Quality of care for remote orthopaedic consultations using telemedicine: a randomised controlled trial

Research on Teleconsultation service quality based on multi-granularity linguistic information: the perspective of regional doctors

Background

Due to the increasing complexity in socioeconomic environments and the ambiguity in human cognition, decision makers prefer to give linguistic cognitive information with different granularities according to their own preferences. Consequently, to consider the uncertainty and preferences in the evaluation process, a method based on Multi-Granularity Linguistic Information (MGLI) for evaluating teleconsultation service quality is proposed, which provides a new research direction for scientific evaluation and improvement of teleconsultation service quality.

Methods

Firstly, this paper explored a service quality evaluation system from the perspective of regional doctors. And then considering the uncertainty and preferences of decision makers, MGLI was used to optimize the index system according to the similarity degree between the linguistic evaluation information and a given linguistic term set. Finally, the empirical research was conducted using Henan Province Telemedicine Center of China (HTCC) as an example to identify the direction for improving the service quality in teleconsultation.

Results

This study found that the number of consulting rooms, attitude of operators, consultation duration, charges, and attitude of experts are the key factors affecting the quality of teleconsultation service.

Conclusions

Suggestions for improving the quality of teleconsultation service are put forward in terms of optimizing the allocation of consulting rooms, improving regional doctors’ experience and standardizing charging standards, which provides a new direction for improving the quality of teleconsultation service.

Telemedicine Evaluation and Techniques in Hand Surgery

The demand for telemedicine has been increasing over the past several years with the growth of technology and digital connectivity in our daily lives. With the impact of the global coronavirus disease 2019 pandemic, telemedicine implementation has become a necessity for many specialties because social distancing measures have greatly affected access to routine medical care. This article presents a detailed and systematic approach to conducting a hand physical examination during a video telemedicine encounter. Although the telemedicine physical examination has limitations, most components of the normal physical examination can be completed remotely with a systematic approach. We enumerate modifications to maximize examination remotely and present considerations for improved delivery of telemedicine care. These methods may be beneficial to providers incorporating telemedicine into their practice.

SARS-CoV-2-Pandemie und ihre Auswirkungen auf Orthopädie und Unfallchirurgie: „Booster“ für die Telemedizin

Mit dem Ausbruch der COVID-19-Pandemie ist das Interesse an telemedizinischen Versorgungsmöglichkeiten gewachsen. Diese betreffen einerseits den Bereich der Diagnostik, aber auch die Überwachung von Therapieverläufen und Rehabilitationsmaßnahmen.

Aufgrund der derzeitigen Ressourcenbeschränkungen sahen sich viele Orthopäden und Unfallchirurgen gezwungen, Videosprechstunden einzurichten, obwohl Standards für orthopädische Konsultationen bisher nur unzureichend entwickelt sind. Um die Effizienz der virtuellen Orthopädie zu maximieren, sollten die Patienten auf den virtuellen Besuch vorbereitet werden (Checkliste mit spezifischen Anweisungen zur Kamerapositionierung, Körperpositionierung, Einstellung und Kleidung, Prüfung der audiovisuellen Fähigkeiten). Klassische diagnostische Maßnahmen wie Anamnese, Inspektion und Beurteilung radiologischer Befunde sind in der Videosprechstunde möglich. Es entfällt jedoch die Möglichkeit der funktionellen Untersuchung (Stabilität des Kniegelenkes, Schultertests). Auch wenn erste wissenschaftliche Studien gezeigt haben, dass die telemedizinische Diagnostik der konventionellen Diagnostik nicht unterlegen ist, so fehlen doch validierte Untersuchungsprotokolle und Methoden. Die postoperative Überwachung von Rehabilitationsmaßnahmen kann z. B. durch den Einsatz von Sensoren erleichtert werden. Mit moderner Sensorik ist mittlerweile eine kostengünstige Erfassung der Gelenkbeweglichkeit und Gelenkstellung möglich und wird bereits im Bereich der Rehabilitation nach Rekonstruktion des vorderen Kreuzbandes eingesetzt. Auch hier ist sicher weitere Forschung notwendig, um diese Methoden zu validieren.

Wir glauben, dass die derzeitige Pandemie Chancen bietet, die Möglichkeiten der Telemedizin für die Orthopädie und Unfallchirurgie auszubauen, um sie auch in der Zukunft weiter zu nutzen (z. B. bei der Versorgung von Patienten aus dem Ausland oder in dünn besiedelten Gebieten sowie der Betreuung von Hochleistungs- und Profisportlern).

Tele-orthopaedics: A systematic mapping study

INTRODUCTION

The use of telemedicine in orthopaedics can provide high-quality orthopaedic services to patients in remote areas. Tele-orthopaedics is widely acknowledged for decreasing travel, time and cost, increasing accessibility and quality of care. In the absence of a comprehensive review on tele-orthopaedics applications and services, here, we systematically identify and classify the tele-orthopaedic applications and services and provide an overview of the trends in the field.

METHODS

In this study, a systematic mapping was conducted to answer six research questions, we searched the databases Scopus, PubMed, IEEE Digital Library and Web of Science up to 2019. Consequently, 77 papers were screened and selected on the basis of specific inclusion and exclusion criteria.

RESULTS

We found that mobile-based teleconsultation was mostly asynchronous, while non-mobile teleconsultation was synchronous. The results showed that the physician-patient relationship was more common than other interactions, such as physician-physician and physician-robot interactions. In addition, more than half of the services provided by tele-orthopaedics have been used for orthopaedic diseases/traumas in which joint replacement and fracture reduction have been the most important orthopaedic procedures. It has been noted that more attention has been paid to tele-orthopaedics in developed countries such as the USA, Australia, Canada and Finland.

DISCUSSION

Telemonitoring (teleconsultation and telemetry) and telesurgery (telerobotics and telementoring) were found to be the two major forms of tele-orthopaedics. Mobile phones were used asynchronously in most of the teleconsultations. The development of different applications may result in the use of multiple smartphones applications in real-time teleconsultation. The use of smartphones is expected to increase in the near future.

The Use of Telemedicine Decreases Unnecessary Hand Trauma Transfers

Purpose: The Arkansas Hand Trauma Telemedicine Program (AHTTP) is a novel telemedicine system that was developed in 2014 within a rural state to address the growing need of access to hand trauma care with one trauma center that cares for mangling hand injuries. The purpose is to compare transfers for hand injuries prior to and after the implementation of this system. Methods: The hospital institutional database was queried for all transfers to a level 1 medical center in the state from 2012 to 2015, allowing the comparison of data prior to and after the institution of the AHTTP. Patient disposition from the emergency department was categorized to evaluate the impact of AHTTP. Distance, mode of transport, and transport cost were assessed. Findings: There were 202 transfers for the treatment of isolated hand trauma (92 from 2012 to 2013 and 110 from 2014 to 2015). Prior to the institution of AHTTP, transfer patients were admitted 47.8% of the time compared with 68.2% of the time after the development of the program (P = .02). The approximate cost of transport for patients who were discharged home directly from the emergency department was 38.5% (US $47,233) of the total costs for the 2012-2013 period and was 21.4% (US $34,017) of the costs for the 2014-2015 period (P < .0001). Conclusions: There was a statistically significant decrease in the number of unnecessary transfers and transportation costs after the telemedicine program was started. The implementation of AHTTP in a rural state reduced health care costs and improved the efficiency of hand specialty care.

Immediate and long-term impact of the COVID-19 pandemic on delivery of surgical services

Background

The ongoing pandemic is having a collateral health effect on delivery of surgical care to millions of patients. Very little is known about pandemic management and effects on other services, including delivery of surgery.

Methods

This was a scoping review of all available literature pertaining to COVID-19 and surgery, using electronic databases, society websites, webinars and preprint repositories.

Results

Several perioperative guidelines have been issued within a short time. Many suggestions are contradictory and based on anecdotal data at best. As regions with the highest volume of operations per capita are being hit, an unprecedented number of operations are being cancelled or deferred. No major stakeholder seems to have considered how a pandemic deprives patients with a surgical condition of resources, with patients disproportionally affected owing to the nature of treatment (use of anaesthesia, operating rooms, protective equipment, physical invasion and need for perioperative care). No recommendations exist regarding how to reopen surgical delivery. The postpandemic evaluation and future planning should involve surgical services as an essential part to maintain appropriate surgical care for the population during an outbreak. Surgical delivery, owing to its cross-cutting nature and synergistic effects on health systems at large, needs to be built into the WHO agenda for national health planning.

Conclusion

Patients are being deprived of surgical access, with uncertain loss of function and risk of adverse prognosis as a collateral effect of the pandemic. Surgical services need a contingency plan for maintaining surgical care in an ongoing or postpandemic phase.

Telemedicine in the Era of COVID-19: The Virtual Orthopaedic Examination

With the onset of the COVID-19 pandemic, the shifting of clinical care to telemedicine visits has been hastened. Because of current limitations in resources, many elective surgeons have been forced to venture into utilizing telemedicine, in which the standards for orthopaedic examinations have not previously been fully developed. We report our experience with protocols and methods to standardize these visits to maximize the benefit and efficiency of the virtual orthopaedic examination. At the time of scheduling, patients are asked to prepare for their virtual visit and are given a checklist. In addition to confirming audiovisual capabilities prior to the visit, patients are given specific instructions on camera positioning, body positioning, setting, and attire to improve the efficiency of the visit. During the examination, digital tools can be utilized as needed. In the setting of outpatient injury evaluations, a systematic virtual examination can aid in triaging and managing common musculoskeletal conditions. With the rapid incorporation of telehealth visits, as well as the unknown future with regard to the pandemic, the utilization and capabilities of telemedicine will continue to expand. Future directions include the development of validated, modified examination techniques and new technology that will allow for improved interactive physical examinations, as we rapidly move forward into the realm of telemedicine due to unexpected necessity.

Establishing Telemedicine in an Academic Total Joint Arthroplasty Practice: Needs and Opportunities Highlighted by the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has prompted rapid restructuring of the health-care system in an effort to stop the spread of the virus and to treat patients who are acutely ill with COVID-19, while continuing to provide outpatient care for the remainder of patients. To help control spread of this pandemic, many centers, including total joint arthroplasty clinics, have boosted telemedicine capability to care for patients who would typically be seen in person in outpatient settings. We review key components relevant to the establishment and effective use of telemedicine, focused on patient education, practice logistics, technological considerations, and sensitive patient health information–associated compliance factors, which are necessary to provide care remotely for total joint arthroplasty patients.

Utilization of Telemedicine in Addressing Musculoskeletal Care Gap in Long-Term Care Patients

A notable proportion of patient transfers in Ontario are from long-term care facilities for consultation of musculoskeletal (MSK) issues. These transfers are costly for patients and the healthcare system. This study evaluated the utility of a telemedicine MSK (TeleMSK) service for long-term care patients requiring an orthopaedic consultation.

Telehealth Utilization in Response to the Novel Coronavirus (COVID-19) Pandemic in Orthopaedic Surgery

INTRODUCTION

The purpose of this investigation is to assess the current utilization of telehealth capabilities at academic orthopaedic departments in the United States and to determine how practice patterns have been directly influenced by the coronavirus disease 19 (COVID-19) pandemic.

METHODS

Orthopaedic surgery programs participating in the Electronic Residency Application Service were identified. One hundred seventy-five (175) programs were presented with a seven-item questionnaire addressing whether each program is using telehealth services in response to the COVID-19 pandemic.

RESULTS

Of the 175 Electronic Residency Application Service participant orthopaedic programs, 168 responded for a total response rate of 96%. Of the 106 institutions using telehealth services, 88 (83%) cited the COVID-19 pandemic as the impetus for implementation of telehealth services. Institutions located in the Northeast and South regions were markedly more likely to offer telehealth services. Heat map analysis demonstrates an associative overlap of regional "hot spots" with direct comparison of COVID-19 cases in the United States and orthopaedic departments providing telehealth services.

DISCUSSION

This study demonstrates the impressive measures academic orthopaedic institutions are taking to meet the needs of our patients by identifying a notable increase in new telehealth offerings throughout the United States with a positive correlation with COVID-19 disease burden.

The role of telehealth as a platform for postoperative visits following rotator cuff repair: a prospective, randomized controlled trial

BACKGROUND

The application of telehealth for surgical follow-up has gained recent exposure in orthopedic care. Although the results following joint arthroplasty are encouraging, the role of telemedicine for postoperative care following arthroscopic rotator cuff repair still needs to be defined. The goal of this study was to evaluate the safety, efficacy, and socioeconomic benefits of telehealth as a platform for postoperative follow-up.

METHODS

This was a prospective, randomized controlled trial that enrolled 66 patients who underwent follow-up in the office vs. via telemedicine for postoperative visits at 2, 6, and 12 weeks after surgery. Post-visit surveys were administered to patients and physicians via e-mail, and the Student t test and Fisher exact test were used to compare responses.

RESULTS

In total, 58 patients (88%) completed the study (28 telehealth vs. 30 control). Patients in each group demonstrated similar pain scores at each follow-up visit (P = .638, P = .124, and P = .951) and similar overall satisfaction scores (P = .304). Patients in the telehealth group expressed a stronger preference for telehealth than their control counterparts (P < .001). Telehealth visits were less time-consuming from both a patient (P < .001) and physician (P = .002) perspective. Telehealth visits also required less time off work for both patients (P = .001) and caregivers (P < .001).

CONCLUSION

Patients undergoing arthroscopic rotator cuff surgery were able to receive safe and effective early postoperative follow-up care using telemedicine. The preference for telehealth increased for both surgeons and patients following first-hand experience. The use of a telehealth platform is a reasonable follow-up model to consider for patients seeking convenient and efficient care following arthroscopic rotator cuff repair.

Telemedicine in Hand and Upper-Extremity Surgery

Smartphones, computers, and Internet access continue to become more available to both patients and physicians. As these technologies develop with respect to health care, opportunities for telemedicine visits continue to emerge. The purpose of this review article was to analyze the current use and potential applications of telemedicine in hand and upper-extremity surgery. Although the literature pertaining to the use of telemedicine in hand surgery is limited, videoconferencing visits may provide benefits to patients. Particularly in rural and underserved regions, patients can decrease considerable travel burdens. Potential applications for this technology include remote inpatient and emergency room consultations, outpatient clinic visits, and postoperative care. There are unique considerations with respect to confidentiality and security. As with any new technology, it is important to analyze safety concerns. Future randomized, prospective investigations are necessary to define the economic implications of telemedicine programs more clearly within hand and upper-extremity surgery.

Validation of Teleconference-based Goniometry for Measuring Elbow Joint Range of Motion

Background 

Range of motion (ROM) is a critical component of a physician’s evaluation for many consultations. The purpose of this study was to evaluate if teleconference goniometry could be as accurate as clinical goniometry.

Methods 

Forty-eight volunteers participated in the study. There was a sample size of 52 elbows. Each measurement was recorded consecutively in person, through teleconference, and still-shot photography by two researchers trained in goniometry. Measurements of maximum elbow flexion and extension were taken and recorded.

Results

 Teleconference goniometry had a high agreement with clinical goniometry (Pearson coefficient: flexion: 0.93, Extension: 0.87). Limits of agreement found from the Bland-Altman test were 7⁰ and -3⁰ for flexion and 10.4⁰ and -7.4⁰ for extension. A t-test revealed a P-value of less than 0.001 between teleconference and clinical measurements, proving the data are significant.

Conclusions

ROM measurements through a teleconferencing medium are comparable to clinical ROM measurements. This would allow for interactive elbow ROM assessment with the orthopedist without having to incorporate travel time and expenses.

Looking Through a Different Lens: Patient Satisfaction With Telemedicine in Delivering Pediatric Fracture Care

Telemedicine may transform health care by overcoming geographical and travel-associated barriers to patient care. This study assesses patient satisfaction with telemedicine for fracture care.

Rural Orthopedics: Providing Orthopedic Care in Rural Communities

Providing orthopedic care to rural communities is challenging. Delivering adequate orthopedic care is challenged by delay in presentation, underestimation of urgency, need for subspecialty services, and deficiencies in local support services. Collaboration efforts, peer-to-peer consultations, outreach clinics, virtual consults, electronic consults, and telemedicine are useful strategies. Individual treatment strategy must accommodate the burden on the patient, and patient education is important. Treatment options that require frequent travel should be avoided. Orthopedic surgery is in high demand in rural communities but unfortunately is limited in availability. Strategies are available for improving access to orthopedic care in rural areas. [Orthopedics. 2019; 42(4):e350-e355.].

Owner satisfaction with use of videoconferencing for recheck examinations following routine surgical sterilization in dogs

OBJECTIVE To evaluate owner satisfaction with a home-based, synchronous videoconferencing telemedicine application as an alternative to in-clinic appointments for conducting recheck examinations after surgical sterilization in dogs. DESIGN Randomized controlled clinical trial. ANIMALS 30 client-owned dogs undergoing elective surgical sterilization and postsurgical recheck examination between September 27, 2017, and February 23, 2018. PROCEDURES Dogs were randomly assigned to have their recheck examinations performed remotely (the telemedicine group) or at the veterinary clinic (the control group). After the recheck examination, owners completed a survey regarding their satisfaction with the recheck examination and their dogs' behavior during it. Information regarding the surgery and recheck examination was obtained from the electronic medical record. Mann-Whitney U tests were used to compare results between the telemedicine and control groups. RESULTS Owners were equally satisfied with recheck examinations performed by videoconference and in-clinic appointments. Owners of dogs in the telemedicine group indicated that their dogs were less afraid during the virtual appointment, compared with what was typical for them during in-clinic appointments, but the difference was not statistically significant. Most owners who completed a postsurgical recheck examination by videoconferencing preferred this method for similar appointments in the future. CONCLUSIONS AND CLINICAL RELEVANCE Results suggested that owners were satisfied with videoconferencing as a means of conducting a postsurgical recheck examination. Further research is needed to assess videoconferencing's ability to reduce signs of fear in dogs during veterinary examinations, its economic feasibility, and the willingness of veterinarians and animal owners to adopt the technology.

The role of electronic medical records in improving the quality of health care services: Comparative study

PURPOSE

The purpose of this study is to identify the quality of health care services' differences between adopted Electronic Medical Record (EMR) and paper-based record hospitals. Moreover, to identify how the quality of electronic medical records affect the quality of health care services.

METHODS

A cross-sectional, descriptive, and comparative design was utilized between two groups in this study. The study was conducted in two public hospitals in Jordan. One hospital which had adopted the EMR system in their works and another hospital that had paper-based record. A convenience sampling technique was used to select 410 health professionals from the selected hospitals (205 participants from each hospital). SERVQUAL and E-S-QUAL questionnaires were adopted to collect the data about the quality of EMR and quality of health care service. Statistical Package for the Social Sciences (SPSS) Version 21 was deployed to analyze the collected data.

RESULT

The results indicate that the quality of health care services (expectation and perception) in EMRs adopted hospital is higher than the quality of health care services in the hospital using paper-based record. Quality of EMRs and its domains (efficiency, availability, fulfilment, and privacy) are high in both perception and expectation of health care professionals in EMR-adopted hospitals. Moreover, there is a significant relationship between the whole perception of the quality of electronic medical records and the quality of services, and between each domain of quality of EMRs and total perception of quality of services.

CONCLUSION

Adoption of a high quality of EMR has a significant impact on improving the quality of health care services.

eHealth Apps Replacing or Complementing Health Care Contacts: Scoping Review on Adverse Effects

Background

The use of eHealth has increased tremendously in recent years. eHealth is generally considered to have a positive effect on health care quality and to be a promising alternative to face-to-face health care contacts. Surprisingly little is known about possible adverse effects of eHealth apps.

Objective

We conducted a scoping review on empirical research into adverse effects of eHealth apps that aim to deliver health care at a distance. We investigated whether adverse effects were reported and the nature and quality of research into these possible adverse effects.

Methods

For this scoping review, we followed the five steps of Arksey and O’Malley’s scoping review methodology. We searched specifically for studies into eHealth apps that replaced or complemented the face-to-face contact between a health professional and a patient in the context of treatment, health monitoring, or supporting self-management. Studies were included when eHealth and adverse effects were mentioned in the title or abstract and when empirical data on adverse effects were provided. All health conditions, with the exception of mental health conditions, all ages, and all sample sizes were included. We examined the literature published between December 2012 and August 2017 in the following databases: PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, and the Cochrane Library. The methodological quality of the studies was assessed using the Critical Appraisal Skills Programme (CASP) checklists.

Results

Our search identified 79 papers that were potentially relevant; 11 studies met our inclusion criteria after screening. These studies differed in many ways and the majority were characterized by small research populations and low study quality. Adverse effects are rarely subject to systematic scientific research. So far, information on real adverse effects is mainly limited to incidental reporting or as a bycatch from qualitative pilot studies. Despite the shortage of solid research, we found some indications of possible negative impact on patient-centeredness and efficiency, such as less transparency in the relationship between health professionals and patients and time-consuming work routines.

Conclusions

There is a lack of high-quality empirical research on adverse effects of eHealth apps that replace or complement face-to-face care. While the development of eHealth apps is ongoing, the knowledge with regard to possible adverse effects is limited. The available research often focuses on efficacy, added value, implementation issues, use, and satisfaction, whereas adverse effects are underexplored. A better understanding of possible adverse effects could be a starting point in improving the positive impact of eHealth-based health care delivery.

Cost-Effectiveness of Telemedicine in Remote Orthopedic Consultations: Randomized Controlled Trial

BACKGROUND

Telemedicine consultations using real-time videoconferencing has the potential to improve access and quality of care, avoid patient travels, and reduce health care costs.

OBJECTIVE

The aim of this study was to examine the cost-effectiveness of an orthopedic videoconferencing service between the University Hospital of North Norway and a regional medical center in a remote community located 148 km away.

METHODS

An economic evaluation based on a randomized controlled trial of 389 patients (559 consultations) referred to the hospital for an orthopedic outpatient consultation was conducted. The intervention group (199 patients) was randomized to receive video-assisted remote orthopedic consultations (302 consultations), while the control group (190 patients) received standard care in outpatient consultation at the hospital (257 consultations). A societal perspective was adopted for calculating costs. Health outcomes were measured as quality-adjusted life years (QALYs) gained. Resource use and health outcomes were collected alongside the trial at baseline and at 12 months follow-up using questionnaires, patient charts, and consultation records. These were valued using externally collected data on unit costs and QALY weights. An extended sensitivity analysis was conducted to address the robustness of the results.

RESULTS

This study showed that using videoconferencing for orthopedic consultations in the remote clinic costs less than standard outpatient consultations at the specialist hospital, as long as the total number of patient consultations exceeds 151 per year. For a total workload of 300 consultations per year, the annual cost savings amounted to €18,616. If costs were calculated from a health sector perspective, rather than a societal perspective, the number of consultations needed to break even was 183.

CONCLUSIONS

This study showed that providing video-assisted orthopedic consultations to a remote clinic in Northern Norway, rather than having patients travel to the specialist hospital for consultations, is cost-effective from both a societal and health sector perspective. This conclusion holds as long as the activity exceeds 151 and 183 patient consultations per year, respectively.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00616837; https://clinicaltrials.gov/ct2/show/NCT00616837 (Archived by WebCite at http://www.webcitation.org/762dZPoKX).

Patient reported outcomes with remote orthopaedic consultations by telemedicine: A randomised controlled trial

Introduction

Decentralised services through outreach clinics or modern technology reduce patient travel time and cost to society. Telemedicine consultation through videoconference is one such modality. Here, we compared patient-reported health outcomes and satisfaction between video-assisted remote and standard face-to-face orthopaedic consultations.

Methods

This randomised controlled trial included two parallel groups: (1) patients receiving video-assisted remote consultation at a regional medical centre (RMC); and (2) patients receiving standard consultation at the orthopaedic outpatient clinic of the University Hospital of North Norway (UNN). This study included patients referred to or scheduled for a consultation at the orthopaedic outpatient clinic. After each consultation, patient satisfaction was determined using patient-completed questionnaires containing questions on patient-reported health (three-level European quality of life five-dimension index (EQ-5D-3L)/European quality of life visual analogue scale (EQ-VAS)) and questions from a validated OutPatient Experiences Questionnaire (OPEQ).

Results

This study included 389 patients, of which 199 received remote consultation and 190 received standard consultation (total of 559 consultations). In all, 99% RMC-randomised patients and 99% UNN-randomised patients evaluated the consultation as very satisfactory or satisfactory. Moreover, 86% RMC-randomised patients preferred video-assisted consultation as the next consultation. No difference was observed in patient-reported health after 12 months between the two groups. EQ-5D index scores were 0.77 and 0.75 for RMC- and UNN-randomised patients, respectively ( p = 0.42).

Discussion

We did not observe any difference in patient-reported satisfaction and health (EQ-5D/EQ-VAS) between video-assisted and standard consultations, suggesting that video-assisted remote consultation can be safely offered to some orthopaedic patients. Moreover, a significantly high proportion of patients selected video-assisted remote consultation as their next consultation, thus strengthening the findings of this study. However, economic aspects should be assessed before widely recommending video-assisted consultation.

Advantages and limitations of virtual online consultations in a NHS acute trust: the VOCAL mixed-methods study

Background

There is much enthusiasm from clinicians, industry and the government to utilise digital technologies and introduce alternatives to face-to-face consultations.

Objective(s)

To define good practice and inform digital technology implementation in relation to remote consultations via Skype™ (Microsoft Corporation, Redmond, WA, USA) and similar technologies.

Design

Multilevel mixed-methods study of remote video consultations (micro level) embedded in an organisational case study (meso level), taking account of the national context and wider influences (macro level).

Setting

Three contrasting clinical settings (Diabetes, Antenatal Diabetes and Cancer Surgery) in a NHS acute trust.

Data collection and analysis

Macro level – interviews with 12 national-level stakeholders combined with document analysis. Meso level – longitudinal organisational ethnography comprising over 300 hours of observations, 24 staff interviews and analysis of 16 documents. Micro level – 30 video-recorded remote consultations; 17 matched audio-recorded face-to-face consultations. Interview and ethnographic data were analysed thematically and theorised using strong structuration theory. Consultations were transcribed verbatim and analysed using the Roter interaction analysis system (RIAS), producing descriptive statistics on different kinds of talk and interaction.

Results

Policy-makers viewed remote video consultations as a way of delivering health care efficiently in the context of rising rates of chronic illness and growing demand for services. However, the reality of establishing such services in a busy and financially stretched NHS acute trust proved to be far more complex and expensive than anticipated. Embedding new models of care took much time and many resources, and required multiple workarounds. Considerable ongoing effort was needed to adapt and align structures, processes and people within clinics and across the organisation. For practical and safety reasons, virtual consultations were not appropriate for every patient or every consultation. By the end of this study, between 2% and 20% of all consultations were being undertaken remotely in participating clinics. Technical challenges in setting up such consultations were typically minor, but potentially prohibitive. When clinical, technical and practical preconditions were met, virtual consultations appeared to be safe and were popular with both patients and staff. Compared with face-to-face consultations, virtual consultations were very slightly shorter, patients did slightly more talking and both parties sometimes needed to make explicit things that typically remained implicit in a traditional encounter. Virtual consultations appeared to work better when the clinician and the patient knew and trusted each other. Some clinicians used Skype adaptively to support ad hoc clinician-initiated and spontaneous patient-initiated encounters. Other clinicians chose not to use the new service model at all.

Conclusions

Virtual consultations appear to be safe, effective and convenient for patients who are preselected by their clinicians as ‘suitable’, but such patients represent a small fraction of clinic workloads. There are complex challenges to embedding virtual consultation services within routine practice in the NHS. Roll-out (across the organisation) and scale-up (to other organisations) are likely to require considerable support.

Limitations

The focus on a single NHS organisation raises questions about the transferability of findings, especially quantitative data on likely uptake rates.

Future research

Further studies on the micro-analysis of virtual consultations and on the spread and scale-up of virtual consulting services are planned.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Real-World Implementation of Video Outpatient Consultations at Macro, Meso, and Micro Levels: Mixed-Method Study

Background

There is much interest in virtual consultations using video technology. Randomized controlled trials have shown video consultations to be acceptable, safe, and effective in selected conditions and circumstances. However, this model has rarely been mainstreamed and sustained in real-world settings.

Objective

The study sought to (1) define good practice and inform implementation of video outpatient consultations and (2) generate transferable knowledge about challenges to scaling up and routinizing this service model.

Methods

A multilevel, mixed-method study of Skype video consultations (micro level) was embedded in an organizational case study (meso level), taking account of national context and wider influences (macro level). The study followed the introduction of video outpatient consultations in three clinical services (diabetes, diabetes antenatal, and cancer surgery) in a National Health Service trust (covering three hospitals) in London, United Kingdom. Data sources included 36 national-level stakeholders (exploratory and semistructured interviews), longitudinal organizational ethnography (300 hours of observations; 24 staff interviews), 30 videotaped remote consultations, 17 audiotaped face-to-face consultations, and national and local documents. Qualitative data, analyzed using sociotechnical change theories, addressed staff and patient experience and organizational and system drivers. Quantitative data, analyzed via descriptive statistics, included uptake of video consultations by staff and patients and microcategorization of different kinds of talk (using the Roter interaction analysis system).

Results

When clinical, technical, and practical preconditions were met, video consultations appeared safe and were popular with some patients and staff. Compared with face-to-face consultations for similar conditions, video consultations were very slightly shorter, patients did slightly more talking, and both parties sometimes needed to make explicit things that typically remained implicit in a traditional encounter. Video consultations appeared to work better when the clinician and patient already knew and trusted each other. Some clinicians used Skype adaptively to respond to patient requests for ad hoc encounters in a way that appeared to strengthen supported self-management. The reality of establishing video outpatient services in a busy and financially stretched acute hospital setting proved more complex and time-consuming than originally anticipated. By the end of this study, between 2% and 22% of consultations were being undertaken remotely by participating clinicians. In the remainder, clinicians chose not to participate, or video consultations were considered impractical, technically unachievable, or clinically inadvisable. Technical challenges were typically minor but potentially prohibitive.

Conclusions

Video outpatient consultations appear safe, effective, and convenient for patients in situations where participating clinicians judge them clinically appropriate, but such situations are a fraction of the overall clinic workload. As with other technological innovations, some clinicians will adopt readily, whereas others will need incentives and support. There are complex challenges to embedding video consultation services within routine practice in organizations that are hesitant to change, especially in times of austerity.

Service provider perceptions of telerehabilitation as an additional service delivery option within an Australian neurosurgical and orthopaedic physiotherapy screening clinic: A qualitative study

BACKGROUND

The Neurosurgical & Orthopaedic Physiotherapy Screening Clinic and Multidisciplinary Service (N/OPSC&MDS) originated as a complementary, non-surgical pathway for patients referred to public neurosurgical and orthopaedic specialist services. Patient access to the N/OPSC&MDS could potentially be improved with the implementation of telerehabilitation as an additional method of service delivery.

OBJECTIVE

To evaluate service provider's views on (1) current barriers to patients' accessing N/OPSC & MD services, and (2) the implementation of telerehabilitation within the N/OPSC&MDS.

DESIGN

Qualitative descriptive study design.

METHODS

Healthcare providers (n = 26) were recruited from six N/OPSC&MD services located throughout Queensland, Australia. Semi-structured interviews were conducted to explore service providers' views with respect to existing barriers to patients accessing the N/OPSC&MDS, and if telerehabilitation could be feasibly adopted to address current barriers.

RESULTS

Template analysis resulted in six themes: (1) barriers to some patients' accessing current N/OPSC&MD services are complex & multifaceted; (2) telerehabilitation could improve patient access to appropriate management for their musculoskeletal condition; (3) telerehabilitation may have limitations when compared to face-to-face healthcare; (4) the delivery of telerehabilitation needs to be flexible; (5) perceived barriers, and (6) facilitators to the successful implementation of telerehabilitation within the N/OPSC&MDS.

CONCLUSION

This study represents a critical step in determining the readiness of service providers for the implementation of telerehabilitation within the N/OPSC&MDS. Although cautious, service providers are overall accepting of the implementation of telerehabilitation, acknowledging that it could eliminate several current barriers, subsequently achieving more equitable access to the service.

Application of Ethics for Providing Telemedicine Services and Information Technology

INTRODUCTION

Advanced technology has increased the use of telemedicine and Information Technology (IT) in treating or rehabilitating diseases. An increased use of technology increases the importance of the ethical issues involved. The need for keeping patients' information confidential and secure, controlling a number of therapists' inefficiency as well as raising the quality of healthcare services necessitates adequate heed to ethical issues in telemedicine provision.

AIM

The goal of this review is gathering all articles that are published through 5 years until now (2012-2017) for detecting ethical issues for providing telemedicine services and Information technology. The reason of this time is improvement of telemedicine and technology through these years. This article is important for clinical practice and also to world, because of knowing ethical issues in telemedicine and technology are always important factors for physician and health providers.

MATERIAL AND METHODS

the required data in this research were derived from published electronic sources and credible academic articles published in such databases as PubMed, Scopus and Science Direct. The following key words were searched for in separation and combination: tele-health, telemedicine, ethical issues in telemedicine. A total of 503 articles were found. After excluding the duplicates (n= 93), the titles and abstracts of 410 articles were skimmed according to the inclusion criteria. Finally, 64 articles remained. They were reviewed in full text and 36 articles were excluded. At the end, 28 articles were chosen which met our eligibility criteria and were included in this study.

RESULTS

Ethics has been of a great significance in IT and telemedicine especially the Internet since there are more chances provided for accessing information. It is, however, accompanied by a threat to patients' personal information. Therefore, suggestions are made to investigate ethics in technology, to offer standards and guidelines to therapists. Due to the advancement in technology, access to information has become simpler than the past. This has prompted hackers to seize the opportunity.

DISCUSSION

This research shows that the ethical issues in telemedicine can be investigated from several aspects like technology, doctor-patient relationship, data confidentiality and security, informed consent, patient's and family's satisfaction with telemedicine services. Following ethical issues in telemedicine is a primary aspect of high quality services. In other words, if therapists abide by ethical rules, they can provide better services for patients. Attention to ethical issues in telemedicine guarantees a safer use of the services.