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 Traumaand Surgical Care, University of Miami Miller School of Medicine,Miami, Florida.

AbstractObjectives: Limited resources and the diminishing physician work-

force in trauma require unique and innovative solutions. Our hy-

pothesis 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 ob-

servations. Comparisons were made between remote and local phy-

sician 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 experi-

ence 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 devel-

opment 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

This 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, se-

cure, bidirectional video and audio feed. This technology has nu-

merous potential uses in the delivery of medical care in general and

can provide access to care, consultation, and training that are des-

perately needed in the today’s 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 popu-

lations, 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 in-

tensivists staffed.3

The main priority of trauma clinicians is to achieve timely assess-

ment 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 techno-

logical innovations such as telemedicine applications.

Early telemedicine studies have documented successes and im-

provement in patient care, particularly in relation to improved and

early triage of severely injured patients, decreased rate of unneces-

sary 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 derma-

tology 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 ex-

tends the reach of the trauma care specialists beyond the limits im-

posed 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.

248 TELEMEDICINE and e-HEALTH APRIL 2013 DOI: 10.1089/tmj .2012.0102

Materials and MethodsA 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 2008–2009. 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 cen-

ter). 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 se-

cure broadband connection. Using high-quality audiovisual com-

munications 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 commu-

nication applications of the robot. Once the patient arrived in the

trauma bay, the remote physician performed the assessment along-

side the locally present doctor, who generally began by relaying

information given to him or her by emergency medical services re-

garding patient status and injury details. The remote physician de-

veloped 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 Miami’s In-

stitutional Review Board.

ResultsFrom 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 de-

ployments 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 patient’s injuries clearly

(92%), to see the screens and monitors presenting patient informa-

tion/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-7’s

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

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physicians consistently had a more positive view of the RP-7’s

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 phy-

sicians 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 phy-

sicians (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.’’ Ad-

ditionally, 70% of local physicians and 98% of remote physicians felt

that a telephone alone would not have been as effective as tele-

presence. In general, overall perceptions of their experience with the

RP-7 robot were positive among both physician populations (Fig. 2).

DiscussionTechnological advances have provided innovative solutions for

medical care, particularly in time-sensitive settings such as emer-

gency 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 consul-

tative purposes, may be an appropriate solution.

The overall results were exceedingly positive, with usability and

acceptability ratings consistently above 90%. There were some dif-

ferences 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 equip-

ment or with the ability of team members to move freely.

Other useful findings documented by the technical support team

included issues with the robot’s 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 patient’s 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 dis-

infect the robot after it was exposed to biohazardous materials. We

recommend further research into developing new and alternative

Table 1. Comparison of Percentages of Local and RemotePhysicians Who ‘‘Strongly Agree/Agree’’ with PositiveCommunication Statements Related to Their Experiencewith the Remote Presence-7 Robot and Teleconsultation

‘‘STRONGLY AGREE/AGREE’’

LOCALPHYSICIAN

REMOTEPHYSICIAN

I was able to effectively communicate

with the remote physician/local staff.

90% 97% (+7%)

I feel that the remote physician/local

staff was able to understand my

questions and comments.

92% 96% (+4%)

I was comfortable communicating with

the remote physician/local staff.

79% 98% (+19%)

I was able to hear the remote clinician’s/

local staff’s communications clearly.

81% 88% (+7%)

Table 2. Comparison of Percentage of Local and RemotePhysicians Who ‘‘Strongly Agree/Agree’’ with PositiveGeneral Statements Related to Their Experience withthe Remote Presence-7 Robot and Teleconsultation

‘‘STRONGLY AGREE/AGREE’’

LOCALPHYSICIAN

REMOTEPHYSICIAN

I felt comfortable using the robot in the

clinical environment.

87% 93% (+6%)

I felt comfortable communicating with a

remote physician/local staff from a remote

location.

92% 100% (+8%)

I feel that having access to a remote

physician at all times would be beneficial.

92% 99% (+7%)

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

SCHULMAN ET AL.

250 TELEMEDICINE and e-HEALTH APRIL 2013

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 physi-

cians 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 at-

tending 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 techno-

logical 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 pa-

tient 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 hos-

pitals 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 coun-

terparts. 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 en-

vironments specifically, but could also include disaster management

scenarios where on-site care must be delivered immediately.

Our findings suggest that the RP-7’s 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 po-

sitions 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 phy-

sician, 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, emer-

gency 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.

AcknowledgmentsThis project was funded under the U.S. Army’s Telemedicine

and Technology Research Center. C.I.S. was responsible for the

study’s design. A.M. provided technical oversight in data collec-

tion. 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 pre-

pared the manuscript.

Disclosure StatementNo 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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