Telemedicine and remote patient monitoring

A retrospective study of the influence of telemedicine in the management of pediatric facial lacerations

A study was carried out to determine the influence of telemedicine on management of facial lacerations in children. Proforma was designed, and information was collected retrospectively over a 4-month period. Of the 2524 telemedicine referrals, 27% (693/2524) were pediatric referrals. One hundred forty-five of these were children with facial lacerations, of which only 98 were admitted for possible surgical management. During the same period, a further 45 children were admitted to the pediatric ward through verbal referral. The average age of the children admitted was 4.85 years and male-to-female ratio was 2:1. Lacerations to the lips (42%) were the most common site of injury, and the majority sustained the injury as a result of a mechanical fall (42%). Among the telemedicine group, 86% had surgery, whereas in the nontelemedicine group it was 82%. On average, 2 to 3 photographs accompanied the referrals, and none of the patients who were treated conservatively by the referring centers following telemedicine referral and discussion with Queen Victoria Hospital required a re-referral. The results from this study confirm that clinical findings together with images from telemedicine provide adequate information to make clinical decisions in children with facial lacerations.

Factors Affecting Frequency of Patient Use of Internet-Based Telemedicine to Manage Cardiovascular Disease Risk

We examined the frequency of use by patients of a web-based reporting system to monitor and control cardiovascular disease (CVD) risk factors. A total of 192 patients with intermediate or high CVD risk were categorized into four quartiles based on their frequency of use of the telemedicine reporting system over one year. The lowest frequency users (Quartile I) averaged 17 reporting days in one year and the highest frequency users (Quartile IV) averaged 211 reporting days in one year. Factors associated with more frequent use were overall knowledge of CVD ( P = 0.014), blood lipids ( P = 0.017), smoking ( P = 0.036), higher scores in medication self-efficacy ( P = 0.016) and higher income ( P = 0.002). All quartiles showed trends of decreasing systolic blood pressure from hypertensive (≥140 mm Hg) to pre-hypertensive (<140) ranges. Patients were able to lower CVD risk with as few as two transmissions per month using the telemedicine system. Telemedicine reporting coupled with self-assessment of health status can promote a strong patient-provider partnership for managing the chronic risk factors of CVD.

Improving access to specialist multidisciplinary palliative care consultation for rural cancer patients by videoconferencing: report of a pilot project

PURPOSE

Palliative care (PC) and palliative radiotherapy (RT) consultation are integral to the care of patients with advanced cancer. These services are not universally available in rural areas, and travel to urban centers to access them can be burdensome for patients and families. The objectives of our study were to assess the feasibility of using videoconferencing to provide specialist multidisciplinary PC and palliative RT consultation to cancer patients in rural areas and to explore symptom, cost, and satisfaction outcomes.

METHODS

The Virtual Pain and Symptom Control and Palliative Radiotherapy Clinic was piloted from January 2008 to March 2011. Cancer patients in rural northern Alberta attended local telehealth facilities, accompanied by nurses trained in symptom assessment. The multidisciplinary team at the Cross Cancer Institute in Edmonton was linked by videoconference. Team recommendations were sent to the patients' family physicians. Data were collected on referral, clinical, and consultation characteristics and symptom, cost, and satisfaction outcomes.

RESULTS

Forty-four initial consultation and 28 follow-up visits took place. Mean Edmonton Symptom Assessment Scale scores for anxiety and appetite were statistically significantly improved at the first follow-up visit (p < 0.01 and p = 0.03, respectively). Average per visit savings for patients seen by telehealth versus attending the CCI were 471.13 km, 7.96 hours, and Cdn $192.71, respectively. Patients and referring physicians indicated a high degree of satisfaction with the clinic.

CONCLUSION

Delivery of specialist multidisciplinary PC consultation by videoconferencing is feasible, may improve symptoms, results in cost savings to patients and families, and is satisfactory to users.

An evaluation of the use of Telehealth within palliative care settings across Scotland

There is a lack of evidence-based research in the use of Telehealth within palliative care in the UK, particularly in Scotland. The aim of this project was to evaluate the current use of Telehealth applications within palliative care across Scotland, and how these and future applications are perceived by patients, carers and professionals. This paper reports on the qualitative findings from focus groups with patients and carers in three geographical areas in Scotland, and individual interviews with key stakeholders from across Scotland, who currently work within areas of high and low Telehealth activity. The key findings indicated that Telehealth initiatives are welcomed by patients and carers but that these should be an adjunct to clinical care rather than an alternative. The stakeholder interviews revealed several notable differences between those working within areas of high and low Telehealth activity. Principally, areas of high Telehealth activity appear to be driven by national and local policy and seem to benefit from a greater level of investment in Telehealth equipment and facilities than in the more central, and hence accessible, parts of Scotland.

Development of a home-based telehealthcare model for improving the effectiveness of the chronic care of stroke patients

This study describes the development of an information technology (IT)-mediated home-based healthcare model designed to improve the effectiveness of caring for stroke patients who require chronic, home care. This model was evaluated at Kaohsiung Medical Hospital in Taiwan between 2005 and 2008; 84 newly diagnosed stroke patients diagnosed as the chronic covalence stage were enrolled for preliminary testing of this model. These patients required 24-hour in-home monitoring of their health status and emergency call service. Over the course of the study, 15 emergency transfers were carried out, and the acute stroke patients were sent to the emergency care within 26 minutes, on average. This system helped physicians, patients, and their families to more efficiently detect the occurrence of recurrent stroke. In addition, we found a statistically significant finding (p < 0.001) that daily blood pressure (BP) monitoring increased from 45.5% in the initial month of the study to 76% after 3-10 months of intervention. Meanwhile, the proportion of patients with an abnormal BP rate decreased from 20.5% in the initial month of the study to 10.9% after 3-10 months of intervention. This suggests that this model helped to improve patient behavior and their ability to care for themselves. This is the first study to develop an IT-mediated, home-based healthcare model in Taiwan. This model integrates both healthcare and clinical services and is capable of enhancing the effectiveness of the care provided to patients with chronic diseases, especially those in situations where self-care is essential for disease management.

UK telehealth initiatives in palliative care: a review

This review paper explores the use of telehealth in relation to palliative care in the UK. Information technology (IT) developments are being harnessed throughout society, and there is growing interest in the ways in which they can be used to meet and support patients' health needs in the community. The aim of the literature review was to scope the information available from published and unpublished research, with particular reference to older people. The evidence suggests that, despite the challenges, there are numerous examples of good practice in relation to telehealth, palliative and end-of-life care, and older people. Developments in technology that have increased the capacity to improve care, through reaching greater numbers of people of all age groups, mean that telehealth has much to offer people living with and dying from advanced illness. However, some of the evaluative evidence is limited and further rigour is needed when evaluating future telehealth innovations.

The development of telehealth as a strategy to improve health care services in Zambia

BACKGROUND

Providing health information and knowledge to health practitioners in rural parts of Africa is a major problem, impacting on the delivery of health care and professional development. In Zambia, as in other African countries, medical expertise, equipment and information resources are concentrated in the major cities with an adverse effect on patients living in rural areas.

OBJECTIVES

We seek to outline the benefits of telehealth initiatives in ameliorating the problems caused by the inequitable distribution of expertise, equipment and knowledge resources in a low-income country. The principles agreed to take advantage of technology and the progress towards implementation are described.

METHODS

This is a descriptive study based on the literature, news reports, and the personal experience of the first author on the Zambian National Telehealth Steering Committee.

RESULTS AND CONCLUSIONS

The introduction of telehealth to solve some of the problems of health delivery in Zambia is a gigantic enterprise, and liable to setbacks. But the librarians at the University of Zambia Medical Library, with a history of making knowledge available and their involvement in the telehealth strategy, are seeking opportunities to provide better outreach services to hospitals and health facilities throughout the country.

Sustainable rural telehealth innovation: a public health case study

OBJECTIVE

To examine adoption of telehealth in a rural public health district and to explain how the innovation became sustainable.

STUDY SETTING

Longitudinal, qualitative study (1988-2008) of the largest public health district in Georgia.

STUDY DESIGN

Case study design provided deep insights into the innovation's social dynamics. Punctuated equilibrium theory helped present and make sense of the process. We identified antecedent conditions and outcomes, and we distinguished between episodes and encounters based on the disruptive effects of events.

DATA COLLECTION

Twenty-five semistructured interviews with 19 decision makers and professionals, direct observations, published papers, grant proposals, technical specifications, and other written materials.

PRINCIPAL FINDINGS

Strong collaboration within the district, with local community, and with external partners energized the process. Well-functioning outreach clinics made telehealth desirable. Local champions cultivated participation and generative capability, and overcame barriers through opportunistic exploitation of technological and financial options. Telehealth usage fluctuated between medical and administrative operations in response to internal needs and contextual dynamics. External agencies provided initial funding and supported later expansion.

CONCLUSIONS

Extensive internal and external collaboration, and a combination of technology push and opportunistic exploitation, can enable sustainable rural telehealth innovation.

Telemedicine: What have we learned?

As the health care industry is facing many challenges and is undergoing extensive change, telemedicine is in the position to address these challenges and be an important part of health care's development. Telemedicine has been used for approximately a half century, in which researchers have explored the different technologies utilized, clinical outcomes, cost benefits, perceptions, and adoption challenges of its use. This paper reviews and summarizes these findings and presents possible future research endeavors. Examining what is known about telemedicine can aid in the development of innovative, sustainable and beneficial health technologies that could positively impact health care delivery and outcomes.

Effectiveness of asynchronous tele-endoscopy

BACKGROUND

Asynchronous tele-endoscopy can improve access and quality of patient care. This is the first published evaluation of the diagnostic accuracy of highly compressed digital video in GI endoscopy.

OBJECTIVE

To determine whether asynchronous tele-endoscopy using highly compressed video can accurately document and diagnose lesions in the upper GI tract.

DESIGN

Local endoscopists performed 50 elective upper GI endoscopies. A high-quality DV compressed video (25 megabits per second [Mbps], 720 x 480 pixels) and highly compressed MPEG-1 video (2.0 Mbps, 352 x 240 pixels) were simultaneously captured. Five endoscopists asynchronously reviewed 20 compressed digital videos (100 case reviews) for endoscopic diagnoses. In addition, demonstration technique and image quality were rated on a Likert scale. Concordance between local and asynchronous endoscopists for major and minor endoscopic findings was evaluated. An independent panel classified discrepancies as caused by image quality, endoscopic technique, or interobserver variability through comparison of the 2 forms of digital video.

RESULTS

Although asynchronous endoscopists rated the image quality of highly compressed video as diagnostic in 85% of cases, only 18% of studies yielded the same clinical diagnoses. There was high discordance for both major (kappa = 0.38, 95% CI, 0.19-0.57) and minor findings (kappa = -0.29, 95% CI, -0.43 to -0.15). Interobserver reporting was responsible for 90% of variability in contrast to only 4.9% for poor image quality.

CONCLUSIONS

The findings suggest that the diagnostic accuracy of low-bandwidth, low-resolution, highly compressed video is well tolerated and comparable to the current standard. Interobserver reporting variability accounted for most of the poor correlation. Improved synoptic documentation is required for effective communication among endoscopists.

Telehealth ethics

The ethical implications of telehealth go well beyond providers' obligations to ensure privacy and confidentiality. The ethical conundrum of telehealth realizes the uniquely positive impact that telehealth can have on patients, providers, and clinical outcomes, as well as the potential for harm and abuse that may ensue. This article explores telehealth as one of many evolving information technologies that have ethical questions extending well beyond the confines of privacy and confidentiality. Providers and systems who utilize telehealth should also consider how it influences relationships with patients, access to healthcare, capacity for equitable treatment, cost, and quality of life. The ability to respond to these concerns will be important to the future development and deployment of this important technology as one means by which to improve access and quality of healthcare for all members of our society.

Parental perceptions toward digital imaging and telemedicine for retinopathy of prematurity management

BACKGROUND

Telemedicine is an emerging technology with potential to improve care for retinopathy of prematurity (ROP). This study evaluates parental perceptions about digital imaging and telemedicine for ROP care.

METHODS

During a 1-year period, one parent of each infant who underwent wide-field retinal imaging for ROP was given a questionnaire designed to evaluate parental perceptions using a 5-point Likert-type scale. Five items assessed perceptions toward digital retinal imaging, and ten items assessed attitudes toward telemedicine. Construct validity of the questionnaire was examined using factor analysis. Responses were summarized using descriptive and correlational statistics.

RESULTS

Forty-two parents participated. Factor analysis extracted two factors explaining 79% of the total variance in digital retinal imaging items (Cronbach's alpha = 0.843), and three factors explaining 63% of the total variance in telemedicine items (Cronbach's alpha = 0.631). Among digital imaging items, the highest mean (+/-SD) score was for "digital pictures of my child's retinopathy should be included in the permanent medical record" (4.4 +/- 0.6), and the lowest was for "digital cameras and computers are reliable" (3.8 +/- 0.8). Among telemedicine items, the highest mean (+/-SD) score was for "technology will improve the quality of medical care for my child" (4.3 +/- 0.6), and the lowest was for "technology will make it harder for a patient and doctor to establish a good relationship" (2.6 +/- 1.1).

CONCLUSIONS

Parents reported positive perceptions about telemedical ROP diagnosis, but expressed some preference for face-to-face care. Telemedicine has potential to alter the nature of the patient-physician relationship.

Can we improve the clinical utility of respiratory rate as a monitored vital sign?

Respiratory rate (RR) is a basic vital sign, measured and monitored throughout a wide spectrum of health care settings, although RR is historically difficult to measure in a reliable fashion. We explore an automated method that computes RR only during intervals of clean, regular, and consistent respiration and investigate its diagnostic use in a retrospective analysis of prehospital trauma casualties. At least 5 s of basic vital signs, including heart rate, RR, and systolic, diastolic, and mean arterial blood pressures, were continuously collected from 326 spontaneously breathing trauma casualties during helicopter transport to a level I trauma center. "Reliable" RR data were identified retrospectively using automated algorithms. The diagnostic performances of reliable versus standard RR were evaluated by calculation of the receiver operating characteristic curves using the maximum-likelihood method and comparison of the summary areas under the receiver operating characteristic curves (AUCs). Respiratory rate shows significant data-reliability differences. For identifying prehospital casualties who subsequently receive a respiratory intervention (hospital intubation or tube thoracotomy), standard RR yields an AUC of 0.59 (95% confidence interval, 0.48-0.69), whereas reliable RR yields an AUC of 0.67 (0.57-0.77), P < 0.05. For identifying casualties subsequently diagnosed with a major hemorrhagic injury and requiring blood transfusion, standard RR yields an AUC of 0.60 (0.49-0.70), whereas reliable RR yields 0.77 (0.67-0.85), P < 0.001. Reliable RR, as determined by an automated algorithm, is a useful parameter for the diagnosis of respiratory pathology and major hemorrhage in a trauma population. It may be a useful input to a wide variety of clinical scores and automated decision-support algorithms.

Policy-Induced Constraints in the Design and Commercialization of Monitoring Devices: An Assessment of Three Technologies’ Reimbursement Models

Successful commercialization of medical technologies increasingly requires developers and manufacturers to think early-on about regulatory approval and reimbursement strategies for their new devices. This can be particularly challenging in the case of monitoring devices, where demonstrating the effectiveness and finding the coding and coverage can often be a complicated and lengthy process, particularly with the given current reimbursement policy. In this paper, we use three technology case studies to examine how firms are navigating the status quo and illustrate the importance of incorporating a comprehensive understanding of current market and regulatory constraints into the development and commercialization process. The case studies suggest that viable approaches can include pairing a monitoring technology with a therapy, or relying on hospital-pay or patient-pay models that are based on demonstration of direct benefits or cost-savings to these parties. The results emphasize that successful innovation in monitoring technologies increasingly requires a very closely aligned engineering, business, and health-economic strategy. Developing a comprehensive understanding of the specific value drivers and policy-induced constraints can contribute substantially to achieving the true benefits of monitoring technologies.

Development of a fully implantable wireless pressure monitoring system

A fully implantable wireless pressure sensor system was developed to monitor bladder pressures in vivo. The system comprises a small commercial pressure die connected via catheter to amplifying electronics, a microcontroller, wireless transmitter, battery, and a personal digital assistant (PDA) or computer to receive the wireless data. The sensor is fully implantable and transmits pressure data once every second with a pressure detection range of 1.5 psi gauge and a resolution of 0.02 psi. In vitro calibration measurements of the device showed a high degree of linearity and excellent temporal response. The implanted device performed continuously in vivo in several porcine studies lasting over 3 days. This system can be adapted for other pressure readings, as well as other vital sign measurements; it represents the first step in developing a ubiquitous sensing platform for telemedicine and remote patient monitoring.

Telemedical diagnosis of retinopathy of prematurity intraphysician agreement between ophthalmoscopic examination and image-based interpretation

OBJECTIVE

To evaluate the intraphysician agreement between ophthalmoscopic examination and image-based telemedical interpretation for retinopathy of prematurity (ROP) diagnosis, when performed by the same expert physician grader.

DESIGN

Prospective, nonrandomized, comparative study.

PARTICIPANTS

Sixty-seven consecutive premature infants who underwent ROP examination at a major university medical center whose parents consented for participation.

METHODS

Infants underwent standard dilated ophthalmoscopy by one of two pediatric ophthalmologists, followed by retinal imaging with a commercially available wide-angle fundus camera by a trained neonatal nurse. Study examinations were performed at 31 to 33 weeks postmenstrual age (PMA) and/or 35 to 37 weeks PMA. Images were uploaded to a Web-based telemedicine system developed by the authors. After a 4- to 12-month period, telemedical interpretations were performed in which each physician graded images from infants upon whom he had initially performed ophthalmoscopic examinations. Diagnoses were classified using an ordinal scale: no ROP, mild ROP, type 2 prethreshold ROP, and treatment-requiring ROP.

MAIN OUTCOME MEASURES

Absolute intraphysician agreement and kappa statistic between ophthalmoscopic examination and telemedical interpretation were calculated by eye. All intraphysician discrepancies were reviewed, and underlying causes were classified by eye as no ROP identified by ophthalmoscopic examination, no ROP identified by telemedical interpretation, discrepancy about presence of zone 1 ROP, discrepancy about presence of plus disease, or other discrepancy in classification of ROP stage.

RESULTS

Absolute intraphysician agreement between ophthalmoscopic examination and telemedical interpretation was 86.3%. The kappa statistic for intraphysician agreement between examinations ranged from 0.657 (substantial agreement) for diagnosis of treatment-requiring ROP to 0.854 (near-perfect agreement) for diagnosis of mild or worse ROP. Among 206 eye examinations (103 infant examinations), there were 28 (13.6%) intraphysician discrepancies in diagnosis, 8 of which resulted from uncertainty about presence of zone 1 disease and 4 from uncertainty about presence of plus disease.

CONCLUSIONS

Intraphysician agreement between ophthalmoscopic examination and telemedical interpretation for ROP was very high. Neither examination modality appeared to have a systematic tendency to overdiagnose or underdiagnose ROP. Diagnosis of zone 1 disease and plus disease were major sources of clinically significant discrepancies.

Nurse and patient communication profiles in a home-based telehealth intervention for heart failure management

OBJECTIVE

This study compared differences in nurse and patient communication profiles between two telehealth modes: telephone and videophone, and evaluated longitudinal changes in communication, nurse perceptions, and patient satisfaction.

METHODS

Subjects were enrolled in a randomized controlled clinical trial evaluating a 90-day home-based intervention for heart failure. Telephone (n=14) and videophone (n=14) interactions were audio taped and analyzed using the Roter Interaction Analysis System.

RESULTS

Nurses were more likely to use open-ended questions, back-channel responses, friendly jokes, and checks for understanding on the telephone compared to videophone. Compliments given and partnership were more common on the videophone. Patients were more likely to give lifestyle information and approval comments on the telephone, and used more closed-ended questions on the videophone. Nurses perceptions of the interactions were not different between the telephone and videophone, nor did their perceptions change significantly over the course of the intervention. There were no significant differences in patient satisfaction between the telephone and videophone.

CONCLUSIONS

The results of this study did not support use of a videophone over the telephone.

PRACTICE IMPLICATIONS

It is critical to match technologies to patient needs and use the least complex technology possible. When considering use a videophone, health care providers should critically examine the trade-offs between additional complexities with the added value of the visual interaction.

Intensive care unit telemedicine: review and consensus recommendations

Intensive care unit telemedicine involves nurses and physicians located at a remote command center providing care to patients in multiple, scattered intensive care units via computer and telecommunication technology. The command center is equipped with a workstation that has multiple monitors displaying real-time patient vital signs, a complete electronic medical record, a clinical decision support tool, a high-resolution radiographic image viewer, and teleconferencing for every patient and intensive care unit room. In addition to communication functions, the video system can be used to view parameters on ventilator screens, infusion pumps, and other bedside equipment, as well as to visually assess patient conditions. The intensivist can conduct virtual rounds, communicate with on-site caregivers, and be alerted to important patient conditions automatically via software-monitored parameters. This article reviews the technology's background, status, significance, clinical literature, financial effect, implementation issues, and future developments. Recommendations from a University HealthSystem Consortium task force are also presented.

Information and communications technology in chronic disease care: what are the implications for payment?

New information and communication technology (ICT) has the potential to improve care for chronic conditions, deliver better health outcomes, and reduce direct and indirect costs. However, realizing these gains necessitates new forms of care delivery, through adoption of ICT, the specific choice of ICT, and changes to existing forms of health care delivery. Realizing these new forms of delivery requires appropriate payment policies. The authors review the literatures on health care payment and ICT in chronic care and then apply theoretical economic analysis to determine how ICT alters health care payment policy recommendations. Using diabetes as an example, the authors identify and illustrate the disease and technology features that determine the optimal form of payment. Overall, ICT shifts the optimal blend of fee-for-service and capitation toward greater capitation. Carve-outs for ICT-supported preventive care enable more high-powered payment while addressing selection concerns.

The role of telemedicine in fostering health-care innovations to address problems of access, specialty shortages and changing patient care needs

The integration of advanced technologies into health-care services promises to aid society in its transition to a coordinated, systems approach which is focused on disease prevention, enhanced wellness, chronic disease management, decision support, quality and patient safety. By incorporating such technologies, clinicians will be able to manage the growing volumes of medical information, research and decision support analytical tools. The deployment of advanced technologies will minimize the barriers of distance and geography to enhance access and facilitate the delivery of integrated health care. This will support and enhance the goals of the US federal Healthy People 2010 initiative.

Impact on quality of life of a telemedicine system supporting head and neck cancer patients: a controlled trial during the postoperative period at home

OBJECTIVES

Telemedicine applications carry the potential to enhance the quality of life of patients, but studies evaluating telemedicine applications are still scarce. The evidence regarding the effectiveness of telemedicine is limited and not yet conclusive. This study investigated whether telemedicine could be beneficial to the quality of life of cancer patients.

DESIGN AND MEASUREMENTS

Between 1999 and 2002, we conducted a prospective controlled trial evaluating the effects of a telemedicine application on the quality of life of patients with cancer involving the head and neck, using quality of life questionnaires that covered 22 quality of life parameters. All patients had undergone surgery for head and neck cancer at the Erasmus MC, a tertiary university hospital in The Netherlands. Patients in the intervention group were given access to an electronic health information support system for a period of six weeks, starting at discharge from the hospital.

RESULTS

In total, we included 145 patients in the control group and 39 in the intervention group. At 6 weeks, the end of the intervention, the intervention group had significantly improved QoL in 5 of the 22 studied parameters. Only one of these five quality of life parameters remained significantly different at 12 weeks.

CONCLUSIONS

This study adds to the sparse evidence that telemedicine may be beneficial for the quality of life of cancer patients.

Deployment and early experience with remote-presence patient care in a community hospital

BACKGROUND

The introduction of the RP6 (InTouch Health, Santa Barbara, CA, USA) remote-presence "robot" appears to offer a useful telemedicine device. The authors describe the deployment and early experience with the RP6 in a community hospital and provided a live demonstration of the system on April 16, 2005 during the Emerging Technologies Session of the 2005 SAGES Meeting in Fort Lauderdale, Florida.

METHODS

The RP6 is a 5-ft 4-in. tall, 215-pound robot that can be remotely controlled from an appropriately configured computer located anywhere on the Internet (i.e., on this planet). The system is composed of a control station (a computer at the central station), a mechanical robot, a wireless network (at the remote facility: the hospital), and a high-speed Internet connection at both the remote (hospital) and central locations. The robot itself houses a rechargeable power supply. Its hardware and software allows communication over the Internet with the central station, interpretation of commands from the central station, and conversion of the commands into mechanical and nonmechanical actions at the remote location, which are communicated back to the central station over the Internet. The RP6 system allows the central party (e.g., physician) to control the movements of the robot itself, see and hear at the remote location (hospital), and be seen and heard at the remote location (hospital) while not physically there.

RESULTS

Deployment of the RP6 system at the hospital was accomplished in less than a day. The wireless network at the institution was already in place. The control station setup time ranged from 1 to 4 h and was dependent primarily on the quality of the Internet connection (bandwidth) at the remote locations. Patients who visited with the RP6 on their discharge day could be discharged more than 4 h earlier than with conventional visits, thereby freeing up hospital beds on a busy med-surg floor. Patient visits during "off hours" (nights and weekends) were three times more efficient than conventional visits during these times (20 min per visit vs 40-min round trip travel + 20-min visit). Patients and nursing personnel both expressed tremendous satisfaction with the remote-presence interaction.

CONCLUSIONS

The authors' early experience suggests a significant benefit to patients, hospitals, and physicians with the use of RP6. The implications for future development are enormous.

Low-Technology Heart Failure Care in Home Health

This article reports a study that pilot tested the effectiveness of a low-technology structured intervention to standardize home healthcare management of patients with heart failure (HF) within a home health agency (HHA). The purpose of this study was to use low-technology equipment to improve care for patients with HF enrolled in a home health agency. The 9-week intervention was targeted toward the home health nurses and included telephone and home visits, a teaching tool, digital scales, and a log/notebook filled out by the patients in the study. Patient outcomes included decreased rehospitalization, decreased symptoms of HF, and increased quality of life.

Rural Outreach in Home Telehealth: Assessing Challenges and Reviewing Successes

Most home health agencies that adopt home telehealth tend to be located in urban or metropolitan areas. This paper discusses a 3-year pilot of home telehealth in four rural areas. Several challenges related to the rural nature of the home health agencies were recognized. These challenges are discussed with recommendations for assessing rural home health agencies for home telehealth. Our findings suggest ways to improve the implementation of home telehealth for rural home health agencies. In addition to the challenges, successes were realized as well. Approximately 145 travel hours and 7500 miles of nurse travel were avoided through the use of home telehealth during the program. Patient examples show improvements in their medical conditions, which the nursing staff thought would not have been accomplished without the more frequent monitoring that home telehealth allowed the agencies to provide.

Urgent Clinical Challenges in Children With Ischemic Stroke

Background and Purpose— Clinical trials are lacking in pediatric stroke. As a result, physicians caring for children with stroke face significant challenges. The patient characteristics and specific nature of clinical challenges facing practicing clinicians can inform the design of and priorities for developing relevant clinical trials.

Methods— Physicians consulted the 1-800-NOCLOTS toll-free pediatric stroke telephone consultation service on children (birth to 18 years) with ischemic stroke. Pediatric neurologist or hematologists provided telephone consultation and documented caller and patient characteristics, antithrombotic treatments and callers’ questions for entry into a computerized database. Children referred from January 1, 1995 to January 1, 2004, comprised the study cohort.

Results— Stroke consults were completed on 1065 children located predominantly in the United States (76%). Children had arterial ischemic stroke (AIS; 679; 64%) or cerebral sinovenous thrombosis (CSVT; 386; 36%) and were 54% male and 16% neonates. Risk factors and antithrombotic agents (none, aspirin, warfarin, and heparins) differed by stroke type. In 60% of patients, callers had not initiated antithrombotic therapy. Callers’ questions for both stroke types usually concerned treatment selection (83%), but for AIS, questions more frequently ( P <0.0001) concerned the selection and interpretation of etiological investigations.

Conclusions— Research is urgently needed in pediatric stroke to provide direction for management in “real-life” settings. Research efforts should address the unique challenges within different stroke types and include observational studies addressing investigation of the child with AIS. For AIS and CSVT, randomized controlled trials investigating the efficacy of antithrombotic treatment are urgently needed.

A randomized trial comparing telemedicine case management with usual care in older, ethnically diverse, medically underserved patients with diabetes mellitus

BACKGROUND

Telemedicine is a promising but largely unproven technology for providing case management services to patients with chronic conditions who experience barriers to access to care or a high burden of illness.

METHODS

The authors conducted a randomized, controlled trial comparing telemedicine case management to usual care, with blinding of those obtaining outcome data, in 1,665 Medicare recipients with diabetes, aged 55 years or greater, and living in federally designated medically underserved areas of New York State. The primary endpoints were HgbA1c, blood pressure, and low-density lipoprotein (LDL) cholesterol levels.

RESULTS

In the intervention group (n = 844), mean HgbA1c improved over one year from 7.35% to 6.97% and from 8.35% to 7.42% in the subgroup with baseline HgbA1c > or =7% (n = 353). In the usual care group (n = 821) mean HgbA1c improved over one year from 7.42% to 7.17%. Adjusted net reductions (one-year minus baseline mean values in each group, compared between groups) favoring the intervention were as follows: HgbA1c, 0.18% (p = 0.006), systolic and diastolic blood pressure, 3.4 (p = 0.001) and 1.9 mm Hg (p < 0.001), and LDL cholesterol, 9.5 mg/dL (p < 0.001). In the subgroup with baseline HgbA1c > or =7%, net adjusted reduction in HgbA1c favoring the intervention group was 0.32% (p = 0.002). Mean LDL cholesterol level in the intervention group at one year was 95.7 mg/dL. The intervention effects were similar in magnitude in the subgroups living in New York City and upstate New York.

CONCLUSION

Telemedicine case management improved glycemic control, blood pressure levels, and total and LDL cholesterol levels at one year of follow-up.

The role of nurses in installing telehealth technology in the home

Home telehealth involves the use of video conferencing or remote monitoring equipment in patients' homes. The installation of hardware and training of patients has historically been performed by nurses, typically RNs. This article examines the experience of RNs as telehealth installers in the Informatics for Diabetes Education and Telemedicine (IDEATel) project, where RNs were responsible for the installation of the Home Telemedicine Units (HTUs) and for training patients in the use of the HTUs, blood pressure cuffs, and fingerstick glucose meters. Average installation and training time was 166 minutes (SD 51 min). Structured interviews with RN installers revealed that patient education and training accounted for roughly two thirds of the in-home time. Technology-related problems, especially those related to telecommunications, were the primary cause of installation difficulties. Thematic analysis of installer interviews identified eight major themes and confirmed the importance of both clinical and technical knowledge during the telehealth installation process.

Computer skills in patients with movement disorders

BACKGROUND

Electronic communication is important in healthcare, but the level of computer proficiency among patients with neurological disorders is unknown.

OBJECTIVE

This study sought to determine the proportion of a movement disorder clinic population that was able to perform basic computer skills, and the effect of specific cognitive and motor features on computer proficiency.

METHODS

One hundred and four movement disorder patients participated. Seventy-four completed both paper and computerized questionnaires to evaluate data entry skills and thirty subjects completed paper questionnaires only. Basic e-mail messaging and Internet skills were evaluated. Demographic information, Mini-Mental Status Examination (MMSE) score, and Hoehn and Yahr stage were assessed.

RESULTS

Ninety-six percent of subjects successfully completed computerized data entry tasks, and over 70% completed e-mail and Internet tasks. Computer data entry had an average accuracy of nearly 95% when compared to paper data entry. Poorer performance on computer tasks was associated with older age, less education, and cognitive impairment. Computer performance was reduced in subjects with a history of parkinsonism and when both tremor and dyskinesia were present during task performance. Nearly three-quarters of subjects have access to a computer. Subjects who completed the paper questionnaire but refused to complete the computer questionnaire were older, less educated and more cognitively impaired.

CONCLUSION

The majority of patients visiting a tertiary movement disorders center were able to perform computer data entry, e-mail messaging and Internet usage. These results reinforce the potential value of electronic communication and information systems in neurology practice.

Electronic and telemedicine techniques to manage heart failure

Electronic monitoring and telemedicine techniques are effective tools to manage patients with moderate and high risk heart failure as part of a multidisciplinary disease management system. They have been shown to reduce hospitalization and emergency room visits, improve quality of life, and possibly impact mortality. In addition, several have been shown to be cost-effective. They encourage patient education and self-management and facilitate guideline-mandated care. These technologies can improve efficiency by allowing a single clinician to closely manage many patients in a high-quality manner. Simultaneously, these systems can burden the existing health care system by adding large volumes of new data that need to be reviewed and acted upon. Payers must develop realistic reimbursement schemes to offset the costs of supervising these systems. Newer devices that collect many physiologic variables, including some that invasively record ambulatory hemodynamics, add significant complexity, but it is unclear whether this additional data will improve management and outcomes to justify the incremental risks and costs.

The current state of telemonitoring: a comment on the literature

Telemonitoring, is defined as the use of information technology to monitor patients at a distance. This literature review suggests that the most promising applications for telemonitoring is for chronic illnesses such as cardiopulmonary disease, asthma, and heart failure in the home. Fetal heart rate monitoring and infant cardiopulmonary functions have also been monitored at a distance, as well as coagulation, or the level of activity of elderly people, assessed by the intelligent home monitoring devices. Hospitals, clinics, and prisons all have used telemonitoring, as have ambulances equipped with systems connected to the receiving hospital. Telemonitoring allows reduction of chronic disease complications thanks to a better follow-up; provides health care services without using hospital beds; and reduces patient travel, time off from work, and overall costs. Several systems have proven to be cost effective. Telemonitoring is also a way of responding to the new needs of home care in an ageing population. Real-time monitoring of patients in ambulances reduces the time to initiate treatment and allows the emergency crew to be better prepared. The obstacles to telemonitoring development include the initial costs of systems, physician licensing, and reimbursement. In the future, virtual reality, immersive environments, haptic feedback and nanotechnology promise new ways in improving the capabilities of telemonitoring.

Organizational and environmental factors affecting the utilization of telemedicine in rural home healthcare

In the last five years, home health agencies have become increasingly interested in telemedicine as a potential means to meet the future healthcare needs of their aged and chronically ill clientele. This case study examines the organizational and environmental conditions that affected the implementation of a telemedicine program in one rural home healthcare organization. Several factors restricted the utilization of telemedicine, including Medicare's Prospective Payment System and corresponding documentation (Outcome Assessment and Information Set), the organization controlling grant funding for the program, and several environmental factors. Findings suggest that in rural communities, older homecare patients may have less opportunity to benefit from telemedicine. The study demonstrates the importance of environmental and organizational factors when implementing a telemedicine program. Recommendations are offered for home healthcare organizations considering development of telemedicine programs.

The telecommunication revolution in the medical field: present applications and future perspective

In the present review, we analyze the achievements of telecommunication innovations in the medical field focusing on patient care and medical-education aspects. In this regard, the telecommunication revolution has offered medical professionals the possibility to transmit information of any sort zeroing transmission time latency and annihilating spatial distances. Although telemedicine is still in its infancy, multiple applications of this science have already been successfully tested. As an example, robotically mediated telesurgery has it made possible for surgeons to operate standing at a considerable distance from the operating table without even touching or directly seeing the surgical field. Moreover, medical education and medical consulting have acquired new and wider ranges of applicability thanks to the introduction of teleproctoring, telementoring, and teleconsulting. Finally, in the very near future, telepresence surgery will permit "virtual" operations on patients where surgeons can project their manual dexterity, psychomotor skills, and problem-solving ability to remote locations. In this context, telemedicine will support a more equal distribution of medical knowledge and promote excellence in patients' care even in the most disadvantaged environments.

Using information technology to improve the management of chronic disease

Information and communications technology (ICT) is increasingly being used in management of chronic illness to facilitate shared services (virtual health networks and electronic health records), knowledge management (care rules and protocols, scheduling, information directories), as well as consumer-based health education and evidence-based clinical protocols. Common applications of ICT include home monitoring of vital signs for patients with chronic disease, as well as replacing home visits by nurses in person with telemedicine videophone consultations. A patient-managed Home Telecare System with integrated clinical signs monitoring, automated scheduling and medication reminders, as well as access to health education and daily logs, is presented as an example of ICT use for chronic disease self-management. A clinical case study demonstrates how early identification of adverse trends in clinical signs recorded in the home can either avoid hospital readmission or reduce the length of hospital stay.

Geographic information systems and public health

Geographic information systems (GIS) and analyses based on GIS have become widespread and well accepted. GIS is not the complete solution to understanding the distribution of disease and the problems of public health but is an important way in which to better illuminate how humans interact with their environment to create or deter health.

Design, methods, and evaluation directions of a multi-access service for the management of diabetes mellitus patients

Recent advances in information and communication technology allow the design and testing of new models of diabetes management, which are able to provide assistance to patients regardless of their distance from the health care providers. The M2DM project, funded by the European Commission, has the specific aim to investigate the potential of novel telemedicine services in diabetes management. A multi-access system based on the integration of Web access, telephone access through interactive voice response systems, and the use of palmtops and smart modems for data downloading has been implemented. The system is based on a technological platform that allows a tight integration between the access modalities through a middle layer called the multi-access organizer. Particular attention has been devoted to the design of the evaluation scheme for the system: A randomized controlled study has been defined, with clinical, organizational, economic, usability, and users' satisfaction outcomes. The evaluation of the system started in January 2002. The system is currently used by 67 patients and seven health care providers in five medical centers across Europe. After 6 months of usage of the system no major technical problems have been encountered, and the majority of patients are using the Web and data downloading modalities with a satisfactory frequency. From a clinical viewpoint, the hemoglobin A1c (HbA1c) of both active patients and controls decreased, and the variance of HbA1c in active patients is significantly lower than the control ones. The M2DM system allows for the implementation of an easy-to-use, user-tailored telemedicine system for diabetes management. The first clinical results are encouraging and seem to substantiate the hypothesis of its clinical effectiveness.