Abstract
Objectives: Distance from expertise in traumatic brain injury (TBI) is often an impediment to appropriate TBI care from local health care providers, especially in rural areas. To overcome this barrier to care and to support a randomized, controlled trial of telephone follow-up after discharge from acute rehabilitation, we demonstrated the use of a confidential consultation Web site to provide expert recommendations and advice to front-line telephone staff at a different site.
Conclusions: This use of Internet communication proved convenient to all users, improved client confidence, and served as an excellent training tool to less experienced staff. In addition, use of a Web-based consultation method provided for archiving of all discussions for later review.
OUTPATIENT treatment models for traumatic brain injury (TBI) have traditionally involved intensive day treatment at sites where experts could provide coordinated patient care. Limitations of cost and access to services have been formidable with this approach, especially in areas of the country with large rural districts. Recent advances in information technology provide an opportunity for innovation in service access for both patients and health care providers.
Most reported uses and early studies of electronic communication have centered on the communication between patients and health care providers. 1-5 Distance medical technology applications have primarily been in the areas of Internet-based communication, telephone follow-up and counseling, telephone reminders, interactive telephone systems, after-hours telephone access, and telephone screening. 6 There are seminal studies by Gustafson et al 7 and McKay et al 8 indicating that Internet-based interventions can be effective for patients with HIV-AIDS and type 2 diabetes mellitus respectively. These preliminary findings relate self-reported improvements in health and quality of life, improved health-promoting behaviors, and a decrease in the need for medical care. Less emphasis has been placed on systematically supporting communication between health care and social service professionals and specialists who are geographically separated. Some clinical trials of online video consultation have been reported. 9 In addition, tertiary medical centers have long provided dedicated telephone lines to provide referrals and, less frequently, consultation to health care providers as part of their marketing programs. However, few initiatives have used the World Wide Web to provide other than nonexpert opinions or informal "chats" between health care providers.
Based on population density, large areas of Washington State are designated as rural by the United States Census Bureau. Additionally, Washington State is surrounded by a number of states without a true tertiary medical program (eg, a medical school). This means that many patients with TBI are being cared for and live in communities many hours distant from the population and medical hubs of Seattle and Spokane. As part of the TBI Model Systems grant awarded to the University of Washington by the National Institute on Disability and Rehabilitation Research, we have attempted to explore alternative means of offering support to health care professionals and lay organizations providing services to persons with TBIs.
The World Wide Web has become a home to many consumer-oriented Web sites (including those for physicians) that allow for informal case and problem discussion. However, many general "medically" based consumer Web sites may not be disseminating complete or reliable information. 10,11 Although one would hope that physician-oriented sites have more accurate information, these have not been analyzed. There have been reports of Web sites devoted to allowing physicians to consult with other physicians 6 and those devoted to interaction between health professionals and patients in areas such as maternal-child health, general health information in rural areas, and even programs concentrating on obesity and alcohol treatment. 1-3,12 However, to our knowledge, there have been no systematic uses of the Internet to provide expert backup to community organizations or other types of health/social care providers who are fielding consumer questions and problems for triage and problem solving.
Our project sought to explore the feasibility of providing expert Web-based support to health care providers using the telephone to contact and provide assistance to persons with TBI. Our goal was to explore the feasibility of such a concept within a clinical trial. The clinical trial was a randomized study that examined the effects of telephone follow-up during the first year after TBI on outcome at 1 year. In the trial, subjects and their significant others were contacted by a research care manager at 1 to 2 weeks, and 1, 2, 3, 5, 7, and 9 months after hospital discharge. The outcome of this intervention was assessed at 1 year after injury using a battery of measures assessing functional status, emotional functioning, and quality of life. The calls were designed to provided direct assistance in the form of brief counseling, problem solving, or providing community and tertiary referrals if necessary. In addition, these calls provided education about commonly encountered problems after TBI. Participants in this study lived in communities throughout both Eastern and Western Washington State. We also had participants who spent all or part of their first year after injury in other states, such as Alaska, Oregon, California, Colorado, Maine, and New York. The eventual intent is to expand the clinical trial to use within a community organization such as the local chapter of the Brain Injury Association.