Journal of Pain & Palliative Care Pharmacotherapy. 2014;28:359–366. Copyright © 2014 Informa Healthcare USA, Inc. ISSN: 1536-0288 print / 1536-0539 online DOI: 10.3109/15360288.2014.969875
ARTICLE
Evaluation of a Clinical Video Telehealth Pain Management Clinic Lauren Desko, Pharm.D. and Mitchell Nazario, Pharm.D., CPE A B STRA CT Objectives: The objectives of this project were to evaluate patient satisfaction with the clinical video telehealth (CVT) pain management clinic, and to evaluate possible benefits of this clinic. Methods: Data collected included the distance from the patient’s home to the main Department of Veterans Affairs (VA) medical center, the distance from the patient’s home to the community based outpatient clinic (CBOC), travel distance saved for the patient, and travel pay status. Following CVT clinic appointments patients were asked to complete a written feedback assessment to evaluate patient satisfaction. All data were analyzed using descriptive statistics. Results: Veterans saved 8,981 miles in travel distance, and the VA saved $2,317.51 due to averted travel reimbursement. There was a 90% satisfaction rate with the CVT pain management clinic services, and 90% of patients agreed that they would recommend telehealth to other veterans. Conclusions: Overall, patients are satisfied with the CVT pain management clinic. Furthermore, the substantial miles saved for the patients, as well as the cost savings for the VA, indicates that this service has tangible benefits. As this clinic continues to operate, it can be expected that miles saved for patients and cost savings for the VA will continue to grow. KEYWORDS pain management, pain, clinical pharmacy, telehealth, ambulatory care, patient satisfaction
symptoms and a variety of mental health issues, which are relatively common among veterans.2 For example, a retrospective review found that 66% of veterans in the study with post-traumatic stress disorder (PTSD) also had chronic pain diagnoses.3 Furthermore, a study of over 2,000 patients found that anxiety and depression were more common in the group of patients with low back pain.4 Another common disease state for veterans to experience is diabetes mellitus, with neuropathy being a common complication.5,6 In addition, the veteran population is largely geriatric, and the occurrence of chronic pain increases as patients get older.7 Another factor impacting veterans and pain management is the combat injuries and traumatic brain injuries (TBIs) experienced by returning veterans from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Traumatic brain injury is considered the “signature injury” from OEF and OIF, and veterans who experience TBIs are more likely to have both psychiatric and pain problems.8 In 2009, there were almost 22,000 OEF and OIF veterans using Veterans Health Administration
BACKGROUND Pain is a common problem for patients in the U.S. and is responsible for over 100 million ambulatory encounters each year.1 Pain issues also cause more than 40% of all symptom-related outpatient appointments per year.1 There are many different types of pain, and there are several reasons that the veteran population is uniquely predisposed to having chronic pain issues. First, there is an association between pain Beckley Veterans Affairs Medical Center, 200 Veterans Ave, Beckley, WV 25801 United States. West Palm Beach Veterans Affairs Medical Center, 7305 N. Military Trail, West Palm Beach, FL 33410 United States. At the time of writing Dr. Desko was a PGY-1 Pharmacy Practice Resident at the West Palm Beach Veterans Affairs Medical Center. Dr. Desko is currently a clinical pharmacy specialist in pain management at the Beckley Veterans Affairs Medical Center. Dr. Nazario is the Clinical Pharmacy Specialist in Pain Management at the West Palm Beach Veterans Affairs Medical Center. Completed poster presentations of this project: 2013 Midyear Clinical Meeting; Orlando, FL 2014 Joint Federal Pharmacy Seminar; Washington, DC Address correspondence to: Lauren Desko, Pharm.D., Beckley VA Medical Center, Pharmacy, 200 Veterans Ave, Beckley, WV, 25801 United States. E-mail: [email protected]
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(VHA) services who were diagnosed with a TBI, and of these patients 89% had a psychiatric diagnosis and 70% had a pain diagnosis.8 A survey also found that OEF and OIF veterans who had experienced combat injuries resulting in “major traumatic limb loss” had phantom limb pain at a rate 76% and 72.2%, respectively, along with chronic back pain (42.1% and 36.2%) and residual-limb pain (62.9% and 48.3%).9 Clinical Video Telehealth (CVT) involves using real-time transmission of clinical video and audio in order to effectively connect a patient with a healthcare professional for care remotely. One benefit to CVT technology is the opportunity to connect veterans at various community based outpatient clinics (CBOCs) with specialist health care providers located at the main Veterans Affairs (VA) medical center.10 The VHA has stated that approximately 41% of veterans receiving care from the VA health care system live in areas of the country where they have limited access to specialty care for a variety of disease states, including complex pain management.11 There are many potential barriers for a veteran trying to receive specialty care, such as transportation and the distance to travel to the specialist location.10,11 The word telehealth is defined as “the use of Telehealth technologies to provide clinical care in circumstances where distance separates those receiving services and those providing services.”12 The VHA definition of telehealth further describes using telehealth technologies to “facilitate access to care and improve the health of designated individuals and populations with the intent of providing the right care in the right place at the right time.”12
METHODS The purpose of this project was to obtain a written feedback assessment (Figure 1) from patients enrolled in the video telehealth pain management clinic in order to evaluate patient satisfaction; as well as to evaluate possible benefits of the video telehealth pain management clinic, including travel distance saved for the veteran and potential cost savings for the VA. The primary objective was to evaluate the patient satisfaction with the CVT pain management clinic through written feedback assessments. The feedback assessment tool used (Figure 1) was adapted from a nationally approved VA feedback assessment form. The secondary objective was to evaluate the benefits of the CVT pain management clinic in regards to travel distance saved for the veterans and potential cost savings for the VA related to travel pay reimbursement.
This was a prospective, quality improvement project. This project was a part of the facility’s ongoing quality assurance program and was approved by the local Residency Project Committee. Institutional Review Board (IRB) approval was not required for this project. Patient confidentiality was maintained, as information collected from the Telehealth Patient Satisfaction Survey did not require patient identifiers. Medication prescribing data was obtained from pharmacy records for database purposes only and no patient identifying information was collected in the database. Database information was only accessible to the resident and advisor and was maintained by the resident in their personal Z drive. After data entry and verification, pharmacy records were destroyed and no other paper records were kept. The West Palm Beach VA Medical Center (WPB VA) has seven affiliated CBOCs that are all located within 70 miles of the main medical center. The CBOCs are located in Vero Beach, Port St. Lucie, Ft. Pierce, Stuart, Delray Beach, Boca Raton and Okeechobee, FL. Community based outpatient clinics are clinics that a veteran patient may utilize for certain outpatient services in order to avoid having to travel to the WPB VA. The VA is committed to providing care for veterans within 30 miles or 30 minutes of their home, and these CBOCs play a large role in fulfilling this goal. Unfortunately, many of the services that the CBOCs are unable to provide veterans on-site are specialty services, including pain management. The CBOCs therefore utilize CVT services in order to bring access to some specialty services to their facility. Typically a CBOC will utilize their CVT equipment for multiple CVT clinics that meet on different days and times during the week, which allows multiple specialty services to see patients remotely at the CBOC. For example, other specialty services at the WPB VA that offer CVT clinics at the CBOCs include mental health and cardiology. The CVT appointments are conducted on large screens that allow the provider at the WBP VA to see and hear the patient in real-time at the CBOC, and the patient can also hear and see the provider. When a patient comes to the CBOC for a CVT appointment, they are brought back by a nurse to the room with the CVT equipment and the nurse is available to take vital signs and/or perform any other brief physical assessment needed by the CVT appointment provider. The nurse is responsible for turning on the CVT equipment and connecting it with the WPB VA, as well as ensuring that the patient can see and hear the provider adequately before the nurse exits the room. The patients then check out and set up any follow-up appointments needed with the CBOC staff after the CVT appointment is over. Journal of Pain & Palliative Care Pharmacotherapy
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FIGURE 1. Telehealth Feedback Assessment.
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The pain management clinic at the WPB VA is a multi-disciplinary clinic that utilizes both pain clinic physicians and the clinical pharmacy specialist (CPS) in pain management, who operates autonomously within a pre-specified scope of practice established by the WPB VA. The CPS sees patients in both the WPB VA pain management clinic and the CVT pain management clinic, and is able to initiate, adjust, or discontinue pain medications and other associated medications in order to adequately treat the patient’s pain condition(s). Patients seen in either the WPB VA or the CVT pain management clinic have a comprehensive treatment plan for pain management, including access to physical therapy services and various interventional pain procedures following evaluation by a pain clinic physician. Referrals are placed by the pain management CPS for these and other services as appropriate for each individual patient. The CVT pain management clinic is a relatively new clinic established at the WBP VA during the first half of 2012. The clinic originally began as one-half day per week, and then expanded to two half-days per week in order to accommodate the increased demand for this service. Patients who are enrolled in the WPB VA pain management clinic and live closer to a CBOC than they do to the WPB VA may be offered the opportunity to enroll in the CVT pain management clinic. Patients can also request enrollment in the CVT pain management clinic. Informed consent to participate in the CVT clinic is obtained prior to enrollment, and patients are always free to return to face-to-face clinic visits at the WPB VA at any time if they wish to do so. Patients must meet the following criteria in order to enroll in the CVT pain management clinic: the patient has been relatively stable on a pharmacologic pain regimen for 1 to 2 visits, it is more convenient for the patient to go to a CBOC than to the WPB VA, the patient has minimal hearing and/or visual defects, and the patient does not require a physical assessment. Enrollment in the CVT clinic does not result in any difference in patient care, and patients are able to have the same type of appointment that they would if they were at the WPB VA including medication regimen adjustments if needed. Data points were collected from all patients seen in the CVT pain management clinic between July 1, 2013, and December 31, 2013, and the data points were analyzed utilizing descriptive statistics. After each patient’s visit between September 1, 2013, and December 31, 2013, the patient was asked to complete a written feedback assessment that was sent back to the WPB VA by the CBOC CVT staff. Descriptive statistics were also used to analyze the written feedback assessments received from patients. Data collected included patient demographics (age,
sex, service connection status), the amount of time the patient was enrolled in the CVT pain management clinic including the number of CVT visits, distance from the patient’s home to the WPB VA, distance from the patient’s home to the CBOC where they participated in the CVT pain management clinic, travel distance saved for the patient, if the veteran received travel pay, if the veteran received special mode transportation services, type of pain condition the patient was being treated for, classes of pain medications the patient was being treated with, baseline pain score, baseline pain score goal, follow-up pain score 3 months later (if applicable), and no-show rates for the CVT clinic and the WPB VA pain management clinic between July 1, 2013, and December 31, 2013. Travel reimbursement status for the patient was determined by a service connection status of ≥30%, a VA travel waiver noted on patient’s chart in the Computerized Patient Record System (CPRS), or primary eligibility noted as non-service connected VA pension on the patient’s chart in CPRS. Patients who meet one of the above criteria receive travel pay at a rate of 41.5 cents per mile for round trip mileage when the appointment is a scheduled appointment, and receive reimbursement at the same rate for one way travel when the appointment is unscheduled. Patients receive travel pay to the nearest facility that offers the service they are utilizing; therefore, costs saved for the VA were calculated using the travel distance saved for the veteran on a round-trip basis.
RESULTS There were a total of 39 patients seen in the CVT pain management clinic between July 1, 2013, and December 31, 2013, with a total of 110 visits during this time period, resulting in an average of 2.8 visits per patient. The average age of the patients followed in the CVT pain management clinic was 64 years old, and 6 (15%) of the patients were women (Table 1). Twenty three (59%) of the patients were eligible for travel pay, and no patients received special mode of transportation services (Table 1). The most common pain condition afflicting patients followed in the CVT pain management clinic was back pain, with 26 (67%) of the patients being treated for this condition (Figure 2). The median baseline pain score was 6/10, while the median baseline pain score goal was 4.5/10 (Table 1). The median followup pain score after 3 months was 6/10 (Table 1). The three most common pain medication classes that patients followed in the CVT pain management clinic were treated with were opioids (97%), Journal of Pain & Palliative Care Pharmacotherapy
Lauren Desko and Mitchell Nazario TABLE 1.
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CVT pain management clinic demographics
Demographic
Result
Average age (years) Sex
63.6
Service connection status
Males 33 (85%) NSC 17 (44%)
Eligible for travel pay Median baseline pain score Median baseline pain score goal Median follow-up pain score
SC ≤50% 6 (15%) 23 (59%) 6/10 4.5/10
Females 6 (15%) SC ≥50% 16 (41%)
6/10
NSC = non-service connected; SC = service connected FIGURE 2. Percentage of patients being treated for specific pain conditions in the CVT pain management clinic.
gabapentin/pregabalin (46%), and muscle relaxants (36%) (Figure 3). The average distance from the patient’s home to the WPB VA was 51.5 miles, and the average distance from the patient’s home to their respective CBOC was 11.6 miles. A total of 8,981 miles was saved among all of the patients for the 110 total visits during this 6-month time period, with an average of 78.4 miles saved per patient visit. There were 66 visits during this 6-month time period where the patient was eligible to receive travel pay, resulting in a total cost savings of $2,317.51 for the WPB VA. The average cost savings for the WPB VA per patient visit was $31.81. A total of 22 feedback assessments were collected between September 1, 2013, and December 31, 2013. One feedback assessment was a confirmed
FIGURE 3. Percentage of patients being treated with specific classes of pain medications in the CVT pain management clinic. NSAIDs indicates non-steroidal anti-inflammatory drugs; SSRIs indicates selective serotonin reuptake inhibitors; SNRIs indicates serotonin norepinephrine reuptake inhibitors; TCAs indicates tricyclic anti-depressants; Topicals indicates various topical pain medications; APAP indicates acetaminophen. C
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duplicate, so the earliest feedback assessment result from that patient was analyzed and the duplicate was excluded. During this time period, there were 33 patients seen in the CVT pain management clinic who were offered the feedback assessment, resulting in a 64% response rate. Overall, there was a 90% satisfaction rate with the CVT pain management clinic appointment, and 90% of patients agreed that they would recommend telehealth to other veterans (Figure 4). The majority of patients reported that they were able to see and hear the pharmacist clearly, that they were comfortable with the equipment used, that someone was available if they encountered problems, that they felt their privacy was respected, and that their needs were met and good care was provided during the CVT pain management appointment (Figure 4). There were mixed results regarding whether the patients would be more comfortable talking with the provider in person, however, the majority of patients reported that it was easier to use telehealth than to see the pharmacist in person (Figure 4). Several patients provided comments on the feedback assessment (Figure 4) with the common theme being that patients felt that the CVT clinic was more convenient for them. The no-show rates between the CVT pain management clinic and the WPB VA pain management clinic between July 1, 2013, and December 31, 2013 were very similar. There was a no-show rate of 8% for the CVT clinic and a 6% no-show rate for the WPB VA pain management clinic (Table 2). TABLE 2. 2013
No-Show rates from July 1, 2013 to December 31,
Pain management clinic CVT WPB VA
Number of no-shows
Total number of patients scheduled
No-show rate (%)
9 35
110 546
8% 6%
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FIGURE 4. Results of the written feedback assessment evaluating patient satisfaction with the CVT pain management clinic. Each category corresponds to a question on the feedback assessment form shown in Figure 1. For each category on the left side of the figure, the bars indicating the results collected from the feedback assessments are listed in the following order from top to bottom: Left Blank; Strongly Disagree; Disagree; Neutral; Agree; Strongly Agree. For each category, if no results were received for a certain answer there is no bar present for that answer. A diagonal striped bar indicates Left Blank; a striped bar indicates Strongly Disagree; a large checker patterned bar indicates Disagree; a diagonal brick patterned bar indicates Neutral; a small checker patterned bar indicates Agree; a solid bar indicates Strongly Agree.
DISCUSSION The purpose of this project was to assess the patient satisfaction with the CVT pain management clinic, as well as to evaluate benefits of this service on travel distance saved for the veteran and potential cost savings for the WPB VA. The potential benefits evaluated
in this project could then be used to justify future resources and possible future expansion of this service. Overall, the responses to the written feedback assessments were positive, with a substantial portion of the responders stating that they were satisfied with the CVT pain management clinic and would recommend the service to other veterans. Furthermore, the Journal of Pain & Palliative Care Pharmacotherapy
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considerable number of miles saved for the patients, as well as the cost savings for the WPB VA, indicates that this service has tangible benefits currently, as well as the possibility of continued benefits in the future. The pharmacist run pain management clinic is a unique setting for which CVT has the potential to provide substantial benefits for both the patients and the VA. One unique factor for this setting is that patients typically have very close follow-up and return to the clinic frequently to be seen, to have their medication regimens adjusted as needed and to receive prescription refills. Having patients that need to have such close follow-up in this setting allows for the CVT service to provide the benefit to patients of saving miles they have to travel, as well as saving the VA money for travel reimbursement. There were some limitations to this project, including that the written feedback assessments were not offered to patients throughout the entire 6-month period that was evaluated, resulting in some patients not having the opportunity to fill out the feedback assessment. Written feedback assessments were only offered to patients between September 1, 2013, and December 31, 2013. Furthermore, there was no process in place to prevent duplicate feedback assessments as some patients had multiple appointments during this time period and may have been offered the assessment more than once. Feedback assessments could be returned anonymously which prevented the investigator from being able to accurately assess for duplicates. One feedback assessment was confirmed a duplicate, and was excluded from evaluation as was explained previously. Lastly, another limitation to this project was the small sample size of patients evaluated over the 6-month data collection period (July 1, 2013, to December 31, 2013). Strengths of this project included that it evaluated a current and relevant topic in healthcare. As patient satisfaction becomes a more prominent issue in the healthcare system, unique and innovative healthcare delivery systems will be needed in order to provide good patient care, as well as to satisfy patients. This project evaluated not only patient satisfaction with CVT pain management clinic services, but also evaluated cost savings for the VA and found benefits for both parties.
CONCLUSION We were successful in evaluating the CVT pain management clinic for patient satisfaction and potential benefits on travel distance saved for the veterans and cost savings for the VA. Overall, patients were very C
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satisfied with the CVT pain management clinic and indicated that most patients would recommend this service to other veterans. The 110 CVT pain management clinic visits resulted in saving patients just under 9,000 miles of travel distance, and also saved the WPB VA just over $2,300 in travel reimbursement costs. The CVT pain management clinic has already expanded once due to high demand, and the benefits that this service provides to both veterans and the WPB VA support further resources and expansion of this clinic in the future if it becomes necessary.
ACKNOWLEDGMENTS We would like to thank Dr. John Melendez-Benabe, MD, and Dr. Ramon Cuevas-Tris´an, MD, for their assistance in completing this project. We would also like to thank the pharmacy department at the West Palm Beach VA Medical Center for all of the help that many of the pharmacists provided in completing this project. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
REFERENCES [1] Kroenke K, Krebs E, Wu J, et al. Stepped Care to Optimize Pain care Effectiveness (SCOPE) trial study design and sample characteristics. Contemp Clin Trials. 2013;34:270–81. [2] Maloney P, McIntosh E. Chronic Low Back Pain and Depression in a Sample of Veterans. Perceptual and Motor Skills. 2001;92:348. [3] Shipherd JC, Keyes M, Jovanovic T, et al. Veterans seeking treatment for posttraumatic stress disorder: What about comorbid chronic pain? J Rehabil Res Dev. 2007;44:153–66. [4] Bener A, Verjee M, Dafeeah EE, et al. Psychological factors: anxiety, depression, and somatization symptoms in low back pain patients. J Pain Res. 2013;6:95–101. [5] Stone RA, Rao RH, Sevick MA, et al. Active care management supported by Home Telemonitoring in veterans with type 2 diabetes. Diabetes Care. 2010;33:478–84. [6] McFarland M, Davis K, Wallace J, et al. Use of home telehealth monitoring with active education therapy management by clinical pharmacists in veterans with poorly controlled type 2 diabetes mellitus. Pharmacotherapy. 2012;32:420–26. [7] Butchart A, Kerr EA, Heisler M, et al. Experience and management of chronic pain among patients with other complex chronic conditions. Clin J Pain. 2009;25:293–98. [8] Taylor BC, Hagel EM, Carlson KF, et al. Prevalence and costs of Co-occurring traumatic brain injury with and without psychiatric disturbance and pain among afghanistan and Iraq war veteran VA users. Med Care. 2012;50:342–46. [9] Reiber GE, McFarland LV, Hubbard S, et al. Servicemembers and veterans with major traumatic limb loss from Vietnam war
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and OIF/OEF conflicts: Survey methods, participants, and summary findings. J Rehabil Res Dev. 2010;47:299–16. [10] U.S. Department of Veterans Affairs. Real-Time Clinic Based Video Telehealth. VHA Office of Telehealth Services. Available at: http://www.telehealth.va.gov. Accessed September, 2013. [11] Pfeifer G. Improving access to specialty care for veterans. Am J Nurs. 2012;112:17–18.
[12] U.S. Department of Veterans Affairs. About the VA Telehealth Services. VHA Office of Telehealth Services. Available at: http://www.telehealth.va.gov. Accessed September, 2013.
RECEIVED: 19 August 2014 REVISED: 27 August 2014 ACCEPTED: 8 September 2014
Journal of Pain & Palliative Care Pharmacotherapy
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ARTICLE
Evaluation of a Clinical Video Telehealth Pain Management Clinic Lauren Desko, Pharm.D. and Mitchell Nazario, Pharm.D., CPE A B STRA CT Objectives: The objectives of this project were to evaluate patient satisfaction with the clinical video telehealth (CVT) pain management clinic, and to evaluate possible benefits of this clinic. Methods: Data collected included the distance from the patient’s home to the main Department of Veterans Affairs (VA) medical center, the distance from the patient’s home to the community based outpatient clinic (CBOC), travel distance saved for the patient, and travel pay status. Following CVT clinic appointments patients were asked to complete a written feedback assessment to evaluate patient satisfaction. All data were analyzed using descriptive statistics. Results: Veterans saved 8,981 miles in travel distance, and the VA saved $2,317.51 due to averted travel reimbursement. There was a 90% satisfaction rate with the CVT pain management clinic services, and 90% of patients agreed that they would recommend telehealth to other veterans. Conclusions: Overall, patients are satisfied with the CVT pain management clinic. Furthermore, the substantial miles saved for the patients, as well as the cost savings for the VA, indicates that this service has tangible benefits. As this clinic continues to operate, it can be expected that miles saved for patients and cost savings for the VA will continue to grow. KEYWORDS pain management, pain, clinical pharmacy, telehealth, ambulatory care, patient satisfaction
symptoms and a variety of mental health issues, which are relatively common among veterans.2 For example, a retrospective review found that 66% of veterans in the study with post-traumatic stress disorder (PTSD) also had chronic pain diagnoses.3 Furthermore, a study of over 2,000 patients found that anxiety and depression were more common in the group of patients with low back pain.4 Another common disease state for veterans to experience is diabetes mellitus, with neuropathy being a common complication.5,6 In addition, the veteran population is largely geriatric, and the occurrence of chronic pain increases as patients get older.7 Another factor impacting veterans and pain management is the combat injuries and traumatic brain injuries (TBIs) experienced by returning veterans from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). Traumatic brain injury is considered the “signature injury” from OEF and OIF, and veterans who experience TBIs are more likely to have both psychiatric and pain problems.8 In 2009, there were almost 22,000 OEF and OIF veterans using Veterans Health Administration
BACKGROUND Pain is a common problem for patients in the U.S. and is responsible for over 100 million ambulatory encounters each year.1 Pain issues also cause more than 40% of all symptom-related outpatient appointments per year.1 There are many different types of pain, and there are several reasons that the veteran population is uniquely predisposed to having chronic pain issues. First, there is an association between pain Beckley Veterans Affairs Medical Center, 200 Veterans Ave, Beckley, WV 25801 United States. West Palm Beach Veterans Affairs Medical Center, 7305 N. Military Trail, West Palm Beach, FL 33410 United States. At the time of writing Dr. Desko was a PGY-1 Pharmacy Practice Resident at the West Palm Beach Veterans Affairs Medical Center. Dr. Desko is currently a clinical pharmacy specialist in pain management at the Beckley Veterans Affairs Medical Center. Dr. Nazario is the Clinical Pharmacy Specialist in Pain Management at the West Palm Beach Veterans Affairs Medical Center. Completed poster presentations of this project: 2013 Midyear Clinical Meeting; Orlando, FL 2014 Joint Federal Pharmacy Seminar; Washington, DC Address correspondence to: Lauren Desko, Pharm.D., Beckley VA Medical Center, Pharmacy, 200 Veterans Ave, Beckley, WV, 25801 United States. E-mail: [email protected]
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(VHA) services who were diagnosed with a TBI, and of these patients 89% had a psychiatric diagnosis and 70% had a pain diagnosis.8 A survey also found that OEF and OIF veterans who had experienced combat injuries resulting in “major traumatic limb loss” had phantom limb pain at a rate 76% and 72.2%, respectively, along with chronic back pain (42.1% and 36.2%) and residual-limb pain (62.9% and 48.3%).9 Clinical Video Telehealth (CVT) involves using real-time transmission of clinical video and audio in order to effectively connect a patient with a healthcare professional for care remotely. One benefit to CVT technology is the opportunity to connect veterans at various community based outpatient clinics (CBOCs) with specialist health care providers located at the main Veterans Affairs (VA) medical center.10 The VHA has stated that approximately 41% of veterans receiving care from the VA health care system live in areas of the country where they have limited access to specialty care for a variety of disease states, including complex pain management.11 There are many potential barriers for a veteran trying to receive specialty care, such as transportation and the distance to travel to the specialist location.10,11 The word telehealth is defined as “the use of Telehealth technologies to provide clinical care in circumstances where distance separates those receiving services and those providing services.”12 The VHA definition of telehealth further describes using telehealth technologies to “facilitate access to care and improve the health of designated individuals and populations with the intent of providing the right care in the right place at the right time.”12
METHODS The purpose of this project was to obtain a written feedback assessment (Figure 1) from patients enrolled in the video telehealth pain management clinic in order to evaluate patient satisfaction; as well as to evaluate possible benefits of the video telehealth pain management clinic, including travel distance saved for the veteran and potential cost savings for the VA. The primary objective was to evaluate the patient satisfaction with the CVT pain management clinic through written feedback assessments. The feedback assessment tool used (Figure 1) was adapted from a nationally approved VA feedback assessment form. The secondary objective was to evaluate the benefits of the CVT pain management clinic in regards to travel distance saved for the veterans and potential cost savings for the VA related to travel pay reimbursement.
This was a prospective, quality improvement project. This project was a part of the facility’s ongoing quality assurance program and was approved by the local Residency Project Committee. Institutional Review Board (IRB) approval was not required for this project. Patient confidentiality was maintained, as information collected from the Telehealth Patient Satisfaction Survey did not require patient identifiers. Medication prescribing data was obtained from pharmacy records for database purposes only and no patient identifying information was collected in the database. Database information was only accessible to the resident and advisor and was maintained by the resident in their personal Z drive. After data entry and verification, pharmacy records were destroyed and no other paper records were kept. The West Palm Beach VA Medical Center (WPB VA) has seven affiliated CBOCs that are all located within 70 miles of the main medical center. The CBOCs are located in Vero Beach, Port St. Lucie, Ft. Pierce, Stuart, Delray Beach, Boca Raton and Okeechobee, FL. Community based outpatient clinics are clinics that a veteran patient may utilize for certain outpatient services in order to avoid having to travel to the WPB VA. The VA is committed to providing care for veterans within 30 miles or 30 minutes of their home, and these CBOCs play a large role in fulfilling this goal. Unfortunately, many of the services that the CBOCs are unable to provide veterans on-site are specialty services, including pain management. The CBOCs therefore utilize CVT services in order to bring access to some specialty services to their facility. Typically a CBOC will utilize their CVT equipment for multiple CVT clinics that meet on different days and times during the week, which allows multiple specialty services to see patients remotely at the CBOC. For example, other specialty services at the WPB VA that offer CVT clinics at the CBOCs include mental health and cardiology. The CVT appointments are conducted on large screens that allow the provider at the WBP VA to see and hear the patient in real-time at the CBOC, and the patient can also hear and see the provider. When a patient comes to the CBOC for a CVT appointment, they are brought back by a nurse to the room with the CVT equipment and the nurse is available to take vital signs and/or perform any other brief physical assessment needed by the CVT appointment provider. The nurse is responsible for turning on the CVT equipment and connecting it with the WPB VA, as well as ensuring that the patient can see and hear the provider adequately before the nurse exits the room. The patients then check out and set up any follow-up appointments needed with the CBOC staff after the CVT appointment is over. Journal of Pain & Palliative Care Pharmacotherapy
Lauren Desko and Mitchell Nazario
FIGURE 1. Telehealth Feedback Assessment.
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The pain management clinic at the WPB VA is a multi-disciplinary clinic that utilizes both pain clinic physicians and the clinical pharmacy specialist (CPS) in pain management, who operates autonomously within a pre-specified scope of practice established by the WPB VA. The CPS sees patients in both the WPB VA pain management clinic and the CVT pain management clinic, and is able to initiate, adjust, or discontinue pain medications and other associated medications in order to adequately treat the patient’s pain condition(s). Patients seen in either the WPB VA or the CVT pain management clinic have a comprehensive treatment plan for pain management, including access to physical therapy services and various interventional pain procedures following evaluation by a pain clinic physician. Referrals are placed by the pain management CPS for these and other services as appropriate for each individual patient. The CVT pain management clinic is a relatively new clinic established at the WBP VA during the first half of 2012. The clinic originally began as one-half day per week, and then expanded to two half-days per week in order to accommodate the increased demand for this service. Patients who are enrolled in the WPB VA pain management clinic and live closer to a CBOC than they do to the WPB VA may be offered the opportunity to enroll in the CVT pain management clinic. Patients can also request enrollment in the CVT pain management clinic. Informed consent to participate in the CVT clinic is obtained prior to enrollment, and patients are always free to return to face-to-face clinic visits at the WPB VA at any time if they wish to do so. Patients must meet the following criteria in order to enroll in the CVT pain management clinic: the patient has been relatively stable on a pharmacologic pain regimen for 1 to 2 visits, it is more convenient for the patient to go to a CBOC than to the WPB VA, the patient has minimal hearing and/or visual defects, and the patient does not require a physical assessment. Enrollment in the CVT clinic does not result in any difference in patient care, and patients are able to have the same type of appointment that they would if they were at the WPB VA including medication regimen adjustments if needed. Data points were collected from all patients seen in the CVT pain management clinic between July 1, 2013, and December 31, 2013, and the data points were analyzed utilizing descriptive statistics. After each patient’s visit between September 1, 2013, and December 31, 2013, the patient was asked to complete a written feedback assessment that was sent back to the WPB VA by the CBOC CVT staff. Descriptive statistics were also used to analyze the written feedback assessments received from patients. Data collected included patient demographics (age,
sex, service connection status), the amount of time the patient was enrolled in the CVT pain management clinic including the number of CVT visits, distance from the patient’s home to the WPB VA, distance from the patient’s home to the CBOC where they participated in the CVT pain management clinic, travel distance saved for the patient, if the veteran received travel pay, if the veteran received special mode transportation services, type of pain condition the patient was being treated for, classes of pain medications the patient was being treated with, baseline pain score, baseline pain score goal, follow-up pain score 3 months later (if applicable), and no-show rates for the CVT clinic and the WPB VA pain management clinic between July 1, 2013, and December 31, 2013. Travel reimbursement status for the patient was determined by a service connection status of ≥30%, a VA travel waiver noted on patient’s chart in the Computerized Patient Record System (CPRS), or primary eligibility noted as non-service connected VA pension on the patient’s chart in CPRS. Patients who meet one of the above criteria receive travel pay at a rate of 41.5 cents per mile for round trip mileage when the appointment is a scheduled appointment, and receive reimbursement at the same rate for one way travel when the appointment is unscheduled. Patients receive travel pay to the nearest facility that offers the service they are utilizing; therefore, costs saved for the VA were calculated using the travel distance saved for the veteran on a round-trip basis.
RESULTS There were a total of 39 patients seen in the CVT pain management clinic between July 1, 2013, and December 31, 2013, with a total of 110 visits during this time period, resulting in an average of 2.8 visits per patient. The average age of the patients followed in the CVT pain management clinic was 64 years old, and 6 (15%) of the patients were women (Table 1). Twenty three (59%) of the patients were eligible for travel pay, and no patients received special mode of transportation services (Table 1). The most common pain condition afflicting patients followed in the CVT pain management clinic was back pain, with 26 (67%) of the patients being treated for this condition (Figure 2). The median baseline pain score was 6/10, while the median baseline pain score goal was 4.5/10 (Table 1). The median followup pain score after 3 months was 6/10 (Table 1). The three most common pain medication classes that patients followed in the CVT pain management clinic were treated with were opioids (97%), Journal of Pain & Palliative Care Pharmacotherapy
Lauren Desko and Mitchell Nazario TABLE 1.
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CVT pain management clinic demographics
Demographic
Result
Average age (years) Sex
63.6
Service connection status
Males 33 (85%) NSC 17 (44%)
Eligible for travel pay Median baseline pain score Median baseline pain score goal Median follow-up pain score
SC ≤50% 6 (15%) 23 (59%) 6/10 4.5/10
Females 6 (15%) SC ≥50% 16 (41%)
6/10
NSC = non-service connected; SC = service connected FIGURE 2. Percentage of patients being treated for specific pain conditions in the CVT pain management clinic.
gabapentin/pregabalin (46%), and muscle relaxants (36%) (Figure 3). The average distance from the patient’s home to the WPB VA was 51.5 miles, and the average distance from the patient’s home to their respective CBOC was 11.6 miles. A total of 8,981 miles was saved among all of the patients for the 110 total visits during this 6-month time period, with an average of 78.4 miles saved per patient visit. There were 66 visits during this 6-month time period where the patient was eligible to receive travel pay, resulting in a total cost savings of $2,317.51 for the WPB VA. The average cost savings for the WPB VA per patient visit was $31.81. A total of 22 feedback assessments were collected between September 1, 2013, and December 31, 2013. One feedback assessment was a confirmed
FIGURE 3. Percentage of patients being treated with specific classes of pain medications in the CVT pain management clinic. NSAIDs indicates non-steroidal anti-inflammatory drugs; SSRIs indicates selective serotonin reuptake inhibitors; SNRIs indicates serotonin norepinephrine reuptake inhibitors; TCAs indicates tricyclic anti-depressants; Topicals indicates various topical pain medications; APAP indicates acetaminophen. C
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duplicate, so the earliest feedback assessment result from that patient was analyzed and the duplicate was excluded. During this time period, there were 33 patients seen in the CVT pain management clinic who were offered the feedback assessment, resulting in a 64% response rate. Overall, there was a 90% satisfaction rate with the CVT pain management clinic appointment, and 90% of patients agreed that they would recommend telehealth to other veterans (Figure 4). The majority of patients reported that they were able to see and hear the pharmacist clearly, that they were comfortable with the equipment used, that someone was available if they encountered problems, that they felt their privacy was respected, and that their needs were met and good care was provided during the CVT pain management appointment (Figure 4). There were mixed results regarding whether the patients would be more comfortable talking with the provider in person, however, the majority of patients reported that it was easier to use telehealth than to see the pharmacist in person (Figure 4). Several patients provided comments on the feedback assessment (Figure 4) with the common theme being that patients felt that the CVT clinic was more convenient for them. The no-show rates between the CVT pain management clinic and the WPB VA pain management clinic between July 1, 2013, and December 31, 2013 were very similar. There was a no-show rate of 8% for the CVT clinic and a 6% no-show rate for the WPB VA pain management clinic (Table 2). TABLE 2. 2013
No-Show rates from July 1, 2013 to December 31,
Pain management clinic CVT WPB VA
Number of no-shows
Total number of patients scheduled
No-show rate (%)
9 35
110 546
8% 6%
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FIGURE 4. Results of the written feedback assessment evaluating patient satisfaction with the CVT pain management clinic. Each category corresponds to a question on the feedback assessment form shown in Figure 1. For each category on the left side of the figure, the bars indicating the results collected from the feedback assessments are listed in the following order from top to bottom: Left Blank; Strongly Disagree; Disagree; Neutral; Agree; Strongly Agree. For each category, if no results were received for a certain answer there is no bar present for that answer. A diagonal striped bar indicates Left Blank; a striped bar indicates Strongly Disagree; a large checker patterned bar indicates Disagree; a diagonal brick patterned bar indicates Neutral; a small checker patterned bar indicates Agree; a solid bar indicates Strongly Agree.
DISCUSSION The purpose of this project was to assess the patient satisfaction with the CVT pain management clinic, as well as to evaluate benefits of this service on travel distance saved for the veteran and potential cost savings for the WPB VA. The potential benefits evaluated
in this project could then be used to justify future resources and possible future expansion of this service. Overall, the responses to the written feedback assessments were positive, with a substantial portion of the responders stating that they were satisfied with the CVT pain management clinic and would recommend the service to other veterans. Furthermore, the Journal of Pain & Palliative Care Pharmacotherapy
Lauren Desko and Mitchell Nazario
considerable number of miles saved for the patients, as well as the cost savings for the WPB VA, indicates that this service has tangible benefits currently, as well as the possibility of continued benefits in the future. The pharmacist run pain management clinic is a unique setting for which CVT has the potential to provide substantial benefits for both the patients and the VA. One unique factor for this setting is that patients typically have very close follow-up and return to the clinic frequently to be seen, to have their medication regimens adjusted as needed and to receive prescription refills. Having patients that need to have such close follow-up in this setting allows for the CVT service to provide the benefit to patients of saving miles they have to travel, as well as saving the VA money for travel reimbursement. There were some limitations to this project, including that the written feedback assessments were not offered to patients throughout the entire 6-month period that was evaluated, resulting in some patients not having the opportunity to fill out the feedback assessment. Written feedback assessments were only offered to patients between September 1, 2013, and December 31, 2013. Furthermore, there was no process in place to prevent duplicate feedback assessments as some patients had multiple appointments during this time period and may have been offered the assessment more than once. Feedback assessments could be returned anonymously which prevented the investigator from being able to accurately assess for duplicates. One feedback assessment was confirmed a duplicate, and was excluded from evaluation as was explained previously. Lastly, another limitation to this project was the small sample size of patients evaluated over the 6-month data collection period (July 1, 2013, to December 31, 2013). Strengths of this project included that it evaluated a current and relevant topic in healthcare. As patient satisfaction becomes a more prominent issue in the healthcare system, unique and innovative healthcare delivery systems will be needed in order to provide good patient care, as well as to satisfy patients. This project evaluated not only patient satisfaction with CVT pain management clinic services, but also evaluated cost savings for the VA and found benefits for both parties.
CONCLUSION We were successful in evaluating the CVT pain management clinic for patient satisfaction and potential benefits on travel distance saved for the veterans and cost savings for the VA. Overall, patients were very C
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satisfied with the CVT pain management clinic and indicated that most patients would recommend this service to other veterans. The 110 CVT pain management clinic visits resulted in saving patients just under 9,000 miles of travel distance, and also saved the WPB VA just over $2,300 in travel reimbursement costs. The CVT pain management clinic has already expanded once due to high demand, and the benefits that this service provides to both veterans and the WPB VA support further resources and expansion of this clinic in the future if it becomes necessary.
ACKNOWLEDGMENTS We would like to thank Dr. John Melendez-Benabe, MD, and Dr. Ramon Cuevas-Tris´an, MD, for their assistance in completing this project. We would also like to thank the pharmacy department at the West Palm Beach VA Medical Center for all of the help that many of the pharmacists provided in completing this project. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.
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and OIF/OEF conflicts: Survey methods, participants, and summary findings. J Rehabil Res Dev. 2010;47:299–16. [10] U.S. Department of Veterans Affairs. Real-Time Clinic Based Video Telehealth. VHA Office of Telehealth Services. Available at: http://www.telehealth.va.gov. Accessed September, 2013. [11] Pfeifer G. Improving access to specialty care for veterans. Am J Nurs. 2012;112:17–18.
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RECEIVED: 19 August 2014 REVISED: 27 August 2014 ACCEPTED: 8 September 2014
Journal of Pain & Palliative Care Pharmacotherapy
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