for cases who were not easily treatable by the on-site medical staff at the local health center or nursing station. Encrypted e-mail-based consultations were received from on-site physicians or nursing staff at the remote sites and reviewed by the resident orthopedic surgeons on the trauma service. The cases were then reviewed with the orthopedic trauma staff in a timely manner as part of the daily morning report/fracture conference and afternoon patient sign-out. More urgent consultations would be reviewed immediately to expedite patient management or transportation. Patient information included in the e-mails would typically include demographic information, a summary of the history and physical examination, clinical images, and radiographs. E-mail exchanges were conducted using institutional e-mail accounts that meet the requirements for protecting and transmitting patient personal information in Canada.

The data collection period was from January 2008 to June 2013. Approval for the study was granted through our institutional ethics review board. Seventy-nine consults were excluded due to incomplete documentation, leaving 921 available for analysis. Trauma patients with suspected isolated orthopedic injuries were not managed using this e-mail-based system but instead referred directly to the trauma team at the McGill University with orthopedic consultation being deferred until the patient's arrival in Montreal. E-mail consults were examined to identify patient demographics, primary diagnosis, and outcomes of the telemedicine consultations. In addition, the potential cost savings related to travel from treating patients in their home communities were also calculated. Costs were calculated by determining the average return airfare from each referring regional center. Patients were included in this calculation if they would have required transport to our orthopedic clinic based on their diagnosis for a face-to-face evaluation before implementing the e-mail telemedicine initiative. One additional return airfare was added to the transportation costs for patients requiring at least one follow-up evaluation, and one additional airfare was allotted for a single escort (i.e., a parent or guardian) to accompany any patients younger than 18 years and older than 65 years (typical expenditures for all patients who travel for medical consultation). Travel costs are reported in Canadian dollars (CAD) using 2015 prices and include the applicable federal and provincial taxes.

Results

For the 921 included consultations, the mean age of all patients was 27 years (range, 3 months–88 years), with 375 patients (40.7%) being younger than 18 years and 546 patients (59.3%) being older than 18 years. Thirty-nine patients (4.2%) were older than 65 years. Of the six villages using the service, 513 consultations (55.7%) were received from Puvirnituq, 364 (39.5%) from Kuujjuaq, 19 (2.1%) from Salluit, and 17 (1.8%) were from Inukjuak, with 6 (0.7%) and 2 (0.2%) being from Chisasibi and Ivujivik, respectively (Table 1). E-mail was the sole form of communication in 465 of the consultations (50.5%), whereas 456 (49.5%) involved the use of e-mail and telephone.

Table 1.

Number of Patient Referrals from Each Location

LOCATION	NUMBER OF PATIENTS (%)
Puvirnituq (Inuulitsivik Health Center)	513 (55.7)
Kuujjuaq (Ungava Tulattavik Health Center)	364 (39.5)
Salluit	19 (2.1)
Inukjuak	17 (1.8)
Chisasibi (Chisasibi Regional Hospital)	6 (0.7)
Ivujivik	2 (0.2)

Seven hundred twenty-nine of the 921 patients were diagnosed with a fracture (79.2%), while the remaining 192 patients (20.8%) presented with other musculoskeletal complaints, including soft tissue injuries of the extremities, soft tissue and joint infections, and joint dislocations (Table 1). The most common anatomic sites for fractures involved the ankle, (140/921, 15.2%), clavicle (103/921, 11.2%), distal radius (103/921, 11.2%), and hindfoot/midfoot/forefoot (93/921, 10.2%). Patients without a fracture most often presented with a soft tissue injury (79/921, 8.6%) or infection (41/921, 4.5%; Table 2).

Table 2.

Primary Diagnosis for All Patients

PRIMARY DIAGNOSIS	NUMBER OF PATIENTS (%)
Fractures
Ankle	140 (15.2)
Clavicle	103 (11.2)
Distal radius	103 (11.2)
Foot (calcaneus/talus/metatarsals)	93 (10.1)
Tibia	51 (5.5)
Forearm	50 (5.4)
Hand	46 (5.0)
Humerus	34 (3.7)
Other	109 (11.8)
Total	729 (79.2)
Nonfracture-related injuries (%)
Soft tissue injury	79 (8.6)
Infection	41 (4.5)
Joint dislocation	37 (4.0)
Other	35 (3.8)
Total	192 (20.8)

One hundred ninety patients (20.6%) ultimately required transfer to the university hospital, whereas 731 patients (79.4%) were treated locally. Of the 190 patients who were transferred, 123 (64.7%) required surgery, 55 (28.9%) required a clinical face-to-face evaluation by an orthopedic surgeon, and 12 (6.4%) required advanced imaging (i.e., CT or MRI).

The consults for the 731 patients who did not require transfer to our university hospital were reviewed to assess whether there would be a need for transfer before the implementation of the e-mail telemedicine program. After analysis, 658 patients were identified as having a diagnosis that would have required evaluation by an orthopedic surgeon before establishing the teleorthopedic initiative. Three hundred sixty-two of these patients were younger than 18 years, and 11 patients were older than 65 years and therefore would require an escort to travel with them. Commercial airline flight prices were reviewed, and the average return flight price per patient was calculated for each regional health center. The total cost for airline travel for patients included the initial consultation, one follow-up visit, and the airfare for a single parent or guardian escorting a pediatric or elderly patient. Cost savings related to return trip travel expenses were calculated to be $5,538,120 CAD for the six villages included in the 5.5-year study period.

Discussion

This study presented the outcomes for an e-mail-based telemedicine initiative designed to assist primary care physicians with managing acute orthopedic injuries in remote communities throughout northern Quebec. The goals of establishing this service were to limit unnecessary patient transportation to our tertiary referral center and allow for appropriate treatment of patients locally. Providing access to specialist consultation through e-mail allowed 79.4% of patients with an acute orthopedic injury to receive treatment at their local health center and forego transportation to a referral center. Given the low rate of patients requiring transport (20.6%), the results suggest that e-mail-based consultation is effective at communicating adequate clinical information to allow for the management of patients in their local community. Similar results were found when examining the outcomes associated with a pediatric orthopedic telehealth initiative in Queensland, Australia, where 58% of patients did not require surgery or face-to-face consultations and were managed effectively remotely.¹ In addition, a program established by the United States Army, which provided an e-mail consultation telemedicine service to connect deployed healthcare providers to orthopedic consultants, reported that of 170 consults requesting treatment recommendations, surgical intervention or medical evacuation was only recommended in 25% and 16% of consults, respectively.¹⁰ Other studies have demonstrated the effectiveness of telehealth initiatives for diagnosing and managing patients with upper extremity orthopedic conditions¹¹ and pediatric orthopedic patients.¹²

Medical transportation costs to access specialty services not available in remote communities are funded through programs managed by the Health Canada. The highest net growth in medical expenditures under the Noninsured Health Benefits Program was in medical transportation for 2012–2013, with total medical transportation expenditures for all of Canada totaling $351.4 million CAD.¹³ Use of an e-mail-based telemedicine program allowed estimated savings of $5,538,120 CAD for patient and escort airfare. A formal economic analysis was beyond the scope of this article; however, previous studies have reported similar results with significantly reduced patient costs through orthopedic telehealth initiatives, including lower out-of-pocket expenses, decreased time travelling, decreased time off work to attend appointments, and less inconvenience.^5,14
–16 Similar cost savings related to patient travel were reported in a previous study by Smith et al., who examined the costs and potential savings associated with the implementation of a novel telepediatric service over a 5-year period in Queensland, Australia.¹⁴ The authors estimated the potential cost of patient travel to a tertiary referral center for a face-to-face appointment with a specialist to be $1,391,670 Australian more than for travel costs associated with the telepediatric service.¹⁴ While the potential savings associated with patient travel were substantial in our study, we feel this is a conservative estimate of the true cost savings this telehealth program offers. Due to the retrospective nature of the study, we were unable to calculate additional costs related to patient travel for face-to-face consultations, including those for accommodations, meal allowances, and lost wages.

While many modalities of telehealth initiatives exist, the reliance on e-mail as the primary means of communication has some distinct advantages and disadvantages. As previous studies have noted, using videoconferencing equipment can be cost prohibitive with smaller communities due to lower demand and subsequent difficulty achieving economies of scale.¹ In addition, videoconferencing presents significant time constraints as the patient, referring physician, and consultant are required to be present for the appointment at the same time. E-mail-based telehealth does not require the same degree of local coordination as videoconferencing and offers less time restraints when responding to a consultation. However, this can become a problem for more time-sensitive referrals that may require transportation or urgent treatment. Our results reported that while e-mail was the sole form of communication in 465 of the consultations (50.5%), 456 (49.5%) required the use of e-mail and telephone services. The need for adjunct communication by telephone likely reflects the inherent time delay in exchanging e-mails, which becomes a problem when urgent management decisions need to be made at the remote site.

Using an e-mail-based teleorthopedic service to manage acutely injured patients in remote communities allowed for 79% of patients to be treated locally. In addition, our results demonstrate a $5,538,120 CAD savings for governmental health agencies due to the reduced costs associated with patient travel. We feel these results are relevant to health service planning for orthopedic healthcare delivery models in rural and remote communities.

Footnotes

Disclosure Statement

No competing financial interests exist.

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