The Laryngoscope

C 2018 The American Laryngological,

V
Rhinological and Otological Society, Inc.

Telemedicine in Otolaryngology Outpatient Setting—Single Center

Head and Neck Surgery Experience

Ryan A. Rimmer, MD ; Vanessa Christopher, BA; Ailsa Falck, BS;

Edmund de Azevedo Pribitkin, MD, MBA; Joseph M. Curry, MD; Adam J. Luginbuhl, MD;
David M. Cognetti, MD

Objectives/Hypothesis: We present our experience with telemedicine visits in an otolaryngology outpatient setting
within our institution’s Center for Head and Neck Surgery.
Study Design: Retrospective chart review.
Methods: A review of telemedicine outpatient encounters examining patient demographics, visit type, and wait times
was conducted. Internet-based navigation applications were used to calculate travel distance and estimate commute time to
our clinic. Patient survey responses were reviewed.
Results: Two hundred fifty telemedicine encounters were reviewed between December 2015 and June 2017. The aver-
age age of patients was 50 years (range, 4–87 years). Patients waited an average of 10 minutes for their telemedicine
appointments and avoided an average estimated commute time of 78 minutes (64 miles). The majority of visits were postop-
erative encounters (70%). Clinical follow-up of recent results or nonpostoperative complaints accounted for the remaining
30% of visits. All patients were offered a post-telemedicine survey, and 78 (31%) completed the survey. Of the respondents,
95% of patients reported that they were satisfied with their visit. Among patients who were dissatisfied, wait time and tech-
nical issues were cited as reasons.
Conclusions: With appropriate patient selection, telemedicine is an effective way to safely conduct outpatient clinic vis-
its while maintaining high patient satisfaction. It can be particularly useful for institutions with large catchment areas to min-
imize travel times and increase ease of communication.
Key Words: Telemedicine, telehealth, otolaryngology, outpatient, clinic.
Level of Evidence: 4.
Laryngoscope, 00:000–000, 2018

INTRODUCTION The use of telemedicine within otolaryngology has

Telemedicine, sometimes referred to as telehealth, been studied in the literature since the 1990s.3 It was
encompasses a broad array of applications that use tele- initially used to link otolaryngologists with general prac-
communications technology to remotely deliver care to titioners in remote areas where specialist care was not
patients.1 The goals of telemedicine are to improve access readily available. This was achieved primarily via two
to care while increasing efficiency for both the patient and methods: synchronous and asynchronous. The synchro-
provider. The practice of otolaryngology is particularly nous method involves live teleconferencing, which is
suited for telemedicine given that otolaryngologists are fre- appealing due to its interactivity; however, it requires
quently located in urban centers without easy access for considerable logistical coordination between all partici-
patients from more rural areas. Furthermore, many diag- pants. Asynchronous methods are delayed and some-
noses within the field are based on objective data such as times referred to as “store and forward.” With
audiometry, endoscopy, laboratory studies, and diagnostic asynchronous methods, the initial provider collects all
imaging that can be reviewed remotely.2 relevant patient data and then forwards this information
to a specialist to be reviewed at a later time.2
Thanks to significant technological advancement
From the Department of Otolaryngology (R.A.R., E.D.A.P., J.M.C., over the past 20 years, the role of telemedicine has
A.J.L., D.M.C.),
Sidney Kimmel Medical College (V.C.), and Department of
Telemedicine (A.F.), Thomas Jefferson University, Philadelphia, Pennsyl- expanded.4 Current applications allow for video-otoscopy,
vania, U.S.A videoendoscopy, remote testing of cochlear implants, and
Editor’s Note: This Manuscript was accepted for publication on overall improved ease and access of teleconferencing.2
January 16, 2018.
Presented orally at the Triological Society Combined Sections
Additionally, telemedicine has been employed in a vari-
Meeting, Scottsdale, Arizona, U.S.A., January 19, 2018. ety of clinical settings, from the initial patient encounter
The authors have no funding, financial relationships, or conflicts to preoperative and postoperative visits.2,5
of interest to disclose.
Send correspondence to Ryan A. Rimmer, MD, Department of Oto- In the fall of 2015, telemedicine launched at our
laryngology, Thomas Jefferson University Hospital, 925 Chestnut Street, institution with scheduled outpatient office visits using
6th Floor, Philadelphia, PA 19107. E-mail: [email protected]
computers and tablet technology. Telemedicine staff
DOI: 10.1002/lary.27123 spent the initial weeks familiarizing themselves with

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the Department of Otolaryngology’s physicians and TABLE I.
patients, introducing staff to the provider application, Telemedicine Visit Demographics (N 5 250).
and registering patients for the telemedicine platform.
Demographic Value
Initially, physicians were completing about four synchro-
nous live video telemedicine visits per month, but that Gender
number has steadily grown as both patients and pro- Male 95
viders became more familiar with the process. We pre- Female 155
sent our experience using telemedicine for outpatient
Age, yr
visits within our institution’s Center for Head and Neck
Mean 53
Surgery.
Range 12–87
Commute distance, miles
MATERIALS AND METHODS
Average 64
We conducted a retrospective chart review of telemedicine
outpatient encounters for four providers in our department’s Range 0.5–325
Center for Head and Neck Surgery from December 2015 Commute time, min
through June 2017. Patient demographics and purpose of the Average 78
visit were analyzed. For the purposes of classification, visits Range 4–310
were classified into one of the following categories: 1) minor
oral cavity/oropharynx surgery, 2) endoscopy surgery, 3) more
extensive neck surgery, 4) less extensive neck surgery), or encounters involved telemedicine visits for the first postop-
5) clinical follow-up. erative visit. Endoscopic procedures (e.g., microdirect lar-
Internet-based navigation applications were used to calcu-
yngoscopy, endoscopic sinus) comprised the remaining 10%
late travel distance and estimate commute time from the
of postoperative visits. The classification of postoperative
patient’s provided home address to our clinic. The shortest
travel time by automobile was selected for inclusion. An visits is summarized in Table II.
optional anonymous postvisit survey was offered to all patients, Thirty percent of telemedicine visits were classified
and we conducted a review of these responses. as clinical follow-up. This classification included nonpos-
toperative visits to discuss recent results (e.g., imaging,
pathology, laboratory tests), preoperative discussions
RESULTS
prior to surgery, or visits to follow-up on symptoms man-
Demographics aged nonoperatively.
A total of 250 visits were included in the analysis.
The majority of visits involved female patients (62%),
with an overall average age of 50 years (range, 4–87 Visit Length and Wait Time
years). The average distance from the clinic was 64 Telemedicine visits typically lasted an average of 11
miles (range, 0.5–325 miles), with an estimated commute minutes depending on the type of visit, and the average
time of 78 minutes (range, 4–310 minutes). Demographic wait time was 10 minutes (range, 0–47 minutes). Wait
analysis is summarized in Table I. time was calculated from the time the technician ini-
tiates a telehealth connection with the patient until the
time the provider begins the visit.
Visit Classification
The largest proportion of telemedicine visits were
for postoperative follow-up (70%). Fifty-seven percent of Survey Results
postoperative telemedicine visits followed neck surgery. At the conclusion of telemedicine visits, patients
More extensive neck surgeries (e.g., thyroidectomy, para- were offered the opportunity to complete an anonymous
thyroidectomy, neck dissection, parotidectomy) repre- survey regarding their experience. The survey was com-
sented 31% of these visits. For these patients, pleted by 78 of the 250 patients included in this analysis
telemedicine was not used for the first postoperative (31%). The results are summarized in Table III.
visit. Instead, a telemedicine visit was scheduled for the The large majority (95%) of respondents were satis-
second postoperative appointment. Patients undergoing fied with their visits. Among the four dissatisfied
less-extensive neck surgeries (e.g., styloidectomy, thyro- patients, wait time and technical issues were cited as
glossal duct cyst excision, brachial cleft cyst excision, the reason. This was the first ever telemedicine visit for
submandibular gland excision) comprised 26% of postop- 79% of respondents, and yet 92% of respondents felt that
erative visits. These less-extensive surgeries did contain the platform was easy to use, and 88% would use tele-
a small number of telemedicine visits for the first post- medicine again. Forty-six percent of respondents felt
operative appointment, at the surgeon’s discretion; that the telemedicine visit saved them greater than 3
however, the large majority of telemedicine visits were hours of total travel time, and 40% felt that the visit
used for the second postoperative appointment. saved them between 1 and 3 hours.
Thirty-three percent of postoperative visits involved
those following minor oral cavity/oropharynx surgeries DISCUSSION
(e.g., sialoendoscopy, tonsillectomy, biopsies), the majority As the practice of healthcare becomes more central-
(78%) of which followed sialoendoscopy. Many of these ized, telemedicine will become an increasingly important

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 TABLE II. telemedicine appointments for the initial postoperative
Telemedicine Postoperative Visit Type (N 5 174). visit. Careful selection of appropriate patients ensures
that telemedicine remains an efficient and safe alterna-
Procedure Type No. %
tive to in-person visits.
Neck surgery, more extensive 53 31% Nonpostoperative clinical follow-up comprised 30%
Neck surgery, less extensive 45 26% of telemedicine visits. During these visits, patients can
Minor oral cavity/oropharynx surgery 58 33% describe new symptoms or their response to recent non-
Endoscopic surgery 18 10%
operative treatments. Providers are able to update the
patient on recent results (e.g., imaging, cytology, labo-
ratory results) without the need to examine the patient
in person. Although it is feasible that such information
component of care.6 Since its introduction at our institu- could be discussed over a telephone call, telemedicine
tion in 2015, telemedicine has shown to be a viable offers several advantages. In contrast to follow-up tele-
option for otolaryngology outpatient visits. Successful phone calls, telemedicine visits feature live video,
implementation requires appropriate technical support which allows for establishment of eye contact between
to ensure seamless operation for patients and the ability patient and provider leading to enhanced rapport and
of the provider to select suitable patient candidates. more impactful clinical messages.7 Furthermore, tele-
Within our Center for Head and Neck Surgery, the phone updates are frequently unscheduled and happen
largest percentage of telemedicine visits were comprised as the clinic schedule permits, whereas telemedicine
of postoperative follow-up visits, most of which followed appointments are scheduled, which makes them a more
neck surgery. Telemedicine was not frequently used for convenient and reliable option for both patient and
the initial postoperative appointment in these cases, as provider.
this visit frequently requires hands on procedures (e.g., We have shown that telemedicine appointments
suture or staple removal, dressing removal), and closer substantially reduce the time associated with patient
inspection of the wound. Instead, telemedicine was used travel to our outpatient office. This benefit is magnified
for the second postoperative visit. Postoperative visits for institutions with large catchment areas where
for minor oral cavity and oropharynx procedures were patients must travel long distances to their appoint-
the second most common postoperative visit type, of ments. In our analysis, the average travel time was 78
which a significant proportion followed sialendoscopy minutes covering a distance of 64 miles. Additionally,
procedures. These visits contained a higher proportion of these estimates do not factor in time and cost associated

TABLE III.
Postvisit Survey Responses.

Response (N 5 78)

Question Strongly Agree Agree Neither Agree Nor Disagree Disagree No Answer

Telemedicine made it easier for 44 25 8 0 1

me to get care when and where
I needed it.
Telemedicine was easy to use. 41 31 4 2 0
I received the same level of care 35 32 7 3 1
as an in-person visit.
I had enough time with the 40 33 4 1 0
provider.
I would use Telemedicine again. 48 21 5 2 1

Question Yes No No Answer

Overall, were you satisfied with 74 4 0

your visit?
Have you ever had a telemedicine 16 62 0
visit before?
Do you use social media? 45 21 12
Have you already recommended 31 47 0
Telemedicine to your family and
friends?
Question >3 hours 1–3 Hours <1 Hour None

How much time do you think tele- 36 31 8 3

medicine saved you (including
travel time, wait time, visit
time)?

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with parking, or other transportation options utilized by future of telemedicine is bright. In addition to scheduled
patients such as public transit or ride sharing. outpatient telemedicine visits, our department has
As anticipated, the most frequent obstacles to the begun implementing virtual rounds on weekends. Dur-
telemedicine process are rooted in technological issues. ing these rounds, attending physicians remotely round
Currently, our department uses Epic’s telemedicine sys- with the on-call residents using mobile videoconference
tem, which integrates with our electronic medical record. technology. In collaboration with the residents, this
Providers use Epic’s Canto application on tablets in the allows attending physicians to remotely see and interact
clinic, whereas patients are able to download Epic’s with patients and hospital staff, answer questions, and
MyChart application on their smartphone, tablet, or guide medical decision making. This development is just
computer with webcam abilities. Although the majority another way in which telemedicine serves to enrich the
of patients have access to at least one of these options, patient experience.
there are occasionally individuals who lack such devices.
Poor Internet connection and malfunctions with down-
loading the necessary applications are periodic occur-
CONCLUSION
With appropriate patient selection and technological
rences, particularly for patients in more remote
locations. To mitigate any issues, the telemedicine staff support, telemedicine can be an effective means of safely
contact patients 24 to 48 hours prior to their scheduled delivering patient care in multiple settings while main-
appointment to confirm the time and to troubleshoot any taining high patient satisfaction. In our experience, this
issues with connectivity. On the day of the appointment, technology is particularly suited for institutions with
the patient logs in to MyChart and connects a few large catchment areas to minimize patient travel time
minutes prior to their scheduled visit time. Telemedicine and improve efficiency.
staff then connect with the patient on a tablet in the
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