Journal of Telemedicine and Telecare recent issues

Integration of diagnostic and communication technologies

Malik, N. N — Thu, 08 Oct 2009 16:27:03 PDT

Three key areas in diagnostics will drive the convergence of diagnostic and communication technologies: point-of-care testing, micro-electromechanical systems and biomarker discovery. In addition, the communications revolution means that increasing numbers of people will be able to send data from their home to their doctor using the Internet. Also, the widespread availability of broadband opens up the possibly of realtime videoconferencing with clinicians. It is already possible for patients at home to monitor simple variables, such as heart rate and blood pressure, and send their results using communication technologies to their doctors, who can promptly review the information to diagnose problems. As diagnostic and communication technologies converge, it will be feasible for patients to transmit more complex health-care data periodically to their doctor, who will be able to identify problems early on and thus modify disease management to prevent exacerbations of patients' medical conditions. This will allow improved patient care in a wide range of health-care situations, from acute medical conditions to chronic disease.

Technologically-assisted behaviour change: a systematic review of studies of novel technologies for the management of chronic illness

Rosser, B. A, Vowles, K. E, Keogh, E., Eccleston, C., Mountain, G. A — Thu, 08 Oct 2009 16:27:03 PDT

A systematic review was conducted to investigate the use of technology in achieving behaviour change in chronic illness. The areas reviewed were: (1) methods employed to adapt traditional therapy from a face-to-face medium to a computer-assisted platform; (2) targets of behaviour change; and (3) level of human (e.g. therapist) involvement. The initial literature search produced 2032 articles. A total of 45 articles reporting 33 separate interventions met the inclusion/exclusion criteria and were reviewed in detail. The majority of interventions reported a theoretical basis, with many arising from a cognitive-behavioural framework. There was a wide range of therapy content. Therapist involvement was reported in 73% of the interventions. A common problem was high participant attrition, which may have been related to reduced levels of human interaction. Instigating successful behaviour change through technological interventions poses many difficulties. However, there are potential benefits of delivering therapy in this way. For people with long-term health conditions, technological self-management systems could provide a practical method of understanding and monitoring their condition, as well as therapeutic guidance to alter maladaptive behaviour.

Application of camera phones in telehaematology

McLean, R., Jury, C., Bazeos, A., Lewis, S M. — Thu, 08 Oct 2009 16:27:03 PDT

We investigated the use of camera phones for telehaematology. First, the minimum requirements for the camera phones to be used in telehaematology were investigated. A single image containing white cells, red cells and platelets was sent from a camera phone to 33 different camera phones. Nine of the camera phones were found to be unsuitable for telehaematology due to low display resolution or no zoom function of the image. Then we examined the agreement between a haematologist using a suitable camera phone for remote diagnosis and the blood film report made in the usual way. Blood samples were collected from nine patients who had conditions in which diagnostically important morphological abnormalities occurred. In seven of the nine cases, the telehaematology responses were similar to the documented blood film reports. We conclude that telehaematology using camera phones offers a quick and potentially valuable method of support for the diagnostic haematology laboratory.

A comparison of in-person home care, home care with telephone contact and home care with telemonitoring for disease management

Bowles, K. H, Holland, D. E, Horowitz, D. A — Thu, 08 Oct 2009 16:27:04 PDT

We compared the effects of evidence-based disease management guidelines delivered to patients with heart failure and diabetes using three different modalities: in-person visits alone (Control), in-person visits and a telephone intervention (Telephone), and in-person visits and telemonitoring (Telemonitoring). Patients were randomized to the three groups. There were 112 patients in the Control group, 93 in the Telephone group and 98 in the Telemonitoring group. During the first 60 days, 10% of the Control group were rehospitalized, 17% of the Telephone group and 16% of the Telemonitoring group. Having heart failure and receiving more in-person visits were significantly related to readmission and time to readmission. However, after adjusting for diagnosis and visits, the differences between the three groups were non-significant. There was a trend for increased risk of readmission for the Telephone group compared to Control alone (P = 0.07, risk ratio 2.2, 95% CI: 0.9 to 5.2) and for readmission sooner (P = 0.02, risk ratio 2.3, 95% CI: 1.2 to 4.6). Patient rehospitalization and emergency department visit rates were lower than the national average, making it difficult to detect a difference between groups. Previous rehospitalization was a consistent predictor of those who were rehospitalized, suggesting that it may be a useful indicator for identifying patients likely to need additional attention.

Interactive emergency communication involving persons in crisis

Nordby, H., Nohr, O. — Thu, 08 Oct 2009 16:27:04 PDT

We studied the dialogue between telephone operators at medical emergency communication centres in Norway and parents of children later diagnosed with sudden infant death syndrome. The aim was to understand how the parents experienced the communication with the telephone operators. The qualitative method involved semi-structured interviews. We interviewed six respondents from urban areas and five from rural areas. An important finding was that all the parents were satisfied with the resuscitation instructions they received. It was also perceived as important that the emergency operators expressed empathy and care. We believe that it is not merely the quality of the resuscitation attempts that the operators' efforts should be measured against. It is also important that the operators provide good explanations and express emotional support. Our findings indicate that this will be enormously appreciated, even if callers do not feel that they are capable of performing optimum resuscitation.

Telehealth in clinical supervision: a comparison of supervision formats

Reese, R. J, Aldarondo, F., Anderson, C. R, Lee, S.-J., Miller, T. W, Burton, D. — Thu, 08 Oct 2009 16:27:04 PDT

Nine counselling psychology students were enrolled in a 12-week pilot practicum (i.e. a work placement) for either one hour of course credit (six students) or three hours (three students). Group supervision was provided both in-person and by videoconferencing. Each trainee completed a measure evaluating their satisfaction with supervision (Supervisory Satisfaction Questionnaire, SSQ) and the supervisory relationship (Supervisory Working Alliance Inventory – Trainee Version, SWAI-T). The student's self-efficacy was also tracked during the semester (Counselling Self-Estimate Inventory, COSE). Trainees rated their satisfaction with videoconferencing similarly to the in-person format. The supervisory relationship also did not appear to be affected by the videoconferencing format. The COSE scores indicated that the students increased in counsellor self-efficacy by the end of the semester. Trainees reported that their supervisory needs were met and believed that videoconferencing was a viable format for supervision, although such a format still needed to be augmented by in-person contact. Providing better access to supervision and professional support using technology is one step towards improving health care in rural areas.

Feasibility of telemonitoring for active surveillance of influenza vaccine safety in the primary care setting in the Netherlands

Vrijhoef, H. J., Janssen, J. J., Greenberg, M. E — Thu, 08 Oct 2009 16:27:04 PDT

We examined the feasibility of a commercial home telemonitoring system for monitoring adverse events related to vaccination and influenza-like illness (ILI) signs and outcomes in the primary care setting in the Netherlands. A prospective cohort of people eligible for influenza vaccination was monitored daily between mid-October 2007 and mid-March 2008. Adults from five primary care centres were invited to participate. A total of 245 people participated (response rate 75%). Their mean age was 61 years (SD = 15), 50% were female and 60% had a chronic disease. Most (73%) had no problems with installation of the system and 67% finished all sets of monitoring dialogues. The reported incidence of adverse events in the first week after vaccination was 8–38%. The reported incidence rates of ILI symptoms varied and were higher than reference data. A total of 39% of individuals consulted their general practitioner, 7% the hospital emergency department, 6% were hospitalized and 27% used medication. Of those in paid work, one-third reported absence of work due to ILI. Home telemonitoring appears to be feasible for monitoring vaccine adverse events and ILI symptoms and outcomes.

Pandemic influenza planning by videoconference

Thu, 08 Oct 2009 16:27:04 PDT

Collaboration between nations and sectors is crucial to improve regional preparedness against pandemic influenza. In 2008, a Virtual Symposium was organized in the Asia-Pacific region by the Asia-Pacific Economic Cooperation Emerging Infections Network (APEC EINet) to discuss pandemic preparedness. The multipoint videoconference lasted approximately 4.5 hours and was attended by 16 APEC members who shared best practices in public-private partnerships for pandemic influenza preparedness planning. Twelve of the 16 APEC members who participated responded to a post-event survey. The overall experience of the event was rated highly. Partnering public health, technology and business communities to discuss best practices in preparedness using videoconferencing may be an effective way to improve regional preparedness. Utilization of videoconferencing on a routine basis should be considered to improve preparedness among APEC members and enhance its usability during a pandemic.

A Brazilian educational experiment: teleradiology on web TV

Silva, A. B., de Amorim, A. C. — Thu, 08 Oct 2009 16:27:04 PDT

Since 2004, educational videoconferences have been held in Brazil for paediatric radiologists in training. The RUTE network has been used, a high-speed national research and education network. Twelve videoconferences were recorded by the Health Channel and transformed into TV programmes, both for conventional broadcast and for access via the Internet. Between October 2007 and December 2009 the Health Channel website registered 2378 hits. Our experience suggests that for successful recording of multipoint videoconferences, four areas are important: (1) a pre-planned script is required, for both physicians and film-makers; (2) particular care is necessary when editing the audiovisual material; (3) the audio and video equipment requires careful adjustment to preserve clinical discussions and the quality of radiology images; (4) to produce a product suitable for both TV sets and computer devices, the master tape needs to be encoded in low resolution digital video formats for Internet media (wmv and rm format for streaming, and compressed zip files for downloading) and MPEG format for DVDs.

Implementation of a broadband video consultation service for children with posture and movement disorders

Visser, J. J., Bloo, J. K., Grobbe, F. A, Vollenbroek-Hutten, M. M. — Mon, 31 Aug 2009 09:11:20 PDT

We evaluated the implementation of a video consultation service in a regional community of paediatric physiotherapists. Twenty-two paediatric therapists in primary care settings and a rehabilitation centre participated in this study. The implementation comprised three phases: introduction, learning and consultation. Evaluation of the implementation focused on the participants' satisfaction with regard to the implementation procedure, the education received, the technical helpdesk support and the usage of the application once put into practice. The introduction phase was very short (only two sessions) but the learning phase took much longer; it took 12 months for 21 therapists to complete the learning phase. Only 14 of the 21 therapists entered the actual consultation phase. Participants were generally satisfied with the education received and judged the helpdesk to be sufficient. The helpdesk was contacted 36 times by 14 participants. Within the 12-month study period, the therapists performed 24 video consultations. The average time to compose a question was 115 min and the average time to answer it was 43 min. Implementation of a video consultation service is possible but takes more time than initially foreseen and only about two-thirds of the professionals actually adopted it into routine practice.

Experience with videoconferencing between a neonatal unit and the families' home from the perspective of certified paediatric nurses

Lindberg, B., Axelsson, K., Ohrling, K. — Mon, 31 Aug 2009 09:11:20 PDT

Parents of preterm-born infants need support after returning to their homes with their baby. We studied the experience of certified paediatric nurses (CPNs) with the use of videoconferencing between the neonatal intensive care unit and the families' home. Families were given a home videoconferencing unit, which allowed them to contact staff at the neonatal unit, day and night. Over a period of 12 months, ten families used the videoconferencing equipment. Families made a median of 4 telemedicine calls each (range 2–30). Narrative interviews were performed with 10 CPNs after the study ended. Qualitative thematic content analysis was applied to the interview data and one theme was identified: smoothing the transition of infants from the neonatal unit to the families' home. The CPNs found that videoconferencing helped them to assess the overall situation at home and facilitated the relationship between parents and the infant. The CPNs felt that they were able to provide security to the family. The use of videoconferencing was considered as a generally positive experience and as a tool to improve nursing care at home.

Feasibility of blood pressure telemonitoring in patients with poor blood pressure control

Mon, 31 Aug 2009 09:11:20 PDT

We examined the feasibility of using home blood pressure (BP) telemonitoring devices for managing patients with poor BP control. We enrolled 591 subjects with a diagnosis of hypertension. Patients were randomized to usual care (n = 147) or to the intervention arm (n = 441). Those in the intervention arm were issued with a home BP telemonitoring device. The device transmitted BP readings automatically via the home telephone line. Technical alerts were generated if patients did not transmit their BP readings according to the protocol. During the first six months, 693 technical alerts were generated by 267 patients. About half of these patients (112) generated more than two technical alerts. Resolution of the alerts showed that 61% were caused by patient non-adherence. Patients who generated >2 technical alerts were younger (61 vs. 64 years; P = 0.001) and were more likely to be non-Caucasian (64% vs. 47%, P = 0.002) than those generating 2 or fewer alerts. Despite the potential for improving health care using home BP telemonitoring, certain patients will require more support to use the equipment successfully.

Telepsychiatry appointments in a continuing care setting: kept, cancelled and no-shows

Leigh, H., Cruz, H., Mallios, R. — Mon, 31 Aug 2009 09:11:20 PDT

We reviewed the appointment data for a psychiatry service in California that provided consultations and also therapy through telepsychiatry. Over an 18-month period, there were 7523 telepsychiatry appointments and 115,148 conventional (face-to-face) appointments. A higher proportion of the telepsychiatry appointments was kept (92% telepsychiatry vs. 87% non-telepsychiatry). Also, telepsychiatry appointments were significantly less likely to be cancelled by patients (3.5% vs. 4.8%) and significantly less likely to be no-shows (4.2% vs. 7.8%). These findings were similar in three of the four counties where the service was delivered. However, one county was different, and further examination suggested that the morale of the staff and patients may have contributed to the unenthusiastic acceptance of telepsychiatry. We conclude that telepsychiatry can be used effectively in continuing care settings as well as in evaluation settings, and that staff and patient morale are important factors in successful telepsychiatry.

The attitudes of multiprofessional teams to telehealth adoption in northern Finland health centres

Mon, 31 Aug 2009 09:11:20 PDT

A telehealth network was established between seven health centres, the local university and the university hospital in the Oulu Arc Subregion in a rural area of northern Finland. During the period 2004–2007, the videophone network was used for different types of teleconsultation (orthopaedics, psychiatry, diabetes, rehabilitation), continuing education and various patient care and administrative meetings. Qualitative research with observation and interviews with 30 professionals (physicians, nurses, psychiatric nurses, physiotherapists) was carried out in early 2007 to find out health-care professionals' attitudes toward telehealth and to see how the attitudes were connected to telehealth usage. Overall, the attitudes were more positive than negative, ranging from negative to enthusiastically positive. Diversity of attitudes occurred in relation to time, situation, profession, health centre and telehealth application. Ten different types of telehealth adopters were recognized: enthusiastic user, positive user, critical user, hesitant user, positive participant, hesitant participant, critical participant, neutral participant, negative participant and positive non-participant. Telehealth was especially well accepted in continuing education and in diabetes teleconsultations. The study showed that a negative attitude was not a definite barrier to telehealth adoption, but it did require additional attention from project workers and managers. Project staff and managers need to take into account the diverse attitudes of health professionals, because different people require different actions to adopt telehealth in their work.

Home-based exercise rehabilitation with telemedicine following cardiac surgery

Scalvini, S., Zanelli, E., Comini, L., Tomba, M. D., Troise, G., Giordano, A. — Mon, 31 Aug 2009 09:11:21 PDT

We evaluated the feasibility of a home-based rehabilitation programme, which was designed to resemble an in-hospital rehabilitation programme. Patients who underwent cardiac surgery (EuroSCORE 0–10) followed a one-month home rehabilitation programme supervised by a nurse-tutor and a physiotherapist. Physiotherapy was performed at home with calisthenic exercises and bicycle-ergometer tests. Patients transmitted the recorded ECGs by telephone to a service centre. They also performed a 6-minute walking test and filled in a satisfaction questionnaire at the end of the programme. A total of 47 patients were enrolled in the study. There were 3050 telephone calls, of which 3012 (99%) were scheduled and 38 were unscheduled. No further action was required in 95% of calls. There were 809 sessions for calisthenic exercises and 1039 for exercise training. There was a significant increase in the 6-minute walking test distance at the end of the programme compared to the baseline (404 m vs. 307 m, P < 0.001). Patient satisfaction, as measured in a questionnaire, was about 95% overall. This type of home rehabilitation using telemedicine appears to be worth implementing in selected categories of patients.

Compliance and technical feasibility of long-term health monitoring with wearable and ambient technologies

Mon, 31 Aug 2009 09:11:21 PDT

We developed a system consisting of both wearable and ambient technologies designed to monitor personal wellbeing for several months during daily life. The variables monitored included bodyweight, blood pressure, heart-rate variability and air temperature. Two different user groups were studied: there were 17 working-age subjects participating in a vocational rehabilitation programme and 19 elderly people living in an assisted living facility. The working-age subjects collected data for a total of 1406 days; the average participation period was 83 days (range 43–99). The elderly subjects collected data for a total of 1593 days; the average participation period was 84 days (range 19–107). Usage, technical feasibility and usability of the system were also studied. Some technical and practical problems appeared which we had not expected such as thunder storm damage to equipment in homes and scheduling differences between staff and the subjects. The users gave positive feedback in almost all their responses in a questionnaire. The study suggests that the data-collection rate is likely be 70–90% for typical health monitoring data.

Telehealth applications in speech-language pathology: a modified narrative review

Reynolds, A. L., Vick, J. L., Haak, N. J. — Mon, 31 Aug 2009 09:11:21 PDT

We conducted a modified narrative review of the literature on telehealth applications used in speech-language pathology assessment and treatment. The following databases and information resources were used: MEDLINE, CINAHL, PSYCInfo, ERIC, Digital Dissertations, CSA Social Services Abstracts, CSA Sociological Abstracts, On-line ASHA publications and personal contacts. Sixty-two full-text documents were located. Twenty-eight provided sufficient detail to be reviewed using a checklist adapted from the Scottish Intercollegiate Guideline Network (SIGN) recommendations for level of evidence rankings and quality assessment ratings. Five of the 28 studies received a ranking indicating a high level of evidence (larger sample sizes, assessed outcomes with valid and reliable measures, performed statistical analysis of study results, measured reliability of study results, ensured internal and external validity, and ensured randomization of participants to groups). These five studies concluded that the service delivery results from telehealth were equivalent to traditional face-to-face results. However, telehealth was not a complete replacement for face-to-face service delivery and further research is required.

A telehealth nursing intervention reduces hospitalizations in children with complex health conditions

Cady, R., Finkelstein, S., Kelly, A. — Mon, 31 Aug 2009 09:11:21 PDT

The U Special Kids Program (USK) at the University of Minnesota provides care coordination and case management services by telephone to children with special health-care needs. We measured the effect of the USK programme on hospital resource utilization using a retrospective record review. Information on hospitalizations was collected for children enrolled in the programme for at least two years and validated for accuracy against inpatient claims data. Hospitalizations were classified as planned, unplanned or due to lack of home care. A total of 43 children enrolled in the USK programme between July 1996 and December 2006 met the study criteria. The children had multiple, complex conditions. During the period of the study, there were 61 planned hospitalizations, 184 unplanned hospitalizations and 3 hospitalizations due to lack of home care. The number of unplanned hospitalizations decreased from 74 in the first year of enrolment to 35 in the second; this reduction was significant (P < 0.007). In the subsequent years, the rate of unplanned admissions stabilized. In contrast, the rate of planned hospitalizations was relatively constant over the five-year enrolment period. Telephone-based care coordination and case management is a promising approach for children with multiple, complex health conditions.

National representative body for e-health in Pakistan

Khoja, S., Durrani, H., Faheem, Z. A. — Mon, 31 Aug 2009 09:11:21 PDT

Physiotherapy at a distance: a controlled study of rehabilitation at home after a shoulder joint operation

Eriksson, L., Lindstrom, B., Gard, G., Lysholm, J. — Thu, 09 Jul 2009 12:39:46 PDT

We explored the benefit of video communication in home rehabilitation after shoulder joint replacement and compared it to referral for physiotherapy in the conventional way. A total of 22 patients were included in the study. The intervention group (n = 10) had training at home under the supervision of a physiotherapist at the hospital using videoconferencing. The control group (n = 12) had physiotherapy training in a conventional way in their home town. All patients had the same postoperative, three-phase-programme for two months. The outcome measures were a Visual Analogue Scale (VAS) for pain, range of motion (ROM), shoulder function ability (Constant score and SRQ-S) and health-related quality of life (SF-36). Questions about areas of priority for improvement and general satisfaction with the shoulder were also included. The telemedicine group received a greater number of treatments compared to the control group. After the intervention, there were significant improvements in VAS-pain, Constant score and SRQ-S for both groups. The telemedicine group improved significantly more in all three measurements than the control group (P < 0.001 for all). When changes from baseline to follow-up were compared, the telemedicine group improved significantly more in terms of decrease in pain (P = 0.004) and vitality (P = 0.001) than the control group. Despite some limitations, there seem to be clear benefits from physiotherapy at a distance with a telemedicine technique that allows patients to obtain access to physiotherapy at home.

A comparative study of teledermatoscopy and face-to-face examination of pigmented skin lesions

Thu, 09 Jul 2009 12:39:46 PDT

We examined the agreement between diagnoses of pigmented skin lesions based on an in-person (face-to-face) dermatological examination and diagnoses based on the study of medical records and images transferred through the web (teledermatoscopy). Two experienced dermatologists examined and diagnosed 64 pigmented skin lesions, which had been surgically excised and undergone histopathology examination. Two years later, the same cases were studied and diagnosed once again by the same dermatologists via the web. There was 72% agreement between the in-person diagnoses and the biopsy results (the gold standard), and 66% agreement between the telediagnoses and the biopsy results. Telemedicine had high sensitivity (87%) and specificity (73%), although there were 4 false-negative diagnoses. A web-based dermatoscopic diagnostic service appears to be feasible and would meet the needs for access to specialized services in rural areas. However, further work is required to decrease the number of false negative cases.

Predicting need for intervention in individuals with congestive heart failure using a home-based telecare system

Biddiss, E., Brownsell, S., Hawley, M. S — Thu, 09 Jul 2009 12:39:46 PDT

We have studied how well the need for a medical intervention can be predicted by a telecare monitoring system. During a study period of about 18 months, 45 elderly individuals with congestive heart failure used a home health monitor to enter daily information pertaining to their symptoms and health status. A total of 8576 alerts were generated by the monitoring system, although in most cases, patient and service provider interaction was not required. When system alerts were considered to be serious, or if symptoms persisted, the patient was contacted. A total of 171 key medical events (6 deaths; 28 hospital admissions; 59 changes in medication; 54 cases of advice given; 24 instances where immediate medical attention was recommended) were recorded in the monitoring logs. A multivariate logistic regression model was developed to predict these medical interventions/events. The model correctly predicted key medical events in 75% of cases with a specificity of 74% and an overall cross-validated accuracy of 74% (95% CI, 68–80%). Key predictors included the number of system alerts, self-rated mobility, self-rated health and self-rated anxiety. This suggests that subjective measures are useful in addition to physiological ones for predicting health status. A multivariate decision support model has potential to supplement practitioners and current telecare systems in identifying heart failure patients in need of medical intervention.

Assessment of communication and swallowing post-laryngectomy: a telerehabilitation trial

Ward, E., Crombie, J., Trickey, M., Hill, A., Theodoros, D., Russell, T. — Thu, 09 Jul 2009 12:39:46 PDT

Ten laryngectomy patients were assessed using a purpose-designed, multimedia videoconferencing system incorporating a freestanding, self-focusing camera. Swallowing, stoma and communication status were assessed simultaneously by a remote clinician and face-to-face, by a second clinician at the patient's site. The remote trial took place over a distance of approximately 1700 km using a commercial 3G phone network. A satisfaction questionnaire was also completed. There was excellent agreement between the two assessing clinicians. Image quality obtained via the freestanding camera was rated as lower than direct observation, but it was sufficient to assess the stoma and status of the voice prosthesis. During the trial, occasional difficulties with audio delays and image distortion were experienced, although these were manageable. Both patient and clinician satisfaction with remote assessment was high. The results provide further evidence to support the use of telerehabilitation for evaluating the speech and swallowing status of laryngectomy patients following discharge from acute care.

The effect of telemedicine on outcome and quality of life in pregnant women with diabetes

Dalfra, M. G., Nicolucci, A., Lapolla, A., on behalf of the TISG — Thu, 09 Jul 2009 12:39:46 PDT

We evaluated the effect of a telemedicine system on maternal and fetal outcome in women with diabetes. A total of 276 pregnant women were enrolled in the study. Women were sequentially assigned to a telemedicine or a control group. There were 88 women with gestational diabetes in the telemedicine group and 115 in the control group; there were 17 women with type 1 diabetes in the telemedicine group and 15 in the control group. Women in telemedicine groups were asked to submit their blood glucose data every week, and had a medical examination at the diabetes clinic once a month. Women in the control groups had a medical examination every two weeks. Subjective outcomes were investigated using the following questionnaires: CES-D for depression, SF-36 for health-related quality of life (QoL), Stress and Distress for the impact of diabetes. Clinical variables and pregnancy outcomes were no different between the two telemedicine groups, whereas women with gestational diabetes in the telemedicine group had a better metabolic control in the 3rd trimester and a lower rate of caesarean sections and macrosomia. As for QoL, women in the telemedicine groups showed lower levels of frustration and concerns about their diabetes, and a better acceptance of their diabetic condition. A questionnaire on the use of the telemedicine system showed a high degree of acceptance (85%). Both telemedicine groups had fewer check-ups at the diabetes clinics. The use of a telemedicine system for glucose monitoring improved pregnancy outcome in women with gestational diabetes and improved QoL in all diabetic pregnancies.

Impact of electronic messaging on the patient-physician interaction

Wallwiener, M., Wallwiener, C. W., Kansy, J. K., Seeger, H., Rajab, T. K. — Thu, 09 Jul 2009 12:39:46 PDT

Patients are interested in secure electronic communication with their health-care providers, but physicians have been slow to adopt the technique into their practice. We have therefore reviewed the literature on secure patient messaging. Relevant studies were identified by Medline search which produced 1065 publications. Of these, 71 relevant articles were read independently by two reviewers. Currently available messaging systems allow for asynchronous communication, physician reimbursement and automated supporting functions such as triaging of patient messages and integration of messaging into medical records. The review showed that patients are satisfied with the use of secure physician messaging systems and find such services to be convenient, time-saving and useful. Physicians do not report adverse effects from their use. Legal concerns with electronic messaging include compliance with privacy standards. The economic benefits of secure messaging systems are most immediately apparent for larger health-care groups and hospitals, although smaller practices will also benefit in the long run. Secure patient-physician messaging is a convenient and useful addition to the health-care infrastructure. It can be expected that the identification of secure providers, integration with reimbursement systems and initial uptake by larger health-care organizations will speed up the adoption into routine health care.

User's perceptions of remote trauma telesonography

Thu, 09 Jul 2009 12:39:46 PDT

We established a pilot tele-ultrasound system between a rural referring hospital and a tertiary care trauma centre to facilitate telementoring during acute trauma resuscitations. Over a 12-month period, 23 tele-ultrasound examinations were completed. The clinical protocol examined both the Focused Assessment with Sonography for Trauma (FAST) and the Extended FAST (EFAST) for pneumothoraxes. Twenty of the examinations were conducted during acute trauma resuscitations and three during live patient simulations. FAST examinations were completed in all 23 cases and EFAST examinations in 17 cases. There were 18 clinical users, of whom 14 completed a survey (76% response rate). Overall, 93% of respondents were either satisfied or very satisfied with the telemedicine interaction and agreed or strongly agreed that the technology could potentially benefit injured patients in the far north of Canada. In addition, 93% of the respondents felt that the project had improved collegiality between the two institutions involved. The majority of respondents (71%) agreed or strongly agreed that the project had improved their ultrasound skills. We believe that as further experience is obtained, tele-ultrasound will prove to be an important aid to the care of remotely injured and ill patients.

Need for tele follow-up - a study at a public sector quaternary referral hospital in India

Pathni, R. K, Satpathy, S., Kailash, S. — Thu, 09 Jul 2009 12:39:46 PDT

The All India Institute of Medical Sciences (AIIMS) is the apex super-specialty, quaternary referral hospital of India. Its outpatient departments (OPDs) handle over 2.5 million patients every year, a large proportion of whom travel up to 2500 km for treatment because specialist facilities are not available in their regions. We conducted a descriptive study of 58 AIIMS faculty staff members, using a self-administered questionnaire followed by interviews with selected faculty members. During the year 2006, a total of 2,566,492 patients attended the various OPDs at the AIIMS, of whom 1,427,466 (56%) were old patients, i.e. they attended the OPD for follow-up. The questionnaire responses revealed that 55 (95%) of the respondents routinely provided follow-up medical advice to their patients using the telephone, email and/or letters. Only 3 (5%) respondents stated that they did not use any such means for follow-up of their patients. Most of the respondents identified benefits in the use of telemedicine and did not envisage any major difficulties in using it for the follow-up of patients. If appropriate tele follow-up facilities were available, probably more than one million OPD visits could be avoided annually at the AIIMS.

Impact of a telemedicine system on acute stroke care in a community hospital

Thu, 09 Jul 2009 12:39:46 PDT

In January 2007, a telestroke system was established between a community hospital lacking a neurologist on call and a stroke centre 70 km away. The telestroke system allowed urgent remote evaluation of the patient by a specialized neurologist, supervised thrombolytic treatment or a decision for urgent transfer to the stroke centre. During the first year of operation of the telestroke system, we studied all acute ischaemic stroke patients admitted to the community hospital and compared the results with the previous year. Approximately the same number of acute stroke patients were admitted to the community hospital in each year (201 cases in 2006 and 198 in 2007). The telestroke system was activated 75 times in 2007, the number of stroke patients evaluated by a specialized neurologist increased (17% vs. 38%, P > 0.001) and interhospital transfers were reduced (17% vs. 6%, P = 0.001). The number of thrombolytic treatments was doubled: 4.5% (n = 9) in 2006 vs. 9.6% (n = 19, 12 of them in the community hospital) in 2007 (P = 0.073). The telestroke system also reduced the time to tPA treatment from symptom onset (210 vs. 162 min, P = 0.05) and increased the number of patients treated in the 0–3 hours window (40% vs. 63%, P = 0.09). Telemedicine improved the quality of care administered to acute stroke patients admitted to a community hospital and reduced the number of inter-hospital transfers.

Complex bioethics consultation in rural hospitals: using telemedicine to bring academic bioethicists into outlying communities

Kon, A. A, Rich, B., Sadorra, C., Marcin, J. P — Thu, 09 Jul 2009 12:39:46 PDT

Bioethics consultations are necessary to ensure excellent patient care and all US hospitals are required to provide access to bioethics consultants for cases raising ethical or moral dilemmas. However, there is a paucity of trained clinical ethicists. While assistance from trained bioethicists may be obtained via telephone or email, such methods of contact do not allow a bioethicist to engage fully with all members of the health-care team, the patient and family members. In two recent cases, rural hospitals contacted our centre for assistance with complex ethics cases. We provided a clinical ethics consultation via videoconferencing. The outcomes of the consultations would probably have been inferior had they been performed via telephone. For example, the non-verbal cues allowed the consultants to have a better understanding of the team dynamics, and led them to ask important questions that directly affected the recommendations which were made. Because patients are likely to benefit significantly from access to bioethicists when ethical questions arise, rural and community hospitals should consider teleconsultation when local ethics committees decide that further assistance is warranted.

Millar, H. — Thu, 09 Jul 2009 12:39:46 PDT

Information architecture of a telecare system

Collinge, W. H, Liu, K. — Tue, 26 May 2009 14:40:20 PDT

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. — Tue, 26 May 2009 14:40:20 PDT

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 — Tue, 26 May 2009 14:40:20 PDT

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. — Tue, 26 May 2009 14:40:20 PDT

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. — Tue, 26 May 2009 14:40:20 PDT

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. — Tue, 26 May 2009 14:40:20 PDT

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. — Tue, 26 May 2009 14:40:20 PDT

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. — Tue, 26 May 2009 14:40:20 PDT

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. — Tue, 26 May 2009 14:40:20 PDT

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. — Tue, 26 May 2009 14:40:20 PDT

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 — Tue, 26 May 2009 14:40:20 PDT

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.