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Synchronous telehealth for outpatient allergy consultations
Ann Allergy Asthma Immunol 116 (2016) 571e575
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Synchronous telehealth for outpatient allergy consultations A 2-year regional experience Kirk H. Waibel, MD Allergy Service, Division of Medicine, Landstuhl Regional Medical Center, Landstuhl, Germany
A R T I C L E
I N F O
Article history: Received for publication February 11, 2016. Received in revised form March 13, 2016. Accepted for publication March 25, 2016.
A B S T R A C T
Background: Telehealth continues to advance as a health care modality; however, reported experience for synchronous TeleAllergy is limited. Objective: To determine the percentage of new and follow-up visits conducted via TeleAllergy in a hospitalbased clinic. Methods: A retrospective study evaluating the first 2 years of a synchronous patient-to-allergist TeleAllergy platform. Results: A total of 112 synchronous TeleAllergy encounters were conducted from January 2014 through December 2015; 66 (59%) of these were new consultations. The mean (SD) age was 26.9 (15.3) years, and 54% of the participants were female. Food allergy (30%), allergic rhinitis (20%), and urticaria (16%) represented the top 3 consultation reasons. Sixteen of 66 patients (24.2%) and 3 of 46 patients (6.5%) attending new and follow-up TeleAllergy visits, respectively, were recommended for an in-person appointment (P ¼ .02). No difference was found between new and follow-up TeleAllergy visits regarding subsequent telephone communication (41% vs 26%, P ¼ .11) or prescriptions ordered (50% vs 33%, P ¼ .08). New TeleAllergy visits were more likely to have more than 1 laboratory test ordered (45% vs 17%, P ¼ .002). On the basis of patient location, the 112 TeleAllergy visits resulted in an estimated savings of 200 workdays or schooldays, US$58,000 in travel-related costs, and 80,000 kilometers not driven. Conclusion: Both new and follow-up visits to the allergist/immunologist were well received by patients and demonstrated significant indirect cost savings, with less than one fourth of the patients recommended for an in-person visit. This appears to be the first systematic assessment of TeleAllergy for new and follow-up patient encounters in a clinic-based allergy/immunology practice. Published by Elsevier Inc. on behalf of the American College of Allergy, Asthma & Immunology.
Introduction Telehealth for allergy/immunology includes multiple modalities (eg, telephone, secure e-mail, asynchronous store and forward, synchronous patient to provider, and mobile applications); however, the reported use of synchronous TeleAllergy has been limited.1 Compared with asynchronous telehealth (also called store and forward), which is a provider-to-provider interaction without the patient involved, synchronous TeleAllergy involves a direct, real-time patient-to-provider encounter. An initial report of 333 synchronous telehealth encounters found that 35% of all encounters were specific for allergy/immunology, but the specific diagnoses and outcomes were not reported.2 More recent studies Reprints: Kirk H. Waibel, MD, Allergy Service, Division of Medicine, Landstuhl Regional Medical Center, MCEUL-LSL-M-A, CMR 402, APO AE 09180; E-mail: Kirk.h. [email protected]. Disclosures: Author has nothing to disclose. Disclaimer: The opinions or assertions herein are the private views of the authors and not to be construed as reflecting the views of the US Department of the Army, US Department of the Air Force, or the US Department of Defense.
using a synchronous platform have been specific for asthma or asthma education without discussion of other allergy/immunology referral indications.3e5 With a recent perspective article highlighting patient’s increasing desire to be directly engaged in their medical care, synchronous TeleAllergy can provide direct engagement with the allergist that is patient centric and provided within the patient’s own primary care clinic.6 However, despite most hospitals listing allergy/immunology as a telehealth capability, there have been no published reports describing TeleAllergy as a synchronous platform for both new consultations and follow-up allergy evaluations for the array of allergy indications. This study retrospectively reports the outcomes of a 2-year regional, synchronous TeleAllergy platform that evaluated both new and follow-up patients. Methods Telehealth is a specific health care modality that the US Army Medical Command has placed specific priority with the establishment of a Telehealth Service Line in 2010.7 Currently, there are 5
http://dx.doi.org/10.1016/j.anai.2016.03.028 1081-1206/Published by Elsevier Inc. on behalf of the American College of Allergy, Asthma & Immunology.
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regional medical commands that use synchronous and asynchronous telehealth but only 1 that conducts synchronous TeleAllergy: the Regional Health Command Europe (RHC-E). TeleAllergy in the RHC-E was supported by 3 board-certified allergists located at Landstuhl Regional Medical Center (LRMC). The LRMC supports approximately 100,000 beneficiaries across 15 primary care clinics located in Germany, Italy, and Belgium. Before 2015, telehealth efforts in the RHC-E were focused on behavioral health and surgical subspecialties; however, in late 2014 the European Advancement for Regional Telehealth (EARTH) project was launched, hiring 3 specifically trained telehealth presenters who supported a comprehensive medical, surgical, and behavioral health telemedicine platform. From January 2014 through December 2015, 30 distinct specialties, including allergy/immunology, were engaged in synchronous telehealth, resulting in a total of 3,933 encounters. Allergists located in the LRMC allergy/immunization outpatient clinic were provided synchronous telehealth education and training by a regional telehealth office, developed TeleAllergyspecific procedures, and were credentialed at all patient locations. All consultations to the allergy/immunology service were reviewed by 1 of 3 board-certified allergists. Clinic booking staff then offered patients the choice to have their appointment conducted in-person or via TeleAllergy at the time of appointment booking based on patient preference, primary care provider preference, or allergist recommendation based on the patient located in a remote clinic site. The primary outcome was to determine the percentage of new and follow-up visits conducted via TeleAllergy. Secondary outcomes included determining the specific referral indication(s) based on current clinic referral guidelines,8 percentage of patients who required an in-person visit, and additional recommendations (eg, medication, laboratory testing). Additional patient-to-provider interactions, including additional TeleAllergy visits, in-person visits, or telephone follow-up, were determined through review of the patient’s electronic health record. All TeleAllergy encounters were reviewed in duplicate by the investigator. All telehealth visits required written patient or parental consent, and study approval was obtained by the LRMC Human Research Protection Program. TeleAllergy visits conducted between patients and providers were performed on a secure, Health Insurance Portability and Accountability Act (HIPAA)ecompliant video link. Primary care medical homes supporting telehealth had one standardized Polycom HDX 9000 Practitioner cart (Polycom Inc, San Jose, California), which included an AMD-2500 General Exam Camera, AMD Fiberoptic Otoscope, and AMD Telephonic Stethoscope (AMD Global Telemedicine Corporation, Chelmsford, Massachusetts). Allergists used a desktop computer installed with Polycom RealPresence software and camera (Polycom Inc). Evaluation and management coding was based on provider documentation and reviewed by hospital coding staff assigned to the clinic. Per current telehealth guidance, all clinic encounters at the patient site are coded as a 99499 visit with a Healthcare Common Procedure Coding System Q3014 added. A GT modifier (via interactive audio and video telecommunications systems) is added to the allergist’s TeleAllergy note. New TeleAllergy visits were allotted 45 minutes, whereas follow-up visits were given 30 minutes to allow synchronization between provider schedules and available telehealth cart time. Briefly, patients arriving at their primary care clinic for a TeleAllergy visit followed normal clinic operating procedures (ie, checked in, 2-patient identifier verification, placed in a HIPAAcompliant examination room, vital signs measured, medication reconciliation, and consented for telehealth). At the allotted appointment time, both the originating site where the patient was located and the distant site (LRMC) dialed in to a video conference bridge. At that time good audio and video was established, a unique access code was provided to both parties, and the video bridge
signed out, which locks the virtual examination room. Again, 2-patient identifier, a 2016 Ambulatory Care National Patient Safety Goal, is established by the allergist, and the appointment begins. Content, such as educational slides for specific diagnoses, can be virtually shared or e-mailed to the patient presenter for printing. At the request of the allergist, the presenter can perform a physical examination using a high-definition camera taking appropriate pictures to be added to the clinical note and perform any aspects of the physical examination with the exception of palpation or percussion. Estimated travel costs were determined using current government per diem reimbursement rates for lodging, meals, and privately operated vehicle mileage reimbursement. Maximum reimbursement for hotel, meals, and incidentals ranged from $353.00 to $275.00 per day from January 2014 to December 2015, whereas reimbursement for driving ranged from $0.56 to $0.575 per mile driven. Statistical analysis was performed using free statistical software (www.socscistatistics.com). Descriptive statistics were used to assess primary and secondary outcomes. TeleAllergy patients were provided an anonymous 16-question regional telehealth survey using a 5-point Likert scale (eFig 1). A 2-tailed t test for independent samples was used for new and follow-up TeleAllergy visits to compare continuous variables, whereas categorical outcomes were assessed with either a c2 or Fisher exact test. An a <.05 was considered significant. Results A total of 112 TeleAllergy encounters for 105 unique patients were conducted from January 2014 through December 2015. A total of 61 of the 112 patients (54%) were female. The age range was 12 months to 58 years, with a mean (SD) age of 26.9 (15.3) years. A total of 76 of the 112 patients (68%) were adults. Patients were located in 10 primary care clinics: 1 in Italy, 2 in Belgium, and 7 in Germany. During the 2-year study period, 3 distinct board-certified allergists overlapped for different lengths of time based on required military moves, resulting in different numbers and types of patients evaluated (Table 1). TeleAllergy visits were conducted in 10 of 15 telehealth-capable clinics (67%), but 76 of 112 visits (68%) occurred in 1 of 3 locations with a dedicated telehealth nurse. A total of 66 of the 112 TeleAllergy appointments (59%) were new consultations; adults accounted for 39 consultations (59%). All 66 allergy consultations (100%) were placed by the patient’s primary care provider. New consultation and follow-up TeleAllergy encounters represented 4.5% (n ¼ 66 of 1,471) and 3.1% (n ¼ 46 of 1,461) of all patient encounters (TeleAllergy and in-person) during this period, respectively. Furthermore, TeleAllergy encounters represented 2.8% (n ¼ 112 of 3,933) of all regional telehealth encounters between patients and 30 distinct specialties during this period. Mean (SD) monthly TeleAllergy encounters were 4.7 (3.2). Compared with 2014, mean (SD) TeleAllergy encounters per month in 2015 (6.4 [3.3] vs 2.9 [1.9], P ¼ .004) and a percentage of all clinic Table 1 Provider Characteristics Characteristic
Time in clinic, mo New visits, No. (%) New patients recommended for in-person visits, No. (%) Follow-up visits, No. (%) Follow-up patients recommended for in-person visits, No. (%)
Provider A
B
C
18 12 (18) 3 (25)
24 40 (61) 11 (28)
3 14 (21) 2 (14)
17 (37) 0 (0)
24 (52) 3 (12.5)
5 (11) 0 (0)
K.H. Waibel / Ann Allergy Asthma Immunol 116 (2016) 571e575
visits (6.0 [3.8] vs 2.1 [1.2], P ¼.004) increased. In addition, more new TeleAllergy visits were conducted in 2015 than 2014 (53 of 78 [68%] vs 13 of 34 [38%], P ¼ .01). New consultations were requested for 71 reasons (1.1 per patient): food allergy (30%), allergic rhinitis (20%), and urticaria (16%) represented the top 3. New consultations requested 90% (n ¼ 9/10) of current referral indications.8 In addition to the 71 reasons for consultation, an additional 43 allergy-related diagnoses were identified (Table 2). A total of 19 of 112 TeleAllergy patients (17%) were recommended for an in-person appointment. New TeleAllergy patients were more likely to be recommended for an in-person visit compared with follow-up TeleAllergy patients (16 of 66 [24.2%] vs 3 of 46 [6.5%], P ¼ .02). The most common reasons for recommending an in-person visit were skin prick testing (n ¼ 9) or oral challenge (n ¼ 6) (Table 3). In total, 11 of 16 new patients (69%) and 3 of 3 follow-up patients (100%) who were recommended for an inperson visit traveled to the clinic during the study period. Regarding follow up, 39 of 66 new consultations (59%) had 1 or more type of follow-up. Five of 66 (7.6%) had 1 follow-up TeleAllergy visit, 11 (16.7%) had an in-person visit, and 27 (40.9%) had telephone follow-up. New TeleAllergy consultations were more likely than follow-up TeleAllergy to have subsequent telephone communication, but this finding was not statistically significant (40.9% versus 26.1%, P ¼ .11). A total of 43% and 34% of all TeleAllergy patients had 1 or more medication or laboratory test, respectively (Table 4). Furthermore, patients were more likely to be recommended for an in-person visit if they had multiple allergy diagnoses (P < .001), food allergy (P < .001), or drug allergy (P < .01) (Table 5). Significant differences were observed between new and followup TeleAllergy visits regarding patient demographics, reason(s) for visit, and recommendations. New TeleAllergy visits involved younger patients (P ¼ .004), these patients were more likely to be evaluated for food allergy (P < .001), and these patients more often had 1 or more laboratory test (P ¼ .002). Specifically, for allergic rhinitis as the TeleAllergy indication, 45 of 67 patients (67%) were undergoing subcutaneous allergen immunotherapy (SCIT); no patients were undergoing sublingual immunotherapy. Thirty-three of 46 follow-up encounters (72%) were conducted for an annual immunotherapy visit compared with 12 of 66 new allergic rhinitis consultations (18%) (P < .001) All 12 new consultations specifically for patients undergoing SCIT were for patients who had moved into the area already undergoing SCIT started by another military allergist. For the 18 new patients who were evaluated for allergic rhinitis but not currently undergoing SCIT, 3 were recommended
Table 2 Primary Care Provider Referral Indication and Allergist Assessment for 66 New Consultations Indication
Initial referral indication, No. (%)
Allergist assessment, No. (%)
Allergic rhinitis Asthma Food allergya Urticaria/angioedema Drug allergy Rashb Stinging insect Latex allergy Anaphylaxis All other Total
15 3 22 12 4 8 1 0 2 4 71
30 7 31 11 6 13 4 1 2 9 114
a
20.3 4.1 29.7 16.2 5.4 10.8 1.4 0.0 2.7 5.4
28.3 6.6 29.2 10.4 5.7 12.3 3.8 0.9 1.9 8.5
Included IgE- and noneIgE-mediated food concerns (eg, eosinophilic esophagitis, food intolerance). b Included eczema, contact dermatitis, and other rashes not consistent with urticaria.
573
Table 3 Reasons for an In-Person Recommendation After TeleAllergy Visit Reason
New TeleAllergy (n ¼ 16)
Follow-up TeleAllergy (n ¼ 3)
Skin testing
Pollen (n ¼ 3), food (n ¼ 3), vaccine (n ¼ 1) Food (n ¼ 2), drug (n ¼ 3) 3
Food (n ¼ 2)
Oral challenge Cluster or rush immunotherapy Asthma
Drug (n ¼ 1)
1
for an in-person visit for skin testing, 12 had a 52-pollen serologic specific IgE performed to an array of seasonal and perennial allergens, and 3 had existing skin or specific IgE testing that was used in the evaluation. No patient who had serologic testing for aeroallergens was subsequently recommended for additional in-person skin testing, and 6 of 10 TeleAllergy sites (60%) supported administration of allergen immunotherapy with regional allergist oversight. To assess patient satisfaction, an anonymous regional telehealth survey was initiated in April 2015 (eFig 1). A total of 58 TeleAllergy visits occurred between April and December 2015 during which time 17 patients (29%) completed a survey. Regarding both “Would you use telehealth again?” and “I am satisfied with my telehealth experience today,” all patients either strongly agreed (16 of 17 [94%]) or agreed (1 of 17 [6%]). When asked, “Will I still have to go see this provider in person,” 6 of 17 (35%) strongly disagreed, 2 of 17 (12%) disagreed, 4 of 17 (24%) were unsure, and 5 of 17 (30%) strongly agreed. On the basis of provider coding and government joint travel regulations, the 112 TeleAllergy visits resulted in 247 work relative value units (wRVUs) and an estimated savings of 200 workdays or schooldays not missed, US$58,000 saved in travel costs, and 80,000 kilometers not driven. With the exception of 1 TeleAllergy encounter occurring at a nearby clinic (50 km), the median distance to the other 9 health clinics was 350 km (range, 107e800 km). Actual appointment time used for TeleAllergy visits compared with in-person visits was not available for evaluation.
Table 4 Comparison Between New and Follow-up TeleAllergy Visits
Female sex Age, mean (SD), y Dedicated presenter Additional TeleAllergy visit In-person visit recommended In-person visit conducted 1 Telephone consultation 1 Medication ordered 1 Laboratory test ordered Potential follow-up time, mean (SD), y Reason for visit Allergic rhinitis Allergen immunotherapy Asthma Food allergy Urticaria/angioedema Drug allergy Atopic dermatitis, eczema, or contact dermatitis Stinging insect allergy Latex allergy Anaphylaxis All other suspected
Initial visit (n ¼ 66)
Follow-up (n ¼ 46)
P value
39 23.4 (15.7) 44 5 16 15 27 33 30 0.50 (0.40)
22 31.8 (13.6) 32 2 3 4 12 15 8 0.66 (0.50)
.30 .004 .84 .70 .02 .07 .11 .08 .002 .07
30 12 7 31 11 6 13
37 33 8 2 5 1 3
<.001 <.001 .40 <.001 .43 .24 .06
4 1 2 9
2 0 1 3
>.99 >.99 >.99 .35
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Table 5 Comparison Between Allergist Diagnoses and In-Person Recommendation for New Consultations In-person visit recommended
No (n ¼ 50)
Yes (n ¼ 16)
P value
Distinct diagnoses per patient, mean (SD)a Allergic rhinitis Asthma Food allergy Urticaria/angioedema Drug allergy Atopic dermatitis, eczema, or contact dermatitis Stinging insect allergy Latex allergy Anaphylaxis All other suspected
1.52 (0.54)
2.38 (1.32)
<.001
23 3 18 10 1 10
7 4 13 1 5 3
>.99 .053 <.001 .27 <.01 >.99
3 0 1 7
1 1 1 2
>.99 .24 .43 >.99
a
Number of distinct allergy clinical conditions diagnosed (maximum, 10).8
Discussion This appears to be the first study to evaluate clinical aspects for both new and follow-up TeleAllergy visits using a “real-time” synchronous platform for the array of allergy referral indications. During a 2-year period, 112 TeleAllergy encounters were conducted, with 66 of 112 (59%) representing new consultations. Overall, TeleAllergy represented a small percentage of all new (4.5%) and follow-up (3.1%) visits to the allergy clinic but increased 270% from 2014 to 2015. Furthermore, based on provider documentation, only 24% of TeleAllergy consultation patients were recommended for an in-person visit. Initially, TeleAllergy was primarily used for annual immunotherapy follow-up but expanded in late 2014 to evaluate all types of allergy consultation. The increase occurred in part because of provider comfort but also because of the EARTH project, which both identified and encouraged specialists to work with dedicated telehealth presenters to develop specialty-specific workflow processes (eg, screening, examination, educational materials). The advantage of synchronous TeleAllergy is that it provides direct interaction with the patient, which has the greatest likelihood of all telehealth modalities to affect the patient-physician relationship and overall patient satisfaction with telemedicine.8 Patient satisfaction reported in this study was extremely high and comparable to a synchronous TeleAllergy asthma study.3 In this study, pediatric TeleAllergy consultation represented 27 of 1,256 regional telehealth consultations (2.1%) for 30 distinct specialties. In comparison, 7% of 1,000 asynchronous pediatric teleconsultations from 2006 to 2009 were for allergy evaluation (C.B. Mahnke, written communication, 2016).9 Another difference between asynchronous and synchronous is the likelihood for an inperson visit. In this study, 6 of 27 new pediatric TeleAllergy consultations (22.2%) were recommended to be in-person, whereas the Mahnke et al10 estimated a 57% to 88% rate for a face-to-face consultation requirement, although the latter represents all specialties, not just allergy/immunology. Understandably, patient satisfaction and need for an in-person visit will likely remain different when comparing asynchronous and synchronous TeleAllergy platforms. Regarding referral indication, this study observed similar reported experience for outpatient allergy consultation with a similarly sized military hospital. In both, chronic rhinitis and food allergy represented 2 of the top 3 consultation reasons. In contrast, TeleAllergy consultation for asthma was significantly lower (4.1% vs 20.4%), whereas referral for urticaria was 4-folder higher (16% vs 4.4%).11 It is unknown why referrals for asthma were lower than expected compared with other referral reasons. One possibility is that the 85% of all regional telehealth involved adults (unpublished data), and these patients could have been referred to
the pulmonologist rather than allergist. Furthermore, none of the outlying 15 clinics could perform pulmonary function testing, which was a surprise and a critical regional need to establish. Of note, only 1 of 7 new patients (14%) with a diagnosis of asthma were recommended for an in-person visit specifically for asthma; 6 of 7 were taking appropriate medication and were determined to have good control based on current guidelines. In addition, TeleAllergy will likely be limited for certain diagnoses, hence the need for an in-person visit. Patients with a diagnosis of either food allergy or drug allergy were significantly more likely to be recommended for an in-person visit. This finding likely reflects the consideration for skin prick testing as part of the initial assessment for food, venom, or drug allergy. Similarly, an inperson visit would be recommended for drug challenges, food challenges, and rush immunotherapy. A specific consideration regarding the patient population in this study (ie, military beneficiaries) is that they may often choose whether to receive their care within a military hospital or with a civilian provider; however, current guidelines require them to be seen at a military hospital for specialty services, such as an allergist if the specialist has an appointment that can be booked within 28 days and who is within a travel distance of 167 km (100 miles). Otherwise, a military beneficiary could be seen by a specialist close to their residence or choose to pay to travel. A total of 88 of 112 TeleAllergy encounters (79%) occurred with a clinic located farther than 167 km, but 14 of 19 (74%) of this group of patients who were recommended for an in-person visit were willing to travel, supporting the likely acceptance of synchronous TeleAllergy for the initial visit.6,8 When interpreting the results of this study, there are a number of aspects and limitations that should be considered. First, TeleAllergy was conducted with the support of a regional telehealth office, which provided equipment, education, training, competency assessment, personnel, and dedicated presenters. As seen with TeleAllergy for asthma, dedicated telehealth presenters can streamline processes while providing specialty-specific education.3,4 These dedicated presenters also handled all aspects of the physical examination, patient education, handouts, and specific consent forms (eg, omalizumab, allergen immunotherapy), whereas clinics without a dedicated presenter could only support the initial intake with a limited presentation and physical examination. Second, the regional telehealth office created a shared electronic appointment scheduling calendar and video teleconference bridge, allowing clinic staff to easily match provider’s clinic schedules with telehealth cart locations and times. Allergists, primary care clinics, and patients all received a secure, HIPAA-compliant e-mail notification regarding appointment location and time, which is likely a major reason why there was only 1 “no-show” (0.9%). Third, both military primary care providers and allergists use the same electronic health record, which allows immediate e-access to each primary care clinic pharmacy and laboratory, thereby overcoming one barrier associated with telehealth: adherence with testing and obtaining medication(s). Although patients overwhelmingly recommended TeleAllergy, certain scenarios will undoubtedly require an in-person visit as evidenced in this study. Skin testing and oral challenges were the most common reasons. In addition, TeleAllergy consultations were allotted 45 minutes, whereas follow-up TeleAllergy were 30-minute appointments. Most “brick-and-mortar” allergists would likely see 2 to 4 new patients or more in that timeframe, which will need to be taken into account when comparing the two.3 Although 274 total wRVUs were generated (2.4 wRVUs per TeleAllergy encounter), most cost savings obtained was from indirect costs (eg, time from work or school, travel costs, etc.).2,9
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One clear barrier for TeleAllergy when compared with the typical “brick-and-mortar” visit is whether the patient or provider perceives a compromise in care. Both patients and providers involved this study were extremely receptive and satisfied with TeleAllergy, but disease-specific outcomes were not compared because the study’s intent was to describe TeleAllergy referral indications, feasibility, provider recommendation for in-person visit, and patient acceptance. Specific disease outcomes were not the primary or secondary objective of this study, and each clinical condition evaluated will likely require a separate study powered to assess differences between matched in-person and TeleAllergy cohorts powered to assess noninferiority. However, when considering whether TeleAllergy, compared with an in-person visit, would result in suboptimal management, physicians should include specific evaluations on all aspects of a patient’s visit (eg, cost, time, expectations, specific diagnosis, likelihood for adherence with prescribed medication regimens, follow-up needs) not just specific disease outcomes. Finally, one recognized gap is that not all allergic disorders have validated outcome assessments (eg, Asthma Control Test, SCORing Atopic Dermatitis, Urticaria Control Test, Sino-Nasal Outcome Test 22), which some may conclude to be a barrier to TeleAllergy. A final consideration was the in-person visit recommendation, which was based on allergist documentation in the electronic medical record. Although all 3 board-certified allergists were trained in 1 of 2 military allergy/immunology fellowship programs, individual decisions based on comfort level, expertise, or individual patient or encounter dynamics could have influenced individual recommendations. Each encounter was reviewed in duplicate, but study investigator bias may have also influenced interpretation of written assessment and plans. Of note, although the study author evaluated most TeleAllergy consultations (61%), the investigator also represented the allergist with the highest percentage recommended for in-person visits for both new and follow up TeleAllergy visits (Table 1). Certainly, each allergist’s recommendations represent one’s practice habits, and caution is advised regarding generalizing this study’s findings and observations to other practicing allergists. This 2-year regional synchronous TeleAllergy experience found that TeleAllergy accounted for 3.8% of all allergy clinic visits with
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significant year-to-year increases. Both new and follow-up visits to the allergist/immunologist were well received by patients and indicated significant indirect cost savings, with only a few patients recommended for an in-person visit. Continued refinement regarding patient selection and identifying TeleAllergy-specific barriers is recommended to leverage this health care technology, with the knowledge that allergic disorders are increasing and the projected allergist workforce is decreasing.12
Supplementary Data Supplementary data related to this article can be found at http:// dx.doi.org/10.1016/j.anai.2016.03.028.
References [1] Portnoy J, Waller M, Dinaker C. TeleAllergy: a new way to manage asthma. J Allergy Clin Immunol Pract. 2015;3:302e303. [2] Karp WB, Grigsby RK, McSwiggan-Harden M, et al. Use of telemedicine for children with special health care needs. Pediatrics. 2000;105(4, pt 1): 843e847. [3] Bergman DA, Sharek PJ, Ekegren K, Thyne S, Mayer M, Saunders M. The use of telemedicine access to schools to facilitate expert assessment of children with asthma. Int J Telemed Appl. 2008;2008:159276. [4] Brown W, Odenthal D. The uses of telemedicine to improve asthma control. J Allergy Clin Immunol Pract. 2015;3:300e301. [5] Romano MJ, Hernandez J, Gaylor A, Howard S, Knox R. Improvement in asthma symptoms and quality of life in pediatric patients through specialty care delivered via telemedicine. Telemed J E Health. 2001;7:281e286. [6] Bloomrosen M, Sennett C. Patient engagement: challenges and opportunities for physicians. Ann Allergy Asthma Immunol. 2015;115:459e462. [7] Army Telehealth website. http://armymedicine.mil/Pages/telehealth.aspx. Accessed January 31, 2016. [8] Landstuhl Regional Medical Center Allergy/Immunization home page. http:// rhce.amedd.army.mil/landstuhl/services.cfm?MTFinfo_id¼838. Accessed January 31, 2016. [9] Weinstock MA, Nguyen FQ, Risica PM. Patient and referring provider satisfaction with teledermatology. J Am Acad Dermatol. 2002;47:68e72. [10] Mahnke CB, Jordan CP, Bergvall E, Person DA, Pinsker JE. The Pacific Asynchronous TeleHealth (PATH) system: review of 1,000 pediatric teleconsultations. Telemed J E Health. 2011;17:35e39. [11] Dietrich JJ, Quinn JM, England RW. Reasons for outpatient consultation in allergy/immunology. Allergy Asthma Proc. 2009;30:69e74. [12] https://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20Documents/Practice %20and%20Parameters/2012-AI-Physician-Workforce-Report.pdf. Accessed January 31, 2016.
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eFigure 1. Telehealth survey.
Contents lists available at ScienceDirect
Synchronous telehealth for outpatient allergy consultations A 2-year regional experience Kirk H. Waibel, MD Allergy Service, Division of Medicine, Landstuhl Regional Medical Center, Landstuhl, Germany
A R T I C L E
I N F O
Article history: Received for publication February 11, 2016. Received in revised form March 13, 2016. Accepted for publication March 25, 2016.
A B S T R A C T
Background: Telehealth continues to advance as a health care modality; however, reported experience for synchronous TeleAllergy is limited. Objective: To determine the percentage of new and follow-up visits conducted via TeleAllergy in a hospitalbased clinic. Methods: A retrospective study evaluating the first 2 years of a synchronous patient-to-allergist TeleAllergy platform. Results: A total of 112 synchronous TeleAllergy encounters were conducted from January 2014 through December 2015; 66 (59%) of these were new consultations. The mean (SD) age was 26.9 (15.3) years, and 54% of the participants were female. Food allergy (30%), allergic rhinitis (20%), and urticaria (16%) represented the top 3 consultation reasons. Sixteen of 66 patients (24.2%) and 3 of 46 patients (6.5%) attending new and follow-up TeleAllergy visits, respectively, were recommended for an in-person appointment (P ¼ .02). No difference was found between new and follow-up TeleAllergy visits regarding subsequent telephone communication (41% vs 26%, P ¼ .11) or prescriptions ordered (50% vs 33%, P ¼ .08). New TeleAllergy visits were more likely to have more than 1 laboratory test ordered (45% vs 17%, P ¼ .002). On the basis of patient location, the 112 TeleAllergy visits resulted in an estimated savings of 200 workdays or schooldays, US$58,000 in travel-related costs, and 80,000 kilometers not driven. Conclusion: Both new and follow-up visits to the allergist/immunologist were well received by patients and demonstrated significant indirect cost savings, with less than one fourth of the patients recommended for an in-person visit. This appears to be the first systematic assessment of TeleAllergy for new and follow-up patient encounters in a clinic-based allergy/immunology practice. Published by Elsevier Inc. on behalf of the American College of Allergy, Asthma & Immunology.
Introduction Telehealth for allergy/immunology includes multiple modalities (eg, telephone, secure e-mail, asynchronous store and forward, synchronous patient to provider, and mobile applications); however, the reported use of synchronous TeleAllergy has been limited.1 Compared with asynchronous telehealth (also called store and forward), which is a provider-to-provider interaction without the patient involved, synchronous TeleAllergy involves a direct, real-time patient-to-provider encounter. An initial report of 333 synchronous telehealth encounters found that 35% of all encounters were specific for allergy/immunology, but the specific diagnoses and outcomes were not reported.2 More recent studies Reprints: Kirk H. Waibel, MD, Allergy Service, Division of Medicine, Landstuhl Regional Medical Center, MCEUL-LSL-M-A, CMR 402, APO AE 09180; E-mail: Kirk.h. [email protected]. Disclosures: Author has nothing to disclose. Disclaimer: The opinions or assertions herein are the private views of the authors and not to be construed as reflecting the views of the US Department of the Army, US Department of the Air Force, or the US Department of Defense.
using a synchronous platform have been specific for asthma or asthma education without discussion of other allergy/immunology referral indications.3e5 With a recent perspective article highlighting patient’s increasing desire to be directly engaged in their medical care, synchronous TeleAllergy can provide direct engagement with the allergist that is patient centric and provided within the patient’s own primary care clinic.6 However, despite most hospitals listing allergy/immunology as a telehealth capability, there have been no published reports describing TeleAllergy as a synchronous platform for both new consultations and follow-up allergy evaluations for the array of allergy indications. This study retrospectively reports the outcomes of a 2-year regional, synchronous TeleAllergy platform that evaluated both new and follow-up patients. Methods Telehealth is a specific health care modality that the US Army Medical Command has placed specific priority with the establishment of a Telehealth Service Line in 2010.7 Currently, there are 5
http://dx.doi.org/10.1016/j.anai.2016.03.028 1081-1206/Published by Elsevier Inc. on behalf of the American College of Allergy, Asthma & Immunology.
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regional medical commands that use synchronous and asynchronous telehealth but only 1 that conducts synchronous TeleAllergy: the Regional Health Command Europe (RHC-E). TeleAllergy in the RHC-E was supported by 3 board-certified allergists located at Landstuhl Regional Medical Center (LRMC). The LRMC supports approximately 100,000 beneficiaries across 15 primary care clinics located in Germany, Italy, and Belgium. Before 2015, telehealth efforts in the RHC-E were focused on behavioral health and surgical subspecialties; however, in late 2014 the European Advancement for Regional Telehealth (EARTH) project was launched, hiring 3 specifically trained telehealth presenters who supported a comprehensive medical, surgical, and behavioral health telemedicine platform. From January 2014 through December 2015, 30 distinct specialties, including allergy/immunology, were engaged in synchronous telehealth, resulting in a total of 3,933 encounters. Allergists located in the LRMC allergy/immunization outpatient clinic were provided synchronous telehealth education and training by a regional telehealth office, developed TeleAllergyspecific procedures, and were credentialed at all patient locations. All consultations to the allergy/immunology service were reviewed by 1 of 3 board-certified allergists. Clinic booking staff then offered patients the choice to have their appointment conducted in-person or via TeleAllergy at the time of appointment booking based on patient preference, primary care provider preference, or allergist recommendation based on the patient located in a remote clinic site. The primary outcome was to determine the percentage of new and follow-up visits conducted via TeleAllergy. Secondary outcomes included determining the specific referral indication(s) based on current clinic referral guidelines,8 percentage of patients who required an in-person visit, and additional recommendations (eg, medication, laboratory testing). Additional patient-to-provider interactions, including additional TeleAllergy visits, in-person visits, or telephone follow-up, were determined through review of the patient’s electronic health record. All TeleAllergy encounters were reviewed in duplicate by the investigator. All telehealth visits required written patient or parental consent, and study approval was obtained by the LRMC Human Research Protection Program. TeleAllergy visits conducted between patients and providers were performed on a secure, Health Insurance Portability and Accountability Act (HIPAA)ecompliant video link. Primary care medical homes supporting telehealth had one standardized Polycom HDX 9000 Practitioner cart (Polycom Inc, San Jose, California), which included an AMD-2500 General Exam Camera, AMD Fiberoptic Otoscope, and AMD Telephonic Stethoscope (AMD Global Telemedicine Corporation, Chelmsford, Massachusetts). Allergists used a desktop computer installed with Polycom RealPresence software and camera (Polycom Inc). Evaluation and management coding was based on provider documentation and reviewed by hospital coding staff assigned to the clinic. Per current telehealth guidance, all clinic encounters at the patient site are coded as a 99499 visit with a Healthcare Common Procedure Coding System Q3014 added. A GT modifier (via interactive audio and video telecommunications systems) is added to the allergist’s TeleAllergy note. New TeleAllergy visits were allotted 45 minutes, whereas follow-up visits were given 30 minutes to allow synchronization between provider schedules and available telehealth cart time. Briefly, patients arriving at their primary care clinic for a TeleAllergy visit followed normal clinic operating procedures (ie, checked in, 2-patient identifier verification, placed in a HIPAAcompliant examination room, vital signs measured, medication reconciliation, and consented for telehealth). At the allotted appointment time, both the originating site where the patient was located and the distant site (LRMC) dialed in to a video conference bridge. At that time good audio and video was established, a unique access code was provided to both parties, and the video bridge
signed out, which locks the virtual examination room. Again, 2-patient identifier, a 2016 Ambulatory Care National Patient Safety Goal, is established by the allergist, and the appointment begins. Content, such as educational slides for specific diagnoses, can be virtually shared or e-mailed to the patient presenter for printing. At the request of the allergist, the presenter can perform a physical examination using a high-definition camera taking appropriate pictures to be added to the clinical note and perform any aspects of the physical examination with the exception of palpation or percussion. Estimated travel costs were determined using current government per diem reimbursement rates for lodging, meals, and privately operated vehicle mileage reimbursement. Maximum reimbursement for hotel, meals, and incidentals ranged from $353.00 to $275.00 per day from January 2014 to December 2015, whereas reimbursement for driving ranged from $0.56 to $0.575 per mile driven. Statistical analysis was performed using free statistical software (www.socscistatistics.com). Descriptive statistics were used to assess primary and secondary outcomes. TeleAllergy patients were provided an anonymous 16-question regional telehealth survey using a 5-point Likert scale (eFig 1). A 2-tailed t test for independent samples was used for new and follow-up TeleAllergy visits to compare continuous variables, whereas categorical outcomes were assessed with either a c2 or Fisher exact test. An a <.05 was considered significant. Results A total of 112 TeleAllergy encounters for 105 unique patients were conducted from January 2014 through December 2015. A total of 61 of the 112 patients (54%) were female. The age range was 12 months to 58 years, with a mean (SD) age of 26.9 (15.3) years. A total of 76 of the 112 patients (68%) were adults. Patients were located in 10 primary care clinics: 1 in Italy, 2 in Belgium, and 7 in Germany. During the 2-year study period, 3 distinct board-certified allergists overlapped for different lengths of time based on required military moves, resulting in different numbers and types of patients evaluated (Table 1). TeleAllergy visits were conducted in 10 of 15 telehealth-capable clinics (67%), but 76 of 112 visits (68%) occurred in 1 of 3 locations with a dedicated telehealth nurse. A total of 66 of the 112 TeleAllergy appointments (59%) were new consultations; adults accounted for 39 consultations (59%). All 66 allergy consultations (100%) were placed by the patient’s primary care provider. New consultation and follow-up TeleAllergy encounters represented 4.5% (n ¼ 66 of 1,471) and 3.1% (n ¼ 46 of 1,461) of all patient encounters (TeleAllergy and in-person) during this period, respectively. Furthermore, TeleAllergy encounters represented 2.8% (n ¼ 112 of 3,933) of all regional telehealth encounters between patients and 30 distinct specialties during this period. Mean (SD) monthly TeleAllergy encounters were 4.7 (3.2). Compared with 2014, mean (SD) TeleAllergy encounters per month in 2015 (6.4 [3.3] vs 2.9 [1.9], P ¼ .004) and a percentage of all clinic Table 1 Provider Characteristics Characteristic
Time in clinic, mo New visits, No. (%) New patients recommended for in-person visits, No. (%) Follow-up visits, No. (%) Follow-up patients recommended for in-person visits, No. (%)
Provider A
B
C
18 12 (18) 3 (25)
24 40 (61) 11 (28)
3 14 (21) 2 (14)
17 (37) 0 (0)
24 (52) 3 (12.5)
5 (11) 0 (0)
K.H. Waibel / Ann Allergy Asthma Immunol 116 (2016) 571e575
visits (6.0 [3.8] vs 2.1 [1.2], P ¼.004) increased. In addition, more new TeleAllergy visits were conducted in 2015 than 2014 (53 of 78 [68%] vs 13 of 34 [38%], P ¼ .01). New consultations were requested for 71 reasons (1.1 per patient): food allergy (30%), allergic rhinitis (20%), and urticaria (16%) represented the top 3. New consultations requested 90% (n ¼ 9/10) of current referral indications.8 In addition to the 71 reasons for consultation, an additional 43 allergy-related diagnoses were identified (Table 2). A total of 19 of 112 TeleAllergy patients (17%) were recommended for an in-person appointment. New TeleAllergy patients were more likely to be recommended for an in-person visit compared with follow-up TeleAllergy patients (16 of 66 [24.2%] vs 3 of 46 [6.5%], P ¼ .02). The most common reasons for recommending an in-person visit were skin prick testing (n ¼ 9) or oral challenge (n ¼ 6) (Table 3). In total, 11 of 16 new patients (69%) and 3 of 3 follow-up patients (100%) who were recommended for an inperson visit traveled to the clinic during the study period. Regarding follow up, 39 of 66 new consultations (59%) had 1 or more type of follow-up. Five of 66 (7.6%) had 1 follow-up TeleAllergy visit, 11 (16.7%) had an in-person visit, and 27 (40.9%) had telephone follow-up. New TeleAllergy consultations were more likely than follow-up TeleAllergy to have subsequent telephone communication, but this finding was not statistically significant (40.9% versus 26.1%, P ¼ .11). A total of 43% and 34% of all TeleAllergy patients had 1 or more medication or laboratory test, respectively (Table 4). Furthermore, patients were more likely to be recommended for an in-person visit if they had multiple allergy diagnoses (P < .001), food allergy (P < .001), or drug allergy (P < .01) (Table 5). Significant differences were observed between new and followup TeleAllergy visits regarding patient demographics, reason(s) for visit, and recommendations. New TeleAllergy visits involved younger patients (P ¼ .004), these patients were more likely to be evaluated for food allergy (P < .001), and these patients more often had 1 or more laboratory test (P ¼ .002). Specifically, for allergic rhinitis as the TeleAllergy indication, 45 of 67 patients (67%) were undergoing subcutaneous allergen immunotherapy (SCIT); no patients were undergoing sublingual immunotherapy. Thirty-three of 46 follow-up encounters (72%) were conducted for an annual immunotherapy visit compared with 12 of 66 new allergic rhinitis consultations (18%) (P < .001) All 12 new consultations specifically for patients undergoing SCIT were for patients who had moved into the area already undergoing SCIT started by another military allergist. For the 18 new patients who were evaluated for allergic rhinitis but not currently undergoing SCIT, 3 were recommended
Table 2 Primary Care Provider Referral Indication and Allergist Assessment for 66 New Consultations Indication
Initial referral indication, No. (%)
Allergist assessment, No. (%)
Allergic rhinitis Asthma Food allergya Urticaria/angioedema Drug allergy Rashb Stinging insect Latex allergy Anaphylaxis All other Total
15 3 22 12 4 8 1 0 2 4 71
30 7 31 11 6 13 4 1 2 9 114
a
20.3 4.1 29.7 16.2 5.4 10.8 1.4 0.0 2.7 5.4
28.3 6.6 29.2 10.4 5.7 12.3 3.8 0.9 1.9 8.5
Included IgE- and noneIgE-mediated food concerns (eg, eosinophilic esophagitis, food intolerance). b Included eczema, contact dermatitis, and other rashes not consistent with urticaria.
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Table 3 Reasons for an In-Person Recommendation After TeleAllergy Visit Reason
New TeleAllergy (n ¼ 16)
Follow-up TeleAllergy (n ¼ 3)
Skin testing
Pollen (n ¼ 3), food (n ¼ 3), vaccine (n ¼ 1) Food (n ¼ 2), drug (n ¼ 3) 3
Food (n ¼ 2)
Oral challenge Cluster or rush immunotherapy Asthma
Drug (n ¼ 1)
1
for an in-person visit for skin testing, 12 had a 52-pollen serologic specific IgE performed to an array of seasonal and perennial allergens, and 3 had existing skin or specific IgE testing that was used in the evaluation. No patient who had serologic testing for aeroallergens was subsequently recommended for additional in-person skin testing, and 6 of 10 TeleAllergy sites (60%) supported administration of allergen immunotherapy with regional allergist oversight. To assess patient satisfaction, an anonymous regional telehealth survey was initiated in April 2015 (eFig 1). A total of 58 TeleAllergy visits occurred between April and December 2015 during which time 17 patients (29%) completed a survey. Regarding both “Would you use telehealth again?” and “I am satisfied with my telehealth experience today,” all patients either strongly agreed (16 of 17 [94%]) or agreed (1 of 17 [6%]). When asked, “Will I still have to go see this provider in person,” 6 of 17 (35%) strongly disagreed, 2 of 17 (12%) disagreed, 4 of 17 (24%) were unsure, and 5 of 17 (30%) strongly agreed. On the basis of provider coding and government joint travel regulations, the 112 TeleAllergy visits resulted in 247 work relative value units (wRVUs) and an estimated savings of 200 workdays or schooldays not missed, US$58,000 saved in travel costs, and 80,000 kilometers not driven. With the exception of 1 TeleAllergy encounter occurring at a nearby clinic (50 km), the median distance to the other 9 health clinics was 350 km (range, 107e800 km). Actual appointment time used for TeleAllergy visits compared with in-person visits was not available for evaluation.
Table 4 Comparison Between New and Follow-up TeleAllergy Visits
Female sex Age, mean (SD), y Dedicated presenter Additional TeleAllergy visit In-person visit recommended In-person visit conducted 1 Telephone consultation 1 Medication ordered 1 Laboratory test ordered Potential follow-up time, mean (SD), y Reason for visit Allergic rhinitis Allergen immunotherapy Asthma Food allergy Urticaria/angioedema Drug allergy Atopic dermatitis, eczema, or contact dermatitis Stinging insect allergy Latex allergy Anaphylaxis All other suspected
Initial visit (n ¼ 66)
Follow-up (n ¼ 46)
P value
39 23.4 (15.7) 44 5 16 15 27 33 30 0.50 (0.40)
22 31.8 (13.6) 32 2 3 4 12 15 8 0.66 (0.50)
.30 .004 .84 .70 .02 .07 .11 .08 .002 .07
30 12 7 31 11 6 13
37 33 8 2 5 1 3
<.001 <.001 .40 <.001 .43 .24 .06
4 1 2 9
2 0 1 3
>.99 >.99 >.99 .35
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Table 5 Comparison Between Allergist Diagnoses and In-Person Recommendation for New Consultations In-person visit recommended
No (n ¼ 50)
Yes (n ¼ 16)
P value
Distinct diagnoses per patient, mean (SD)a Allergic rhinitis Asthma Food allergy Urticaria/angioedema Drug allergy Atopic dermatitis, eczema, or contact dermatitis Stinging insect allergy Latex allergy Anaphylaxis All other suspected
1.52 (0.54)
2.38 (1.32)
<.001
23 3 18 10 1 10
7 4 13 1 5 3
>.99 .053 <.001 .27 <.01 >.99
3 0 1 7
1 1 1 2
>.99 .24 .43 >.99
a
Number of distinct allergy clinical conditions diagnosed (maximum, 10).8
Discussion This appears to be the first study to evaluate clinical aspects for both new and follow-up TeleAllergy visits using a “real-time” synchronous platform for the array of allergy referral indications. During a 2-year period, 112 TeleAllergy encounters were conducted, with 66 of 112 (59%) representing new consultations. Overall, TeleAllergy represented a small percentage of all new (4.5%) and follow-up (3.1%) visits to the allergy clinic but increased 270% from 2014 to 2015. Furthermore, based on provider documentation, only 24% of TeleAllergy consultation patients were recommended for an in-person visit. Initially, TeleAllergy was primarily used for annual immunotherapy follow-up but expanded in late 2014 to evaluate all types of allergy consultation. The increase occurred in part because of provider comfort but also because of the EARTH project, which both identified and encouraged specialists to work with dedicated telehealth presenters to develop specialty-specific workflow processes (eg, screening, examination, educational materials). The advantage of synchronous TeleAllergy is that it provides direct interaction with the patient, which has the greatest likelihood of all telehealth modalities to affect the patient-physician relationship and overall patient satisfaction with telemedicine.8 Patient satisfaction reported in this study was extremely high and comparable to a synchronous TeleAllergy asthma study.3 In this study, pediatric TeleAllergy consultation represented 27 of 1,256 regional telehealth consultations (2.1%) for 30 distinct specialties. In comparison, 7% of 1,000 asynchronous pediatric teleconsultations from 2006 to 2009 were for allergy evaluation (C.B. Mahnke, written communication, 2016).9 Another difference between asynchronous and synchronous is the likelihood for an inperson visit. In this study, 6 of 27 new pediatric TeleAllergy consultations (22.2%) were recommended to be in-person, whereas the Mahnke et al10 estimated a 57% to 88% rate for a face-to-face consultation requirement, although the latter represents all specialties, not just allergy/immunology. Understandably, patient satisfaction and need for an in-person visit will likely remain different when comparing asynchronous and synchronous TeleAllergy platforms. Regarding referral indication, this study observed similar reported experience for outpatient allergy consultation with a similarly sized military hospital. In both, chronic rhinitis and food allergy represented 2 of the top 3 consultation reasons. In contrast, TeleAllergy consultation for asthma was significantly lower (4.1% vs 20.4%), whereas referral for urticaria was 4-folder higher (16% vs 4.4%).11 It is unknown why referrals for asthma were lower than expected compared with other referral reasons. One possibility is that the 85% of all regional telehealth involved adults (unpublished data), and these patients could have been referred to
the pulmonologist rather than allergist. Furthermore, none of the outlying 15 clinics could perform pulmonary function testing, which was a surprise and a critical regional need to establish. Of note, only 1 of 7 new patients (14%) with a diagnosis of asthma were recommended for an in-person visit specifically for asthma; 6 of 7 were taking appropriate medication and were determined to have good control based on current guidelines. In addition, TeleAllergy will likely be limited for certain diagnoses, hence the need for an in-person visit. Patients with a diagnosis of either food allergy or drug allergy were significantly more likely to be recommended for an in-person visit. This finding likely reflects the consideration for skin prick testing as part of the initial assessment for food, venom, or drug allergy. Similarly, an inperson visit would be recommended for drug challenges, food challenges, and rush immunotherapy. A specific consideration regarding the patient population in this study (ie, military beneficiaries) is that they may often choose whether to receive their care within a military hospital or with a civilian provider; however, current guidelines require them to be seen at a military hospital for specialty services, such as an allergist if the specialist has an appointment that can be booked within 28 days and who is within a travel distance of 167 km (100 miles). Otherwise, a military beneficiary could be seen by a specialist close to their residence or choose to pay to travel. A total of 88 of 112 TeleAllergy encounters (79%) occurred with a clinic located farther than 167 km, but 14 of 19 (74%) of this group of patients who were recommended for an in-person visit were willing to travel, supporting the likely acceptance of synchronous TeleAllergy for the initial visit.6,8 When interpreting the results of this study, there are a number of aspects and limitations that should be considered. First, TeleAllergy was conducted with the support of a regional telehealth office, which provided equipment, education, training, competency assessment, personnel, and dedicated presenters. As seen with TeleAllergy for asthma, dedicated telehealth presenters can streamline processes while providing specialty-specific education.3,4 These dedicated presenters also handled all aspects of the physical examination, patient education, handouts, and specific consent forms (eg, omalizumab, allergen immunotherapy), whereas clinics without a dedicated presenter could only support the initial intake with a limited presentation and physical examination. Second, the regional telehealth office created a shared electronic appointment scheduling calendar and video teleconference bridge, allowing clinic staff to easily match provider’s clinic schedules with telehealth cart locations and times. Allergists, primary care clinics, and patients all received a secure, HIPAA-compliant e-mail notification regarding appointment location and time, which is likely a major reason why there was only 1 “no-show” (0.9%). Third, both military primary care providers and allergists use the same electronic health record, which allows immediate e-access to each primary care clinic pharmacy and laboratory, thereby overcoming one barrier associated with telehealth: adherence with testing and obtaining medication(s). Although patients overwhelmingly recommended TeleAllergy, certain scenarios will undoubtedly require an in-person visit as evidenced in this study. Skin testing and oral challenges were the most common reasons. In addition, TeleAllergy consultations were allotted 45 minutes, whereas follow-up TeleAllergy were 30-minute appointments. Most “brick-and-mortar” allergists would likely see 2 to 4 new patients or more in that timeframe, which will need to be taken into account when comparing the two.3 Although 274 total wRVUs were generated (2.4 wRVUs per TeleAllergy encounter), most cost savings obtained was from indirect costs (eg, time from work or school, travel costs, etc.).2,9
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One clear barrier for TeleAllergy when compared with the typical “brick-and-mortar” visit is whether the patient or provider perceives a compromise in care. Both patients and providers involved this study were extremely receptive and satisfied with TeleAllergy, but disease-specific outcomes were not compared because the study’s intent was to describe TeleAllergy referral indications, feasibility, provider recommendation for in-person visit, and patient acceptance. Specific disease outcomes were not the primary or secondary objective of this study, and each clinical condition evaluated will likely require a separate study powered to assess differences between matched in-person and TeleAllergy cohorts powered to assess noninferiority. However, when considering whether TeleAllergy, compared with an in-person visit, would result in suboptimal management, physicians should include specific evaluations on all aspects of a patient’s visit (eg, cost, time, expectations, specific diagnosis, likelihood for adherence with prescribed medication regimens, follow-up needs) not just specific disease outcomes. Finally, one recognized gap is that not all allergic disorders have validated outcome assessments (eg, Asthma Control Test, SCORing Atopic Dermatitis, Urticaria Control Test, Sino-Nasal Outcome Test 22), which some may conclude to be a barrier to TeleAllergy. A final consideration was the in-person visit recommendation, which was based on allergist documentation in the electronic medical record. Although all 3 board-certified allergists were trained in 1 of 2 military allergy/immunology fellowship programs, individual decisions based on comfort level, expertise, or individual patient or encounter dynamics could have influenced individual recommendations. Each encounter was reviewed in duplicate, but study investigator bias may have also influenced interpretation of written assessment and plans. Of note, although the study author evaluated most TeleAllergy consultations (61%), the investigator also represented the allergist with the highest percentage recommended for in-person visits for both new and follow up TeleAllergy visits (Table 1). Certainly, each allergist’s recommendations represent one’s practice habits, and caution is advised regarding generalizing this study’s findings and observations to other practicing allergists. This 2-year regional synchronous TeleAllergy experience found that TeleAllergy accounted for 3.8% of all allergy clinic visits with
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significant year-to-year increases. Both new and follow-up visits to the allergist/immunologist were well received by patients and indicated significant indirect cost savings, with only a few patients recommended for an in-person visit. Continued refinement regarding patient selection and identifying TeleAllergy-specific barriers is recommended to leverage this health care technology, with the knowledge that allergic disorders are increasing and the projected allergist workforce is decreasing.12
Supplementary Data Supplementary data related to this article can be found at http:// dx.doi.org/10.1016/j.anai.2016.03.028.
References [1] Portnoy J, Waller M, Dinaker C. TeleAllergy: a new way to manage asthma. J Allergy Clin Immunol Pract. 2015;3:302e303. [2] Karp WB, Grigsby RK, McSwiggan-Harden M, et al. Use of telemedicine for children with special health care needs. Pediatrics. 2000;105(4, pt 1): 843e847. [3] Bergman DA, Sharek PJ, Ekegren K, Thyne S, Mayer M, Saunders M. The use of telemedicine access to schools to facilitate expert assessment of children with asthma. Int J Telemed Appl. 2008;2008:159276. [4] Brown W, Odenthal D. The uses of telemedicine to improve asthma control. J Allergy Clin Immunol Pract. 2015;3:300e301. [5] Romano MJ, Hernandez J, Gaylor A, Howard S, Knox R. Improvement in asthma symptoms and quality of life in pediatric patients through specialty care delivered via telemedicine. Telemed J E Health. 2001;7:281e286. [6] Bloomrosen M, Sennett C. Patient engagement: challenges and opportunities for physicians. Ann Allergy Asthma Immunol. 2015;115:459e462. [7] Army Telehealth website. http://armymedicine.mil/Pages/telehealth.aspx. Accessed January 31, 2016. [8] Landstuhl Regional Medical Center Allergy/Immunization home page. http:// rhce.amedd.army.mil/landstuhl/services.cfm?MTFinfo_id¼838. Accessed January 31, 2016. [9] Weinstock MA, Nguyen FQ, Risica PM. Patient and referring provider satisfaction with teledermatology. J Am Acad Dermatol. 2002;47:68e72. [10] Mahnke CB, Jordan CP, Bergvall E, Person DA, Pinsker JE. The Pacific Asynchronous TeleHealth (PATH) system: review of 1,000 pediatric teleconsultations. Telemed J E Health. 2011;17:35e39. [11] Dietrich JJ, Quinn JM, England RW. Reasons for outpatient consultation in allergy/immunology. Allergy Asthma Proc. 2009;30:69e74. [12] https://www.aaaai.org/Aaaai/media/MediaLibrary/PDF%20Documents/Practice %20and%20Parameters/2012-AI-Physician-Workforce-Report.pdf. Accessed January 31, 2016.
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eFigure 1. Telehealth survey.