The assessment of cognitive function in the elderly using videoconferencing

Computerized assessment of executive functioning: Validation of the CNS Vital Signs executive functioning scores in a sample of community-dwelling older adults

Objective: Computerized assessment of cognitive functioning has gained significant popularity over recent years, yet options for clinical assessment of executive functioning (EF) are lacking. One computerized testing platform, CNS Vital Signs (CNS-VS), offers tests designed to measure EF but requires further validation. The goal of the present study was to validate CNS-VS executive scores against standard clinical measures of EF. We also sought to determine whether a modified CNS-VS composite score that included variables purported to measure inhibition, switching, and working memory would outperform the currently available CNS-VS Executive Function Index. Method: A sample of 73 cognitively healthy older adults completed four tests from the Delis-Kaplan Executive Function System, the Digit Span subtest from the Wechsler Adult Intelligence Scale-fourth edition, and three CNS-VS tasks purported to measure inhibition, switching, and working memory. Results: Performances on the CNS-VS tests were predicted by performances on standard paper-and-pencil measures. Although the currently available CNS-VS Executive Function Index predicted unique variance in a well-validated paper-and-pencil EF composite score, our Modified CNS-VS EF composite accounted for unique variance above and beyond the original CNS-VS Executive Function Index, while the reverse was not true. Conclusions: The present results support the construct validity of CNS-VS EF tests but also suggest that modifications to their current composite scores would improve the prediction of EF performance.

Geriatric Telepsychiatry: Systematic Review and Policy Considerations

Telemental health (TMH) for older patients has the potential to increase access to geriatric specialists, reduce travel times for patients and providers, and reduce ever growing healthcare costs. This systematic review article examines the literature regarding psychiatric assessment and treatment via telemedicine for geriatric patients. English language literature was searched using Ovid Medline, PubMed, and PsycINFO with search terms including telemedicine, telemental health, aging, and dementia. Abstracts were reviewed for relevance based on inclusion criteria. Multiple study types were reviewed, including open label, qualitative and randomized controlled trial study designs. Data was compiled regarding participants, study intervention, and outcomes. 76 articles were included. TMH was shown to be feasible and well accepted in the areas of inpatient and nursing home consultation, cognitive testing, dementia diagnosis and treatment, depression in integrated and collaborative care models, and psychotherapy. There is limited data on cost-effectiveness of TMH in the elderly. This article will discuss the current barriers to broader implementation of telemedicine for geriatric patients including reimbursement from the Medicare program. Medicare reimbursement for telemedicine is limited to rural areas, which does not allow for the widespread development of telemedicine programs. All Medicare beneficiaries would benefit from increased access to telemedicine services, not only those living in rural areas. As many elderly and disabled individuals have mobility problems, home-based telemedicine services should also be made available. There are efforts in Congress to expand the coverage of these services under Medicare, but strong advocacy will be needed to ensure these efforts are successful.

The reliability of the Montreal Cognitive Assessment using telehealth in a rural setting with veterans

Background

Telehealth neuropsychological services can increase the availability of specialised care for individuals in rural areas where barriers to these services are faced. As this practice becomes more commonplace, the reliability and validity of neuropsychological assessment administered by telehealth continues to be established. The Montreal Cognitive Assessment, a screener for general neurocognitive dysfunction, may be particularly useful since this measure can be given by telehealth with minimal adaptation.

Methods

Veterans from a rural area of the country who were referred to an outpatient neuropsychology clinic were administered the Montreal Cognitive Assessment either in-person or by telehealth by a clinician. A second clinician observed the administration in-person or by telehealth and independently scored the each participant’s performance. The inter-rater reliabilities across conditions were compared to assess for differences between in-person and telehealth consultations.

Results

The inter-rater reliability of the Montreal Cognitive Assessment across the three conditions of interest was acceptably high and values ranged from r = 0.88 to r = 0.98. Reliability correlations were compared and no significant differences among the conditions were observed ( p’s > 0.10). Beyond reliability, univariate comparison of the absolute mean differences of clinician scores showed no significant differences among the actual raw scores of the three conditions tested, indicating good accuracy ( p = 0.56).

Conclusions

The inter-rater reliabilities of Montreal Cognitive Assessment scores across conditions were all acceptably high, and administration of the Montreal Cognitive Assessment using telehealth technology did not significantly alter the total scores. Overall, the lack of significant differences suggests that administering the Montreal Cognitive Assessment by telehealth is reliable, accurate and well received by participants.

Assessing Cognitive Function in Older Adults Using a Videoconference Approach

BACKGROUND

The use of communication technologies is an emerging trend in healthcare and research. Despite efficient, reliable and accurate neuropsychological batteries to evaluate cognitive performance in-person, more diverse and less expensive and time consuming solutions are needed. Here we conducted a pilot study to determine the applicability of a videoconference (VC, Skype®) approach to assess cognitive function in older adults, using The Telephone Interview for Cognitive Status-Modified - Portuguese version (TICSM-PT).

METHODS

After inclusion and exclusion criteria, 69 individuals (mean age=74.90±9.46years), selected from registries of local health centers and assisted-living facilities, were assessed on cognitive performance using videoconference, telephone and in-person approaches.

FINDINGS

The videoconference administration method yielded comparable results to the traditional application. Correlation analyses showed high associations between the testing modalities: TICSM-PT VC and TICSM-PT telephone (r=0.885), TICSM-PT VC and MMSE face-to-face (r=0.801). Using the previously validated threshold for cognitive impairment on the TICSM-PT telephone, TICSM-PT VC administration presented a sensitivity of 87.8% and a specificity of 84.6%.

INTERPRETATION

Findings indicate for the range of settings where videoconference approaches can be used, and for their applicability and acceptability, providing an alternative to current cognitive assessment methods. Continued validation studies and adaptation of neuropsychological instruments is warranted.

Usefulness of telepsychiatry: A critical evaluation of videoconferencing-based approaches

Telepsychiatry, i.e., the use of information and communication technologies to provide psychiatric services from a distance, has been around for more than half a century now. Research over this period has shown that videoconferencing-based telepsychiatry is an enabling and empowering form of service delivery, which promotes equality of access, and high levels of satisfaction among patients. The range of services offered by videoconferencing-based telepsychiatry, potential users and points of delivery of such services are theoretically limitless. Telepsychiatry has both clinical utility and non-clinical uses such as administrative, learning and research applications. A large body of accumulated evidence indicates that videoconferencing-based telepsychiatric assessments are reliable, and clinical outcomes of telepsychiatric interventions are comparable to conventional treatment among diverse patient populations, ages and diagnostic groups, and on a wide range of measures. However, on many aspects of effectiveness, the evidence base is still relatively limited and often compromised by methodological problems. The lack of cost-effectiveness data in particular, is a major hindrance, raising doubts about the continued viability of telepsychiatric services. Added to this are the vagaries of technology, negative views among clinicians, poor uptake by providers, and several legal, ethical and administrative barriers. These hamper the widespread implementation of telepsychiatry and its integration with routine care. Though further advances in technology and research are expected to solve many of these problems, the way forward would be to promote telepsychiatry as an adjunct to conventional care, and to develop hybrid models, which incorporate both traditional and telepsychiatric forms of mental health-care.

Video teleconference-based neurocognitive screening in geropsychiatry

Validation of remote video teleconference (VTC)-based procedures for geropsychiatry applications is essential to ensure validity and reliability of diagnostic procedures. The current study demonstrates the similarity of scores obtained from several brief neurocognitive screening measures in an outpatient VA geropsychiatry clinic population when participants were tested in-person and via VTC. Results revealed similar mean scores and moderate to good consistency among our mixed geropsychiatric sample on brief measures of global cognition, attention, and visuospatial function.

Teleneuropsychology: evidence for video teleconference-based neuropsychological assessment

The use of videoconference technology to deliver health care diagnostics and treatment continues to grow at a rapid pace. Telepsychiatry and telepsychology applications are well-accepted by patients and providers, and both diagnostic and treatment outcomes have generally been similar to traditional face-to-face interactions. Preliminary applications of videoconference-based neuropsychological assessment (teleneuropsychology) have yielded promising results in the feasibility and reliability of several standard tests, although large-scale studies are lacking. This investigation was conducted to determine the reliability of video teleconference (VTC) - based neuropsychological assessment using a brief battery of standard neuropsychological tests commonly used in the evaluation of known or suspected dementia. Tests included the Mini-Mental State Examination (MMSE), Hopkins Verbal Learning Test-Revised, Digit Span forward and backward, short form Boston Naming Test, Letter and Category Fluency, and Clock Drawing. Tests were administered via VTC and in-person to subjects, counterbalanced using alternate test forms and standard instructions. Two hundred two adult subjects were tested in both rural and urban settings, including 83 with cognitive impairment and 119 healthy controls. We found highly similar results across VTC and in-person conditions, with significant intraclass correlations (mean=.74; range: 0.55-0.91) between test scores. Findings remained consistent in subjects with or without cognitive impairment and in persons with MMSE scores as low as 15. VTC-based neuropsychological testing is a valid and reliable alternative to traditional face-to-face assessment using selected measures. More VTC-based studies using additional tests in different populations are needed to fully explore the utility of this new testing medium.

Teleneuropsychology: evidence for video teleconference-based neuropsychological assessment

The use of videoconference technology to deliver health care diagnostics and treatment continues to grow at a rapid pace. Telepsychiatry and telepsychology applications are well-accepted by patients and providers, and both diagnostic and treatment outcomes have generally been similar to traditional face-to-face interactions. Preliminary applications of videoconference-based neuropsychological assessment (teleneuropsychology) have yielded promising results in the feasibility and reliability of several standard tests, although large-scale studies are lacking. This investigation was conducted to determine the reliability of video teleconference (VTC) - based neuropsychological assessment using a brief battery of standard neuropsychological tests commonly used in the evaluation of known or suspected dementia. Tests included the Mini-Mental State Examination (MMSE), Hopkins Verbal Learning Test-Revised, Digit Span forward and backward, short form Boston Naming Test, Letter and Category Fluency, and Clock Drawing. Tests were administered via VTC and in-person to subjects, counterbalanced using alternate test forms and standard instructions. Two hundred two adult subjects were tested in both rural and urban settings, including 83 with cognitive impairment and 119 healthy controls. We found highly similar results across VTC and in-person conditions, with significant intraclass correlations (mean=.74; range: 0.55-0.91) between test scores. Findings remained consistent in subjects with or without cognitive impairment and in persons with MMSE scores as low as 15. VTC-based neuropsychological testing is a valid and reliable alternative to traditional face-to-face assessment using selected measures. More VTC-based studies using additional tests in different populations are needed to fully explore the utility of this new testing medium.

The 60 most highly cited articles published in the Journal of Telemedicine and Telecare and Telemedicine Journal and E-health

Summary

We analysed the most highly cited articles in two specialist telemedicine journals, the Journal of Telemedicine and Telecare (JTT) and Telemedicine Journal and E-health (TJEH). Articles were extracted from the Science Citation Index Expanded in September 2012. A total of 1810 articles were listed for the JTT and 1550 for TJEH. In the JTT, the mean number of citations was 43 (SD 13); in TJEH the mean number of citations was 30 (SD 11). The average number of citations for the JTT was significantly higher than for TJEH ( P < 0.001). In each journal, the 60 articles which had the most citations were identified as highly cited publications (HCPs). The 60 HCPs in the JTT originated from 16 countries; the 60 HCPs in TJEH originated from 10 countries. Considering both journals together, the majority of HCPs came from the US, UK, Australia and Canada. In the JTT, the mean number of authors for each HCP was 4.6 (SD = 3.1); in TJEH, the mean number of authors for each HCP was 4.5 (SD = 2.3). There was no difference between the two journals ( P = 0.84) and the characteristics of the HCPs published in the JTT and TJEH were broadly similar. Although HCPs are not a direct method of measuring quality, they are an indicator of the scientific impact of the articles.

Videoconference-based mini mental state examination: a validation study

BACKGROUND

Neuropsychological testing is a prime criterion of good practice to document cognitive deficits in a rapidly aging population. Telecommunication technologies may overcome limitations related to test administration. We compared performance of the Italian videoconference-based version of the Mini Mental State Examination (VMMSE) with performance of the standard MMSE administered face-to-face (F2F), to validate the Italian version of the 28-item VMMSE.

MATERIALS AND METHODS

To validate the Italian version of the VMMSE, we compared its performance with standard F2F. The sample (n=342) was administered three VMMSEs within 6 weeks after F2F testing. We identified the optimal cutoff through the receiver operating characteristic curve, as well as the VMMSE consistency through inter- and intrarater reliability (Inter/RR and Intra/RR) analysis.

RESULTS

We found high levels of sensitivity and specificity for the optimal VMMSE cutoff identification and an accuracy of 0.96 (95% confidence interval 0.94-0.98). Intra/RR and inter/RR were highly significant.

CONCLUSIONS

This study demonstrates that VMMSE is a valid instrument in clinical and research screening and monitoring of subjects affected by cognitive disorders. This study shows a significant correlation between videoconference assessment and the F2F one, providing an important impetus to expand studies and the knowledge about the usefulness of tele-assistance services. Our findings have important implications for both longitudinal assistance and clinical care of demented patients.

Telepsychogeriatrics: a new horizon in the care of mental health problems in the elderly

BACKGROUND

The use of telemedicine for the care of mental health problems has developed significantly over the last decade thanks to the emergence of a number of stable telepsychiatry programs in many countries. Parallel to this development, this care modality has also targeted specific populations with higher difficulty in gaining access to mental health services such as the elderly. Telepsychogeriatrics is expected to have an increasing role in providing care to geographically isolated rural communities, with a particular focus on long-term care facilities, in light of the high prevalence of psychiatric disorders in these centers and the lack of available specialized care.

METHODS

A thorough search of the literature was conducted using Medline, Web of Science, and PsychINFO databases in order to gather available evidence on the applicability of telepsychiatry, specifically the use of videoconferencing for remote consultation, in the elderly population with mental disorders. A succinct description of the selected studies is given along with a general reflection on the state-of-the-art in the field of psychogeriatric clinical practice and research.

RESULTS

Research on the use of telemedicine in this age group has taken into account their special characteristics, and has focused on demonstrating its applicability, the acceptance and satisfaction of elderly users and their healthcare providers, the possibility of carrying out cognitive and diagnostic assessments, and the efficiency of these programs.

CONCLUSIONS

Despite limited experience, telepsychogeriatrics appears to be a viable option, well accepted by patients, including those having dementia. More systematized studies are needed in this new field based on larger sample sizes, including comparison with traditional consultations and assessment of the clinical outcomes.

The diagnostic accuracy of telegeriatrics for the diagnosis of dementia via video conferencing

INTRODUCTION

The suitability of video conferencing (VC) technology for clinical purposes relevant to geriatric medicine is still being established. This project aimed to determine the validity of the diagnosis of dementia via VC.

METHODS

This was a multisite, noninferiority, prospective cohort study. Patients, aged 50 years and older, referred by their primary care physician for cognitive assessment, were assessed at 4 memory disorder clinics. All patients were assessed independently by 2 specialist physicians. They were allocated one face-to-face (FTF) assessment (Reference standard--usual clinical practice) and an additional assessment (either usual FTF assessment or a VC assessment) on the same day. Each specialist physician had access to the patient chart and the results of a battery of standardized cognitive assessments administered FTF by the clinic nurse. Percentage agreement (P(0)) and the weighted kappa statistic with linear weight (K(w)) were used to assess inter-rater reliability across the 2 study groups on the diagnosis of dementia (cognition normal, impaired, or demented).

RESULTS

The 205 patients were allocated to group: Videoconference (n = 100) or Standard practice (n = 105); 106 were men. The average age was 76 (SD 9, 51-95) and the average Standardized Mini-Mental State Examination Score was 23.9 (SD 4.7, 9-30). Agreement for the Videoconference group (P(0)= 0.71; K(w) = 0.52; P < .0001) and agreement for the Standard Practice group (P(0)= 0.70; K(w) = 0.50; P < .0001) were both statistically significant (P < .05). The summary kappa statistic of 0.51 (P = .84) indicated that VC was not inferior to FTF assessment.

CONCLUSIONS

Previous studies have shown that preliminary standardized assessment tools can be reliably administered and scored via VC. This study focused on the geriatric assessment component of the interview (interpretation of standardized assessments, taking a history and formulating a diagnosis by medical specialist) and identified high levels of agreement for diagnosing dementia. A model of service incorporating either local or remote administered standardized assessments, and remote specialist assessment, is a reliable process for enabling the diagnosis of dementia for isolated older adults.

The Rowland Universal Dementia Assessment Scale (RUDAS) as a reliable screening tool for dementia when administered via videoconferencing in elderly post-acute hospital patients

The Rowland Universal Dementia Assessment Scale (RUDAS) is a six-domain screening tool for dementia. We measured the practicality and reliability of administering the RUDAS in a telemedicine setting. Inpatients were recruited from a Geriatric and Rehabilitation Unit. Each patient was administered the RUDAS both face-to-face (FTF) and via videoconferencing (VC). The assessment format (FTF or VC) and the allocation of doctor (Doctor 1 or Doctor 2) to format were randomized. Scores from each assessment format were compared. The outcome of no difference was decided based on a difference in mean of no more than ± one point. Percentage agreement (agreement being ±2 points) was calculated on individual test scores. Forty-two patients (average age 75 years) completed the two assessments. Their mean Mini-Mental State Examination (MMSE) score was 24.7 (range 10-30). The mean RUDAS score for both FTF and VC assessment was 24.9 (difference between the means 0.04), i.e. there was no significant difference. The results suggest that the RUDAS can be reliably administered via VC in post acute patients as an alternative to FTF administration.

Evaluation of Telehealth for Preclinic Assessment and Follow-Up in an Interprofessional Rural and Remote Memory Clinic

Using data from a sample of 169 patients, this study evaluates the acceptability and feasibility of telehealth videoconferencing for preclinic assessment and follow-up in an interprofessional memory clinic for rural and remote seniors. Patients and caregivers are seen via telehealth prior to the in-person clinic, and followed at 6 weeks, 12 weeks, 6 months, one year, and yearly. Patients are randomly assigned to in-person (standard care) or telehealth for the first follow-up, then alternating between the two modes of treatment, prior to 1-year follow-up. On average, telehealth appointments reduce participants' travel by 426 km per round trip. Findings show that telehealth coordinators rated 85% of patients and 92% of caregiversas comfortable or very comfortable during telehealth. Satisfaction scales completed by patient-caregiver dyads show high satisfaction with telehealth. Follow-up questionnaires reveal similar satisfaction with telehealth and in-person appointments, but telehealth is rated as significantly more convenient. Predictors of discontinuing follow-up are greater distance to telehealth, old-age patient, lower telehealth satisfaction, and lower caregiver burden.

Telemedicine and the mini-mental state examination: assessment from a distance

The objective of this study was to determine the reliability of the Mini-Mental State Examination (MMSE) administration via telehealth with a focus on the auditory and visual test components. Reliability was assessed through use of an in-person collaborator and by assessment of faxed test copies. The MMSE was administered via telehealth with the assistance of a face-to-face collaborator. Patient responses were recorded by both the remote and in-person nurse and compared item by item; total scores for each subject were also compared. Visual items were assessed through a blinded separate scoring of a faxed copy. Percent agreement per item and total score were calculated and correlations between scores were determined by Pearson correlation coefficients. Mean score differences and associated 95% confidence intervals were calculated. Eighty percent of individual items demonstrated remote to in-person agreement of >95% and all items were >85.5% in agreement. Pearson correlation coefficients demonstrated high correlations (>0.86) between 80% of the items examined. Mean differences in scored test items were not significantly different from zero. This study demonstrates the utility of using telehealth for cognitive assessment by MMSE. It supports the use of telehealth to improve healthcare access among patients for whom distance, cost, and mobility are potential barriers to attending face-to-face clinical visits. Continued validation and reliability testing is warranted to ensure that all healthcare provided via telehealth maintains an equal quality level to that of in-person care.

Assessment of post-traumatic stress disorder in veterans by videoconferencing and by face-to-face methods

We compared videoconferencing and face-to-face (FTF) assessments for veterans seeking a mental health evaluation for post-traumatic stress disorder (PTSD). The Clinician-Administered PTSD Scale (CAPS) interview was used in 20 male veterans. There were significant correlations (ranging from 0.74 to 0.92) between the CAPS administered FTF and by videoconferencing on all three subscales, as well as on the total severity score. The confidence intervals for the CAPS scores indicated statistical equivalence between administration FTF and by videoconferencing. The sensitivity of videoconferencing was 0.94 and the specificity was 0.33, compared with FTF assessment. The total and subscale scores suggested that there was a moderate working alliance with both methods. The patients indicated general satisfaction with the videoconferencing method. Most of them indicated that they would prefer to see a clinician FTF, but would utilize videoconferencing if there were distance barriers to services. Overall, the results of the present study support the use of videoconferencing in the assessment of PTSD.

Improving access to dementia care: development and evaluation of a rural and remote memory clinic

The availability, accessibility and acceptability of services are critical factors in rural health service delivery. In Canada, the aging population and the consequent increase in prevalence of dementia challenge the ability of many rural communities to provide specialized dementia care. This paper describes the development, operation and evaluation of an interdisciplinary memory clinic designed to improve access to diagnosis and management of early stage dementia for older persons living in rural and remote areas in the Canadian province of Saskatchewan. We describe the clinic structure, processes and clinical assessment, as well as the evaluation research design and instruments. Finally, we report the demographic characteristics and geographic distribution of individuals referred during the first three years.

Feasibility of telecognitive assessment in dementia

Videoconferencing (VC) technology has been used successfully to provide psychiatric services to patients in rural and otherwise underserved settings. VC-based diagnostic interviewing has shown good agreement with conventional face-to-face diagnosis of dementia in several investigations, but extension of this technology to neurocognitive assessment has received little attention. To this end, the authors administered a brief battery of common neuropsychological tests via VC technology (telecognitive) and traditional face-to-face methods to 14 older persons with mild cognitive impairment (MCI) and 19 persons with mild to moderate Alzheimer's disease (AD). Highly similar test scores were obtained when participants were tested in-person or via VC. Telecognitive assessment appears to be a valid means to conduct neuropsychological evaluation of older adults with cognitive impairment. Furthermore, continued development of VC technology has implications for expanding neuropsychological assessment options in under-served populations.

Moving research into practice: A decision framework for integrating home telehealth into chronic illness care

Home telehealth is an effective alternative for some aspects of traditional care in chronic illnesses such as diabetes, congestive heart failure and asthma. However, in spite of evidence to support use of home telehealth technologies, they have not been adopted as predicted. A significant challenge for decision-makers is applying results from multiple small studies to the care of large numbers of clients in a health region. Aside from the technology, this complex decision must also include expected client outcomes, variations in nursing resources and their deployment in service delivery. This paper presents research evidence supporting the effectiveness of home telehealth for diabetes care, with attention to the range of technologies and outcome measures reported. It also discusses implications of a recently released national study on "Homecare Indicators" that reported resource allocation and outcomes in home care. The burden of illness, evidence of technology effectiveness and proposed home care outcome indicators are considered together in a decision framework to demonstrate an approach for decision-makers and practitioners to transfer home telehealth research into practice. The resulting decision framework is applied to diabetes care within one large health region in Canada to illustrate its utility as a research transfer strategy.

Clinical outcomes associated with telemedicine/telehealth

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

Can patients with dementia be assessed at a distance? The use of Telehealth and standardised assessments

BACKGROUND

Telehealth could be a medium for the provision of cognitive assessments to distant sites.

AIMS

The aims of the present study were to determine the interrater reliability of the Standardized Mini Mental State Exam (SMMSE) and the Geriatric Depression Scale (GDS) through Telehealth as compared to face-to-face administration.

METHODS

Duplicate interviews of subjects with crossover of interview modality were carried out. Twenty patients were interviewed between two sites 11 km apart. Subjects were persons older than 65 years (mean age 82 years) who consented to Telehealth assessments. The outcome measures were the differences in assessment scores between the two media.

RESULTS

The average SMMSE score by remote assessment was 24.0 (range 11.0-30.0) and by direct assessment was 24.3 (range 9.0-30.0). The correlation between direct and remote SMMSE scores was 0.90. The mean difference between direct and remote SMMSE scores was -0.3 (95% confidence interval (CI): -4.6 to 4.0). In 8 of 20 participants (40%) the difference between Telehealth and direct assessments was two points or more on the SMMSE. The average GDS by remote assessment was 6.1 (range 1.0-14.0) and by direct assessment was 5.8 (range 2.0-13.0). The correlation between direct and remote GDS scores was 0.78. The mean difference between direct and remote GDS assessment was 0.3 (95% CI: -3.8 to 4.4).

CONCLUSION

Remote assessments with SMMSE and GDS using Telehealth methods yielded similar results to direct assessments. However, there was a moderate difference between face-to-face and Telehealth assessments in some subjects, which could influence clinical decision-making.

Telemedicine in the state of Maine: a model for growth driven by rural needs

As of mid-2002, Maine had one of the largest state-wide telemedicine systems, comprising over 150 facilities among 90 health, mental health, and social service provider organizations in two collaborative networks. The rapid growth of telemedicine in this rural, economically disadvantaged state is largely attributable to collaborative development and the service activities of the Maine Telemedicine Services division of a rural community health center, HealthWays/Regional Medical Center at Lubec (RMCL). Annual clinical uses of the system across a broad array of interactive videoconferencing applications currently exceed 1,000 instances for institutional telemedicine and 800 instances for home telehealth. The major applications include mental health/psychiatry, endocrinology/diabetes management, primary care, specialty pediatrics, genetics, and dermatology. Primary care usage derives from a relatively novel use of a mobile telemedicine boat to serve small islands off mid-coastal Maine. Strong future growth is expected in prison telemedicine, emergency medical triage, and nontraditional services such as video relay interpretive services for the deaf, domestic violence advocacy and legal services, and case management for community reintegration of juvenile offenders. The relative success of the two large networks managed by RMCL's Maine Telemedicine Services is evident from the criteria that system usage (1) addresses defined clinical needs, (2) has demonstrable organizational support, (3) is accepted by physicians and patients, (4) exhibits measurable cost and clinical benefits, and (5) is moving toward sustainable operations. Potential bases for this success are discussed in comparison with other networks.

Telemedicine, rural elderly, and policy issues

Historically, rural America has had a difficult time providing health care to its residents, particularly its frail elderly population. Rural health care is often faced with a shortage of health care specialists, facilities with inferior equipment, and insufficient resources compared to health care in more urban areas. It is anticipated that the use of telemedicine will help address many of the problems facing the delivery of health care services to rural elderly. This paper reviews some innovative projects delivering services to the elderly. Also, the paper discusses several issues that need to be addressed before telemedicine can reach its full potential in improving access to health care, including reimbursement policies, patient and provider liability and confidentiality, and the infrastructure supporting telemedicine. Although telecommunications has tremendous potential to address the care needs of frail isolated elderly, without comprehensive reimbursement policies, guidelines for ethical conduct of a teleconsultation, acceptable security measures of patient records, and adequate as well as compatible infrastructure, that potential cannot be completely realized.

Applications of computer-based neuropsychological assessment

OBJECTIVES

To present current applications of computer-based neuropsychological assessment, including the assessment of sports-related concussion, symptom validity testing, and the remote administration of tests through the Internet.

PROBLEM AREAS

If computer-based assessment benefits are to become popularized, a few issues will need to be addressed: the development of psychometric data based on comparisons with long-standing empirically sound test measures; additional validation of measures by parties not involved in their commercial development; increased focus on ecological validity; exploration of the usefulness of remote data storage and automated posting to databases; and improved documentation of specific computer hardware and software used in experimental methods.

CONCLUSIONS

Beyond ease of administration and data collection, computer-based assessment offers benefits over paper-and-pencil measures in the form of millisecond timing accuracy, reliable and randomized presentation of stimuli over multiple trials and repeat administrations, and unobtrusive measurement of cognitive skills and response times during all aspects of the assessment process.

Telepsychiatry and geriatric care

The use of telecommunications--telephone, computer, videoconferencing equipment--to provide mental health services at a distance has grown rapidly. This review encompasses reports from programs that provide telepsychiatry services, including telephone- and computer- based education and support services, telephone screening for dementia, and the use of videoconferencing to provide psychiatric consultations, health education, and administrative support. The extensive experience to date supports the value of telepsychiatry. Applications in geriatric settings and research involving geriatric subjects are reviewed. Cost analyses and economic evaluations of telepsychiatry are preliminary at this time and need further refinement. There is great potential for using telecommunications to expand access to mental health services to underserved geriatric populations.

Telepsychiatry in psychogeriatric service: a pilot study

A pilot study on telepsychiatry was conducted in which a videoconferencing link was established between a regional hospital and a care and attention home. Using this system, a psychogeriatric outreach team provided 149 psychiatric assessments to 45 residents of the care and attention home over 11 months. Videoconferencing was found to be highly feasible. It was acceptable to staff and patients and more cost-effective than on-site visits.

Using videoconferencing in palliative care

Recent technological advances and reducing costs have meant that videoconferencing is a possible new medium for health-care teams. The IMPaCT (Interactive Multimedia Palliative Care Training) project began in 1997 with the aims of assessing the practicalities of videoconferencing in palliative care and assessing its educational effectiveness. The use of videoconferencing was closely evaluated during the first 2 years of the project and this paper presents the results of that monitoring. Twenty-two sites were linked worldwide, reaching 136 professionals without the costs or time needed to travel. The savings on travel and time within the UK alone would have paid for the equipment in 1 year. Sites only continued with videoconferencing if they reached a point where their organization saw the advantages of videoconferencing. Links were easy to establish and rarely failed regardless of distance. Users rapidly adapted to the new medium, and links could be used in a variety of settings and audiences, including journal clubs and expert workshops. Videoconferencing offers a new and unique way of supporting palliative care professionals while reducing time and costs for both tutors and learners.

The future of Australasian psychiatrists: online or out of touch?

OBJECTIVE

The aim of this paper is to examine the delivery of mental health care which will be enabled by the various communications technologies over the next 5 to 10 years.

METHOD

A literature review, reviews of multiple Internet websites and the author's personal experience and opinions are combined to provide a commentary on the group of new technologies for communication available within health, and how they will affect the practice of psychiatry and psychiatrists over the next decade. The driving forces for these changes are the rise of consumerism, technological change and financial necessity, and it is evident that patients will have in future much greater choice of access to their therapists than at present. The health-care environment of the future will be different to today, as will the roles of psychiatrists, who will increasingly have to work as members of teams in an expert capacity rather than in traditional one-to-one practice.

CONCLUSIONS

It is concluded that it is essential for psychiatrists to become involved in online health care, and in particular to join their patients on the Internet, and that there are major opportunities for Australasian psychiatrists to provide high quality psychiatric care across national boundaries, particularly into the Asia-Pacific region.

A telemedicine system as a care modality for dementia patients in Korea

Because dementia is a chronic debilitating disease, there are the issues of the difficulty in continuous long-term care and limited accessibility to medical service. We developed the telemedicine system for dementia patients and aimed to examine the acceptance, reliability, and clinical outcome of our telemedicine service. We established the Dementia Telemedicine Center in connection with two recipient sites in 1996. The reliability of the center, which provides telemedicine, tele-education, and telecounseling services, was tested by comparing assessment via our system with in-person assessment, and the clinical outcome was assessed by rating the changes of behavioral symptoms. There have been 140 registered patients for 2 years. The general acceptance of our system by the patients and caregivers was good, and the consistency rates between the assessment via our telemedicine system and in-person assessment ranged from 76% to 89%. A considerable proportion of dementia patients in nursing homes (46%) showed relative clinical improvements through our service. Our telemedicine system seems to be reliable and effective for the assessment and care of dementia patients. Our future direction is to promote our system as a core model of the home-based care system for dementia patients.