Telemedicine: a new health care delivery system

Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP): 18-month experience with telemedicine screening

PURPOSE

To report the 18-month experience of the Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP) telemedicine initiative.

DESIGN

Retrospective analysis of the SUNDROP archival data between 1 December 2005 and 30 May 2007, evaluating this new diagnostic technology for ROP screening.

PARTICIPANTS

All 97 consecutively enrolled infants in the SUNDROP network.

METHODS

All patients were screened using the RetCam II, and evaluated by the SUNDROP reading center at Stanford University. Nurses were trained to obtain five images in each eye. All patients were screened by an ophthalmologist trained in diagnosing ROP within 1 week of discharge from the hospital.

MAIN OUTCOME MEASURES

Outcomes included referral-warranted disease, need for treatment, and anatomic outcomes. Referral-warranted disease was defined as any Early Treatment Retinopathy of Prematurity Disease Type 2 or greater, threshold disease, any plus disease, and any stage 4 or higher disease.

RESULTS

In the initial 18-month period, the SUNDROP telemedicine screening initiative has not missed any referral-warranted disease for ROP. A total of 97 infants (194 eyes) were enrolled, resulting in 443 unique examinations and 4,929 unique images. The mean birth weight of the infants was 1,186.9 grams, with a mean gestational age at birth of 28.9 weeks. Seven infants were identified with referral-warranted disease; six patients underwent laser photocoagulation and completely regressed. The one remaining patient regressed spontaneously, and did not require intervention. Calculated sensitivity and specificity was 100% and 98.9% respectively. No patient progressed to retinal detachment or other adverse outcome. Inadequate exposure, artifact, poor visualization of the periphery, and lack of a complete standardized image set in some patients were identified as areas requiring further assessment.

CONCLUSIONS

The SUNDROP telemedicine screening initiative for ROP has proven to have a high degree of sensitivity and specificity for identification of referral-warranted disease. Training was easily implemented. All cases of referral-warranted disease were captured. There were no adverse outcomes.

Retinopathy of prematurity management using single-image vs multiple-image telemedicine examinations

PURPOSE

To compare performance of single-image vs multiple-image telemedicine examinations for retinopathy of prematurity (ROP) diagnosis.

DESIGN

Prospective comparative study.

METHODS

A total of 248 eyes from 67 consecutive infants underwent wide-angle retinal imaging by a trained neonatal nurse at 31 to 33 weeks and/or 35 to 37 weeks postmenstrual age (PMA) at a single academic institution. Data were uploaded to a web-based telemedicine system and interpreted by three masked retinal specialists. Diagnoses were provided based on single images, and subsequently on multiple images, from both eyes of each infant. Findings were compared to a reference standard of indirect ophthalmoscopy by a pediatric ophthalmologist. Primary outcome measures were recommended follow-up interval, presence of plus disease, presence of type-2 or worse ROP, and presence of visible peripheral ROP.

RESULTS

Among the three graders, mean sensitivity/specificity for detection of infants requiring follow-up in less than one week were 0.85/0.93 by single-image examination and 0.91/0.88 by multiple-image examination at 35 to 37 weeks PMA. Mean sensitivity/specificity for detection of infants with type-2 or worse ROP were 0.82/0.95 by single-image examination and 1.00/0.91 by multiple-image examination at 35 to 37 weeks PMA. Mean sensitivity/specificity for detection of plus disease were 1.00/0.86 by single-image examination and 1.00/0.87 by multiple-image examination at 35 to 37 weeks PMA. There were no statistically-significant intragrader differences between accuracy of single-image and multiple-image telemedicine examinations for detection of plus disease.

CONCLUSIONS

Single-image and multiple-image telemedicine examinations perform comparably for determination of recommended follow-up interval and detection of plus disease. This may have implications for development of screening protocols, particularly in areas with limited access to ophthalmic care.

Supporting patients and their caregivers after-hours at the end of life: the role of telephone support

Twenty-four hour access is accepted as a gold standard for palliative care service delivery, yet minimal data exist to justify the cost of this initiative to health care planners and policy makers. Further, there is scant information concerning optimal and efficient methods for delivering after-hours palliative care advice and support, particularly in regional and rural settings. This article reports on an evaluation of a local after-hours telephone support service in regional Australia. A centralized after-hours telephone support service was provided by generalist nurses at a Multipurpose Service in a rural community. A mixed-method evaluation, including semistructured interviews, was undertaken after 20 months of operation. During the period March 31, 2005 until November 15, 2006, 357 patients were registered as part of the Mid North Coast Rural Palliative Care Program. Ten percent of patients or their caregivers accessed the After-Hours Telephone Support Service, representing 55 occasions of service. The most common reason for contacting the service was for reassurance surrounding medication usage, symptom management, and anxiety. This experience demonstrates proof of concept that acceptable palliative care advice can be provided by generalist nurses in a cost-efficient manner. Common patterns emerged in utilization that can assist in service planning and staffing formulae. There is also a need to investigate mechanisms of interfacing with larger scale call centers, to explore the differences within generic and disease-specific approaches, and assess the appropriateness of after-hours telephone support with different cultural groups.

Telemedicine technology assessment part I: setup and validation of a quality control system

The remarkable development of telemedicine applications has brought about the need for a telemedicine quality control system to prevent application failures and guarantee users. The aim of this paper was to report on the setup of a quality control system and validate it on a testing set of telemedicine products and services. The quality control system followed two main phases. Phase I was focused on data acquisition and preliminary evaluation of the telemedicine products and services. A classification form and an informative questionnaire were used to gather all the relevant information about the telemedicine application under test. Phase II was focused on evaluation and quality control of the telemedicine product. A Technical File and a Quality Assessment Checklist were used to assess the telemedicine product and service. The telemedicine quality control system was suitable for the efficient evaluation of telemedicine applications. A quality level was assigned to each product according to a threshold and an algorithm. All telemedicine products tested passed the test with a quality level higher than the threshold. The quality control system assured the definition of standardized quality levels for the telemedicine products and services. The study presented in this paper could be useful for promoting the use of standardized telemedicine applications, and therefore speeding up their integration process in the national health service.

Telemedicine Taxonomy: A Classification Tool

Telemedicine allows medical doctors and specialized skilled experts to provide services to patients who are in remote locations using advanced telecommunications. This paper presents a taxonomy that systematically classifies various telemedicine efforts worldwide using five major dimensions: application purpose, application area, environmental setting, communication infrastructure, and delivery options. To identify relationships and patterns between these different dimensions telemedicine programs survey data from the Telemedicine Information Exchange (TIE) was analyzed using multiple regression and path analysis. Major findings indicate that interactive video is the most preferred modality. Store-and-forward technology is preferred for ophthalmology, radiology, and pathology. However, a negative correlation exists between store-and-forward and interactive video with mental health application. The study also indicates that the Internet is still not the dominant communications infrastructure when it comes to telemedicine. We showed that these dimensions can capture almost all efforts in telemedicine and also help program planners to understand the issues in telemedicine deployment. Our findings indicate that the taxonomy is useful for categorizing and comparing existing programs, and can be used for planning future programs.

Remote image based retinopathy of prematurity diagnosis: a receiver operating characteristic analysis of accuracy

BACKGROUND/AIMS

Telemedicine offers potential to improve the accessibility and quality of diagnosis of retinopathy of prematurity (ROP). The aim of this study was to measure accuracy of remote image based ROP diagnosis by three readers using receiver operating characteristic (ROC) analysis.

METHODS

64 hospitalised infants who met ROP examination criteria underwent two consecutive bedside procedures: dilated examination by an experienced paediatric ophthalmologist and digital retinal imaging with a commercially available wide angle camera. 410 images from 163 eyes were reviewed independently by three trained ophthalmologist readers, who classified each eye into one of four categories: no ROP, mild ROP, type 2 prethreshold ROP, or ROP requiring treatment. Sensitivity and specificity for detection of mild or worse ROP, type 2 prethreshold or worse ROP, and ROP requiring treatment were determined, compared to a reference standard of dilated ophthalmoscopy. ROC curves were generated by calculating values for each reader at three diagnostic cut-off levels: mild or worse ROP (that is, reader was asked whether image sets represented mild or worse ROP), type 2 prethreshold or worse ROP (that is, reader was asked whether image sets represented type 2 prethreshold or worse ROP), and ROP requiring treatment.

RESULTS

Areas under ROC curves ranged from 0.747-0.896 for detection of mild or worse ROP, 0.905-0.946 for detection of type 2 prethreshold or worse ROP, and 0.941-0.968 for detection of ROP requiring treatment.

CONCLUSIONS

Remote interpretation is highly accurate among multiple readers for the detection of ROP requiring treatment, but less so for detection of mild or worse ROP.

Implementing telehealth to support medical practice in rural/remote regions: what are the conditions for success?

Background

Telehealth, as other information and communication technologies (ICTs) introduced to support the delivery of health care services, is considered as a means to answer many of the imperatives currently challenging health care systems. In Canada, many telehealth projects are taking place, mostly targeting rural, remote or isolated populations. So far, various telehealth applications have been implemented and have shown promising outcomes. However, telehealth utilisation remains limited in many settings, despite increased availability of technology and telecommunication infrastructure.

Methods

A qualitative field study was conducted in four remote regions of Quebec (Canada) to explore perceptions of physicians and managers regarding the impact of telehealth on clinical practice and the organisation of health care services, as well as the conditions for improving telehealth implementation. A total of 54 respondents were interviewed either individually or in small groups. Content analysis of interviews was performed and identified several effects of telehealth on remote medical practice as well as key conditions to ensure the success of telehealth implementation.

Results

According to physicians and managers, telehealth benefits include better access to specialised services in remote regions, improved continuity of care, and increased availability of information. Telehealth also improves physicians' practice by facilitating continuing medical education, contacts with peers, and access to a second opinion. At the hospital and health region levels, telehealth has the potential to support the development of regional reference centres, favour retention of local expertise, and save costs. Conditions for successful implementation of telehealth networks include the participation of clinicians in decision-making, the availability of dedicated human and material resources, and a planned diffusion strategy. Interviews with physicians and managers also highlighted the importance of considering telehealth within the broader organisation of health care services in remote and rural regions.

Conclusion

This study identified core elements that should be considered when implementing telehealth applications with the purpose of supporting medical practice in rural and remote regions. Decision-makers need to be aware of the specific conditions that could influence telehealth integration into clinical practices and health care organisations. Thus, strategies addressing the identified conditions for telehealth success would facilitate the optimal implementation of this technology.

Impacts of Telehomecare on Patients, Providers, and Organizations

Over the last decades, development of home care services is an important component of ongoing health care systems reforms. However, their full integration into hospital or primary care services is still progressing slowly. It appears that telehomecare (THC) could help create networks of services between hospital and primary care providers. Even though their potential to increase access to services and improve quality of care and health outcomes is recognized, their widespread adoption has not yet been achieved. Various barriers need to be overcome. In this paper, we present our comparative exploratory process analysis of the use of THC to follow the treatment of elderly people suffering from severe chronic conditions (chronic obstructive pulmonary disease [COPD], hypertension, cardiac insufficiency). The technology was first introduced as a pilot project in three sites (one site in Quebec and two sites in Manitoba, Canada). Our study is based on qualitative methods. It includes a longitudinal analysis of implementation processes and monitoring of results. Our analysis allows us to identify some of the major impacts on patients and providers, and explain how they may be achieved. Also, because of the major changes in work processes, THC introduces new models of home care delivery. Two models are identified: a specialized model and a planned polyvalent model. Such profound changes raise two major challenges for managers and providers. First, the organisation of work, traditionally based upon preestablished intervention plans, must adapt to respond to ad hoc patients' needs and alerts. Second, constant linkages between the traditional and new models of services delivery become mandatory.

Evaluating telemedicine: a focus on patient pathways

Evaluations of telemedicine have sought to assess various measures of effectiveness (e.g., diagnostic accuracy), efficiency (e.g., cost), and engagement (e.g., patient satisfaction) to determine its success. Few studies, however, have looked at evaluating the organizational impact of telemedicine, which involves technology and process changes that affect the way that it is used and accepted by patients and clinicians alike. This study reviews and discusses the conceptual issues in telemedicine research and proposes a fresh approach for evaluating telemedicine. First, we advance a patient pathway perspective, as most of the existing studies view telemedicine as a support to a singular rather than multiple aspects of a health care process. Second, to conceptualize patient pathways and understand how telemedicine impacts upon them, we propose simulation as a tool to enhance understanding of the traditional and telemedicine patient pathway.

A clinical monitoring and management system for residential aged care facilities

In response to an extended user needs analysis, a home telecare system designed for the management of patients with chronic disease was adapted for use in residential aged care facilities (RACFs). The system architecture and hardware and software components are described for both the client- and server-side. The client-side includes medication dispensing, scheduled clinical measurements and questionnaire delivery. The server-side supports Web-based administrative tools for scheduling and medications management, as well as automated reporting functions. A brief discussion on a trial of the system in five different RACFs focuses on how clinical information technology can support and improve care standards and deliver better health outcomes for residents in Australian aged care homes.

Clinical outcomes associated with telemedicine/telehealth

This paper is a comprehensive review and synthesis of the literature concerning clinical outcomes associated with various telemedicine applications. It starts out with a brief description of the findings reported by similar literature reviews already published. Subsequently, it proposes a conceptual model for assessing clinical outcomes based on Donabedian's formulation of the Medical Care Process. Accordingly, research findings are reported in terms of the relevant components of the medical care process, namely, diagnosis, clinical management, and clinical outcomes. Specific findings are organized according to the designated clinical and diagnostic application. This is followed by a general report of studies dealing with patient satisfaction.

Willingness to use telemedicine for psychiatric care

The aim of this study was to assess potential users' willingness to use telepsychiatry and its correlates within a theoretical framework guided by the principles of social-cognitive models. The conceptual model proposed willingness to use telepsychiatry to be associated directly to attitudes toward telemedicine, attitudes toward the patient-physician relationship, and satisfaction with current medical care, and indirectly to anxiety to technology. Phone interviews were conducted with a representative sample of 1,204 Jewish, noninstitutionalized adults in Israel (mean age = 58; 51% female). Structural equation modeling was used to examine hypothesized relationships. Willingness to use telepsychiatry was relatively high and was affected by the participants' attitudes toward telemedicine, the patient-physician relationship, and by the level of anxiety toward technology. Efforts aimed at encouraging the use of telemedicine for psychiatric care should target potential users' attitudes, as well as feelings of uneasiness and anxiety regarding technology.

Telehealth adoption in hospitals:an organisational perspective

PURPOSE

The purpose of this study is to explore the influence of hospitals' organisational characteristics on telehealth adoption by health-care centres involved in the extended telehealth network of Quebec (French acronym RQTE) DESIGN/METHODOLOGY/APPROACH: The article is based on a review of the literature and a questionnaire, which was administered via telephone interviews to the 32 hospitals involved in the Extended Telehealth Network of Quebec. Contingency analyses were performed to determine which organisational factors have influenced telehealth adoption. Subsequently, a multiple case study was conducted among nine hospitals representative of different categories of telehealth adopters. In-depth interviews with various actors involved in telehealth activities have permitted a deepening of one's understanding of the impact of clinical and administrative contexts on telehealth adoption.

FINDINGS

The results from both the questionnaire and interviews support the observation made by Whitten and Adams in 2003 that telehealth programs are not isolated, but located within larger health organisations. Moreover, health-care organisations are also positioned in a larger geographical, economical and socio-political environment. Therefore, it is important to investigate the context in which telehealth projects are taking place prior to experimentation.

ORIGINALITY/VALUE

This study has highlighted the relevance of considering the characteristics and the dynamics of health-care organisations at each stage of telehealth implementation in order to take their specific needs into account.

Usability in the real world: assessing medical information technologies in patients' homes

OBJECTIVE

This paper presents an approach to usability evaluation of computer-based health care systems designed for patient use in their homes. Although such devices are becoming more prevalent, there is very little known about their usability.

DESIGN

The theoretical foundations for the methods are discussed. The approach incorporates a cognitive walkthrough usability evaluation and new methods for usability testing that can be conducted in patient's homes. The method was applied to the IDEATel intervention, a multi-institution randomized controlled trial of the feasibility, acceptability, and clinical utility of a home-based telemedicine system for diabetic Medicare population. The usability study was designed to assess barriers to optimal use of the system. The focus was both on dimensions of the interface and on dimensions of patient skills and competency. The usability field research involved testing 25 patients in their homes using the system. The analysis included a range of video-analytic methods of varying levels of granularity.

RESULTS

The usability evaluation revealed aspects of the interface that were sub-optimal and impeded the performance of certain tasks. It also found a range of patient-related factors such as numeracy and psychomotor skills that constituted barriers to productive use.

CONCLUSIONS

A multifaceted usability approach provided important insight regarding use of technology by an elderly chronic-care patient population and more generally, for understanding how home health initiatives can more effectively use such technology.

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.

A prospective evaluation of ENT telemedicine in remote military populations seeking specialty care

This study evaluated telemedicine use in remote military treatment facilities (MTFs) ashore over a 4-month period to help guide telemedicine applications for shipboard medical departments. A prospective study design was used to evaluate specialty care provided by an ear/nose/throat (ENT) physician via videoconferencing (VC) for patients at remote MTFs in TRICARE Region 9. The study provided a complete and continuous sample of ENT consultations during a planned 4-month period. Data sources included a telemedicine database and telephone interviews to assess attitudes of physician and nonphysician medical personnel. A total of 193 VC consultations (hereafter referred to as teleconsultations) were conducted following referrals from primary providers. Patients were mostly young, male, active-duty personnel. Forty-five percent of the 193 teleconsultations resulted in changed diagnosis by the ENT specialist relative to initial diagnosis by the referring provider. This rate of clinical impact was substantial, and it generalized across various ENT conditions, demographics, and MTFs. Medical personnel reported generally positive attitudes about telemedicine technologies and the telemedicine process in TRICARE Region 9. Nonphysician providers reported slightly more favorable attitudes compared to physicians. These results suggest that ENT telemedicine has substantial clinical impact in the military populations treated at MTFs. A high rate of changed diagnoses (45%) was observed across age, gender, military status, ENT conditions, and treatment facilities. Medical personnel reported positive attitudes about using the telemedicine system. These results support the use of telemedicine in shipboard medical departments.

The rural context of health care provision

By first laying out some of the major threads involved in the fabric of rurality and rural care, we consider the major interrelated issues in rural care provision before reviewing the larger universal contextual issues of rurality and care. By reflecting on the many definitions of 'rural', we infer that defining 'rural' is a difficult research and practice challenge. We conclude by suggesting that a holistic, place-specific definition of 'rural' may provide the basis to best understand the attributes and challenges of rural places in addressing the complex and problematic professional context of rural interprofessional care provision.