Usability of Telepresence in a Level 1 Trauma Center

Carl Ivan Schulman, MD, PhD, MSPH, FACS, Antonio Marttos, MD, Jill Graygo, MA, MPH, MDEd, Paul Rothenberg, BA, Gabriel Alonso, Shannon Gibson, PhD, Jeffrey Augenstein, MD, PhD, and Elizabeth Kelly, MA William Lehman Injury Research Center, Division of Trauma and Surgical Care, University of Miami Miller School of Medicine, Miami, Florida.

Abstract
Objectives: Limited resources and the diminishing physician workforce in trauma require unique and innovative solutions. Our hypothesis is that telepresence by a remote physician is an appropriate application in an urban trauma setting. The purpose of this study is to assess user satisfaction and usability of a mobile telemedicine robot in trauma care. Materials and Methods: A usability study of trauma patient assessments utilizing the Remote Presence-7 (RP-7) robot (InTouch Health, Santa Barbara, CA) with real-time, two-way communication between remote and local physicians was conducted at a Level 1 trauma center. Usability and acceptability was measured using survey questionnaires, open-ended feedback, and general observations. Comparisons were made between remote and local physician responses. Results: One hundred fourteen patient encounters utilizing telepresence were performed. Remote and local physicians expressed a high level of satisfaction with the mobility (92% and 79%, respectively), communication (97% and 90%, respectively), and visual abilities (91% and 97%, respectively) of the RP-7 robot for remote consultation purposes. On average, 89% of remote and local physician participants rated their overall telemedicine experience as excellent or above average. Conclusions: This study suggests that telepresence of a remote trauma surgeon may be a useful and functional adjunct in the trauma setting. Further development of these technologies could mitigate current and future concerns about gaps in rural and urban trauma care and critical care staffing shortages and during mass casualty or disaster scenarios. Key words: robotic surgery, telemedicine, telesurgery, technology

Introduction

his study evaluates physician acceptance of the Remote Presence-7 (RP-7) mobile unit (InTouch Health, Santa Barbara, CA) for use in a Level 1 trauma center. The RP-7 mobile unit presents a unique technological innovation consisting of a fully capable bidirectional communication system housed in the robot itself and a control station through which phy-

sicians can remotely monitor, interact with, and communicate with patients and on-site medical staff. The RP-7 provides real-time, secure, bidirectional video and audio feed. This technology has numerous potential uses in the delivery of medical care in general and can provide access to care, consultation, and training that are desperately needed in the todays trauma care environments. The RP-7 links on-site clinicians with remote physicians who can provide particular expertise that would not otherwise be available on-site in the timely manner required in trauma care. It has long been acknowledged that there are multiple challenges confronting the trauma profession and trauma care delivery in the United States.1 Current dissatisfaction with trauma as a surgical residency rotation and a career choice is on the rise. Residents are generally dissatisfied because of nonoperative care duties and the structure of trauma rotations, whereas career trauma surgeons suffer from burnout and stress as a result of in-house call, night shifts, heavy workloads, and insufficient income. As a result of these and other factors such as the increase in the general and elderly populations, it is predicted that by 2020, there will be a 6% deficit of surgeons in the United States.2 Furthermore, it has been argued that by the year 2020, the critical care sector will be unable to provide even the current level of care let alone increase the amount of intensivists staffed.3 The main priority of trauma clinicians is to achieve timely assessment and diagnosis of all incoming patients. Any delay in both patient assessment and physician response can result in lost opportunities to improve patient outcome and can result in increased morbidity and length of stay.4 The increased concern over future intensivist staffing has led to proposals for alternatives such as unique staffing paradigms, the regionalization of critical care, and the increased use of technological innovations such as telemedicine applications. Early telemedicine studies have documented successes and improvement in patient care, particularly in relation to improved and early triage of severely injured patients, decreased rate of unnecessary patient transfer, and improved communication from ground and air ambulance providers. The application of telemedicine has been explored in a growing number of medical specialties, from dermatology to psychiatry, over the last three decades.5,6 Only in the last few years has telemedicine been applied to trauma, critical care, and emergency surgical specialties.7,8 The integration of telemedicine into the trauma environment extends the reach of the trauma care specialists beyond the limits imposed by time and distance. This study hypothesizes that telepresence is a useful and acceptable technology for an experienced trauma physician to successfully participate in the assessment and care of a trauma patient from a remote location.

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DOI: 10.1089/tmj.2012.0102

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Materials and Methods

A prospective study of the usability of telepresence for conducting trauma patient assessments was performed in a Level 1 trauma center. Perceptions of appropriateness and usability were obtained from both the local and remote physicians using survey data collection during 114 trauma teleconsultations performed over a 16-month period in 20082009. Our sample size was limited to patients who presented when remote physicians who had completed full training courses on use of the RP-7 technology were available to participate in the survey. These cases were presented from the trauma resuscitation unit or an operating room at our Level 1 trauma center; however, the remote physicians accessed the RP-7 robot from multiple locations (from home, office, and/or the stationary telemedicine control center). Local physicians consisted of attending, fellow, and resident physicians. The one exclusion criterion set forth for this study was that the remote physician had to be a trauma surgeon on staff with our facility; therefore telemedicine deployment and case selection depended on the availability of such remote physicians who were able to take the time to participate in the study. For this study, we utilized the RP-7 system (Fig. 1). The RP-7 is a mobile robotic communications platform that enables a physician to have remote access to the hospital from the home, office, or any remote location where Internet access is available. The system is composed of the Control Station and the RP-7 robot (operating on an 802.11 Wi-Fi network), which are linked via the Internet over a secure broadband connection. Using high-quality audiovisual communications equipment integrated with robotic mobility, the RP-7 allows physicians to remotely interact with other clinicians as well as to monitor the patient. The RP-7 is also equipped with a full tilt, pan and zoom camera that allows the remote physician to focus on areas of interest or to zoom out to get a wide shot of the trauma bay. Once connected with the consultation site, the local physicians do not have to be physically present to assist the robot or the remote physician as the mobility, video, and audio transmit continuously and can all be completely controlled from the remote Control Station. Remote

presence, therefore, allows a physician to be virtually present and unassisted in the trauma resuscitation area or the trauma intensive care unit. Activation of the telepresence system occurred once the center was notified by emergency medical services of an incoming trauma. The remote physician accessed the laptop Control Station from which he or she could control both the movement and audiovisual communication applications of the robot. Once the patient arrived in the trauma bay, the remote physician performed the assessment alongside the locally present doctor, who generally began by relaying information given to him or her by emergency medical services regarding patient status and injury details. The remote physician developed his or her patient note based on the pictures, vitals, and diagnostics viewed through the RP-7. The remote physician was also able to ask questions of staff in the trauma bay. In order to assess usability of the telepresence system in the trauma bay, surveys were administered in real time to both local and remote physicians. The usability survey forms varied somewhat, with the remote physician survey having 13 additional questions. The 5-point Likert scale survey questions addressed three issues: (1) equipment functionality (primarily visuals, communication, and mobility), (2) user satisfaction, and (3) qualitative feedback. Once the data were acquired, a frequency distribution analysis was performed. Data were compared using a z-test for proportions with significance at the 0.05 level. This study was approved by the University of Miamis Institutional Review Board.

Results
From April 2008 to July 2009, 114 teleconsultations with the RP-7 robot were conducted at our Level 1 trauma center. The RP-7 robot was deployed primarily in the resuscitation unit (95%), with six deployments in the operating room (5%). Of the patients evaluated, the majority suffered from blunt trauma (64%), followed by penetrating trauma (29%), burn trauma (4%), and non-trauma injuries (3%). In order to assess usability, remote and local physicians were given surveys to complete following each teleconsultation. From the 114 teleconsultations conducted, 114 surveys were completed by remote physicians and 62 by local physicians. Evaluation of the visual component demonstrated that remote physicians on average were able to see the patient well (94%), to see the local staff well (97%), to see all of the patients injuries clearly (92%), to see the screens and monitors presenting patient information/vitals (98%), and to see x-rays and other diagnostic tests clearly (96%). Additionally, 91% of remote physician respondents agreed that the picture relayed by the RP-7 robot was clear and crisp. Local physicians reported similarly positive perceptions of the RP-7s mechanical performance. They reported that the picture they viewed on the RP-7 robot was clear and crisp (97%), and they reported that they were able to see the remote physician well (98%). Perceptions of communication quality were relatively high for remote (97%) and local (90%) physicians. However, there was a significant difference in experienced comfort levels with telepresence communication between local and remote physicians. Remote

Fig. 1. The Remote Presence-7 robot in use during surgery.

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Table 1. Comparison of Percentages of Local and Remote Physicians Who Strongly Agree/Agree with Positive Communication Statements Related to Their Experience with the Remote Presence-7 Robot and Teleconsultation
STRONGLY AGREE/AGREE LOCAL PHYSICIAN
I was able to effectively communicate with the remote physician/local staff. I feel that the remote physician/local staff was able to understand my questions and comments. I was comfortable communicating with the remote physician/local staff. I was able to hear the remote clinicians/ local staffs communications clearly. 90% 92%

REMOTE PHYSICIAN
97% ( + 7%) 96% ( + 4%)

79% 81%

98% ( + 19%) 88% ( + 7%)

Fig. 2. Comparison of perceptions of overall experience with the Remote Presence-7 robot.

physicians consistently had a more positive view of the RP-7s communication abilities (Table 1). Whereas 79% of local physicians felt comfortable communicating with the remote physician, 98% of remote physicians felt comfortable communicating with staff during the consultation ( p < 0.001). Similar differences in perception between remote and local physicians were found in relation to questions on mobility. For example, 79% of local physicians felt the robot did not interfere, whereas 92% of remote physicians felt the robot was unobtrusive ( p < 0.025). Likewise, remote physicians (98%) were more likely than local physicians (84%) to feel that the robot appeared to maneuver effectively ( p < 0.001). In terms of general satisfaction and comfort with telemedicine technology, remote physicians had a more positive perception using the RP-7 robot (Table 2). Both sets of physicians were asked questions about their future preferences and overall experience with the RP-7

robot. Seventy-five percent of local physicians agreed that In the future, I would like to have the ability to participate on patient cases from a remote location as a standard operating procedure. Additionally, 70% of local physicians and 98% of remote physicians felt that a telephone alone would not have been as effective as telepresence. In general, overall perceptions of their experience with the RP-7 robot were positive among both physician populations (Fig. 2).

Discussion
Technological advances have provided innovative solutions for medical care, particularly in time-sensitive settings such as emergency departments and trauma centers. The busy nature of the trauma center or the complex injuries often requires consultation or communication with a specialist who may not be immediately available. It is at these crucial times that robotic telepresence, which can connect a local physician with a remote physician for consultative purposes, may be an appropriate solution. The overall results were exceedingly positive, with usability and acceptability ratings consistently above 90%. There were some differences such as the perception of the intrusiveness of the robot between the remote and local physicians. This may be due to the inability of the remote physician to perceive the changes that are required by the local staff to accommodate the robot. The trauma bay is often a limited space shared by multiple personnel and equipment. For example, the robot may interfere with portable imaging equipment or with the ability of team members to move freely. Other useful findings documented by the technical support team included issues with the robots inability to deal with debris (i.e., rubber gloves on floor) and difficulty maneuvering in small or crowded spaces. A selective microphone might prove beneficial to avert transmission of peripheral conversations and ambient noise. Additionally, the angle of visibility was sometimes limited when attempting to view a patients thoracoabdominal area. Our research suggests that the addition of a camera on a boom or the construction of a taller robot may help to correct this visibility limitation in the future. Also of concern was the ability to effectively clean and disinfect the robot after it was exposed to biohazardous materials. We recommend further research into developing new and alternative

Table 2. Comparison of Percentage of Local and Remote Physicians Who Strongly Agree/Agree with Positive General Statements Related to Their Experience with the Remote Presence-7 Robot and Teleconsultation
STRONGLY AGREE/AGREE LOCAL PHYSICIAN
I felt comfortable using the robot in the clinical environment. I felt comfortable communicating with a remote physician/local staff from a remote location. I feel that having access to a remote physician at all times would be beneficial. 87% 92%

REMOTE PHYSICIAN
93% ( + 6%) 100% ( + 8%)

92%

99% ( + 7%)

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technologies, including camera booms to enhance visibility and lower the risk of damage to the robot resulting from debris in the operating room and the potential spread of contamination through the robot itself. Limitations of this study include variations in response rates due to heavy workloads in the trauma unit, which prevented local physicians from completing long surveys at the end of a case. Network connectivity limited data collection and functionality at various times during the study period. requiring upgrades in the network infrastructure. This study did not collect data from all trauma attending surgeons on staff. A core group of attending physicians participated more frequently than others, which may lead to some bias. In addition, those who did participate varied in their technical expertise and experience using the remote system. Our results confirmed that telepresence is an appropriate technological solution allowing a remote physician to participate in the care of trauma patients, thus potentially alleviating current and future staffing shortages. As is often the case in our urban trauma center, care facilities can become overburdened because of unexpected patient surges. The ability to utilize remote physicians or specialists for triage and consultation purposes would be extremely beneficial not only to urban trauma centers like ours, but also to other rural hospitals where trauma specialty care is unavailable. In their 2005 study, Latifi et al.9 noted that rural communities often lack specialized trauma care and experience much higher levels of morbidity and mortality in patients with traumatic injury than their urban counterparts. These authors found that real-time telemedical systems were consistently viewed as improving care and were often perceived as life-saving in rural healthcare settings. Their model suggests that in rural settings, telemedicine could enable trauma centers to form the centers of larger networks capable of delivering expert trauma care to patients in settings where it is simply not feasible to have on-site trauma specialists.9 These locations need not be limited to rural environments specifically, but could also include disaster management scenarios where on-site care must be delivered immediately. Our findings suggest that the RP-7s application of telemedicine may be a useful and functional adjunct in the trauma setting. Such telepresence systems may help to mitigate current trauma surgeon and intensivist shortages. According to the National Foundation for Trauma Care there are twice as many available trauma surgeon positions as there are current practicing trauma specialists to fill them.10 The introduction of teletrauma could thus allow trauma surgeons in urban areas to assist in consultations in rural areas that may be lacking adequate staff. Additionally, telemedicine applications may provide unique solutions for staff burnout and stress, which could reduce the amount of in-house call, burnout, and stress that trauma surgeons frequently list as negative aspects of their career choice.11 Telemedicine will not only extend the reach of the trauma physician, but it will also help bridge the gap among limited resources, lack of available staff, and reduced reimbursement. The results of our study suggest that telemedicine may be successfully applied in other time-sensitive settings such as during pre-hospital transport, emergency surgical consults, disaster medical response, and battlefield

medical response. Further research of the applicability and clinical effectiveness of particular forms of telemedicine technology in these fields is warranted.

Acknowledgments
This project was funded under the U.S. Armys Telemedicine and Technology Research Center. C.I.S. was responsible for the studys design. A.M. provided technical oversight in data collection. J.G. provided total project oversight. S.G., P.R., and G.A. collected the data, and G.A. provided technical support for data collection. J.A. provided project guidance. E.K. edited and prepared the manuscript.

Disclosure Statement
No competing financial interests exist.

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Address correspondence to: Carl Ivan Schulman, MD, PhD, MSPH, FACS University of Miami Miller School of Medicine T221 JMH, Ryder Trauma Center Miami, FL 33136 E-mail: CSchulman@med.miami.edu Received: April 25, 2012 Revised: August 21, 2012 Accepted: August 22, 2012

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