Joseph R. Anticaglia, MD
Unless changes are made to improve the delivery of health care in the United states, there may be a work force shortage of45,000 PCPs and 46,100 Surgeons and Medical Specialists in the year 2020.(1) The number of Otolaryngologist in 2020 is expected to be insufficient to meet the needs of a growing and aging population of Americans.(2) The challenge is how to deliver appropriate Ear, Nose &Throat care in remote areas without in-person contact between patient and physician?
Otolaryngologists and “specialty extenders” (non-physician health workers), such as physician’s assistants, nurse practitioners, community health workers and audiologists have utilized Teleotolaryngology to treat ENT patients.
Using telecommunication systems, an audiologist over a 57 month period travelled to remote areas of Alaska and relayed medical information to an Otolaryngologist for evaluation and treatment.
The audiologist created Telemedicine cases by taking a clinical history, performing hearing tests, and other appropriate studies. These patient encounters resulted in special diagnostic testing, initiation of medical treatment, or referral for monitoring. Some patients were referred for surgery, but about 27% of patients were triaged out of the ENT (Ear, Nose & Throat) clinic and did not need specialty follow up. In 85% of the examinations, travel was avoided resulting in travel cost savings in airfare of $496,420. (3)
Teleotolaryngology helps servicemen in remote military facilities obtain ENT specialty care. A high rate of changed initial diagnoses and subsequent treatment recommendations resulted after Telemedicine consultation with Otolaryngologist-Head & Neck Surgeons. (4)
In another study, after the insertion of ventilation tubes in the ears, video-otoscopy (examination of the ear) was used by non-physician health care workers in rural areas of Alaska to monitor the progress of patients and transmit the findings to Otolaryngologists for evaluation. (5)
These resources have improved care and reduced the waiting time for in-person patient examination by an Otolaryngologist. (6)
Digital Imaging & Communication in Medicine (DICOM) was created by the National Electrical Manufacturers Association (NEMA) and is a network that can store, retrieve, forward and print medical images and information. Radiologists have been in the forefront of its development and made great use of its innovations with CT scans (Computed Axial Tomography), Magnetic Resonance Imagining and other imaging studies. (7)
Although Telemedicine can bridge the distance between doctor and patient in the delivery of health care, and is gaining acceptance by the public and medical community, there are challenges to its implementation.
There is a need for control studies to better predict the surplus and shortage of physicians. Startup costs, insurance reimbursement and state licensing issues are limitation to its application. Some specialists will not accept a new paradigm for the delivery of health care and others are concerned with privacy issues equipment breakdowns and the cost of malpractice insurance.
Some propose to increase the supply of Otolaryngologists by shortening the length of the residency program in Otolaryngology. (8) The reality is no matter how you increase the supply side of the work force, many physicians are not inclined to practice their specialty in remote areas because of cultural and professional reasons. What is one to do if physicians elect not to practice in remote areas?
Telemedicine has proven effective in Qweensland, Australia, in prison population, aboard US airlines with medical emergencies and in the military. (9) In spite of the limitations noted above, which seem manageable, Teleotolaryngology along with other “tele-entities,” can deliver quality care, lower costs and provide a solution to the health care specialty shortage.
The solution is to provide reliable care at a distance and telemedicine has proven effective in Queensland, Australia, in the prison population, aboard US airlines with medical emergencies, and in the military. (9)JRA article
The blending of medical knowledge with digital innovations is changing the patient’s “point of care.”
Telemedicine is changing the definition of “point of care” Telemedicine has given new meaning to our understanding of point of service
Telemedicine is redefining the delivery of health care and with the anticipated specialty work force shortage it can play a positive role in alleviating this shortfall.
A working definition of “point of service” care, Teleotolaryngology is a complementary specialty care delivery system alternative health care delivery system.
References:
Association of American Medical Colleges (AAM C); Alicia Gallegos; February, 2014.
1. Health Resources &Services Administration, HRSA; Physicians Supply and Demand; October, 2006.
2. Traveling an audiologist to provide otolaryngology care using store and forward telemedicine; Kokesh, J., Ferguson, AS;’ et al.; 2009; online lieberpub.com
3. ENT telemedicine in remote military population seeking specialty care: Melcher, T., Phd; Hunsaker, D., MD; et al
4. Kokesh, J.; et al; Digital images for postsurgical follow-up of tympanostomy tubes in remote Alaska. Otolaryngol Head –Neck Surgery 2008 139 (1) 87-93.
5. The impact of telemedicine wait time for ENT specialty care. Hofstetter, John et al Telemedicine and eHealthe; June, Vol.16;551-5562010
6. The DICOM Standard
7. Otolaryngology – Head & Neck Surgery, Physician Work Force Issues; Otolaryngology – Head & Neck 2012;146:196.