Journal of Telemedicine and Telecare current issue

Information architecture of a telecare system

Collinge, W. H, Liu, K. — 2009-05-26

An information architecture is a high-level, conceptual design for a system which describes the fundamental requirements and principles of a system, and details its essential elements and characteristics. I conducted a comprehensive review of published literature on telecare, including government reports and case study papers. This enabled a complete picture to be constructed of telecare system components. The components can be divided into four separate categories: human components, ICT components, telecare operational units and supportive elements. The system requirements cover functional, non-functional and informational requirements. Telecare holds great potential for all sectors of society. Its true value may only be realised when the nature of information within the telecare system is fully understood. The thorough analysis, manipulation and usage of system data are the key to the future success of telecare services.

A retrospective study of adult telephone triage calls in a US call centre

North, F., Varkey, P. — 2009-05-26

We conducted a retrospective study of symptom assessment calls for adult patients at a US call centre, Ask Mayo Clinic. A total of 27,979 symptom assessment calls were received from July 2006 to June 2007. Calls concerning female patients predominated in all age groups and accounted for 71% of calls, but decreased significantly with increasing age. The average duration of an adult call was 10 min, and the duration increased with increasing age of the adult patient. The greatest frequency (8%) of calls were related to symptoms of abdominal pain, followed in frequency by skin problems (6%), pregnancy-related issues (6%), cold symptoms (4%), and chest pain or chest discomfort (4%). Surrogate calls accounted for 14% of adult calls but the proportion was significantly higher (40%) if the patient's age was 80 years or greater. Call centres should recognize the sex- and age-related trends in calls and adjust the training of their registered nurses accordingly.

Informed consent for videoconsultations in Canada

Chouinard, I., Scott, R. E — 2009-05-26

We performed a qualitative study of the practice of informed consent for videoconsultation in Canada. Fourteen cases were examined: the 13 provinces and territories, and the Federal jurisdiction representing aboriginal groups. Twenty-seven interviews were conducted with key informants (14 telehealth experts, 13 legal experts). The telehealth experts were people with direct experience of telehealth practice. The majority of the telehealth experts agreed that videoconsultations had not been integrated into the health-care system. An interesting finding of the study was that the integration status of videoconsultations was not indicative of informed consent practices. Telehealth providers favoured express written consent, or risk management practices, although there was a desire to move towards implied consent models for videoconsultations. The study also showed that the legal ramifications of the electronic transmission of non-recorded, real-time, personal health information had not been explored. This represents an important factor in guiding future consent for videoconsultations in Canada.

A systematic review of the use of telehealth in Asian countries

Durrani, H., Khoja, S. — 2009-05-26

We conducted a systematic review of the literature on telehealth in Asia. The Medline database was searched, together with three specialist journals, for peer-reviewed articles published in the ten years to June 2007 which were related to any telehealth application involving one or more Asian country. Out of the 1504 abstracts retrieved, 109 articles were selected by two independent reviewers for the final review. The number of published articles on telehealth in Asia increased during the review period. The largest number of studies were conducted in Japan (37%). Most telehealth applications were based on the store-and-forward modality (43%), with 35% using videoconferencing and 15% using a hybrid approach. Most of the studies were descriptive (75%) and only eight included a control group against which telehealth was compared. The most common means of telecommunication was ISDN lines, which were employed in 32% of the studies. Some 40% of the studies mentioned improved quality of health care; about 20% mentioned improved access to health care. Although most studies mentioned cost, only 13 of them assessed resource utilization and cost. The overall findings gave a generally optimistic picture of telehealth in Asia. However, there is a lack of good quality studies.

A randomized controlled trial of telephone-supported care coordination in patients with congestive heart failure

Wootton, R., Gramotnev, H., Hailey, D. — 2009-05-26

An evaluation was undertaken on the effectiveness and efficiency of care coordination as a means of delivering health services to Australian veterans with a diagnosis of congestive heart failure. The veterans participated in a randomized controlled trial of care coordination that was supported by the Department of Veterans' Affairs (DVA). Of 490 veterans who were recruited, 409 were surveyed at baseline (214 in the intervention group and 195 controls). At follow-up, 288 were surveyed (155 intervention and 133 controls). Information on cost of care and quality of life (QOL) was collected before the commencement of coordinated care and at follow-up after 12 months. Cost of care data were obtained from DVA records. Information on QOL was obtained from telephone interviews, using the Short Form (SF-12) Health Survey and the EuroQol Group EQ-5D survey. There were no significant differences in costs of care between the intervention (coordinated care) and control groups of veterans. Nor were there significant differences between the intervention and control groups in QOL measurements with either of the evaluation tools that were used. Because evidence of benefit from coordinated care may be slow to emerge in patients with chronic disease, it would be desirable for future work in this area to include long term, good quality comparative studies on selected veteran populations. Such studies should measure QOL and economic outcomes in addition to clinical indicators.

Telehospice: reasons for slow adoption in home hospice care

Whitten, P., Holtz, B., Meyer, E., Nazione, S. — 2009-05-26

We investigated why hospice nurses were slow to adopt videophones to care for their patients. We used the unified theory of acceptance and use of technology (UTAUT) model and the organizational readiness for change (ORC) assessment via interviews and focus groups with hospice staff. Twenty-five hospice employees participated. Eighteen (72%) were in clinical positions and seven were in non-clinical positions (28%). Thirty-nine percent of respondents reported no videophone training, despite the fact that every employee had received training. Only four staff members actually used a videophone with patients. The respondents overwhelmingly stated that they had the organizational resources necessary to use the videophone and that it was easy to operate. Despite initial enthusiasm, leaders in the hospice agency did not endorse the videophones for work, nor offer incentives for using the videophones or providing them to patients. It is important to note that videophone technology is not meant to replace face-to-face visits, but to supplement them and to provide an additional tool for the nurses.

A comparison of telesonography with standard ultrasound care in a rural Dominican clinic

Sutherland, J. E., Sutphin, H D., Rawlins, F., Redican, K., Burton, J. — 2009-05-26

We compared telesonography to usual patient care in a rural clinic in the Dominican Republic. A total of 108 low-income Dominican and Haitian patients volunteered to participate. The patients were randomly assigned to either telesonography or control groups. Patients in the telesonography group were scanned and sonographic images and Request for Interpretation (RFI) forms were sent by email to six volunteer radiologists in the USA. Completed RFI forms were transmitted back to the clinic at the radiologists' earliest convenience. Patients in the control group received an ordinary ultrasound referral, which required travel to a tertiary medical centre where their scans were completed by a local sonographer. Sonographic reports from the control group were hand delivered to the referring physician at patient follow-up. The telesonography system provided a four-fold increase in the proportion of patient follow-ups and a six-fold increase in the proportion of returned radiological reports. In the telemedicine group, the median total elapsed time from referral to report return was 17.8 h (interquartile range, IQR 12.2–27.1) and the median time to patient follow-up was 67.1 h (IQR 45.9–113.7). The latter was similar in the control group, where the median total elapsed time was 76.7 h (IQR 65.8–144.7). The pilot study demonstrated that store-and-forward telesonography reduced time to diagnosis and increased the continuity of care compared to the usual ultrasound referral system in the region of the Dominican Republic which was studied.

Validation of home telehealth for pressure ulcer assessment: a study in patients with spinal cord injury

Hill, M. L, Cronkite, R. C, Ota, D. T, Yao, E. C, Kiratli, B J. — 2009-05-26

The reliability and validity of assessments and diagnoses made via home telehealth was measured in 42 patients with spinal cord injury. Two telehealth modalities were investigated: telephone-only contact and videoconferencing. The results were compared with a reference (gold-standard) method, the in-person assessment and diagnosis of skin integrity and pressure ulcers. The agreement on the presence of a pressure ulcer was excellent for both telephone and videoconferencing approaches (92% for telephone, 97% for videoconferencing). The diagnoses of the stage of pressure ulcer (on an ordinal scale of 0–4) made via telephone and videoconferencing showed substantial to almost perfect agreement with the in-person diagnoses (Spearman's rho of 0.76 and 0.83, respectively). There was a tendency for the measurements of wound volume to be somewhat larger in the telephone and videoconferencing modalities compared to those made in-person. Bland-Altman plots showed that videoconferencing gave substantially narrower 95% limits of agreement. The findings of the study indicate that telephone contact can be a useful tool for identifying the presence of a pressure ulcer, but videoconferencing is required to obtain an evaluation reasonably close to that of a home visit.

Preliminary results from a telemedicine referral network for early diagnosis of sleep apnoea in sleep laboratories

Boehning, N., Blau, A., Kujumdshieva, B., Staubitz, A., Boehning, W. — 2009-05-26

We conducted a feasibility study to find out whether a simple preliminary examination using telemedicine for diagnosis was sufficient to identify sleep-related breathing disorders (SRBD). Night-time pulse oximetry recordings were made in normal home surroundings on patients suffering from sleep apnoea/SRBD by doctors with a range of non-specialist backgrounds. The readings were transmitted to the relevant sleep laboratory, examined and the results returned to the referring doctor. From 80 patients (aged 29 to 60 years), 58 complained about characteristic symptoms (snoring, daytime sleepiness); 33 of these patients showed additional symptoms of associated diseases. In eight patients associated diseases were found without any symptoms. The findings were compatible with SRBD in 58 cases (73%); 12 of these were asymptomatic patients. A total of 57 patients had to be referred to a sleep laboratory for differential diagnosis by full polysomnography. Of the 22 patients (28%) without pathological findings following pulse-oximetry, 12 were symptomatic. The system described here is suitable for the creation of referral networks and for the identification of patients from institutions not trained in sleep medicine, who would otherwise not have been referred for specific diagnosis to a sleep laboratory.

Case report: an example of international telemedicine success

Froehlich, W., Seitaboth, S., Chanpheaktra, N., Pugatch, D. — 2009-05-26

An 8-month old girl presented to the Angkor Hospital for Children in Siem Riep, Cambodia with fevers, bilateral eye discharge and an extensive body rash. The rash consisted of large, fluid-filled bullae and significant desquamation. The patient was admitted to the hospital and given intravenous cloxacillin for presumed bullous impetigo. Despite treatment with antibiotics, the skin lesions did not improve and the fevers continued. Telemedicine consultations were initiated by email between Angkor Hospital for Children and paediatric specialists in the USA. Several diagnoses were entertained throughout the subsequent collaborative dialogue. Ultimately, teleconsultation led to a diagnosis of chronic bullous dermatosis of childhood (CBDC), a rare sub-epidermal blistering disease. The child was started on appropriate medications. Within 24 hours, the lesions showed significant improvement and fevers resolved. By enabling advice from distant providers on diagnosis and treatment of paediatric patients, telemedicine may improve health care in developing countries.

Family-focused therapy via videoconferencing

Dausch, B. M, Miklowitz, D. J, Nagamoto, H. T, Adler, L. E, Shore, J. H — 2009-05-26

A 30-year-old veteran with a diagnosis of schizoaffective disorder and his mother were referred for family-focused therapy (FFT), an empirically-supported, manual-based treatment. The veteran had had multiple hospitalizations and experienced chronic auditory hallucinations for self-harm. Minor modifications to FFT were made for implementation via videoconferencing (at a bandwidth of 384 kbit/s). This may have enhanced the treatment by making the process of communication and problem-solving more explicit. The course of FFT was successfully completed, and the veteran and family showed a high level of satisfaction with care as well as improved medication adherence, good quality of life, high levels of hope, good interpersonal functioning, and very mild negative and positive psychiatric symptoms. This veteran had previous exposure to telemental health, which may have influenced his willingness to receive tele-FFT and perhaps affected the outcome of the case. The ability to provide this type of service to people in rural areas is important.