Clinical assessment and management of general surgery patients via synchronous telehealth

Background

Landstuhl Regional Medical Center (LRMC) in Landstuhl, Germany, is centrally located in Western Europe and is surrounded by 18 United States (US) Army and Air Force clinics ranging in distance from a 2- to a 15-hour drive. Many Army clinics are clustered in the Bavaria area in southeast Germany. After more than a decade of caring for thousands of wounded soldiers from multiple theaters of operation, surgeons at LRMC in Germany saw a precipitous drop in the number of operative cases beginning in late 2013. This dip was largely attributed to the troop and military operations drawdowns in Iraq and Afghanistan, but also to the deferral of beneficiaries and retirees to local civilian networks during high-demand periods. At the same time, the strategic requirement for forward-positioned surgeons in Europe remained unchanged as surgical readiness is vital to the Army Medical Mission. The Army’s Telehealth (TH) Service Line, a guiding team from the Army’s Office of the Surgeon General (OTSG) vision, aims in part “To place standardized use of Telehealth (TH) into the toolkit of every clinician in Army Medicine….” Leaders, surgeons and clinical staff across Europe are taking this to heart and implementing novel TH initiatives.

Introduction

This paper outlines the implementation of a synchronous TH program from January 2014 to January 2015 in the General Surgery Clinic located within the US military regional medical center situated in Landstuhl, Germany. The outcome envisioned was to maintain high quality of care while accurately diagnosing the surgical condition and providing a safe and satisfactory clinical experience both for patient and surgeon. Many new innovations such as smart phones, smart glasses as well as management and workflow systems are finding surgical applications in clinics and hospitals to improve surgical efficiency, patient education and outcomes.^1–4 Review of current literature shows examples of ambulatory surgical patients following up after surgery via synchronous TH.^5,6 However, the initial evaluation of the surgical patient using a synchronous TH platform has not been examined. In late 2013, the General Surgery Clinic staff at Landstuhl began to explore ways to re-capture elective surgical cases, many of which had been referred to local civilian Tricare provider networks. Synchronous TH was examined as an option to help bridge the distance for surgery patients scattered throughout Europe. With a robust but somewhat underused Army TH system, Landstuhl along with the outlying clinics seemed to provide the perfect incubator for synchronous TH activities. The distances are not so far that the patient could not make the drive, but far enough that in most cases multiple trips would be onerous. Synchronous TH could bridge these distances and reduce the number of trips to the hospital for those patients travelling from a distance. TH made choosing LRMC a more attractive option. Both the Landstuhl Otorhinolaryngology and Orthopedics clinics had completed successful pilot programs using the Army’s synchronous TH platform.^7,8 These previous experiences served as a foundation and justification for the development of a general surgery TH program.

Program organization

After defining the need for the scope of the project, the process started with development of a General Surgery Clinic TH Standard Operating Procedure (SOP) and appointing guidelines for TH. Appointing guidelines helped ensure that the appropriate condition would be scheduled for a TH appointment. Clearly defined roles and activities were codified so that everyone including key leadership stakeholders clearly understood the process from the onset. One of the guiding principles was that the process should be sustainable. We worked to integrate TH into normal clinic processes. Another principle we employed was that of “incrementalism”—start slow and fine-tune processes early on. We wanted our first 10 patients to have excellent TH experiences. We proceeded by dividing TH tasks according to patient care timeline, or flow: (1) pre-appointment activities, (2) day-of-appointment activities for both the originating and distant sites, and (3) Post appointment activities including surgical scheduling and pre-op planning. Participants in the program development process included a general surgeon who is the clinic chief, two surgical PAs and the clinic nursing officer in charge (CNOIC). The two civilian physician assistants (PAs) are experienced graduates of American university PA programs and nationally certified by the National Commission on Certification of Physician Assistants. Both had greater than five years of surgical experience in the areas of first assisting in the operating theater, managing ward patients as well performing pre- and post-operative evaluations of surgical patients in the clinical setting. Surgical PAs are supervised by general surgeons.

TH surgical conditions were limited to hernias, gallbladder, hemorrhoids, pilonidal cysts, lipomas, gynecomastia and bariatrics. We chose conditions that could either be visible using the general exam camera at the originating site, or in the case of gallbladder and hernias, could additionally be confirmed by an imaging study obtained prior to the TH visit. We excluded conditions requiring a nuanced physical exam or complex decision making based on physical exam such as breast masses, complex abdominal pain problems and cancer. TH has limitations and participants understood that all surgical conditions were not appropriate for TH. Many surgical conditions require a nuanced physical exam such as suspected breast cancer or vague abdominal complaints in which the exam would be difficult to perform via surrogate. In addition, surgeon and patient often develop a rapport and trust before an operation and for many conditions this is best accomplished in person. Built into the appointing guidelines was some measure of flexibility. We received many requests to see patients via TH for conditions not in the guidelines. Each request was considered on a case-by-case basis. The team saw 17 TH patients with a variety of conditions including wounds, retained foreign body and even one case of a child requiring circumcision.

In order for this program to be effective, we needed competent, consistent patient presenters at the originating sites. As of 2014 most US Army synchronous TH encounters were face to face, primarily behavioral health, counseling and nutritional medicine. As the Army’s European region began to offer expanded and more comprehensive TH services, the need for well-trained, competent and consistent presenters for specialty TH encounters grew. This need led to implementation of the TH Nurse Care Coordinator Program employing full-time registered nurses (RNs) to staff major patient centers of Wiesbaden, Stuttgart and Vilseck Army Health Clinics in the fall 2014. These nurses participated in direct hands-on training with surgical and medical specialists at Landstuhl and have proved critical in creating a robust, effective TH program in Europe. Moreover, these nurses act as clinic ambassadors for TH, educating originating clinic staff on TH issues, specialty clinic TH-appointing guidelines and originating site staff training.

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Table 1.

General surgery telehealth appointment guidelines.

Diagnosis	Specialty VTC initial visit	Follow-up VTC	Special request for VTC
Hernia	Yes	Will be specified by General Surgery	Gown or cloth drape may be needed for visit.
Gynecomastia	Yes	Will be specified by General Surgery	May require initial imaging if unilateral or “mass.”
Hemorrhoids	Yes. Primarily external	Will be specified by General Surgery	Gown or cloth drape may be needed for visit.
Gallbladder	Yes	Will be specified by General Surgery	Gown or cloth drape may be needed for visit. Prefer labs be drawn prior to appointment: CBC, LFTs/lipase/amylase RUQ Ultrasound preferred if capable from referring site.
Pilonidal cysts	Yes	Will be specified by General Surgery	Gown or cloth drape may be needed for visit.
Lipomas	Yes	Will be specified by General Surgery	Gown or cloth drape may be needed for visit.
Miscellaneous	Contact surgical PA or surgical clinic chief

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Table 2.

General surgery synchronous telehealth patient encounters January 2014 through January 2015.

Conditions evaluated via synchronous telehealth	Number of initial TH encounters/% and follow-ups in parentheses ()	Completed surgeries or procedures. Non-TH case totals in parentheses ()	Recommended but not scheduled	Surgery not recommended
Umbilical hernia	19/19% (7)	15 (74)	1	3
Inguinal hernia	18/18% (4)	13 (87)	3	2
Male gynecomastia	14/14% (10)	11 (28)	2	1
Soft tissue mass	12/12% (2)	9 (41)	2	1
Pre-scope evaluation (EGD, C-scope)	11/12%	9 (19)	2
Gallbladder	10/11% (4)	9 (91)	1
Pilonidal cyst	7/7% (2)	4 (23)	2	1
Gunshot wound (wound care)	1			1
Hemorrhoids	1	1 (63)
Diastasis recti	1			1
Constipation	1		1
Circumcision	1	1 (0)
Ventral hernia	1		1
Wound care	1			1
Retained foreign body	1	1 (40)
Pancreatitis	1			1
Bariatric (gastric sleeve)	1		1
Totals	101	73	16	12
Total follow-up appointments via TH (in parentheses)	(29)
Total TH patient encounters (initial and follow-up)	130
Total of non-TH cases for the same period in our hospital (in parentheses)		(466)

TH: telehealth; EGD: esophagogastroduodenoscopy.

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Table 3.

Estimated cost savings for telehealth general surgery patients.

Originating location/ roundtrip miles (mi)	Number of encounters	Roundtrip mi × number of encounters  × $.575 a
Vilseck, Germany/546 mi	33	$10,360.00
Graffenwoehr, Germany/546 mi	19	$5651.00
Katterbach, Germany/336 mi	4	$772.00
Stuttgart, Germany/270 mi	18	$2794.50
Wiesbaden, Germany/136 mi	20	$1564.00
SHAPE (Mons, Belgium)/474 mi	5	$1362.00
Brussels, Belgium/436 mi	1	$250.70
Vicenza, Italy/1034 mi	3	$1783.65
Total	103	$24,539.00

a

Joint travel regulation mileage reimbursement rate and United States Department of Defense Table of Official Distances (DTOD).

SHAPE: Supreme Headquarters Allied Powers Europe.

All patients participating in specialty TH encounters provided consent per Army TH instructions prior to participating in synchronous TH. Consents were obtained from patients at the time of their appointment at the originating site. Finally, provided the condition requiring surgery is identified accurately during the TH encounter, the patient was scheduled for surgery.

Methods and materials

Data

Results

Between January 2014 and January 2015, five general surgeons and two surgical PAs at LRMC working with nurses and technicians at eight originating sites completed 101 initial and 29 follow-up synchronous TH encounters for 101 surgery patients. Patient ages ranged from 2 to 86 years old with a median age of 34.9 years. Gender ratio was 71 (70%) males and 31 females (31%). These encounters resulted in 64 completed surgeries and nine screening endoscopies (nine colonoscopies and two esophoduodenoscopies). In 16 initial encounters surgery was recommended but not yet scheduled, and in 12 cases surgery was not recommended. All operations and procedures were elective. Seventeen patients were seen for conditions not included in the guidelines but were approved for TH encounters on a case-by-case basis. During the one year of activity many of our surgeons began performing esophagogastroduodenoscopy (EGD) and colonoscopies, and a new bariatrics program was started. The surgical PAs would see the patients from a distance via TH first performing a pre-procedure history and physical as well as counselling and preparing the patient prior to the procedure date. Including both completed and recommended surgeries resulted in a surgical yield from TH patient encounters of 88% (92/101). No surgeries were delayed or cancelled for TH patients. Although beyond the focus of this paper, travel cost savings were significant. Using the US Department of Defense Table of Official Distances and current US Government Joint Travel Regulation (JTR) reimbursements rates of $0.575 cents per mile, this cohort of 101 patients saved 130 car trips to Landstuhl resulting in a conservative savings estimate of $24,539.00 in travel costs. Physician and PA peer review was performed by clinic colleagues with no standard-of-care issues identified. Outpatient peer review is a required process within our hospital for all outpatient clinics and is monitored closely by an administrator to ensure standards of care are met. All practicing providers’ outpatient notations are subject to the peer review process.

Discussion

In the past, general surgery patients coming from distant Army clinics in Europe would have required multiple separate trips to Landstuhl for pre-operative and operative visits. Synchronous TH eliminates two or more trips saving thousands in travel costs and lost productivity. Because the patient sees the surgeon on the initial appointment virtually, we built into our process that surgical consents are signed and an in-person re-examination of the patient accomplished in person in the morning before surgery both by the surgeon and anesthetist. To further save time for patients, we have trained 12 certified registered nurse anesthetists to perform pre-operative appointments via synchronous TH. Surgeon buy-in has been excellent. Anecdotally, only about 30%–40% of all patients who come to the clinic need surgery. The TH to operating room (OR) rate in this cohort was higher than for normal clinic visits because time was taken with this group to make sure they were “teed up” with appropriate imaging studies, etc. prior to their TH appointment. This “concierge” service or management of patients coming from a distance resulted in an 88% likelihood of surgery—much higher than routine clinic visits. Outlying clinic providers and patients see TH now as a way to access the distant hospital surgical services in a more efficient way. The organic growth one year post-implementation has been excellent. Patients’ satisfaction is very high because they are able to see a specialist without having to drive long distances.

Conclusions

Synchronous TH is an effective and reliable method for evaluating many common general surgical conditions both initially and on follow-up.

The collaborative TH efforts between the Landstuhl general surgery staff and outlying clinics have resulted in high-quality, seamless and predictable TH activities that continue to grow. As TH services permeate outlying clinics and hospital specialty clinics, the activity becomes a normal part of clinic business and indeed a patient expectation. It must be said that this project occurred within a military health care delivery system consisting of both a regional medical center and a number of outlying clinics with excellent infrastructure, equipment and highly trained staff at all levels. Duplication of this kind of effort would certainly be possible but not without significant investment. Applications for a synchronous TH program would fit well in similar military or civilian health care delivery systems in which there is a large multidisciplinary center with multiple distant primary care satellites. University, military and public health systems in large states with rural outlying health clinics seem the most applicable. Synchronous TH for surgery patients at Landstuhl is growing. The LRMC General Surgery Clinic now has seven general surgeons seeing synchronous TH encounters regularly. In the first nine months of CY 2015, the LRMC general surgery clinic saw 239 synchronous TH appointments representing about 9% of all clinic encounters with general surgeons. Other LRMC synchronous TH surgical services include Orthopedics, Ortho Spine, and ear, nose and throat (ENT) and a number of medical specialties as well. Plastic surgery, bariatric and gynecology TH surgical services are coming online in the near future. Limiting factors in implementing TH programs seem to lie in the judicious selection of patients service by service. Some surgical specialties lend themselves well to synchronous TH. Others, such as gynecology and ophthalmology, present greater challenges due the need for a nuanced exam. Many patients would like to be seen via synchronous TH but because of their condition may not meet TH appointing criteria and require face-to-face clinical evaluation instead. As technologies and processes improve, TH activities will of course evolve, improve and expand. Despite some limitations, innovative and enduring synchronous TH programs when thoughtfully employed can produce tangible benefits to the surgeon, patient and organization.

For more information about Landstuhl synchronous TH surgical programs, please contact the Landstuhl TH Program Office at DSN 314-590-4600.