Telemedicine Proof of Concept and Cost Savings During Underway Naval Operations

Introduction

Telemedicine and telehealth: the Centers for Medicare and Medicaid Services (CMS) defines telehealth as the exchange of medical information from an originating site to a distant site to improve a patient's health. ¹ Across the literature, the most frequently cited specialties that take advantage of electronic consultation are endocrinology, dermatology, and cardiology, with the capability to provide care to many patients in the absence of an in-person physical examination (e.g., EKG, laboratory, and medical photodocumentation review). ² From a patient perspective, the primary benefit of telemedicine is access to care or consultation with specialists, which has been shown to substantially improve specialty access in a timely manner. ^2,3 The efficiency of electronic consult systems extends access by allowing primary care providers to remotely consult with specialty care to determine and implement a treatment plan or streamline a referral in advance of an in-person consultation.

Of equal importance is the avoidance of unnecessary in-person consultations. Inappropriate consults unnecessarily consume time and resources of the patient and specialist and come at an opportunity cost of taking an appointment slot of a more appropriate consult. In a single-center e-Consult study, unnecessary face-to-face referrals were avoided in 33.4% of all e-Consults and in nearly 50% of cases where the Primary Care Provider (PCP) initially planned a formal referral. ⁴ These are critical findings in the world of increasingly restrictive time and resource management.

The U.S. Navy (USN) routinely congregates subspecialists at the tertiary care military treatment facilities (MTFs) in the continental United States, while a lower concentration of subspecialists is deployed on ships or at remote medical treatment facilities. Before telemedicine initiatives, patients were often sent to host nation civilian physicians and facilities if they required specialty evaluation and treatment or they were preemptively medically evacuated (MEDEVACed) back to a stateside MTF, sometimes unnecessarily. Telemedicine systems have been shown to improve access to care in various specialties, including within military medicine. As previously mentioned, these systems can improve wait times to consult appointments, decrease proximity to care, reduce unnecessary visits, and provide cost savings. ^{2 –4} Specifically within the military, asynchronous systems have prevented unnecessary MEDEVACs and lost productivity, resulting in considerable cost savings across multiple specialties. ⁵

Both consult management aboard a ship underway and utilization of an asynchronous, telemedicine consultation system for military otolaryngology–head and neck surgery have not previously been examined. The aim of this study was to demonstrate the ability of consult management while aboard a deployed U.S. Navy ship and to determine the costs associated with an electronic consultation system for military otolaryngology–head and neck surgery consults.

Methods

The USN utilizes an asynchronous, telemedicine consult management system called the Pacific Asynchronous Tele-Health (PATH) for consultation in the Indian and Pacific Ocean areas of responsibility. From February to May 2018, consults for subspecialty care were submitted through PATH from military comprehensive otolaryngologists located around the world. These consults were managed by a separate military comprehensive otolaryngologist deployed aboard the USNS MERCY (T-AH 19) deployed to multiple Pacific Rim mission stops during Pacific Partnership 2018. The MERCY is one of two dedicated hospital ships that are deployable worldwide. This forward-deployed surgeon had integral access available to personnel and resources required for MEDEVACs. Once screened by the underway otolaryngologist, consultations were subsequently deemed necessary to forward to the neurotologist/skull base surgeon at the Naval Medical Center San Diego (NMCSD) for review and action. Coordination of this process was through the PATH system. Final MEDEVAC was authorized by the approving authorities while concurrently establishing appropriate administrative actions on the receiving side to facilitate a timely transfer and initiation of care. These consults were then remotely directed to the appropriate subspecialist at a tertiary care hospital in the United States. The subspecialist reviewed the consult and patient records, then directed a treatment plan, which included recommendations for further workup, active surveillance, and interventional care.

Retrospectively, all of the cases received and treated during this time frame were reviewed and the costs associated with them were analyzed. The retrospective review was approved as an exempt quality improvement project by the NMCSD Institutional Review Board (2019.0008) in compliance with all applicable federal regulations governing the protection of human subjects.

Costs for each consult were obtained by reviewing medical records for visits associated with the primary consult diagnosis. These included imaging, laboratories, and additional testing such as audiograms and vestibular testing. The direct cost of maintaining treatment of the patient within the military health care system was compared with the estimated calculated cost that would have been incurred had the patient been treated in the host nation at a civilian facility.

Travel costs were obtained using historical costs from Fed Travel. Treatment cost estimates were obtained using the applicable Current Procedure Terminology (CPT) codes from the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS). This system was used to determine the maximum allowable charges and is based on U.S. currency. ⁶ Costs included in the estimates were those that would have reasonably been covered by the military, whether related to travel or care rendered at civilian facilities. Travel, lodging, and meal/incidental costs for the patient to be treated at an MTF within the continental United States were calculated. The direct cost of care rendered at the MTF was not included in cost estimates as those facilities exist to treat such beneficiaries and often have relatively fixed operating costs, irrespective of utilization. The estimated cost for care in the host nation was based on the equivalent of the care that was received at the MTF.

These data are demonstrated as an overall treatment estimate in Table 1 and a line-item categorization based on CHAMPUS-based maximum allowable charges in Table 2. The reimbursement price for all surgeries, testing, and evaluation could not be verified given the scattered geographic locations where host nation care would be required and is a limitation to this study. Therefore, estimates for costs were based on costs from the Military Health System and used as a proxy for host nation treatment costs. However, this was deemed a reasonable approach as all patients would have received care in developed nations with robust medical infrastructure.

Results

One-hundred percent of consultations (n = 8) were successfully managed with five of the eight consultations being MEDEVACed to NMCSD. Table 1 additionally displays the specified locations of individual MEDEVAC patients. One consult was canceled after the patient was reassigned to a base within the United States and thus had access to care there after his move. This patient was excluded from the analysis as the individual would have no access to host nation facilities after reassignment. Two patients elected to be treated in the host nation and declined medical evacuation; these patients were included in our analysis.

The consult diagnoses included four cases of cholesteatoma (chronic, locally aggressive middle ear, and temporal bone growth), two vestibular schwannomas (cerebropontine angle tumor), and 1 vertigo (dizziness) with suspected Meniere's disease. Those MEDEVACed were three patients with cholesteatoma, 1 with vestibular schwannoma, and the patient with vertigo. The remaining patient with cholesteatoma had surgery in the host country. One patient with vestibular schwannoma had imaging in the host country and had a stable tumor and thus elected for continued observation after images and options were reviewed remotely by the consulted surgeon.

The total cost of treatment of all cases, if they were to be completed in the host nation, was estimated at $124,037. The total MEDEVAC cost was $27,330 for the five patients who came to the United States. Two of the five MEDEVACed patients were both retiree beneficiaries and thus would have been responsible for their own travel costs, so no adjustment was made to the travel cost estimate accounting for $0. The estimated cost savings of the telemedicine system were $96,707 for the study period.

Discussion

Telemedicine allows major military medical centers to extend their human resources to those who are forward deployed or overseas. One of the major benefits of this capability includes greater accessibility to subspecialist care that is maintained within the military medical system.

Telemedicine consultation, based on our analysis, has the potential to save nearly $400,000 when extrapolated to a 12-month period for otolaryngology–head and neck surgery. Other cases that may have been captured and would have created significant cost savings within the network include multidisciplinary treatment of head and neck oncologic disease as these cases are frequently treated with primary radiotherapy ⁷ —similar treatment patterns to a vestibular schwannoma—but have additional treatment costs such as speech therapy and nutrition, which can be completed through telemedicine. ⁸ Maintaining care within the network provides a tremendous cost saving to the military health care system as well as to the patient who would avoid excess co-pays, insurance negotiations, and navigating a new health care system. Additionally, more frequently performed, but nonetheless expensive, surgeries such as cochlea implants or hypoglossal nerve stimulators can maintain a preoperative workup with the down-range otolaryngologist and receive surgical intervention stateside through coordinated care.

Given the patient populations and number of retirees that fall within the coverage umbrella, medically complex cases meeting criteria for MEDEVAC are not only likely but also inevitable. ^9,10 While this study showed that the more commonplace cholesteatoma was more expensive to treat stateside, it is the more rare condition that heavily leverages the cost savings, while aligning further incentives of concentrating surgically complex cases in centers of excellence for both faculty and resident surgeon benefit.

We would also expect the use and capability to increase as this store-and-forward provide-to-provider system expands and becomes incorporated with secure patient messaging and synchronous consultation platforms. It is important to note that two of the five MEDEVACed patients were considered to have no cost to the government based on their military retiree status. Realistically, in the long-term, the majority of patients brought to the continental United States for treatment would be on active duty and therefore incur the travel/lodging cost. However, even if there is an additional estimated cost of $7,000–9,000 per patient evacuated for those two patients, the overall cost savings would continue to be substantial (∼$80,000) and more than justify the minimal resource input for these asynchronous consultations and MEDEVACs. These cost savings may increase even further in the future as increased comfort with remote postoperative care gains momentum. ¹¹

There are also significant intangible benefits in addition to the monetary savings. This case series demonstrates the ability for specialists in any area in the world—including a deployed naval ship—to potentially receive, manage, and render a medical opinion to any provider. Furthermore, telemedicine aggregates higher case complexity in a lower number of centers, therefore increasing the capabilities of subspecialists to maintain proficiency in skills with downline benefits for their patient population. Evacuating patients to the tertiary care facilities increases resident graduate medical education by keeping cases at the military's teaching hospitals. Furthermore, patients are also more familiar with the U.S. Navy hospitals and their staff, as opposed to host nation facilities, and the comfort in care provided by peers in a navigable system cannot be quantified. When care is rendered at host nation facilities, medical records are returned in the host nation language and can be difficult to access and transfer once the patient has returned.

The critical aspect of maintaining the treatment record within the same electronic record cannot be overstated. Active duty members frequently change geographic locations to new duty stations, and ensuring the appropriate transfer of medical information is an essential part of medical readiness. This becomes of increasing importance when taking into account the special duty standards that may limit service members' qualification should there be any question of care.

Another benefit that has been described, but was not observed during our limited study period, is providing accurate diagnosis and treatment during the virtual consultation, which may prevent an unnecessary evacuation or expensive referral to a host nation facility. For example, one unnecessary MEDEVAC was prevented for the stable vestibular schwannoma case. This is critical for the active duty population to maintain watch station schedules, particularly in resource-stressed deployments. This case series was based on a surgeon-to-surgeon consultation for overall management, as opposed to a diagnostic conundrum, therefore appropriate consultation had already been vetted. However, these cases could have similarly come directly from the primary care with initial consultation through the asynchronous consultation platform to then facilitate remote workup and initial management based on the recommendations provided. The ultimate goal would be for the active participation of the primary care provider for initial telemedicine consultation. This can substantially limit the possibility of inappropriate consultation and subsequent MEDEVAC in some cases. The consult management by a deployed otolaryngologist onboard the USNS MERCY (T-AH 19) also demonstrates the relatively low bandwidth required for asynchronous telemedicine consultation and can be utilized to facilitate/coordinate with MEDEVAC logistics and in-transit management.

Limitations of this study are associated with the limited scope, and the sample size (n = 8) with the disease processes is even more limited. Additionally, there are no widely published costs for these interventions that are available in the specific countries they occurred, leading to domestic costs being used as a proxy. Additional ancillary costs of surgery include hospital stay and outpatient follow-up, etc., all of which widely vary by national practice patterns. It is also difficult to take into account cost savings and quality of life changes for patients receiving care near the homeport where caregivers are more readily available compared with an abroad setting. This study is also likely not generalizable as the military medical system is unique in its worldwide umbrella for service members compared with civilian counterparts. However, despite the small sample size, these findings are proof of concept for leveraging the capabilities of telemedicine, particularly for the use of deployed service members who will be able to receive world-class care in a relatable medical system. While asynchronous telemedicine is not a new concept in the military, this shows a novel use for underway vessels.

Conclusions

Telemedicine consultation expands access to subspecialty physicians by service members stationed around the world, with portability and ability to provide care in austere circumstances. Furthermore, it has the potential for substantial cost savings within the military health care system, which are well beyond the intangible benefits to the patients and providers alike.