Wednesday, September 26, 2018 2:00 PM – 3:00 PM Integrating Technology into Practice: 2016 Research Grant: Effects of telemedicine triage on efficiency and cost-effectiveness in spinal care

BACKGROUND CONTEXT Low back pain and neck pain are second only to ischemic heart disease for the greatest disability-adjusted life-years in rich nations. It also accounts for the third highest amount of health care spending within the United States. In 2013, there were over 57.1 million ambulatory visits for back pain, yet very few cases are surgical. Providers and health systems must optimize efficient triage while improving access to specialists. PURPOSE The purpose of this study was to evaluate our model of telemedicine/electronic-triage for ambulatory spinal complaints for quantitative and qualitative measures of cost savings and efficiency. STUDY DESIGN/SETTING This study was performed at the West Virginia University (WVU) Spine Center. PATIENT SAMPLE All patient referrals made to the WVU Spine Center between 2011–2014. OUTCOME MEASURES Cost-savings and efficiency data were collected from electronic medical record (EMR) systems and analyzed for time from intake to appointment, rate of referral to surgeons versus nonoperative providers, and additional testing required. We extrapolated cost savings based on estimated avoidance of unnecessary office visits and travel. METHODS All new referrals between January 2011 and December 2014 were included. All referrals undergo “intake” to collect history, disease symptoms, prior treatment, imaging and test results, and data are then entered into queue within our electronic triage system (Cordata Healthcare Innovations, Cincinnati, OH). Cases are then electronically reviewed/triaged, by a spine surgeon, to a surgical provider, nonoperative spine provider, or other provider. The Cordata database was mined for data from intake until triage completion. Hospital EMR (Epic Systems Corporation, Verona, WI, USA) were then mined for data on initial clinic visit, tests ordered, follow-up appointments, and presence of surgical encounters. Financial savings were estimated from the number of “trips saved” and based on the cost of visit and mileage. RESULTS There were 16,174 records created between 2011-2014 of which 10,832 records (in 10,271 patients) were triaged by a spine surgeon. Average time from referral to surgeon review was 11 days (pre-Cordata, wait time for the first clinic visit/opportunity for a surgeon to review patient information was 2.5 to 8 months). After E-triage, 4,446 (43%) patients were offered an appointment with a spine surgeon, 4,959 patients (48%) were directed to a provider other than the spine surgeon, and 6,723 patients (65%) received recommendations for additional testing or conservative treatment. In patients with complaints consistent with spinal etiology but no initial treatment, diversion to a nonoperative spine provider generated 3,718 ambulatory visits in 2,444 patients. This diversion resulted in an estimated savings of $793,835 ($649,572 for unnecessary appointment with a surgeon and $144,263 in travel costs), or $325 per patient ($266 for clinic visit, $59 for travel). After E-triage, 4,446 patients were deemed to have surgical problems and were offered an appointment with a spine surgeon. Under the current system, average wait time for a surgeon appointment was 44 days. This is compared to historical wait times prior to Cordata of 2.5 to 8 months. Among patients directed to surgical appointments, 40% were “expedited” appointments, and 15% were felt to need “urgent” appointments (not including patients “fast-tracked” to clinic or emergency department for presence of “red flag” symptoms identified during intake). Of the 4,446 surgical patients, 3,528 arrived within 6 months of their most recent telemedicine review. Once seen, 2,331 (66%) did not require any further workup (indicating they already had a complete set of images/tests required for full surgical assessment at the initial visit) and 1,197 (34%) patients required additional testing/treatment ordered during the index visit. Among this cohort, 745 patients (26%) underwent spine surgery within 2 years of the index visit. CONCLUSIONS Appropriate triage and management of spine patients improves access and quality of care. This study is our attempt to quantify the anecdotally vast affect E-triage has had on our health care system and patient population. By appropriately funneling patients to the most appropriate provider utilizing an E-triage system, we showed decreased wait-times, nearly $800,000 of cost savings to the patients, and more effective use of surgeon time on surgical patients (26% surgical conversion rate in new patients). Further studies are required to fully evaluate the effects of an E-triage system on ambulatory spinal care. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.