Launch of telemedicine in community oncology practice

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Background: Tennessee Oncology (TO) is a community medical, radiation and gynecology oncology practice with 90 physicians and 40 advanced practice providers (APPs) in 33 locations in Tennessee. TO participates in the Oncology Care Model (OCM), a CMMI experimental payment model to improve access, quality of care, patient experience and lower costs. Methods: To promote provider-patient communication to improve outcomes and lower healthcare costs, TO launched a telemedicine pilot. The pilot was designed to understand Tennessee’s rules and regulations, reimbursement policies for Medicare, Medicaid and commercial payers and technology requirements. As survivorship was aligned with clinical workflow, supported by existing technology and required minimal staff training, the Survivorship Program for OCM was selected as proof of concept for telemedicine. Education surrounding Survivorship is required as part of the OCM model. A portion of the MEOS payment was considered as reimbursement for this initiative. The goal was to increase the delivery and review of survivorship documents to eligible breast cancer patients using the telemedicine platform from 0% to 80%. Results: 4000 potential patients were eligible for survivorship visits within TO. The selection was narrowed to include only OCM patients with breast cancer. TO identified 4 APPs who were given special training. TO’s front office staff coordinated scheduling of the technology, provider and space available. There were 99 patients eligible for a Telemedicine visit. 36 patients completed a Telemedicine visit with 23 patients declining. 19 patients did not respond to requests for these visits. 10 patients completed surveys and were 100% satisfied with their visits. The APPs felt Telemedicine visits were more productive than in person visits. Conclusions: Telemedicine is an effective tool for delivery of health care. There are challenges that make this technology difficult to implement such as reimbursement and limitations to the use of technology in elderly. In our pilot we found that the APPs and patients found this to be an effective way of communication and delivery of care. In the future telemedicine could answer some of the shortages in health care delivery and could also improve coordination of care.

The path to simulated learning: developing a valid and reliable tool to evaluate performance of radiological technology students in patient interactions

BACKGROUND

Simulation-enhanced education is being used in many health care curricula as an answer to an increasing demand for allied health professionals and a paucity of clinical sites crucial to providing requisite clinical education. The effective use of simulation may reduce and provide better use of the time required in clinical environments. If the use of simulation is to become a valuable addition to traditional clinical experiential learning, a reliable and valid measurement tool designed to measure a radiological technologist's performance in a practice environment is vital.

OBJECTIVE

This study assessed the reliability of a clinical competency evaluation tool used in the radiological technology setting. The objective was to determine the inter-rater reliability of the evaluation tool as applied to six clinical scenarios.

METHODS

In order to test the clinical competency evaluation tool, standardized patients portrayed radiological technologists and patients in six videotaped scenarios depicting one-on-one interactions between these two groups. Nine trained and qualified participants watched the videos and used the study tool to evaluate each radiological technologist's clinical communication competency.

RESULTS

Inter-rater and intraclass correlations were generated to examine the internal consistency of rater scores on the videotaped scenarios. Face and content validity were established through an authenticity exercise involving content educator experts.

CONCLUSION

Overall, this tool was shown to be a reliable, valid, feasible, and usable methodology to assess communication skills with clinical students. Further investigation of the tool is required to examine the tool's ability to reliably identify borderline or mixed skill level students under cultural and non-culture-based scenarios.

Electrocardiographic ST-segment elevation: the diagnosis of acute myocardial infarction by morphologic analysis of the ST segment

Acute myocardial infarction (AMI) is one of many causes of ST-segment elevation (STE) in emergency department (ED) chest pain (CP) patients. The morphology of STE may assist in the correct determination of its cause, with concave patterns in non-AMI syndromes and non-concave waveforms in AMI.

OBJECTIVES

To determine the impact of STE morphologic analysis on AMI diagnosis and the ability of this technique to separate AMI from non-infarction causes of STE.

METHODS

The electrocardiograms (ECGs) of consecutive ED adult CP patients (with three serial troponin I determinations) were interpreted in two-step fashion by six attending emergency physicians (EPs): 1) the determination of STE by three EPs followed by 2) STE morphologic analysis (either concave or non-concave) in those patients with STE. The impact of STE morphology analysis was investigated in the identification of AMI and non-AMI causes of STE. Acute myocardial infarction was diagnosed by abnormal serum troponin I values (>0.1 mg/dL) followed by a rise and fall of the serum marker; STE diagnoses of non-AMI causes were determined by medical record review. Interobserver reliability concerning STE morphology was determined. Study inclusion criteria included at least three troponin values performed in serial fashion no more frequently than every three hours, initial ED ECG, ED diagnosis, and final hospital diagnosis.

RESULTS

Five hundred ninety-nine CP patients were entered in the study, with 171 (29%) individuals having STE on their ECGs. Of the 171 patients who had STE, 56 had AMI, 50 had unstable angina pectoris (USAP), and 65 had non-coronary final diagnoses. Forty-nine patients had non-concave STE, 46 with AMI and three with USAP; no patient with a non-coronary diagnosis had a non-concave STE morphology. The sensitivity and specificity of the non-concave STE morphology for AMI diagnoses were 77% and 97%, respectively; the positive and negative predictive values for non-concave morphology in AMI diagnoses were 94% and 88%, respectively. Interobserver reliability in the STE morphology determination revealed a kappa coefficient of 0.87.

CONCLUSIONS

A non-concave STE morphology is frequently encountered in AMI patients. While the sensitivity of this pattern for AMI diagnosis is not particularly helpful, the presence of this finding in adult ED chest pain patients with STE strongly suggests AMI. This technique produces consistent results among these EPs.