Abstract
We studied the use of videoconferencing for the pre-operative patient-surgeon interaction. Subjects were recruited from otolaryngology patients undergoing surgery at a tertiary hospital. They were randomised to a conventional face-to-face interaction with their surgeon or a videoconference call via tablet computer. Afterwards, subjects and surgeons completed questionnaires about the experience. Various time points in patient flow were also recorded. Thirty-one patients were enrolled and 25 completed the study; five surgeons participated. The mean overall patient satisfaction scores were similar in the face-to-face and videoconferencing groups (9.88 and 9.89, respectively), as were mean interaction times (119 and 82 s, respectively); neither difference was significant. The mean waiting times in the pre-operative holding area were not significantly different between the groups. Surgeons were satisfied with the videoconferencing and 60% indicated they were somewhat likely to incorporate the technology into their daily practice. Overall patient satisfaction with a pre-operative patient-surgeon interaction via videoconferencing did not differ significantly from that for a conventional face-to-face discussion. It is feasible to incorporate videoconferencing into a busy surgical practice and there is the potential for improved efficiency.
Introduction
The use of smartphones and tablet devices by healthcare staff has grown rapidly in the last few years. The ease of use of these devices, their adaptability and multi-functional capabilities have allowed their introduction into selected areas of the medical system. There is now interest in spreading these devices throughout the medical workflow to improve the patient experience of care and system efficiency.1–5
One area that may be suitable is the operating room. Interruptions in the pre-operative patient flow and delays with starting cases have been identified in recent studies. A high incidence of case start delays has been identified due to the tardiness of attending surgeons. 6 These, among other common delays, are a source of inefficiency, which increase the cost of care and reduce patient satisfaction. Identifying and minimizing these delays could reduce wasted time and produce cost savings. 7
We have studied the use of videoconferencing on a mobile device for the pre-operative patient-surgeon interaction. There appear to be no previous reports regarding the use of mobile devices in this part of the operating room workflow.
Methods
We performed a prospective, randomized controlled study from May to August 2012. The study was approved by the appropriate ethics committee. Surgeons from the Department of Otolaryngology–Head and Neck Surgery were invited to participate via email.
Subjects were drawn from patients scheduled for surgery performed by one of the participating surgeons. The inclusion criteria were: (1) aged 18 years or older; (2) scheduled for an ambulatory or day of admission surgical procedure. The exclusion criteria were: (1) scheduled for inpatient surgery; (2) unable to speak or understand English fluently; (3) unable to phonate; (4) undergoing a procedure involving multiple surgeons.
All initial discussions regarding the surgical procedure occurred in person during the subjects’ initial office visits. All subjects were contacted before the day of surgery about the possibility of taking part in the study. On the day of surgery, they were approached by the investigators to further discuss the study and to obtain formal written consent. Patients were randomly assigned (using computerized random numbers) to a control or a videoconferencing group. All patients enrolled in the study underwent the standard pre-operative process at our institution, consisting of an interview by a nurse, anaesthetist and surgeon.
During the pre-operative process, patients in the control group had their interaction with the operating surgeon in the ordinary (face-to-face) way. Patients in the videoconferencing group had their discussion with the surgeon using a videoconferencing program (FaceTime) on a tablet computer (iPad, Apple Inc., Cupertino, CA), see Figure 1. The tablet computers of the patient and surgeon were linked through the hospital network via a secure Wi-Fi connection to ensure patient confidentiality. Once connected, the patient and surgeon discussed the planned surgical procedure. Patients placed calls from the pre-operative holding area and the surgeons answered calls from wherever they were located at the time, after finding a private area. The tablet computer was simply used for videoconferencing and did not provide any additional information. Patients could opt out of the experimental group at any time and request the standard face-to-face interaction.
A videoconference between two surgeons using a tablet computer.
After their pre-operative processes were completed (including site marking and patient verification), subjects completed an anonymous questionnaire assessing their experience with the interaction and background (highest level of education attained, number of prior surgical procedures) (Appendix 1). Subjects were then escorted to the operating room.
All participating surgeons were given an introduction to the tablet computer and the videoconferencing program. Participating surgeons agreed to carry the tablet device during the study period. At the end of the study, the surgeons completed an anonymous questionnaire assessing their experiences with the technology. The questionnaire asked them to rate their overall satisfaction with the two types of interactions, their perception of their patients’ overall satisfaction, the likelihood of them incorporating the technology into their daily practice and to provide any comments they had on using the device for patient care (Appendix 2).
Throughout the process, various times were recorded: arrival in the pre-operative holding area, completion of nurse/anaesthetist/surgeon interview, elapsed time for the patient-surgeon interaction, time into the operating room, elapsed time in the holding area and location of the surgeon during videoconferencing calls. The data were analysed using Student’s t-test assuming unequal variances for continuous data and a Fisher exact test for categorical data.
Results
Out of 43 patients who were evaluated for study participation, 31 enrolled in the study (Figure 2). Of these, 25 completed the full protocol. Four subjects (31% of those randomized to the experimental group) did not complete a videoconferencing call and had face-to-face interactions instead and two subjects randomised to the control group went directly into the operating room prior to completing the study questionnaire. The final sample consisted of 14 men and 11 women. There was no significant difference between the study groups for gender, age, highest education attained and type of planned procedure (Table 1).
Patient flow diagram. Study groups.
In total, there were 13 videoconferencing interactions. Eight participants were able to connect with their surgeon on the first attempt. One interaction necessitated two calls prior to successful connection due to the surgeon having set a low ring volume on the device. Four subjects randomised to the experimental group converted to face-to-face interactions; two experienced Wi-Fi connection problems, one requested a face-to-face interaction and one surgeon forgot to bring the tablet computer on the day of the study.
Patient questionnaire results. Response scores were on a 10-point Likert scale (1 = strongly disagree/highly dissatisfied to 10 = strongly agree/highly satisfied).
Types of interactions with patients amongst participating surgeons.
Surgeon questionnaire results. Response scores on a 5-point Likert scale (1 = highly dissatisfied/unlikely to 5 = highly satisfied/likely).
Discussion
The physician-patient relationship is a complex type of interpersonal interaction and a foundation of the practice of medicine. 8 Both verbal and non-verbal cues are important aspects of the physician-patient interaction and are engrained in humans. Contrary to popular belief, emotion is not well conveyed by the verbal and tonal components of speech. It is predominately conveyed by non-verbal signals such as posture, gaze and eye contact, aspects of communication that may be altered or obscured in virtual interactions. 8 If a virtual conversation replaces a face-to-face one, this raises the question whether the interaction will be equivalent, and whether it will be perceived as such.
The results of the present study provide evidence that the quality of the interaction and the satisfaction of both patients and physicians with a virtual conversation are similar to a conventional one; there was no significant difference in overall patient satisfaction between the two study groups. There appear to be no previous reports of videoconferencing in the pre-operative setting. Other studies have examined the outcomes and satisfaction of videoconferencing in primary consultation and short-term follow-up and have found them similar to face-to-face interactions.9–12 Evidence also suggests that appropriate treatment and counselling can be delivered via videoconferencing while still establishing strong therapeutic alliances.11,12 However, not all studies have found positive outcomes when examining virtual communication. 10
The idea of virtual communication, despite being commonplace in everyday life, is still a new concept for many patients. We had a 61-year-old patient who was initially apprehensive of the technology, expressing concerns that it would “hinder the interaction between him and his surgeon.” However, after the videoconference call those concerns had disappeared, and the patient commented that he was “able to spend more time with his surgeon”, and was “able to ask questions and [had] his complete attention.”
We found a difference between what surgeons perceived as the patients’ experience with videoconferencing and what patients actually reported. Surgeons reported believing that patients were only somewhat satisfied with videoconferencing. They also commented on concerns about the use of the technology with elderly patients, the notion that patients preferred the human interaction and that they themselves lacked the comfort of interacting with patients via this medium. This disagrees with what patients actually reported when asked about their experience, since all responded that they were highly satisfied with the encounter.
If the new procedure was to be widely adopted, there would be some problems. First, the size of the iPad (24 × 19 cm) was seen as a hindrance to its portability by some of the participating surgeons. Second, a reliable Wi-Fi network connection is required for efficient connection and conversation. We had three subjects for whom no connection could be established and several instances of temporary connection interruptions or minor speech/video delays. Both surgeons and patients felt that these problems did not prevent communication, but impeded it. Third, the requirement for operation-site marking and completion of paperwork prior to entry into the operating room may be an obstacle if the surgeon is not present. This might be overcome by having a surgical team member (e.g. resident, physician assistant) in the pre-operative area to serve as a liaison, initiate the videoconference call and complete other tasks. To ensure patient safety and confidentiality, it may be necessary to encrypt the transmitted data, use a dedicated network for communication, and introduce a means of verifying patient identity.
In the present study, there was no improvement in pre-operative flow and efficiency, as measured by patient time spent in the pre-operative holding area (Table 2). However, we believe that when routinely implemented, videoconferencing has the potential to streamline the pre-operative process significantly. Patients’ waiting times in the pre-operative holding area would be decreased because they would not have to wait for their surgeons to arrive before going into the operating room, improving patient satisfaction and operating room efficiency. Conversely, not having to be physically in the operating room until the start of the procedure would allow surgeons to make full use of their time by seeing other patients or dealing with other tasks. As one surgeon in the study pointed out, videoconferencing saved time when the surgeon was on the run between places. These timesavings have the potential to improve the patient and surgeon experience of surgical care, and could also produce cost savings.
There are several limitations of the study. First, the sample size was small which limited our ability to detect a small effect size. Second, despite assurances of anonymous responses, patients may still have feared the consequences of not giving positive assessments of their operating surgeon, thus biasing the results. Third, a selection bias cannot be ruled out, as patients comfortable with the technology may have more readily consented to participate in the study. In the videoconferencing group the subjects were not evenly distributed between surgeons, which may have skewed the results.
Future studies should include a larger sample of patients and surgeons, more preparatory work to ensure smooth incorporation of the technology, consideration of other devices (i.e. smartphones) to improve the process and collection of broader types of data to allow assessment of system-wide effects.
In conclusion, the present study suggests that it is feasible to incorporate videoconferencing into a busy surgical practice. Overall patient satisfaction with a pre-operative videoconferenced patient-surgeon interaction did not differ significantly from that for a conventional face-to-face discussion. There is potential for improved efficiency.