and Iraq (26), and primarily regarding U.S. service members; (Army-36, Navy-18, Air Force-10, and Marines-3). Consults were answered on average in 3.3 hours ...
MILITARY MEDICINE, 176, 12:1417,2011
Deployed Provider Satisfaction With Infectious Disease Teleconsulation Capt Thomas Schmidt, USAF MC*; Charles M. Lappan, MSf; COL Duane R. Hospenthai, MC USA*f; LTC Clinton K. Murray, MC USA*t ABSTRACT The Army Knowledge Online provides an e-mail service to assist deployed health care providers with specialty consultation. This performance improvement project evaluated the impact and utility of the infectious disease Army Knowledge Online teleconsultation service. Health care providers using the service from January 2010 through December 2010 were emailed a 9-question survey. The survey sought to determine if teleconsultation changed care or evacuation plan, and if responses were timely and clear. 123 consults were received, primarily from Afghanistan (58) and Iraq (26), and primarily regarding U.S. service members; (Army-36, Navy-18, Air Force-10, and Marines-3). Consults were answered on average in 3.3 hours. Completed surveys were obtained from 87 of the total 123 consultations. Responses to survey questions were as follows [scored on a 5-point scale from 1 (no, not at all) to 5 (yes, absolutely)]; Response Helpful (4.6), Response Changed Care (3.3), Response Changed Evacuation Plan (1.8), If Evacuation Plan Changed; was Evacuation Prevented (2.4), Response Timely (4.8), Response Verbose (1.1), Recommendations Clear (4.6), Too Many Recommendations (1.2), and Response Answered Your Question (4.8). The infectious disease teleconsultation service provides timely, helpful, and relevant feedback and plays an important role in influencing patient evacuation plan.
INTRODUCTION The U.S. military health care system faces a unique challenge of providing services to a geographically dispersed population. Telemedicine programs were developed to assist in the care of deployed service members in these isolated environments. The expansion of telemedicine and access to the internet have greatly influenced how health care providers communicate and treat patients.'"' Teleconsultation, a type of telemedicine, allows deployed providers access to expert advice that previously was unavailable. Through electronic communication, providers are able to exchange a patient's medical history, physical exam findings, and diagnostic results with a specialty consultant and gain expert opinion to support the management of patients. The communication can be through realtime video teleconferencing or is performed through e-mail consultation with attached digital images.'"' The U.S. Army Medical Department has successfully initiated several specialty and subspecialty telemedicine services throughout the world. Since 2004, the U.S. Army telemedicine program has used a service-wide internet platform. Army *San Antonio Military Medical Center, 3551 Roger Brook Drive, Fort Sam Houston, TX 78234. tSouthern Regional Medical Command, 4070 Stanley Road, Fort Sam Houston, TX 78234. ^Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814. This article was presented in part at the 26th Army/Air Force American College of Physicians Regional Meeting, Bethesda, MD, November 18-21, 2010. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Department of the Army, Department of the Air Force, Department of Defense, or the U.S. Government. This work was prepared as part of their official duties and, as such, there is no eopyright to be transferred.
MILITARY MEDICINE, Vol. 176, December 2011
Knowledge Online (AKO), to assist with telemedicine consultations. AKO allows deployed health care providers access to specialty groups through e-mail consultations. These consultations are routed to the appropriate specialty group, where they are retrieved and reviewed by one or more board-certified physicians in the respective field."*' Telemedicine originated with teleradiology and now encompasses multiple medical specialties and subspecialties. An infectious disease (ID)-specific AKO teleconsultation service was initiated in January 2005.''' The use of telemedicine has been validated in multiple clinical fields and has been shown to be beneficial in the U.S. military's geographically dispersed medical system.'"'" As telemedicine advances and becomes more commonplace, continued improvements in this service are necessary. To our knowledge, direct feedback from consulting providers on the value of these services has not been obtained previously. It is assumed that these services are beneficial to deployed providers; however, the impact and utility of this service has not previously been evaluated. This study is designed to evaluate the effectiveness of the ID component of the AKO teleconsultation program in addressing clinical dilemmas in ID, specifically analyzing areas where the program is successful and areas that the program could improve. MATERIALS AND METHODS Requests for consultation from the ID AKO teleconsultation service are reviewed by one or more board-certified ID physicians, and expert advice is provided. Each consult is retrospectively and prospectively reviewed to catalog epidemiology of disease and the purpose of the consultation. A survey for the 2010 calendar year was established to allow consulting providers an opportunity to rate their experience and
1417
IDAKO to evaluate the utility and impact of the remote teleconsultations. The survey consisted of 9 questions using a 5-point Likert Scale with 1 representing "no, not at all" and 5 representing "yes, absolutely" (Table I). The survey also requested the military service of the patient, the location of the consult, and the general focus of the problem (diagnostic, therapeutic, or preventive). All specific patient identifiers were omitted. At the end of each survey, providers were given an opportunity to express general comments. Each survey was emailed to the consulting provider along with their original consult to help minimize recall bias approximately 1 week after the consult was requested. To maximize participation, unanswered surveys were emailed up to 3 times (at approximately 1-week intervals). Surveys were returned by consulting providers using their personal e-mail account. All ID teleconsults, the monthly summaries, and the completed surveys between January 2010 and December 2010 were reviewed. The completed survey responses were analyzed and average scores, range of scores, and standard deviation were computed for each individual question. If a participant TABLE I.
did not respond to a particular question, that question was not incorporated into the analysis. Consults were also reviewed and average response time per consult was calculated; the number of co-consultants was tabulated and median number of responses per consult was calculated. Along with reviewing the survey and consult responses, we continued analyzing the cohsults in a similar fashion to a previous review of the consultative service.^ We categorized the consults by consult question and separated them by location. The final analysis involved calculating evacuation data (Table II). An evacuation was deemed prevented only when an individual responded positively to the "prevented evacuation" and "changed evacuation plan" questions. Similarly, a change in evacuation plan from not to evacuate to evacuate was estimated by taking the total number of individuals that responded positively to "changed evacuation plan" but responded negatively to "prevented evacuation." RESULTS From January 2010 through December 2010, there were 123 ID teleconsults placed by 100 different providers. Of 123
Average Scoring of Responses by Deployed Providers Utilizing ID AKO Teleconsultation Service Responses by First Consult Only
Responses by all Consultants Survey Question Did the response help you in the care of the patient? Did the response change the care you provided the patient? Did the response modify your plans to evacuate the patient to a higher level of care? If so, did it prevent evacuation to higher level of care? Was the response provided in a timely fashion? Was the response too verbose? Were the recommendations clear? Were there too many responses to the question? Did the response answer your specific question?
Respondents
Average Score (1-5) and Range
Standard Deviation (+/—)
Number that Responded
0.65
84
4.6 (1-5)
0.67
11
3.3 (1-5)
1.48
84
3.2 (1-5)
1.47
11
1.8(1-5)
1.31
77
1.8(1-5)
1.33
70
2.4 (1-5)
1.8
33
2.3 (1-5)
1.8
30
4.8 (2-5)
0.51
84
4.8 (2-5)
0.53
11
1.1(1-3) 4.6(1-5) 1.2(1-5)
0.40 0.77 0.65
84 85 85
1.1 4.7 1.2
0.41 0.79 0.67'
11 78 78
4.8 (1-5)
0.57
85
4.7
0.59
78
Average Score (1-5)and Range
Standard Deviation (+/-)
4.6(1-5)
Scoring based on 5-point Likert scale with 1 representing "No, not at all" and 5 representing "Yes, absolutely".
TABLE II.
Changed Evacuation Plan Prevented Evacuation Prevented Evacuation and Changed Evacuation Plan" Changed Evacuation Plan and Did Not Prevent Evacuation^
Evaluation of Evacuation Data Submitted by Consulting Providers
Positive Response"
Negative Response'
Unsure''
Not Applicable''
Did Not Respond
Total
13 12 —s
64 20 —
2 2 —
6 16 —
0 35 —
85 85 4
—
—
—
—
—
8
"Response deemed positive if given a numbered score of 4, 5, or free text "yes." 'Response deemed negative if given a numbered score of 1, 2, or free text "no." 'Response deemed unsure if given score of 3. ''Response on survey with free text "not applicable." "Paired positive prevented evacuation plan responses with positive changed evacuation plan responses. Paired positive changed evacuation plan responses with negative prevented evacuation plan responses. *(—) Represents section of table where data is not applicable.
1418
MILITARY MEDICINE, Vol. 176, December 2011
ID AKO
requests for participation, a total of 87 surveys were received, a 71% response rate. Average ratings to the 9-survey questions are available in Table I. Consults were placed most frequently from Afghanistan (58) and Iraq (26); other locations included U.S. Navy ships (5), Qatar (2), the United States (1), Egypt (1), Africa (1), the Philippines (1), and Kuwait (1). For 27 consults, location was not given or unavailable. Providers were most frequently requesting therapeutic (42) or diagnostic recommendations (55); with prevention questions accounting for 21 of the consults. Other consultants assisted with additional recommendations in 54 of the total consults, with 10 of the consults utilizing multiple coconsultants. The total number of co-consultations was 70, with Dermatology (26) and Preventive Medicine (24) most frequently providing responses (Table III). The median number of responses per consult was 2 (range, 1-10). Utilizing a co-consultant increased the median by 1 additional response per consult (range, 1-8). When analyzing only consults that were associated with a returned survey, the median number of total responses remained 2 (range, 1-10), with a median of 2 additional responses with co-consultant participation. The average response time per consult was 3.3 hours. The patients were most frequently U.S. service members (U.S. Army, 36; U.S. Navy, 18; U.S. Air Force, 10; and U.S. Marines, 3). Other U.S. citizens were consulted on 4 times. Patients from the host nation accounted for 12 consults, followed by "other non-U.S." (4) and coalition forces (1). The clinical question most frequently encountered pertained to Staphylococcus aureus (11) followed by tuberculosis and leishmaniasis (10 each) (Table IV). Questions about bacterial infections predominated, followed by parasitic and then viral. Clinical questions that did not fit a traditional category were tabulated as "other."
TABLE III. Number of Occasiotis iti Which Other Specialty or Subspecialty Consultants Assisted With Telecotisultations Received by the ID AKO Telecotisultation Service Consulting Service
Number of Times Consulted
Dermatology Preventive Medicine Rheumatology Otolaryngology Dentistry Experimental Therapeutics Flight Medicine Gastroenterology Malaria Vaccine Program Microbiology Obstetrics-Gynecology Ophthalmology Oral Pathology Pédiatrie TD Pédiatrie Intensive Care Pulmonology Toxicology Vaccine Network Veterinary Medicine
26 24 3 2
MILITARY MEDICINE, Vol. 176, December 2011
TABLE IV. Pathogens, Diseases, or Syndromes for Which the ID AKO Telecotisultation Service was Consulted Bacteria Staphylococcus aureus Tuberculosis Pseudomonas Syphilis Escherichia coll Brucellosis Closlridium difficile Leptospirosis Lyme Disease Staphylococcus haemolyticus Acinetobacter Morganella morganii Polymicrobial Infection Shigella Viral Herpes Simplex Virus Varicella Epstein Ban- Virus Viral Fever, NOS Viral Meningitis Parasite Leishmaniasis Malaria Giardia Schistosomiasis Cutaneous Larval Migrans Dracunculiasis Entamoeba histolytica Paederus Beetle Bite Other Malaria Prophylaxis Needle Stick Injury Rash, NOS Diarrhea, NOS Blood Exposure Vaccine Reaction Meningitis Kerion Polyarthritis Primaquine Drug Reaction Ventilator-associated Pneumonia Small Pox Vaccine Cough, NOS Cellulitis/Folliculitis Pneumonia Doxycycline Drug Reaction Mumps Vaccine Indication Necrotizing Granulomatous Lymphadenitis Blistering Disease, NOS BinaxNow Testing Chronic Diarrhea Digital Ulcer, NOS Enbrel and Risk of Tuberculosis Facial Lesion, NOS Nasal Abscess Oral Ulcers Peritonsillar Abscess Pemphigus vulgaris Pharyngitis Porphyria Prepatellar Bursitis Burn Sepsis
37 11 10 3 2 2
10 3 2
r 1 1 26 10 9 2
49 4 3 3 3 3 2 2 2 2 2
1419
IDAKO
DISCUSSION The purpose of this study was to evaluate the impact of the ID AKO teleconsultation service at providing subspecialty support to deployed physicians. By providing consulting providers an opportunity to critique the ID teleconsultation service, we could better evaluate how the service is beneficial and how the service could be adjusted to better support deployed health care providers. This study is unique in that we obtained direct feedback from the providers utilizing the ID AKO teleconsultation service. Overall the ID AKO service was evaluated favorably with regards to timeliness of responses, overall helpfulness, and ability to clearly answer the requesting health care provider's question. Correct patient disposition is a decision all providers face. As a consulting service, we can help assist primary health care managers with the decision of whether or not to evacuate a patient. The goal being to prevent unnecessary evacuations, btit also ensuring those patients that need evacuation get optimal medical treatment. Table II provides evacuation data and supports that the ID AKO teleconsultation service is meeting its intended purpose. Deployed providers are getting recommendations that assist with patient disposition, leading to changes in evacuation plan and expediting proper treatment and intervention. The ID AKO teleconsultation service was entering its fifth year of service at the beginning of 2010. From 2005 to 2008, Morgan et aP reported that the average number of consults received by the ID AKO teleconsultation service was 105 per year (range 98-116) and that the most common consult questions pertained to tuberculosis, leishmaniasis, and malaria. Our analysis is very similar with the one exception being S. aureus slightly overtaking tuberculosis as the most common bacterial consult question. It was assumed that over time there would be a shift in the most common consult questions as deployed providers became more familiar with common ID topics and as predeployment education focused on the most common clinical questions. However, the commonality of these ID topics likely explains why they continue to generate frequent consults. Overall this study has many strengths. The high percent- ' age of responders helps add reliability to the data. With nearly 70% of all consults receiving feedback and 79% of all users providing feedback, the data likely represents an accurate assessment of the ID AKO teleconsultation service. Another strength of this study is that it is the first to our knowledge that used user feedback to directly assess its utility. Despite the strengths of this study, there are some weakness and areas for future research. Providers were only given the option to
1420
address if the encounter prevented evacuation. Examining the data indicates that evacuation plans were changed and that change included evacuating the patient. Furthermore, evacuating a patient is either a "yes" or "no" response. Thus, by changing the questionnaire to provide a specific "yes" or "no" response on how the consultation effected evacuation, one could better assess total number of patients evacuated and likewise one could assess total number of evacuations prevented. Another limitation of this study is that it does not provide information about success of the treatment plan. Other than evacuation plan, there is no indication of how the consult benefited the patient. In the future, we would recommend adding additional section that addresses treatment success. Telemedicine has been utilized since the late 1980s, but to our knowledge this is the first study to use direct provider feedback to evaluate the effectiveness of the service. From the survey results, one can conclude that currently the ID AKO teleconsultation service is providing beneficial and relevant recommendations. These recommendations are reaching the consulting provider in a timely fashion and infiuencing evacuation plans. This information can be used to help guide ID AKO teleconsultation recommendations in the future; furthermore, changes can be made to the existing survey to better qualify patient response and evacuation data.
REFERENCES 1. Grigsby J, Sanders JH: Telemedicine: where it is and where it's going. Ann Intern Med 1998; 129: 123-7. 2. Grigsby J, Brega AG, Devor PA: The evaluation of telemedicine and health services research. Telemed J E Health 2005; 11: 317-28. 3. Reed C, Burr R, Melcer T: Navy telemedicine: a review of current and emerging research models. Telemed J E Health 2004; 10: 343-55. 4. McManus J, Salinas J, Morton M, Lappan C, Poropatich R: Teleconsultation program for deployed soldiers and healthcare professionals in remote and austere environments. Prehosp Disaster Med 2008; 23: 210-6. 5. Morgan AE, Lappan CM, Fraser SL, Hospenthal DR, Murray CK: Infectious disease teleconsultative support of deployed healthcare providers. Mil Med 2009; 174: 1055-60. 6. Poropatich RK, DeTreville R, Lappan C, Barrigan CR: The U.S. Army telemedieine program: general overview and current status in Southwest Asia. Telemed J E Health 2006; 12: 396-408. 7. Blanchet KD: The U.S. Army Telemedieine and Advanced Technology Researeh Center (TATRC). Telemed J E Health 2006; 12: 390-5. 8. Gomez E, Poropatieh R, Karineh MA, Zajtehuk J: Tertiary telemedicine support during global military humanitarian missions. Telemed J 1996; 2: 201-10. 9. Calgani DE, Clyburn CA, Tomkins G, et al: Operation Joint Endeavor in Bosnia: telemedicine systems and case reports. Telemed J 1996; 2: 211-24. 10. Crowther JB, Poropatieh R: Telemedicine in the U.S. Army: case reports from Somalia and Croatia. Telemed J 1995; 1: 73-80.
MILITARY MEDICINE, Vol. 176, December 2011
Copyright of Military Medicine is the property of Association of Military Surgeons of the United States and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
