Can telemedicine be used to improve communication between primary and secondary care?

Digitally-mediated coordination in healthcare: the effects of teleconsultation on doctor-to-doctor relational coordination

BACKGROUND

Digitalization transforms the way in which interdependent work is coordinated, especially in healthcare settings. This work deepens the effect of teleconsultation use on health professionals' coordination. For this aim, we rely on Relational Coordination Theory (RCT), which explores coordination as an interactive process among group participants within the context of task interdependency.

METHODS

We collected data through an online survey administered to Italian specialist doctors between March and April 2023. 489 complete answers were gathered. Hypotheses have been tested through Structural Equation Modelling.

RESULTS

We found that teleconsultation frequency of use has a positive and significant effect on both components of relational coordination, confirming our hypotheses.

CONCLUSIONS

Theoretically, this research contributes to our understanding of the effect of digitally mediated coordination mechanisms on relational coordination. In practice, we shed light on the organizational implications of telemedicine under a novel perspective, focusing on the role of professional interactions in digitally mediated work and providing useful elements for the organizational design of telemedicine.

Telehealth in Primary Health Care: A Scoping Review of the Literature

BACKGROUND

The use of telehealth as a viable mobility to deliver quality services steadily increases in various levels of the health system. Despite the increasing use of telemedicine in secondary and tertiary health care services, there is a long way to go in the use of this technology in public health and primary health care (PHC). This study aimed to explore the features, approaches, and various dimensions of telehealth in PHC.

METHODS

A scoping review was conducted using the Arksey and O'Malley framework. A search was conducted in three bibliographic databases including PubMed, Web of Sciences, and Scopus and in Google Scholar to collect papers published in November 2018 to 2000. Data were extracted according to a predefined form and check for completeness and accuracy by a second reviewer.

RESULTS

Through reviewing papers, the authors extracted information on the general characteristics and features of telehealth services, kinds of PHC services delivered via telehealth, hardware and software facilities used for providing health care through telehealth services packages, as well as their benefits, outcomes and obstacles.

CONCLUSION

Telehealth can be used for different purposes of PHC through deploying a full range of communication channels available to the public. Due to the opportunistic use of existing devices and platforms, telehealth can provide scalable PHC services nationwide and worldwide. However, implementing telehealth in PHC faces challenges from technical, organizational, and human perspectives. Digital equity (in terms of technology access and e-health literacy) is required to expand telehealth services to the populations in underserved areas.

Respiratory specialists working in different ways: Development of a GP hotline and respiratory support service during the COVID-19 pandemic

Integration of primary and secondary care for the management of respiratory disease is a long-held ambition. Here, we describe how respiratory specialists at a large NHS trust, working with primary care clinicians in the area, set up a GP hotline and respiratory support service in response to the COVID-19 pandemic, with the aim of enhancing delivery of care to patients in this unprecedented time. Working across traditional organisational boundaries in this way confers benefits to patients and clinicians, illustrating the value of new, integrated models of care.

The Use of Patient-Facing Teleconsultations in the National Health Service: Scoping Review

BACKGROUND

The National Health Service (NHS) Long-Term Plan has set out a vision of enabling patients to access digital interactions with health care professionals within 5 years, including by video link.

OBJECTIVE

This review aimed to examine the extent and nature of the use of patient-facing teleconsultations within a health care setting in the United Kingdom and what outcome measures have been assessed.

METHODS

We conducted a systematic scoping review of teleconsultation studies following the Joanna Briggs Institute methodology. PubMed, Scopus, the Cochrane Library, and the Cumulative Index to Nursing and Allied Health Literature were searched up to the end of December 2018 for publications that reported on the use of patient-facing teleconsultations in a UK health care setting.

RESULTS

The search retrieved 3132 publications, of which 101 were included for a full review. Overall, the studies were heterogeneous in design, in the specialty assessed, and reported outcome measures. The technology used for teleconsultations changed over time with earlier studies employing bespoke, often expensive, solutions. Two-thirds of the studies, conducted between 1995 and 2005, used this method. Later studies transitioned to Web-based commercial solutions such as Skype. There were five outcome measures that were assessed: (1) technical feasibility, (2) user satisfaction, (3) clinical effectiveness, (4) cost, (5) logistical and operational considerations. Due to the changing nature of technology over time, there were differing technical issues across the studies. Generally, teleconsultations were acceptable to patients, but this was less consistent among health care professionals. However, among both groups, face-to-face consultations were still seen as the gold standard. A wide range of clinical scenarios found teleconsultations to be clinically useful but potentially limited to more straightforward clinical interactions. Due to the wide array of study types and changes in technology over time, it is difficult to draw definitive conclusions on the cost involved. However, cost savings for health care providers have been demonstrated by the goal-directed implementation of teleconsultations. The integration of technology into routine practice represents a complex problem with barriers identified in funding and hospital reimbursement, information technologies infrastructure, and integration into clinicians' workflow.

CONCLUSIONS

Teleconsultations appear to be safe and effective in the correct clinical situations. Where offered, it is likely that patients will be keen to engage, although teleconsultations should only be offered as an option to support traditional care models rather than replace them outright. Health care staff should be encouraged and supported in using teleconsultations to diversify their practice. Health care organizations need to consider developing a digital technology strategy and implementation groups to assist health care staff to integrate digitally enabled care into routine practice. The introduction of new technologies should be assessed after a set period with service evaluations, including feedback from key stakeholders.

Efficiency as a determinant of loyalty among users of a Community of Clinical Practice: a comparative study between the implementation and consolidation phases

BACKGROUND

A community of clinical practice called the Online Communication Tool between Primary and Hospital Care (ECOPIH) was created to enable primary care and specialist care professionals to communicate with each other in order to resolve real clinical cases, thereby improving communication and coordination between care levels. The present work seeks to analyse whether ECOPIH makes it possible to reduce the number of referrals. To that end, the objectives are: (1) To find out the degree of loyalty among ECOPIH users, by comparing the medical professionals' profiles in the tool's implementation phase to those in its consolidation phase. (2) To evaluate the degree of fulfilment of users' expectations, by establishing the determining factors that had an influence on the physicians' intention to use ECOPIH in the implementation phase and observing whether its use had an effective, direct impact on the number of patient referrals that primary care physicians made to specialist care professionals.

METHODS

Two studies were conducted. Based on a survey of all the physicians in a Primary Care area, Study 1 was a descriptive study in ECOPIH's implementation phase. Study 2 was a randomised intervention study of ECOPIH users in the tool's consolidation phase. The results from both studies were compared. Various bivariate and multivariate statistical techniques (exploratory factor analysis, cluster analysis, logistic regression analysis and ANOVA) were used in both studies, which were conducted on a sample of 111 and 178 physicians, respectively.

RESULTS

We confirmed the existence of an ECOPIH user profile stable across both phases: under-50-year-old women. Regarding the second objective, there were two particular findings. First, the discriminant factors that had an influence on greater ECOPIH use were habitual Social media website and app use and Perceived usefulness for reducing costs. Second, PC professionals who were ECOPIH members made fewer referrals to SC professionals in Cardiology, Endocrinology and Gastroenterology than older PC professionals who were not ECOPIH members.

CONCLUSIONS

The use of a community of clinical practice by primary care and specialist care professionals helps to reduce the number of referrals among medical professionals.

Completeness of obstetric referral letters/notes from subdistrict to district level in three rural districts in Greater Accra region of Ghana: an implementation research using mixed methods

OBJECTIVE

To assess the completeness of obstetric referral letters/notes at the district level of healthcare.

DESIGN

An implementation research within three districts in Greater Accra region using mixed methods. During baseline and intervention phases, referral processes for all obstetric referrals from lower level facilities seen at the district hospitals were documented including indications for referrals, availability and completeness of referral notes/forms. An assessment of before and after intervention availability and completeness of referral forms was carried out. Focus group discussions, non-participant observations and in-depth interviews with health workers and pregnant women were conducted for qualitative data.

SETTING

Three (3) districts in the Greater Accra region of Ghana.

PARTICIPANTS

Pregnant women referred from lower levels of care to and seen at the district hospital, health workers within the three districts and pregnant women attending antenatal clinic in the district and their family members or spouses.

INTERVENTION

An enhanced interfacility referral communication system consisting of training, provision of communication tools for facilities, formation of hospital referral teams and strengthening feedback mechanisms.

OUTCOME

Completeness of obstetric referral letters/notes.

RESULTS

Proportion of obstetric referrals with referral notes improved from 27.2% to 44.3% from the baseline to intervention period. Mean completeness (95% CI) of all forms was 71.3% (64.1% to 78.5%) for the study period, improving from 70.7% (60.4% to 80.9%) to 71.9% (61.1% to 82.7%) from baseline to intervention periods. Health workers reported they do not always provide referral notes and that most referral notes are not completely filled due to various reasons.

CONCLUSIONS

Most obstetric referrals did not have referral notes. The few notes provided were not completely filled. Interventions such as training of health workers, regular review of referral processes and use of electronic records can help improve both the provision of and completeness of the referral notes.

Development of A Textile Capacitive Proximity Sensor and Gait Monitoring System for Smart Healthcare

Gait is not only one of the most important functions and activities in daily life but is also a parameter to monitor one's health status. We propose a single channel capacitive proximity pressure sensor (TCPS) and gait monitoring system for smart healthcare. Insole-type TCPS (270 mm in length) was designed consisting of three layers including two shield layers and a sensor layer. Analyzing the step count and stride time are the basic indicators in gait analysis, thus they were selected as evaluation indicators. A total of 12 subjects participated in the experiment to evaluate the resolution of our TCPS. To evaluate the accuracy of TCPS, step count and its error rates were simultaneously detected by naked eye, ZIKTO Walk (ZIKTO Co., Korea), and HJ-203-K pedometer (Omron Co., Japan) as reference. Results showed that the error rate of 1.77% in TCPS was lower than those of other devices and correlation coefficient was 0.958 (p-value = 0.000). ZIKTO Walk and pedometer do not provide information on stride time, therefore it was detected by F-scan (Tekscan, USA) to evaluate the performance of TCPS. As a result, error rate of stride time measured by TCPS was found to be 1% and the correlation coefficient was 0.685 (p-value = 0.000). According to these results, our proposed system may be helpful in development of gait monitoring and measurement system as smart healthcare.

Managing professional knowledge boundaries during ECHO telementoring consultations in two Veterans Affairs specialty care liver clinics: A theme-oriented discourse analysis

INTRODUCTION

Consultations are the traditional method of communication between generalist and specialist providers managing patients with specialty care needs. Traditional written consultations have limitations, including inadequate clinical information and inappropriate, or unclear consultation questions. Teleconsultations minimize these limitations through real-time communication between generalist and specialist providers to actively manage professional knowledge boundaries about specialty care problems.

METHODS

We video-recorded 37 teleconsultation sessions, resulting in 115 consultations between generalist and specialty care providers participating in Veterans Affairs (VA) Extension for Community Healthcare Outcomes (ECHO) liver clinics. Data were collected at two US sites across nine months to observe consultation communication among 33 primary care generalists and three liver specialists. Video recordings were transcribed verbatim and analysed using theme-oriented discourse analysis to characterize consultation question content and format.

RESULTS

Generalists' consultation question content addressed a range of topics, including treatment, diagnosis, interpreting results, patient communication, screening and surveillance, and care coordination. Some generalists relied on descriptive narratives rather than a specific question to convey complex patient cases. Consultation question format showed nearly even division between targeting general medical knowledge and specialty care knowledge domains, including specialty care, medical, organizational, and experiential knowledge.

DISCUSSION

Timely access to specialists through teleconsultation has the potential to transform specialty care delivery. This article examines provider-to-provider interactions to understand how the communication process contributes to knowledge management during teleconsultations. Video studies of health information technology use provide a rich opportunity for analysing real-time communication that may help improve cross-specialty collaboration and the coordinated management of patients with specialty care needs.

Telemedicine and telecare: what can it offer mental health services?

With new developments in image generation and transmission, researchers have studied the feasibility of using comunications technology for remote diagnosis and care delivery. The term ‘telepsychiatry’ has been used to describe the application of telemedicine and telecare to mental health. This article reviews the development of telepsychiatry and key research findings. Results suggest that service users are more comfortable with mediated services than are professsonals. Most work has been done in areas of low population density, where accessibility to conventional services is limited by economics and geography. In urban settings, with distributed community services, telepsychiatry can improve communication between primary and secondary sectors and within secondary services.

Recruitment difficulties in a home telecare trial

We analysed the difficulties encountered in recruiting predominantly older patients, suffering from an acute exacerbation of a chronic illness, to a randomized controlled trial of home telecare. Of 653 patients approached for study participation, after full assessment, 80% (519) met the trial eligibility criteria. Of these, 104 (20%) consented to study participation and 415 (80%) refused. A logistic regression model was constructed to examine independent effects of patient factors on probability of trial participation. Only two independent variables were associated with decreased likelihood of consent: increasing age (1 year older: odds ratio [OR] = 0.96); and being on inhaled steroid medication (OR = 0.60). The most common reason for refusal to participate, accounting for almost one-third of respondents, was a stated preference for a face-to-face nurse visiting service rather than a telecare service. Perhaps home telecare services should continue to be targeted at the more stable chronically ill population and not at those suffering from acute illness.

Do online communities change power processes in healthcare? Using case studies to examine the use of online health communities by patients with Parkinson's disease

OBJECTIVE

Communication technologies, such as personal online health communities, are increasingly considered as a tool to realise patient empowerment. However, little is known about the actual use of online health communities. Here, we investigated if and how patients' use of online communities supports patient empowerment.

SETTING

A network of primary and secondary care providers around individual patients with Parkinson's disease.

PARTICIPANTS

We conducted case studies to examine our research question. We interviewed 18 patients with Parkinson's disease and observed the use of online health communities of 14 of them for an average of 1 year.

PRIMARY OUTCOME MEASURES

We analysed the interviews and the online conversations between patients and healthcare providers, using Foucault's framework for studying power processes.

RESULTS

We observed that patient empowerment is inhibited by implicit norms that exist within these communities around the number and content of postings. First, patients refrained from asking too many questions of their healthcare providers, but felt obliged to offer them regular updates. Second, patients scrutinised the content of their postings, being afraid to come across as complainers. Third, patients were cautious in making knowledge claims about their disease.

CONCLUSIONS

Changing implicit norms within online communities and the societal context they exist in seems necessary to achieve greater patient empowerment. Possibilities for changing these norms might lie in open dialogue between patient and healthcare providers about expectations, revising the curriculum of medical education and redesigning personal online health communities to support two-way knowledge exchange.

Patient Satisfaction with Health Care Services Via Videoconferencing

In 1998, a project was started in Northern Finland which concentrates in the implementation and usability of six telemedicine systems. One of the telemedicine systems included in the project was videoconferencing. This substudy aims to point out the problems and benefits of teleconsultation via videoconferencing as reported by the patients. The consultation was carried out between two remote sites; the general practitioner (GP) and the patient were at a health care centre and the specialist at a hospital. The patients' opinions of the new method of health service were elicited using a questionnaire. Altogether 51 patients filled in the questionnaire, including 33 females and 18 males living in Northern Finland. The mean age of the patients was 42 years (SD = 18 years). Almost all the patients were ready to use video consultation again based on this experiment. In general, 46 (90 %) of the patients were satisfied with the new method of care. The most important benefit of video consultation was the savings in travelling costs and time. A rapid response without a long waiting time was attained. However, there was also a need to develop the interaction and communication in the consultation situation.

Patient satisfaction in telemedicine

Recent improvements in technology and telecommunications have resulted in renewed interest in telemedicine [1]. The UK’s National Health Service (NHS) Executive has recently published an ‘Information for Health’ strategy which states that ‘telemedicine and telecare will undoubtedly come to the fore as a way of providing services in the future. They have a key role to play in the Government’s plans to modernize the NHS’ [2]. Within the current climate, the future success of telemedicine will depend on patient and provider acceptance of such technologies. It is, therefore, imperative that the views and experiences of the users and providers of healthcare services are sought to enable problems to be resolved and issues addressed before telemedicine is fully implemented: ‘Information about the patients’ experiences can be an important lever for change, both highlighting where, and what sort of quality improvements are needed’ [3].

This paper provides an overview of telemedicine and patient satisfaction and considers the satisfaction studies to date. It finally discusses some of the problems in assessing patient satisfaction within telemedicine and how future studies may be improved in light of the findings. It is based upon work that is presently being carried out at the School of Health and Related Research (ScHARR) at the University of Sheffield as part of a Randomized Controlled Trial of telemedicine in dermatology, funded by the NHS Executive Research and Development Programme.

Efficacy and cost effectiveness of telemedicine for improving access to care in the Paris region: study protocols for eight trials

BACKGROUND

With the development of information and communication technologies, telemedicine has been proposed as a way to improve patient management by facilitating access to appropriate diagnosis and treatment. The Paris Ile de France Regional Health Agency is currently funding a comprehensive program of telemedicine experiments. This article describes the protocols for the evaluation of the implementation of telemedicine in the Paris region.

METHODS/DESIGN

Over 2,500 patients have been included in eight studies addressing the use of telemedicine in the context of specific diseases or settings. Two projects are randomized controlled trials, while the six other projects are based on before-after designs (differences in differences studies). Based on the MAST model and the French national framework, we identified endpoints to assess the impact of telemedicine on five dimensions: clinical effectiveness, cost-effectiveness, security of the application, patient satisfaction and quality of life and perception of professionals.

DISCUSSION

Telemedicine encompasses a wide range of services and stakeholders, and thus study protocols must be tailored to the specific constraints and interests of the users.

TRIAL REGISTRATION

NCT02110433 (03/07/2014), NCT02157740 (05/27/2014), NCT02374697 (02/05/2015), NCT02157727 (05/27/2014), NCT02229279 (08/28/2014), NCT02368769 (02/05/2015), NCT02164747 (NCT02164747), NCT02309905 (11/27/2014).

Impact of Chest Pain Protocol with Access to Telemedicine on Implementation of Pharmacoinvasive Strategy in a Private Hospital Network

BACKGROUND

Brazilian registries have shown a gap between evidence-based therapies and real treatments. We aim to compare the use of the pharmacoinvasive strategy and mortality in patients with ST elevation myocardial infarction (STEMI) transferred pre- and post-chest pain protocol with access to telemedicine (CPPT) in a private hospital network.

MATERIALS AND METHODS

A CPPT was implemented in 22 private emergency departments in 2012. Emergency physicians and nurses of all facilities were trained to disseminate the information to comply with a chest pain protocol focusing on reperfusion therapy (pharmacoinvasive strategy) for STEMI. To conduct clinical discussions using telemedicine, a cardiologist from a reference hospital in cardiology (RHC) was available 24 h/day, 7 days/week. Using the database of all consecutive admissions, we compared the data of patients with STEMI transferred to the RHC in 2011 (pre-CPPT) and 2013-2014 (post-CPPT).

RESULTS

We included 376 patients (113 pre-CPPT and 263 post-CPPT) with STEMI. All patients admitted in the RHC were transferred from the 22 emergency departments. Comparing pre-CPPT and post-CPPT, we did not find differences regarding age, gender, hypertension, dyslipidemia, diabetes, smoking, previous myocardial infarction, or Killip classification. However, the use of CPPT was associated with a greater use of pharmacoinvasive strategy (55.8% versus 38%; p = 0.002) and a trend toward lower in-hospital mortality (3% versus 8%; p = 0.06).

CONCLUSIONS

The implementation of a CPPT was associated with a significant increase in the use of pharmacoinvasive strategy in patients with STEMI and a trend toward reduced in-hospital mortality in a private hospital network.

Telemedicine Interest for Routine Follow-Up Care Among Neurology Patients in Arkansas

BACKGROUND

Teleneurology in Arkansas has been used primarily for management of acute stroke with a state-funded hub-and-spoke model allowing physicians at rural hospitals to access vascular neurologists in time to facilitate tissue plasminogen activator administration. Routine neurologic care has been provided only in small pilot studies. We wished to determine patient interest in participating in teleneurology for routine follow-up visits as well as demographic and medical factors associated with interest.

MATERIALS AND METHODS

New and established patients of the Neurology Outpatient Clinic at the University of Arkansas for Medical Sciences (UAMS) were surveyed between March 2011 and December 2012 to assess their interest in participating in teleneurology as well as potential factors associated with their interest.

RESULTS

Of 1,441 respondents, 52.4% were interested in telemedicine. Of those interested versus uninterested in telemedicine, respectively, 68.9% versus 36.32% traveled more than 1 h to the clinic, 64.7% versus 35.3% had difficulty secondary to neurological conditions, 22.6% versus 6.8% had missed medical appointments due to travel problems, and 43.1% versus 9.4% had travel-imposed financial hardship.

CONCLUSIONS

Telemedicine interest for routine follow-up visits was strong among patients at the UAMS Neurology Outpatient Clinic. Factors positively associated with interest included long travel distances, travel expenses, and transportation difficulties. These results suggest that implementing a telemedicine program for follow-up visits would be acceptable to neurology patients for routine ongoing care.

Implementation of a successful electronic wound documentation system in rural Victoria, Australia: a subject of collaboration and community engagement

To describe the steps needed for a successful implementation of an e-health programme (the Mobile Wound Care system) in rural Victoria, Australia and to provide recommendations for future e-health initiatives. Wound care is a major burden on the health care system. Optimal wound care was found to be impeded by issues that included the limited access to health care providers, incomplete and inconsistent documentation and limited access to expert review. This study trialled the use of a shared electronic wound reporting and imaging system in combination with an expert remote wound consultation service for the management of patients with chronic and acute wounds in Gippsland. The trial sites included four rural Home and Community Health Care providers. Considerable effort was put into designing a best practice e-health care programme. There was support from managers and clinicians at regional and local levels to address an area of health care considered a priority. Various issues contributing to the successful implementation of the wound care project were identified: the training model, quality of data collected, demands associated with multiple sites across a vast geographic region, computer access, hardware and computer literacy.

Self-reported "communication technology" usage in patients attending a cardiology outpatient clinic in a remote regional hospital

PURPOSE

This study assessed the perceived usage of, and attitudes toward, communication technologies (mobile phone and texting, e-mail, and the World Wide Web) in patients attending a cardiology clinic with a view to guiding future health service redesign.

METHODS

This was performed in a remote regional hospital serving both urban and rural populations. A self-completion questionnaire was completed by a convenience sample of 221 patients attending a general cardiology clinic. The questions asked about patients' access to and use of technology at home. Data collected also included age, gender, travel time to the clinic, mode of travel, and whether the respondent was accompanied to the clinic. Appropriate statistical tests were used with significance taken at the 0.05 level.

FINDINGS

Age was the strongest predictor of use of communication technologies, with younger patients more likely to use e-mail, Web, mobile phone, and texting. However, frequency of use of e-mail was not related to age. It is encouraging that over 99% of patients used at least one communication technology.

CONCLUSIONS

This study has highlighted that there may be several potential barriers to the widespread implementation of communication technologies in general cardiology patients. Cognizance should be taken of these findings when attempting service redesign.

Collaborative work by using videoconferencing: opportunities for learning in daily medical practice

In this article, I explore what happens when general practitioners (GPs) and specialists meet using videoconferencing to collaborate on a patient's treatment. By using videoconferencing, GPs and specialists are offered opportunities to share and produce knowledge. The data corpus was 42 videotaped videoconferences. The treatment of one specific patient was selected.This patient was discussed over a period of 9 days, which constituted five videoconferences. I describe how GPs and specialists discuss treatment strategies and exemplify how knowledge sharing creates opportunities for learning in boundary zones across activity systems as a part of daily practice.The talk about the treatment occurs by information exchange and by consultation. Information exchange without any dilemmas presented might support decisions already made. Consultations wherein dilemmas are presented and solved by bridging knowledge gaps between the general practitioner and the specialist create opportunities for learning.

Low-cost remote patient monitoring system based on reduced platform computer technology

Telemedicine is a well-accepted method providing healthcare benefits to people over long distances. However, in normal telemedicine practices, dedicated complex hardware and network backbones for data collection and communication make the system unintelligible to the common man. Centralization of telemedicine units also makes it accessible only to the immediate surrounding community. In an attempt to address these issues, a study aimed at developing a low-cost remote patient monitoring (RPM) system based on reduced platform computer technology has been carried out. The main focus of the work was to develop a real-time, universal serial bus plug-in module for a portable RPM system, specifically the XO Laptop. In addition, this system is also intended to serve as an educational tool especially for the One Laptop per Child target community. This article discusses data collection, preprocessing, and constraints such as network bandwidth and power availability prior to data transmission over a user datagram protocol (UDP)-based network.

Teleconsultation service to improve healthcare in rural areas: acceptance, organizational impact and appropriateness

Background

Nowadays, new organisational strategies should be indentified to improve primary care and its link with secondary care in terms of efficacy and timeliness of interventions thus preventing unnecessary hospital accesses and costs saving for the health system. The purpose of this study is to assess the effects of the use of teleconsultation by general practitioners in rural areas.

Methods

General practitioners were provided with a teleconsultation service from 2006 to 2008 to obtain a second opinion for cardiac, dermatological and diabetic problems. Access, acceptance, organisational impact, effectiveness and economics data were collected. Clinical and access data were systematically entered in a database while acceptance and organisational data were evaluated through ad hoc questionnaires.

Results

There were 957 teleconsultation contacts which resulted in access to health care services for 812 symptomatic patients living in 30 rural communities. Through the teleconsultation service, 48 general practitioners improved the appropriateness of primary care and the integration with secondary care. In fact, the level of concordance between intentions and consultations for cardiac problems was equal to 9%, in 86% of the cases the service entailed a saving of resources and in 5% of the cases, it improved the timeliness. 95% of the GPs considered the overall quality positively. For a future routine use of this service, trust in specialists, duration and workload of teleconsultations and reimbursement should be taken into account.

Conclusions

Managerial and policy implications emerged mainly related to the support to GPs in the provision of high quality primary care and decision-making processes in promoting similar services.

The opening phase of telemedicine consultations: an analysis of interaction

This paper describes communication in the opening phases of real-time, video-mediated telemedicine consultations, using the method of conversation analysis, in three NHS settings in the UK. The literature on interaction analysis in face-to-face medical consultations indicates that physicians' capacity to determine topics in consultations is established in the opening phases of the encounter. This is because patients concede the communicative floor to physicians who claim it for themselves by using well-established patterns of interaction. Drawing on 10 teleconsultations, the analysis shows that, for health care professionals and patients, video-mediated telemedicine is unfamiliar terrain, where communication requires constant negotiation of skills and roles, this complexity being added to by the fact that more than one professional participates in the encounter. Analysis of the opening phases of teleconsultations shows them to involve 'floor negotiation' between professionals and between professionals and patients in which they experience discrepancies between suggested 'frames', a term coined by Goffman [Goffman, E. (1974). Frame analysis. New York: Harper and Row.] to indicate interpretive schemas that allow people to understand the meaning of events in interactions in which they participate. Frame attunement is achieved during floor negotiation through various interruptions, interjections and attachments that professionals produce to defend their agenda. The novelty of the setting also made participants negotiate the physical space in which the encounter took place. We make tentative suggestions for the training of participants, based on the limited evidence of this study, which requires extending by further studies based on direct observation.

Teleconsultation – collaborative work and opportunities for learning across organizational boundaries

Over a period of five months we observed teleconsultations between general practitioners (GPs) in community care and specialists in hospitals in two Norwegian health regions (A and B). In total, 47 teleconsultations between GPs and specialists were recorded. In region A, teleconsultations were organized when needed to discuss specific medical problems. In region B, teleconsultations took place during the specialists' daily morning meeting. The teleconsultations lasted for 5–40 min. There were three categories of talk. In the first two there was information exchange for patient updates and practical organization of the service. The third category, consultation, was the communicative process in which the GP and the specialist engaged in collaborative work, primarily discussing medical problems related to decision-making in patient care. Regular use of teleconsultation opens access to different repertoires of knowledge and experience, and brings knowledge to the point of patient care and medical decision-making.

Validation of Remote Cardiopulmonary Examination in Patients With Heart Failure With a Videophone-Based System

BACKGROUND

The aim of this study was to evaluate feasibility and accuracy of a videophone-based system for remote cardiopulmonary examination of patients with heart failure.

METHODS AND RESULTS

Fifty patients were examined by 2 cardiologists, 1 with a conventional stethoscope and 1 remotely with a videophone-based method, employing an electronic stethoscope and transmitting through an integrated services digital network line. During both sessions, the cardiologists filled out a 27-item questionnaire, which was then compared; concordance between standard and remote examination was evaluated. In 92% of patients, electronic and acoustic auscultation concurred. Only in 3 patients (4%) did teleauscultation not permit a correct interpretation of lung examination. In one patient, bilateral fine crepitant rales were not detected during teleauscultation. Conversely, in the second, patient bilateral fine crepitant rales were recognized during teleauscultation, which were not confirmed during real-life auscultation. In the third nonconcordant patient, moderate-degree wheezing was not detected during teleauscultation. Fine crepitant rales were present at the lungs lower fields in 12 and wheezing in 3 additional patients, and were always correctly identified during teleauscultation. Overall, sensitivity, specificity, positive, and negative predictive value of remote lung auscultation were 88%, 97%, 94%, and 94%, respectively.

CONCLUSIONS

Remote cardiopulmonary examination appears as a feasible method for assessing patients with heart failure. Telestethoscopy can therefore be reliably used in the context of comprehensive telecare programs.

The use of telemedicine in psychiatry

This paper examines the potential effects of using video-conferencing within the field of mental health in the UK. In order to assess the usefulness of telepsychiatric services, an electronic search was conducted for articles published between August 1998 and July 2006 using the MEDLINE, EMBASE, PsychINFO and Telemedicine and Information Exchange (TIE) databases. The search was carried out using the following terms: telepsychiatry, videoconferencing and telepsychology. A total of 178 articles were identified and based on review of the abstracts 72 were identified as being specific to efficacy, cost-effectiveness and satisfaction with psychiatric services delivered via videoconferencing. This paper concludes that the use of video conferencing can enhance psychiatric services within the UK especially for those patients who live in rural areas. Current advances in technology make this an increasingly more reliable and cost-effective method for assessing patients. The limitations of telemedicine are discussed and it is clear that this type of care is not suitable for all patients. Further research is required to assess the types of patients that telepsychiatry is most suitable for.

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.

Patients' perceptions of joint teleconsultations: a qualitative evaluation

OBJECTIVE

To determine patient perceptions of joint teleconsultations (JTC), with particular reference to reasons underlying, and factors contributing to, patient satisfaction and dissatisfaction with this mode of health delivery.

BACKGROUND

Telemedicine has been welcomed as one way of improving health-care delivery, by improving patient access to secondary care and specialist services hence widening patient choice, particularly for patients outside major conurbations. However, a recent systematic review found currently available data on patient satisfaction with telemedicine to be methodologically flawed. Qualitative evaluations offer the opportunity to elucidate the details of patient satisfaction with this mode of health-care delivery.

DESIGN

Qualitative study using semi-structured interviews.

SETTING AND PARTICIPANTS

Purposive sample of 28 participants of a major randomized controlled trial (Virtual Outreach study) of JTC conducted in one urban and one rural area in Britain.

INTERVENTION

Joint teleconferenced consultations with the patient, patient's general practitioner (GP), and a hospital specialist. The patient and GP were sited in the local practice, while the hospital specialist was in the hospital outpatient department, and the two parties were connected by an ISDN2 link and video-conferencing software.

MAIN OUTCOME MEASURES

Patient experiences of JTC, with particular reference to reasons underlying, and factors contributing to, overall satisfaction or dissatisfaction.

RESULTS

Two major themes were identified: customer care and doctor-patient interaction. Patients appreciated the customer care aspects of JTC, particularly the enhanced convenience, reduced costs and improved punctuality associated with JTC. However, there were divergent views about the doctor-patient interactions with some patients expressing a sense of alienation arising from the use of technology, and problems with doctor-patient communication.

CONCLUSIONS

These data add significantly to the existing literature on patient satisfaction with telemedicine, by elucidating the factors underlying overall satisfaction scores and hence have implications for future service delivery and implementation of telemedicine.

Evaluation of teleconsultation systems

The aim of this study was to identify criteria used for evaluation of teleconsulatation systems in evaluation studies, and to estimate trend of their changes. Evaluation of teleconsultation (TC) systems was made on the basis of 82 evaluation studies from the inventory of evaluation studies in medical informatics consisting of all the information and communication technology (ICT) evaluation studies published in 1982-2002. In order to estimate trend of changes in using evaluation criteria, the whole period with at least one evaluation study, it means the period of 1995-2002 was divided to 2 of 4 years, 1995-1998 and 1999-2002. Proportions of evaluation studies according to any single criterion were calculated. Index of changes I(ci) for ith criterion was defined as difference of proportion of studies evaluating teleconsultation by using a certain criterion in the second period and the same proportion in the first period divided by the number of all studies evaluating teleconsultation systems. This research showed that hardware and technical aspects were the leading evaluation criterion, but it has been decreasing (from 74.2% in the first period to 43.1% in the second one). Satisfactions of both health care provider and patient achieved the highest increase in the second period (from 3.2 to 19.6% and from 0 to 15.7%, respectively). Appropriateness and cost of patient care were on the second place (from 22.6 to 33.3% and from 16.1 to 23.5%, respectively). Considering defined index of changes it can be concluded that there are four criteria for evaluation of teleconsultation systems, having a positive trend (in frequency of evaluation studies): user satisfaction (Ic=0.20), satisfaction of patient with patient care (Ic=0.19), appropriateness of patient care (Ic=0.13) and cost of patient care (Ic=0.09). Hardware and technical aspects shows negative trend in the number of evaluation studies (Ic=-0.38), as well as cost of IT (Ic=-0.10).

Introducing problem-based learning into research methods teaching: student and facilitator evaluation

The evidence base for the effectiveness of problem-based learning (PBL) has never been substantively established, although PBL is a generally accepted approach to learning in health care curricula. PBL is believed to encourage transferable skills, including problem-solving and team-working. PBL was used to deliver a postgraduate research methods module and a small evaluation study to explore its efficacy was conducted amongst the students (n = 51) and facilitators (n = 6). The study comprised of an evaluation questionnaire, distributed after each themed group of PBL sessions, and a group discussion conducted 4 weeks after the conclusion of the module, which was attended by student representatives and the facilitators. Questionnaire data was analysed using SPSS, and a transcript of the interview was subjected to content analysis. The results indicated that students felt that a PBL approach helped to make the subject matter more interesting to them and they believed that they would retain knowledge for a longer period than if their learning had used a more traditional lecture format. Students also perceived that PBL was effective in its ability to enhance students' understanding of the group process. All those involved in the PBL process reinforced the pivotal role of the facilitator. This study indicates that there is potential for PBL to be used beyond the more usual clinical scenarios constructed for health care professional education and further exploration of its use in areas such as building research capability should be undertaken.

Telemedicine services in the Republic of Ireland: an evolving policy context

The Republic of Ireland is characterised by few urban conurbations and a high rural population, including significant numbers of island dwellers. Information communication technologies (ICT), including telemedicine, present opportunities to address rural health-service delivery issues. As in other countries, the recent National Health Information Strategy is regarded as pivotal to the modernisation of the Irish health care system. There is, however, a dearth of research about telemedicine in Ireland. This paper reports, to the best of our knowledge, the first systematic review of telemedicine in the two regional health boards in the Republic of Ireland. Details of 11 telemedicine services, all initiated by local policy, will be presented. Results of an interview study with service providers about their experiences of the practices and processes involved in telemedicine service delivery are also provided. The focus of our analysis is two-fold. We assess the resonance of these Irish data with the international literature with particular reference to a recently developed model for the normalisation of telemedicine. For the first time, this model which was developed in the United Kingdom is applied to a fresh set of empirical data in a different health care context. We then discuss a number of health information policy issues for Ireland and elsewhere arising from our analysis.

Patient Followup After Radical Prostatectomy by Internet Medical File

PURPOSE

The development of the Internet and the need for regular followup of patients often living a long way from the hospital led us to develop a followup dossier for those with localized prostate cancer treated with laparoscopic radical prostatectomy.

MATERIALS AND METHODS

This feasibility study was based on 140 patients who agreed to test this system. The website was opened on a server specifically devoted to this project with all required computer security. The website is composed of pages comprising the hospital discharge summary, and operative and histology reports. A quality of life questionnaire based on the assessment of urinary continence and sex life, and a prostate specific antigen (PSA) assay form are also included.

RESULTS

The patient is able to enter his PSA data and complete the questionnaire at home. Results are then sent to the treating physician. A contact page allows the patient and physician to exchange information by text. Of these 100 patients 92 connected regularly to the site with a mean connection rate of 8 per patient (range 1 to 22). Of the patients 98% were satisfied with the various sections of the site, 95% were satisfied with the medical file, 11% noticed connection problems and 14% reported technical problems essentially attributable to incorrect PSA data entry or incorrect functioning of videos due to the absence of appropriate software.

CONCLUSIONS

This type of Internet medical service for patients who have undergone surgery requiring regular followup appears to be a useful approach for the future by allowing the maintenance of close contact between the patient and physicians, while avoiding problems related to hospital visits regardless of the patient place of residence. It also provides general practitioners with access to the patient file with patient permission.

Outcomes and Methods in Telemedicine Evaluation

One hundred and four articles, published from 1966 to 2000, were reviewed to investigate telemedicine evaluation studies in terms of methods and outcomes. A total of 112 evaluations were reported in these 104 articles. Two types of evaluations were evaluated: clinical and nonclinical. Within the clinical evaluations, three were on clinical effectiveness, 26 on patient satisfaction, 49 on diagnostic accuracy, and nine on cost. In the non-clinical evaluations, 15 articles discussed technical issues relating to digital images, such as bandwidth, resolution, and color, and 10 articles assessed management issues concerning efficiency of care, such as avoiding unnecessary patient transfer, or saving time. Of the 112 evaluations, 72 were descriptive in nature. The main methods used in the remaining 40 articles used quantitative methods. Nineteen articles employed statistical techniques, such as receiver operating characteristics curve (three evaluations) and kappa values (seven evaluations). Only one article utilized a qualitative approach to describe a telemedicine system. Currently, there are a number of good reports on diagnostic accuracy, satisfaction, and technological evaluation. However, clinical effectiveness and cost-effectiveness are important parameters, and they have received limited attention. Since telemedicine evaluations tend to explore various outcomes, it may be appropriate to evaluate from a multidisciplinary perspective, and to utilize various methodologies.

Understanding the normalization of telemedicine services through qualitative evaluation

OBJECTIVE

Qualitative studies can help us understand the "successes" and "failures" of telemedicine to normalize within clinical service provision. This report presents the development of a robust conceptual model of normalization processes in the implementation and development of telemedicine services.

DESIGN

Retrospective and cumulative analysis of longitudinal qualitative data from three studies was undertaken between 1997 and 2002. Observation and semistructured interviews produced a substantial body of data relating to approximately 582 discrete data collection episodes. Data were analyzed separately in each of three studies. Cumulative analysis was conducted by constant comparison.

RESULTS

(1) Implementation of telemedicine services depends on a positive link with a (local or national) policy level sponsor. (2) Adoption of telemedicine systems in service depends on successful structural integration so that development of organizational structures takes place. (3) Translation of telemedicine technologies into clinical practice depends on the enrollment of cohesive, cooperative groups. (4) Stabilization of telemedicine systems in practice depends on integration at the level of professional knowledge and practice, where clinicians are able to accommodate telemedicine through the development of new procedures and protocols.

CONCLUSION

A rationalized linear diffusion model of "telehealthcare" is inadequate in assessing the potential for normalization, and the political, organizational, and "ownership" problems that govern the process of development, implementation, and normalization need to be accounted for. This report presents a model for assessing the potential for successful implementation of telehealthcare services. This model defines the requirements for the successful normalization of telemedicine systems in clinical practice.

Health technology assessment in its local contexts: studies of telehealthcare

Health technology assessment (HTA) is one of the major research enterprises of late modernity, reaching into fields of previously autonomous professional practice, and critically interrogating the organisation and delivery of health care. The 'evaluation' of new health technologies within the field of HTA is increasingly a normative political expectation, as discourses of 'evidence-based' practice run through health policy in the UK and elsewhere. Despite its importance in governing the direction of innovation in health care delivery, there are hardly any empirical studies of HTA in practice. In this paper, we draw on two ethnographic studies of telehealthcare implementation and evaluation in the UK to explore the practical conduct of HTA, and we focus specifically on the social organisation and conduct of randomised controlled trials of these new technologies. The paper examines how evaluation forms a mediating set of practices that make the embedding or normalisation of a new technology possible; and present a simple model of the social and technical contingencies within the evaluation process.

Design and performance of a multicentre, randomized controlled trial of teleconsulting

We have designed and performed a multicentre, randomized controlled trial of teleconsulting. The trial investigated the effectiveness and cost implications in rural and inner-city settings of using videoconferencing as an alternative to general practitioner referral to a hospital specialist. The participating general practitioners referred a total of 3170 patients who satisfied the entry criteria. Of these, 1040 (33%) failed to provide consent or otherwise refused to participate in the trial. Of the patients recruited to the trial, a total of 1902 (91%) completed and returned the baseline questionnaire. Although the trial was successful in recruiting sufficient patients and in obtaining high questionnaire response rates, the findings will require careful interpretation to take account of the limits which the protocol placed on the ability of general practitioners to select patients for referral.

A cost-minimization analysis of orthopaedic consultations using videoconferencing in comparison with conventional consulting

We compared the costs of conventional outpatient visits to the surgical department of the University Hospital of Oulu with those of videoconferencing between the primary care centre in Pyhäjärvi and the University Hospital (separated by 160 km). The cost data were obtained from a randomized controlled trial that included 145 first-admission and follow-up orthopaedic patients. In the telemedicine group the annual fixed costs were 6074 in the hospital and 3910 in the primary care centre. The additional variable costs were 2 in the hospital and 19 in primary care. At a workload of 100 patients, the total cost, including travel and indirect costs, was 87.8 per patient in the telemedicine group and 114.0 per patient in the conventional group (i.e. a total cost saving from the use of teleconsultation of 2620). A cost-minimization analysis showed that telemedicine was less costly for society than conventional care at a workload of more than 80 patients per year. If the distance to specialist care were reduced from 160 km to 80 km, the break-even point increased to about 200 patients per year. Wider utilization of the videoconferencing equipment for other purposes, or the use of less expensive videoconferencing equipment, would make services cost saving even at relatively short distances. The study showed that orthopaedic outpatient telecare can be cost minimizing.

Joint teleconsultations (virtual outreach) versus standard outpatient appointments for patients referred by their general practitioner for a specialist opinion: a randomised trial

BACKGROUND

The current model of general practitioner referral of patients to hospital specialists in the UK is sometimes associated with unnecessary duplication of investigations and treatments. We aimed to compare joint teleconsultations between general practitioners, specialists, and patients (virtual outreach) with standard outpatient referral.

METHODS

Virtual outreach services were established in London and Shrewsbury. The general practitioners referred 3170 patients, of whom 2094 consented to participate in the study and were eligible for inclusion. 1051 patients were randomly assigned virtual outreach, and 1043 standard outpatient appointments. We followed up the patients for 6 months after their index consultation. The primary outcome measure was the offer of a follow-up outpatient appointment. Analysis was by intention to treat.

FINDINGS

More patients in the virtual outreach group than the standard group were offered a follow-up appointment (502 [52%] vs 400 [41%], odds ratio 1.52 [95% CI 1.27-1.82], p<0.0001). Significant differences in effects were observed between the two sites (p=0.009) and across different specialties (p<0.0001). Virtual outreach increased the offers of follow-up appointments more in Shrewsbury than in London, and more in ear, nose, and throat surgery and orthopaedics than in the other specialties. Fewer tests and investigations were ordered in the virtual outreach group by an average of 0.79 per patient (0.37-1.21, p=0.0002). Patients' satisfaction (analysed per protocol) was greater after a virtual outreach consultation than after a standard outpatient consultation (mean difference 0.33 scale points [95% CI 0.23-0.43], p<0.0001), with no heterogeneity between specialties or sites.

INTERPRETATION

The trial showed that allocation of patients to virtual outreach consultations is variably associated with increased offers of follow-up appointments according to site and specialty, but leads to significant increases in patients' satisfaction and substantial reductions in tests and investigations. Efficient operation of such services will require appropriate selection of patients, significant service reorganisation, and provision of logistical support.

Limitations of patient satisfaction studies in telehealthcare: a systematic review of the literature

The objective of this study is to provide a systematic review of studies on patient satisfaction with telemedicine. The review included empirical studies that investigated patient satisfaction with that telemedicine service. The search strategy involved matching at least one of 11 'telemedicine' terms with one of 5 'satisfaction' terms. The following databases were searched: Telemedicine Information Exchange (TIE) database, MEDLINE, Science Citation Index (SCI), Social Science Citation Index (SSCI), Psycinfo, and Citation Index of Nursing and Allied Health (CINAHL). A highly structured instrument was used for data extraction. The review included 93 studies. Telepsychiatry represents the largest portion of these studies (25%), followed by multispecialty care (14%), nursing (11%), and dermatology (8%). Real-time videoconferencing was used in 88% of these studies. Only 19 (20%) included an independent control group, including 9 (10%) randomized control trial (RCT) studies. One third of studies were based on samples of less than 20 patients, and only 21% had samples of over 100 patients. Aspects of patient satisfaction most commonly assessed were: professional-patient interaction, the patient's feeling about the consultation, and technical aspects of the consultation. Only 33% of the studies included a measure of preference between telemedicine and face-to-face consultation. Almost half the studies measured only 1 or 2 dimensions of satisfaction. Reported levels of satisfaction with telemedicine are consistently greater than 80%, and frequently reported at 100%. Progression of telemedicine services from "trial" status to routine health service must be supported by improved research into patients' satisfaction with telemedicine. Further investigation of factors that influence patient acceptance of telemedicine is indicated.

Design and performance of a multi-centre randomised controlled trial and economic evaluation of joint tele-consultations [ISRCTN54264250]

BACKGROUND

Appropriate information flow is crucial to the care of patients, particularly at the interface between primary and secondary care. Communication problems can result from inadequate organisation and training, There is a major expectation that information and communication technologies may offer solutions, but little reliable evidence. This paper reports the design and performance of a multi-centre randomised controlled trial (RCT), unparalleled in telemedicine research in either scale or range of outcomes. The study investigated the effectiveness and cost implications in rural and inner-city settings of using videoconferencing to perform joint tele-consultations as an alternative to general practitioner referral to the hospital specialist in the outpatient clinic.

METHODS

Joint tele-consultation services were established in both the Royal Free Hampstead NHS Trust in inner London, and the Royal Shrewsbury Hospitals Trust, in Shropshire. All the patients who gave consent to participate were randomised either to joint tele-consultation or to a routine outpatients appointment. The principal outcome measures included the frequency of decision by the specialist to offer a follow-up outpatient appointment, patient satisfaction (Ware Specific Questionnaire), wellbeing (SF12) and enablement (PEI), numbers of tests, investigations, procedures and treatments.

RESULTS

A total of 134 general practitioners operating from 29 practices participated in the trial, referring a total of 3170 patients to 20 specialists in ENT medicine, general medicine (including endocrinology, and rheumatology), gastroenterology, orthopaedics, neurology and urology. Of these, 2094 patients consented to participate in the study and were correctly randomised. There was a 91% response rate to the initial assessment questionnaires, and analysis showed equivalence for all key characteristics between the treatment and control groups.

CONCLUSION

We have designed and performed a major multi-centre trial of teleconsultations in two contrasting centres. Many problems were overcome to enable the trial to be carried out, with a considerable development and learning phase. A lengthier development phase might have enabled us to improve the patient selection criteria, but there is a window of opportunity for these developments, and we believe that our approach was appropriate, allowing the evaluation of the technology before its widespread implementation.