Pain Medicine Advance Access published April 27, 2016
Pain Medicine 2016; 0: 1–6
doi: 10.1093/pm/pnw069
Brief Research Report
Development and Patient Satisfaction of a New
Telemedicine Service for Pain Management at
Massachusetts General Hospital to the Island of
Martha’s Vineyard
George M. Hanna, MD,* Irina Fishman, MD,†
David A. Edwards, MD, PhD,‡ Shiqian Shen, MD,*
Cheryl Kram, RN,§ Xulei Liu, BS,‡ Matthew
Shotwell, BS,‡ and Christopher Gilligan, MD, MBA†
*Department of Anesthesia, Critical Care and Pain
Medicine, Center for Pain Medicine, Massachusetts
General Hospital, Boston, Massachusetts;
†
Department of Anesthesiology, Beth Israel
Deaconess Medical Center, Boston, Massachusetts;
‡
Department of Anesthesiology, Vanderbilt University
Medical Center, Nashville, Tennessee; §Pain
Management Center, Martha’s Vineyard Hospital, Oak
Bluffs, Massachusetts, USA
Correspondence to: George M. Hanna, MD,
Department of Anesthesia, Critical Care and Pain
Medicine, Center for Pain Medicine, Massachusetts
General Hospital, 55 Fruit Street, Boston, MA 02114,
USA. Tel: 617-726-8810; Fax: 617-726-3441; E-mail:
ghanna2@mgh.harvard.edu.
Conflicts of interest: There are no conflicts of interest
to report.
Abstract
Objective. Patients in remote areas lack access to
specialist care and pain management services. In
order to provide pain management care to patients
remote from our center, we created a telemedicine
pain clinic (telepain) at Massachusetts General
Hospital (MGH) in Boston, MA to extend services to
the Island of Martha’s Vineyard.
Design. Over 13 months, 238 telepain video clinic
evaluations were conducted. A pain physician
visited the island 1–2 days per month and
performed 121 in- terventions. Given the novelty of
telemedicine clinics,
VC 2016 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
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we surveyed patients to gauge satisfaction and iden-
tify perceived weaknesses in our approach that
could be addressed. Forty-nine consecutive
patients an- swered a 14-question, 5-point balanced
Likert-scale survey with 1 (no, definitely not) being
most negative and 5 (yes, definitely) being most
positive.
Setting. Patients on Martha’s Vineyard referred for
pain management consultation services via
telemedicine.
Patients. Forty-nine consecutive patients evaluated
via telemedicine.
Interventions. Likert-scale survey administered.
Measures. Questions measured patient impres-
sions of video-based visits with their doctor, conve-
nience of the visit, concerns about privacy, and
whether they would recommend such a visit,
among other items.
Results. Mean respondent scores for each question
were >4.3 indicating a favorable impression of the
telepain clinic experience. Lowest mean scores
were found when respondents were asked to com-
pare the care they received by telepain versus an in-
person visit, or whether they were able to develop a
friendly relationship with the doctor.
Conclusions. The results suggest an overall posi-
tive reception of telepain by patients, yet highlight
the challenge of building a patient-physician rela-
tionship remotely.
Key Words. Telemedicine; Telehealth; Pain
Medicine; Pain Management
Introduction
Chronic pain affects over 100 million American adults
[1]. As reported by the Institute of Medicine, “pain costs
society at least $500–$635 billion annually [1].” To
1
Hanna et al.

2
appreciate its profound cardiology, psychiatry, the need for continuing educated in a
impact, one must and neu- rology. In the support A Telemedicine
and education Service for Pain Management
multidisciplinary
appreciate that the costs field of neurology, in treating patients with approach with didactics
of chronic pain are telemedicine has im- chronic non-cancer pain provided by specialists in
higher than those of pacted stroke [10]. Project ECHO the fields of neurology,
diabetes mellitus, heart management enabling (Extension for Community internal medicine,
disease, and cancer early intervention by Healthcare Outcomes) addiction psychiatry, and
combined. Furthermore, specialist care remotely, focused on addressing pain management. From
back pain alone is the improved patient the needs of rural and the period of January
leading cause of outcomes, and has underserved 2010 to December
disability in Americans helped to overcome communities by 2012, there were 3,835
under 45 years old [2]. neurologist shortages providing weekly chronic total instances of
The costs of chronic pain [4,5]. Similarly, pain didactics and case participation, repre-
care results from work- telemedicine in pain presentations to primary senting: 763 individuals,
day and produc- tivity management has been care physicians 191 sites, 29 states and
loss, as well as high reported to improve care [11,12]. Providers the District of Columbia
healthcare resource in patients with multiple were (DC). Ninety-three
utilization such as sclerosis and phantom individuals pre- sented
prolonged hospitalizations, limb pain [6,7]. In the 304 cases: 261 new, and
and more frequent Canadian province of 43 follow-up. It is
emergency room visits. Ontario, telemedicine has noteworthy that CME

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Future challenges of been used to sup- port evaluations completed by
chronic pain medicine are primary care physicians the pro- viders showed
multifold including in caring for chronic pain statistically significant
overcoming the patients [8]. Pain improvement in
geographical barriers that management participant self-reported
separate pain sufferers psychologists have also knowledge, skills, and
from accessible care and successfully used similar practice [11]. This project
the discomfort of some technology to provide aimed at equipping
primary care providers in services to chronic pain providers in under- served
managing complicated patient populations [9]. areas with the necessary
chronic pain. tools to meet the ever-
Nonetheless, Distance separates many growing needs of their
telemedicine offers a chronic pain patients patients.
unique solution to these from ob- taining
obstacles by extending necessary care from Another advantage of
medical care to patients pain specialists. This telemedicine is that it has
in distant communities dis- tance is particularly shown itself in certain
and providing readily noticeable in rural studies to be more
accessible counseling to communities where efficacious than the
primary care physicians patients are not only current standard of pain
caring for this challenging physically separated care provided by primary
subset of patients. from pain specialists, but care physicians. The
they tend to be SCOPE trial enrolled 250
Telemedicine is defined financially burdened with patients with chronic
as the use of medical higher rates of poverty, musculoskeletal pain of
informa- tion exchanged lack of insurance, and greater than 3 months
from one site to another less formal education and randomized 124
via electronic [10]. Additionally, some people to the
communications to primary care providers intervention group and
improve a patient’s have expressed the remaining 126 people
clinical health status. It discomfort with caring to the usual care group.
includes a growing for chronic pain patients, This study involved 12
variety of applications especially those with months of telephone-
and services using two- high opioid requirements. delivered collaborative
way video, e-mail, The lack of comfort of care management
smart phones, wireless primary care physi- cians intervention by nursing
tools and other forms of in caring for chronic pain staff along with one in-
telecommunications patients was suggested person meeting with a
technology [3]. by a recent survey of nurse who presented the
Telemedicine dates back 856 primary care patient’s care to a pain
to the early twentieth physicians and nurse specialist physi- cian in
century and has been practitioners in order to develop a
implemented in many Washington State, where treatment plan. All
medical fields such as pro- viders expressed patients in the

3
intervention group were associated with taking a
Hannaby
treated et an
al. algorithm 45-minute ferry ride
ap- proach to optimize followed by a 2-hour
analgesia. Control drive for evaluations,
patients continued to inter- ventions, and
have their usual care follow-up visits with pain
provided by their primary specialists [14].
care providers. Initially
the baseline BPI (Brief M
Pain Inventory) scores e
were 5.32 for the t
intervention group and h
5.12 for the control o
group. The results of the d
study were signifi- cant s
for the intervention group
having 1.02 points lower The study protocol was
on BPI score compared approved by the
to the control group and Institutional
at least Review Board of MGH
20% improvement in and all patients were
pain score at the 12- asked to
month follow- up. Those
in the control group were
more likely to experi- ence
worsening of pain 36%
versus 19% compared
with
intervention group [13].
This study suggested
that tele- medicine can
provide a better
standard of care com-
pared to the current
practices, and prevent
worsening of pain in its
participants. It
highlighted the role of
midlevel providers in
bridging the gap
between the high
demand for pain medicine
and the low supply of
pain specialists.

Our program was aimed

at extending pain
management services to
the residents of Martha’s
Vineyard in
Massachusetts. Martha’s
Vineyard is an island
accessible only by sea or
air that is home to 15,000
residents year- round,
with an increased
population of 115,000
during the summer
months. Prior to the
telehealth pain program,
residents of the island
would have to endure the
inconve- nience and cost
($63-$127 per vehicle
and an additional
$17 per adult traveler)
4
A Telemedicine Service for Pain Management

5
 review a privacy and five responses for each assigned to the Likert
Hanna et al. question were calculated
confidentiality agreement To evaluate patient scale responses. The
describ- ing telemedicine satisfaction with the and presented in a mean nu- merical score
services before telepain experi- ence, a diverging stacked bar and its associated 95%
undergoing care. The 14-question survey was chart, in which the confidence inter- val
MGH Telehealth Program, created using the prin- fraction of respondents were then computed
a hospital-wide program ciples of survey who agreed with the for each question and
cre- ated to support development for statement are shown to presented in a forest
distance medicine in New telemedicine suggested the right of the zero line; plot, adjacent to the
England, in- stituted a by Demiris [15] respondents who diverging stacked bar
collaboration with emphasizing: the disagreed were shown chart (Figure 1).
Martha’s Vineyard importance of designing to the left. Numerical
Hospital (MVH) in 2013 a survey based on a values from one through R
to develop a telepain detailed definition of what five were e
program. Patients at it intends to measure; s
MVH were seen in testing it before u
telepain clinic 3 days per administer- ing it to the l
month by a physician larger sample; and t
located at MGH for reliability, validity, and s
initial consultations and generalizability. The
follow-up visits. patients were asked by In the first 13 months of

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Communication was the RN to voluntarily the telemedicine program,
mediated by live complete the survey after a to- tal of 238 virtual
videoconference (Vidyo, either telepain initial or telepain evaluations were
Inc. Hackensack, NJ, follow-up visit. Forty-nine performed (185 initial
USA) controlled by the consecutive patients consultations and 53
physician at MGH. The were asked, and all follow-up visits). One
patient and family agreed to participate. hundred twenty-one on-
members, along with a Questions were chosen site evaluations and
registered nurse were to measure overall procedural interventions
ori- ented approximately satisfaction, specific were conducted during
five feet away from a experi- ence using the the same period. The
media tower consisting technology, convenience most commonly
of a large television to the patient, patient- performed procedures
screen and live audio/vi- physician relationship, included epidural steroid
sual capabilities in a and ability to communi- injections (N ¼ 48) and
patient exam room at cate. Answers to all medial branch blocks (N
MVH. Vital signs were questions used a 5-point ¼ 29). Forty-nine
recorded in a shared balanced Likert scale to consecutive patients
electronic medical re- avoid ceiling effect [16]. agreed to be
cord. A registered nurse, Response range was anonymously surveyed
trained in physical anchored between 1 after their telepain visit
examination of pain (no, definitely not) to 5 and responded to the
conditions and medical (yes, definitely) (Table 1). majority of questions
management, performed positively.
the exam of the patients Out of the 14 survey
at MVH during the clinic statements, 11 were Questions measured
visit under direct written with positive tone, patient impressions of
physician supervision via that is, greater video-based visits with
live videoconfer- ence agreement was their doctor,
and also verbally associated with greater convenience of the visit,
announced all findings. satisfaction and vice con- cerns about
Physical examinations versa. The remaining privacy, and whether
were again repeated by three questions were they would recom- mend
the physician dur- ing on- written in a negative such a visit, among
site visits prior to any tone. In order to present other items (Table 1).
patient intervention. the results with Mean respondent scores
Laboratory data and consistent tone, the for each question were
imaging studies were responses to the >4.3 indicat- ing an
reviewed in the shared negative tone questions overall favorable
electronic medical record. were reversed (e.g., “No, impression of the
One or 2 days per month, definitely not” was telepain clinic experience.
MGH physicians would converted to “Yes, Mean respondent score
travel to MVH to perform definitely”). for all questions was
on-site pain interventions. 4.57. Lowest mean
The percentages of the
6
scores were found when state of Wyoming has
re- spondents were approximately 13 pain A Telemedicine Service for Pain Management
asked to compare the specialists [17].
care they re- ceived by Additionally, prior to the
telepain versus an in- establishment of this
person visit (Question 4, tele- medicine program,
4.32), or whether they patients had to bear the
were able to develop a inconve- nience and
friendly relationship with costs of boarding a
the doctor (Question 11, ferry and traveling
4.34). Highest mean several hours to obtain
scores were found when medical care. Our
respondents were asked telepain pro- gram was
if they were satisfied able to eliminate these
with the telehealth visit unfavorable conditions
(Question and deliver services with
2, 4.75), if they were overall patient
comfortable talking by satisfaction.
video with a specialist
(Question 7, 4.75), and if This report is one of the
there was any diffi- culty few known existing
hearing or seeing the programs that allow
doctor (Question 10, patients to have direct
4.76). contact with a pain

D
i
s
c
u
s
s
i
o
n

This study demonstrates

that it is possible to
success- fully develop
and maintain a
telemedicine pain
manage- ment program
in an area as remote
as Martha’s Vineyard,
which contains one of
the top 20 critical ac-
cess hospitals in the
United States and was
previously lacking
dedicated pain medicine
services. With an esti-
mated 8,000-9,000
pain medicine
specialists in the United
States mainly
congregated in large
cities, the geographical
barriers create a true
health care disparity for
residents in such areas
as Martha’s Vineyard.
For example, highly
desired areas such as
California have upwards
of 900 pain medicine
specialists, while the
7
Hanna et al.

Table 1. Survey questions and response options

Questions:
1. Appointments by video are better than I expected.I am satisfied with my Telehealth visit.

2. I worried about my privacy.

3. The care I received by Telehealth was just as good as with an in-person appointment.

4. The Telehealth visit saved me travel time.

5. The Telehealth visit saved me money.

6. I was comfortable talking by video to the specialist.

7. I felt that everything was well covered during my visit.

8. I would rather travel to have my next visit in-person than use Telehealth.

9. I had difficulty hearing or seeing the doctor through the video.

10. I was able to develop a friendly relationship with my doctor.

11. I was able to explain my problems clearly to my doctor during the Telehealth visit.

12. The Telehealth visit was convenient.

13. I would recommend the Telehealth option to other patients.

Responses:
1 – No, definitely not
2 – I don’t think so
3 – Maybe yes, maybe no
4 – Yes, I think so
5 – Yes, definitely

8
medicine specialist via that telemedicine can be A Telemedicine Service for Pain Management
live video- used as a tool to reach
teleconferencing. Previous out to a poorly accessible
studies feature a system patient population, to
whereby primary care greatly expand the
providers are able to use number of participants
telemedicine to contact during the initial study
spe- cialists regarding period, and to achieve
management of their high patient satisfaction
chronic pain pa- tients or with the services
attend applicable didactic provided.
sessions [10,11,13]. For
example, the Specialty With the heightened
Care Access Network- interest in using
ECHO pain management telemedicine in pain
program (SCAN-ECHO- medicine care, there
PM) provided primary have been efforts to
care providers with identify the limitations of
case-based pain such programs. For
manage- ment specialist patients residing in rural
consultation that led to

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areas with very limited
increased utiliza- tion of access to physicians,
physical medicine tele- medicine offers
services and initiation hope of access to
of nonopioid analgesics appropriate health- care.
for patients in the However, much work
Veterans Health remains to be done to
Administration [18]. examine its efficacy
Another study compared with in-person
demonstrated rapid and physician visits. In a
cost-effective access of comprehensive review of
telehealth consultation telehealth programs in
vis- its between primary pain medicine, the
care providers in authors identified that at
Washington State and a the pre- sent time there
team of pain medicine has been a lack of
specialists compared outcomes research
with addressing the short-
‘in-clinic visits,’ as it and long-term benefits
pertains to transaction of tele- health. [20,21].
cost analysis Much of the outcomes
[19]. In our study, the research, includ- ing our
quality of care was featured survey, report on
maintained via direct patients’ subjective
videoconferences with experiences with the
patients and pain program. It would be
special- ists, physical imperative to collect
exams performed by objective patient data on
appropriately trained telemedicine programs,
nursing staff, and
monthly physician visits
to the island for
procedural interventions.
Our project
demonstrated

9
Hanna et al.

Figure 1 Forest plot shows percentage of responses for each survey question (Q1-Q14) on the left, with the mean
response score with 95% confidence interval on the right.

1
0
such as recording population being treated. favorably. Further studies National Academy of
A Telemedicine Service for Pain Management
patients’ longitudinal It must also be noted must also be performed Sciences; 2011.
opioid medica- tion that patient survey to de- termine the
usage once appropriate responses may be reproducibility of these 2 U.S. Department of
telemedicine treatment skewed because of findings and to es- Health and Human
is established and social desirability to tablish threshold values Services, National
maintained. There are respond defining successes and Center for Health
also financial limi- tations failures of responses Statistics.
to such programs given. Chartbook on trends
including the expenses of The future of this in the health of
initi- ating such program will include Americans. Special
programs, and collecting objec- tive data
challenges in obtaining comparing the efficacy of
financial reimbursement telemedicine with in-
from third parties for person physician visits.
services that are not in This will include
person with physicians. comparing pain scores
On the other hand, these between patients
programs may prove to randomized to
be rather cost ef- fective telemedicine in-
by reducing the number

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terventions versus
of “no shows to ap- control group receiving
pointment” and standard via in person
decreasing the number visits, performing cost
of hospitalizations and effectiveness analysis of
emergency department the program, and
visits for pa- tients who examining whether opioid
previously had no usage decreases once
access to care. There appropriate telemedicine
are also concerns about intervention and follow-up
the shortcomings of is established. While
technology in- cluding much remains to be
bandwidth strength and investigated in the
its ability to maintain emerging field of
good connectivity during telemedicine, our project
these sessions. Finally, demonstrates success in
there is thought that bridging the geograph-
telemedicine ical gaps in healthcare
compromises the quality disparities in the field of
of care by limiting ability pain medicine and that
to obtain pertinent patients have an overall
clinical informa- tion over positive re- ception of the
such telehealth sessions. service.

Specific to our study,

there are limitations that
exist. Although a random R
selection of 49 e
consecutive patients were f
surveyed, this sample e
size may not be entirely r
rep- resentative of the e
chronic pain patients on n
Martha’s Vineyard, or c
e
other pain populations
s
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