Outcomes and cost savings of free clinic care.

Healthcare costs and client health status were measured in a 10-month period before and after an index free clinic visit for 26 poor, working, uninsured patients. A significant number of patients reported overall improvement in their health. During the period of free clinic management, the equivalent of dollar 6500 of care was provided. Compared to utilization before the free clinic period, a savings of dollar 33,145 was realized, largely due to decreased emergency department care and hospitalization.

A practice-based rural health fellowship: an innovative approach to support for rural care.

Efforts to support recruitment and retention of rural providers have sometimes included local postgraduate training. An innovative approach that includes training fellows entirely in a rural area with most of the costs supported locally was found to be cost-effective and to produce the expected positive effects. Training goals and objectives were accomplished in the areas of rural health and advanced maternity care, and the community gained an experienced provider as well as a new continuing education activity. This model may be applicable to many rural sites that have adequate clinical volume, experienced and motivated local faculty, and connection to a supportive regional medical center.

Telemedicine screening of glaucoma.

OBJECTIVES: Glaucoma is a major cause of blindness. More than 80,000 Americans suffer permanent vision loss from the disease. Widespread screening is fundamental in limiting the incidence of glaucoma-associated blindness. This pilot study explored the use of stereo digital images taken at a primary care center for telemedicine review by an off-site specialist as a means of screening for glaucoma. MATERIALS AND METHODS: Thirty-two diabetic patients were screened at a family medicine clinic. None had previously been diagnosed with glaucoma. A senior optometry student took stereoscopic digital and 35-mm optic disc photographs with a nonmydriatic retinal camera. The digital images were forwarded to a remote ophthalmologist for review. The conventional color stereo slide pairs of the same eyes were subsequently reviewed for comparison. Agreement on signs of glaucomatous disc changes between the two imaging systems was analyzed. RESULTS: Twenty-six of 32 eyes' digital and 35-mm photographs were analyzed. Six of 32 eyes (18.8%) could not be compared due to lack of matching 35-mm slides or digital images. Out of 26 eyes, lamina cribosa visibility was undeterminable in 8 eyes' digital images and 3 other eyes' 35-mm slides. Agreement among digital images and 35-mm slides of the remaining eyes was: 100%-vertical elongation, barring of vessels, bayoneting of vessels, and drance hemorrhage; 96.2%-focus notching of rim and rim pallor; 93.3%-lamina cribosa visability; 92. 3%-overpass cupping; 88.5%-focal enlargement; 84.6%-parapapillary halo; 80%-nerve fiber visibility; 65.4%-parapapillary atrophy. Parapapillary halo (p = 0.046) and nerve fiber layer visibility (p = 0.18) were detected on some 35-mm slides but not seen on matching digital views. CONCLUSION: Evaluations of cup-to-disc ratio (C/D) using both methods were in general agreement. However, some digital images were noted as too dark for assessing fine glaucomatous disc changes. Stereo digital images taken with a nonmydriatic camera by nonophthalmic photographers is a promising alternative for glaucoma screening in primary care settings. Telemedicine offers efficient communications with off-site glaucoma specialists. A larger study population is necessary to determine the overall effectiveness of using stereo digital imagery and teleophthalmology for glaucoma screening.

The community continuity experience: generalist training for preclinical medical students.

Many medical schools are planning community-based experiences for preclinical students. In August 1994, The University of Texas Medical Branch at Galveston began placing all 200 first-year medical students in generalists' offices in a new course called the Community Continuity Experience. The office nurse served as site facilitator. Activities during the second term provided more opportunities for students to interview patients as well as to observe the site physicians. The course committee used feedback from student evaluations and focus groups to change the implementation of the curriculum. We found that nurses as site facilitators effectively managed the students' activities, that continuity of site was more important to students than breadth of exposure, that the optimum focus of activities was the examination room, that training in actual skill development (e.g., methods of patient education) was desired before site activities, and that careful integration of preclinical patient-oriented courses was important to expose students to a coherent approach to learning skills for patient assessment.

A field trial of 2 telemedicine camera systems in a family practice.

Previous reports of telemedicine consultations have demonstrated that the technology is effective but inefficient. Little attention has been directed to the use of telemedicine in a primary care practice, especially the use of the medical peripheral devices. We used a functioning primary care practice as a telemedicine test bed, providing unselected patients in the study group. The goal was to study the performance of a new generation of a compact set of medical peripheral devices specifically designed for telemedicine examinations. In a 3-week field trial, 2 second-generation camera systems were used by physician faculty and residents in family practice to examine the skin, ears, and pharynx of 34 patients, ranging in age from 10 months to 78 years. Evaluations by the clinicians and patients were obtained. The average duration of an examination using these systems was 2 minutes. Patients' response was uniformly positive. A "pistol grip" video otoscope obtained an acceptable image, unless canal debris obscured the view. The system that provided pneumatic otoscopy was preferred, with some modifications necessary to obtain an airtight seal. The preferred skin camera was one that provided an image of a size that clinicians were most accustomed to viewing, although stability of this handheld camera was a problem. This camera also worked well to visualize the pharynx, especially in children with symptoms of pharyngitis. Color was deemed important in all 3 anatomical areas, and using auto-white balance and excluding fluorescent lights were preferred. Thus, the second-generation telemedicine peripheral devices were effective for use in a group of unselected primary care patients. These camera systems can be used by nursing personnel and require a minimum of time per examination.

The department without walls. Acceptability, cost, and utilization of interactive video technology.

As groups of physicians continue to provide more of their activities in sites remote from the central office, communication among providers and staff and the provision of common educational activities are important priorities. An analysis of a 12-month period of the use of full-motion interactive video technology to accomplish these goals in a decentralized academic department shows this method to be acceptable and cost-effective. Careful attention to room environment and staff support were found to be important. Practical recommendations are provided for those considering the use of this technology.

Communication in integrated practice networks: using interactive video technology to build the medical office without walls.

As groups of physicians join networks to maximize their effectiveness with managed care systems, frequent communication and joint development of standardized clinical protocols become important. For physicians who are accustomed to being independent, frequent meetings are necessary to make these networks succeed. In larger networks, travel time becomes a significant drain on clinical effectiveness. Interactive video technology (IVT) providing full-motion two-way video communication is one potential solution to this problem of geography and time. The experience of our academic department with IVT is summarized and practical advice is provided for those considering the use of this new technology.

A field trial of the NASA Telemedicine Instrument Pack in a family practice.

BACKGROUND: Previous studies of telemedicine applications have demonstrated that the technology is effective but inefficient. Little attention has been directed to the primary care portion of the connection, especially the use of the medical peripheral devices. This study used a telemedicine testbed that simulates a rural practice environment to describe the effectiveness and efficiency of the NASA Telemedicine Instrument Pack, a small self-contained system of medical peripheral devices. METHOD: This study was an 8-week field trial of a suitcase-sized pack containing a fundus camera, flexible nasopharyngoscope, dermatology macrolens, light source, and video monitor. The pack was first studied in specialty clinics and then was used in a family practice office connected to the consultant node by digital lines. Evaluations were obtained from technicians, patients, and consultants. RESULTS: During 20 video clinic sessions, 59 patients with 38 different diagnoses were examined. The ear, nose, and throat portion of the exam was effective, with some decrement in color and clarity with compression of the signal. The eye portion was marginally effective, limited by a field of view that was too narrow and also by rigorous technician requirements. The skin exam was largely unacceptable primarily because the macrolens did not meet the requirements for color or clarity prior to compression of the signal. CONCLUSIONS: Subsequent design efforts for medical peripheral devices for telemedicine use will require significant modifications to "off the shelf" equipment to be effective and efficient. A family practice telemedicine testbed provides the appropriate environment for such field trials.

Initial community site development for first--and second-year medical students.

BACKGROUND: Many medical schools are planning community-based experiences for preclinical students. As part of a generalist physician initiative, the University of Texas Medical Branch in Galveston placed all 200 first-year medical students in generalists' offices in a new course, called the "Community Continuity Experience." METHODS: Driven by significant time, class size, and geographic constraints, a process managed by the local Area Health Education Center was formulated for identifying and developing potential sites. The final process included identification of candidate generalist sites, departmental participation, and a detailed site assessment. The individual office nurses were the focus of site development activities. RESULTS: Feedback indicated that having office nurses serve as site facilitators was effective, and a key enabling strategy was having a nurse site coordinator serve as a single point of contact for all the sites. The students expressed positive views of the site experience and an interest in assignment, rather than student choice, for site allocation. CONCLUSIONS: Important components of site development for such a new course are development of an accurate database of available generalist community faculty, a methodical site selection process, an early orientation for all involved, and consideration of nonphysician site facilitators during the start-up phase.

An application of telemedicine technology for otorhinolaryngology diagnosis.

Applications of interactive video communications for providing remote telemedicine consultations are under study. Most of these applications use "off the shelf" medical peripheral devices that are not specifically designed for telemedicine examinations. This study reports a field trial of the telemedicine instrument pack (TIP), a small self-contained unit under development by the National Aeronautics and Space Administration for use in spaceflight. Patients with otorhinolaryngology problems were selected from a primary care practice and examined with the TIP by a technician under the direction of a remote consultant. The equipment proved adequate for examination of the posterior nose, hypopharynx, and larynx. Examinations of the ear and oropharynx with the TIP were not optimal, suggesting a need for further modifications of this prototype unit.

A telemedicine primer. An introduction to the technology and an overview of the literature.

The examination of patients by telemedicine is currently experiencing a resurgence of interest, perhaps spurred by the increase in activity in managed care and major technologic advances. The history and recent publications show rapid change in the areas of interactive video and store-and-forward equipment, available communications media, and medical peripherals. Several existing demonstration projects serve as practical examples of the potential of telemedicine systems. Important research and clinical care issues and opportunities for constituency building await participation by primary care physicians.

The medical school without walls: who will be the faculty?

To involve community physicians as medical school faculty, a survey was completed to establish the needs of 64 community physicians participating in a third-year family medicine clerkship. We received 48 responses that indicated issues of practice regulation, training office staff, and local continuing medical education were highest priority needs. The 27 respondents in rural areas placed more emphasis on issues of referral/consultation, recruiting of physician associates, and faculty development. As a result of the survey, The University of Texas Medical Branch at Galveston has implemented a comprehensive strategy to address the stated needs, with special emphasis on a rural health initiative. This strategy includes a special program for faculty to provide rural practice coverage technical assistance for practice management, a rural communications network, faculty development, and provider recruitment. The goal of this strategy is to continue developing the "medical school without walls."

Hyperemesis, hyperthyroidism, or both?

Nausea and vomiting are common during pregnancy and, when severe enough to require intervention, may develop into the syndrome known as hyperemesis gravidarum. When the diagnosis of hyperemesis is considered, a careful search for secondary causes is necessary. The list of secondary causes includes hyperthyroidism, a relatively uncommon condition during pregnancy. Because many of the signs and symptoms of hyperthyroidism are common, and thyroid function tests are more difficult to interpret during normal pregnancy, making the diagnosis of hyperemesis gravidarum is a challenge. The decision to treat or to await spontaneous resolution depends on the severity of the illness and the likelihood of the presence of true Graves' disease. The case summarized here demonstrates these issues, and includes treatment options for hyperemesis-associated hyperthyroidism.

The decision to suggest screening lower gastrointestinal endoscopy: the effect of training.

Primary care residency directors in the Southeastern US were surveyed to obtain information on training in lower gastrointestinal endoscopy (LGIE). All residents in a sample of programs were asked to complete a similar questionnaire. Response was 77% for family practice residencies and 60% for internal medicine residencies. Significantly fewer (43%) internal medicine residents reported receiving training in either 35 cm or 60 cm LGIE than family practice residents (77%). When asked if they would suggest LGIE to screen an asymptomatic patient, 67% of family practice and 84% of internal medicine residents replied affirmatively. Those residents who had received training were significantly more likely to suggest screening LGIE. The screening decision was not influenced by the specialty of the physician who supervised the resident training. Out-of-pocket cost to the patient was expected to be a major consideration in the screening decision, but this was not supported statistically. Greater availability of residency training in LGIE will likely increase its use in screening.

Teaching lower gastrointestinal endoscopy: a comparison of family medicine and internal medicine residencies.

Lower gastrointestinal endoscopy (LGIE) is an important procedure in primary care for detecting colorectal cancer. This survey of family practice (FP) and internal medicine (IM) residency directors in the southeastern United States shows that 100 percent of FP and 92 percent of IM programs provide training in LGIE. Less than half of all programs had certification criteria, and both disciplines showed a clear preference for the 60-cm flexible sigmoidoscope. LGIE procedures in IM programs were more frequently supervised by gastroenterologists, and in FP programs they were more frequently supervised by FP faculty. Only 55 percent of FP and 56 percent of IM residents were predicted to suggest screening LGIE to their patients, and 80 percent of FP and 63 percent of IM residents were predicted to include sigmoidoscopy in the evaluation of hematochezia.

Grateful Med: getting started.

When a local medical library is not available, it is often necessary for physicians to discover alternate ways to receive medical information. Rural physicians, particularly, can make use of a computer program called Grateful Med that provides access to the same literature available to physicians in large cities. This program permits the user to perform database searches on the National Library of Medicine database (MEDLINE), corresponding to the primary index to medical literature, Index Medicus. In this article, we give the procedure for procuring a National Library of Medicine password and for making efficient use of the Grateful Med program.