Article in the AAO-HNS Bulletin: Transition to in-office treatments

As a surgeon, I see firsthand that many of the advances in techniques for surgery are directly associated with new medical devices. Part of the challenge of my job is balancing an appropriate skepticism of new technology with an intellectual curiosity and drive to find innovation that can improve my patients’ lives.

Recently, the FDA reached out to the Academy of Otolaryngology to seek our opinion on a new medical device for our field. I think one of the most important reasons to be an active member of the Academy is it gives physicians a voice in the direction of new innovation. It’s only through this constant dialogue between innovators and clinicians that we can keep improving patient outcomes.

Rahul Shah MD and I wrote a quick article discussing the Academy’s consideration of and opinion on the recent FDA approval of the Tusker TULA device in this month’s bulletin. You can read our article below.

Article: Transition to in-office treatments

One of the trends we will continue to see in Otolaryngology and all of healthcare is a transition from operating-room based procedures to in-office procedures. These tend to be safer for patients, who avoid the risks of general anesthesia, but also more cost-effective for our healthcare system because they avoid the large facility fees often associated with hospital-based procedures. The other benefit in-office treatments offer is quicker access to care, since they don’t require physicians to coordinate with a hospital, where multiple physicians often share operating-room time. This aligns well with the other trend we will see in healthcare, as well as all fields, of patients wanting faster means of solving their problems. Ultimately, the combination of being safer, more cost-effective, and quicker will lead to this in-office field burgeoning.

Telemedicine in Otolaryngology Panel Discussion at the Academy Meeting

It was an honor to sit on the panel for a presentation on ‘Telemedicine: practical tips for implementation into your daily practice’ at this past years’ Academy of Otolaryngology Head and Neck Surgery Annual Meeting. Since it was in New Orleans, I wasn’t that upset about traveling to the city of Jazz and beignets.IMG_5654.JPG

I was honestly surprised and impressed by how well the talk was attended, and it was great to see so many other otolaryngologists looking to incorporate telemedicine into their practice to improve patient care.

The other members of the panel were inspiring: Dr. John Kokesh helped create a system of telehealth to provide otolaryngology care to the underserved across the vast distances of Alaska, and Dr. David Cognetti has been utilizing telehealth in an urban settings in innovative ways to improve the quality of Jefferson University Health’s Head and Neck Cancer Care. If you have an interest in telemedicine in ENT, you should read about these two innovators work.

The full video of the panel can be found on the AAO-HNS website, under the AcademyU (however you must be an Academy member to view it).

We hope to expand upon the panel next year. Thank you to everyone who attended.

Telemedical dizzy consult article published in The Laryngoscope

Our manuscript on Telemedical non-acute vertigo consults was published recently in the Laryngoscope. The abstract is posted below. You can read the full article on pubmed here.

Ultimately, I think the paper outlines an easy and pragmatic example of how our specialty can utilize telemedical technology to improve patient outcomes and decrease healthcare costs. I believe each specialty in medicine can pick specific use cases where telemedical care can be safe and effective. Some easy examples are wound checks for nearly any surgical specialty, or ER consults for ‘hematuria’ for urology (my urology colleagues tell me often their definition of hematuria is not in line with those of first line providers). Our practice offers patients the option for telemedical consults after hours for on-call questions like ‘Is my nose bleed serious enough to go to the ER?’ or ‘Is this swelling normal or concerning?’ and we’ve found it has increased patient satisfaction while also providing the physicians with helpful visual data to make safer decisions.

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Telemedicine in Otolaryngology

My latest piece, telemedicine in Otolaryngology, written with one of the key opinion leaders in the field, Dr. John Kokesh, was just published in the Bulletin of the Academy of Otolaryngology. Ultimately, I believe that as adoption of telemedicine increases, it will be one of the many techniques we will use to bring down costs of specialty care in our healthcare system.

You can view it below, or at the Academy’s website:

Read the Article here

 

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ENT and telemedicine: BPPV telemedicine consults are feasible and could save money

We will be exhibiting the initial results of our tele-medical BPPV consult study as a poster for the Triological Society session at the Combined Otolaryngology Spring Meetings for 2017.Telemedical BPPV Consults Poster .001Discussion posted below for ease of reading:

Within our small sample size, a number of patients who were referred for an evaluation of their dizziness had initially undergone a CT or MRI in the emergency department to evaluate their complaint of dizziness.

Our initial proof of concept study found that for a small sample size, remote diagnosis of BPPV via telemedical consults is possible with high specificity. Based on the specificity, it is appears unlikely that a trained otologist or neurologist reviewing videos of ocular findings of a DHT would misdiagnose a more concerning cause of dizziness as BPPV. Thus, this could easily serve as a screening tool to quickly triage dizzy patients into those requiring more costly work-up and those who do not.

While other authors have suggested using video-oculography [3] or educational algorithms [4] to help distinguish benign versus concerning causes of dizziness, the barriers to adoption of these methods are the cost of equipment and ER workflow. However, due to the prevalence of HIPAA-compliant texting applications and the ubiquity of smartphones, adoption of smartphone-based video consults into an ER workflow is feasible. This is supported by a recent survey of worldwide ER physicians, which found that many wanted assistance with evaluating and distinguishing causes of dizziness [5]. While academic centers may have neurologists or otolarygologists on call, rural and community centers could gain access to these specialists through telemedical means.

Since the DHT is easily taught, having an otolaryngologist interpret the resulting eye movements remotely may increase usage of the test and may lead to cost savings.

 

Presenting on tele-otology at the AAO-HNS Academy

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We recently presented the data from our study on use by parents of the CellScope iPhone Otoscope at the annual meeting for the Academy of Otolaryngology Head and Neck Surgery.

Overall, the study showed that more research is required on whether parents can reliably use tele-ENT devices to help diagnose their own children. In trained hands, however, it appeared to provide images that are suitable for diagnosis by other physicians. In the future, devices like these could be used as low-cost methods of avoiding unnecessary consults, or providing telemedical access to ENT specialists for specific otological questions in rural area

Above, I have posted the slides from the presentation, and the text of the presentation has been posted below.

 

Academy presentation

*None of the researchers have any disclosures or ties to the product being discussed. CellScope, Inc. provided the device for this study. 

In areas with limited access to otolaryngologists, tele-otology, or diagnoses based on video recordings of the tympanic membrane, has been validated as a reliable method for remote tympanostomy tube surveillance and diagnosis of otologic diseases.

Based on this concept, a company called CellScope has released an attachment that is able to turn an iPhone into an otoscope, which allows parents to record videos of their child’s ears and send them for remote diagnosis by a physician. This device is available in all 50 states and offers to save time by bypassing a pediatric visit. All of the prior studies validating tele-otoscopy, however, have been based on images recorded by trained professionals. Our study aimed to assess whether tele-otoscopy was reliable for diagnosis when parents took videos, instead of health professionals.

This prospective, randomized, blinded study was conducted at a tertiary academic children’s hospital. To simulate parents using the device at home, parents of children ages 1 month to 17 years were placed in an exam room and given the entire Cellscope box. They were allowed time to set up the device and to watch the company’s tutorial videos. They then used the device without any outside help.

With the attachment device, they attempted to record videos of their child’s ears. To tease out whether reliability was based on the user or the device, a physician subsequently used the device to record the same ears. Finally, the child was examined by the gold standard of pneumatic otoscopy by a pediatric otolaryngologist.

Later, a pediatric otolaryngologist attempted diagnosis based only on the videos. To avoid bias, the pedi-ENT was blinded as to whether the recording was obtained by a parent or a physician. The agreement between video diagnosis and original diagnosis on pneumatic otoscopy was recorded, as well as the number of objective landmarks visualized on each recording.

Overall, eighty ears were enrolled. Using a kappa value to measure inter-rater agreement, we found that there was low agreement between the remote diagnosis based on videos taken by parents and original diagnosis by a pediatric otolaryngologist with pneumatic otoscopy. In contrast, there was high agreement, kappa of 0.71, between diagnosis based on videos of ears taken by a physician and diagnosis by pneumatic otoscopy. There was also nearly no agreement between the number of objective landmarks identified when a parent recorded an ear versus when a physician recorded the same ear

100% of parents watched the tutorial, and 87.5% of parents reported experience using an iPhone. Still, a majority of parent videos provided a limited view of the tympanic membrane landmarks. Many recorded only cerumen, making diagnosis impossible, even when diagnosis had been possible with pneumatic otoscopy.

Based on this poor agreement, we feel further studies are needed to ensure there is no significant risk of missed diagnosis or inappropriate antibiotic prescriptions when parents utilize this service. Furthermore, it is possible that the parent tutorials need improvement.

On the other hand, when used by trained physicians in this limited study, it provided high-quality videos of the tympanic membrane, which other smaller studies have noted as well, and at a price of $79 it is relatively low cost, especially when compared to previously used endoscopes for tele-otoscopy. In the future, ACOs or healthcare systems could potentially utilize tele-otoscopy by frontline providers for tympanostomy tube surveillance to diminish unnecessary specialist consults or avoid missed diagnosis. As we strive towards cost-saving measures, we believe further research on the utility of smartphone otoscopes for tele-otoscopy should be conducted.

*The full manuscript for this paper is currently being prepared for submission