Telehealth and the diagnosis and management of cardiac disease

The financial and personal burden of chronic cardiac disease is high. Costs are likely to increase over the next few decades. Promising applications of telehealth have appeared in the diagnosis and management of cardiac disease and there are indications that telehealth services can improve the management of chronic cardiac disease as well as extend services to remote and rural populations. Telehealth has been applied to the capture of symptoms of cardiac disease with electrocardiography and echocardiography, to the management and rehabilitation of recently discharged patients, and in peer-to-peer consultation where remote expertise can facilitate diagnosis. Telehealth promises cost reductions in service delivery, although there is a need for properly controlled cost-effectiveness trials to underpin telehealth with a firm evidence base.

Minimum acceptable standards for digital compression of a fetal ultrasound video-clip

If the Internet could be used as a method of transmitting ultrasound images taken in the field quickly and effectively, it would bring tertiary consultation to even extremely remote centres. The aim of the study was to evaluate the maximum degree of compression of fetal ultrasound video-recordings that would not compromise signal quality. A digital fetal ultrasound videorecording of 90 s was produced, resulting in a file size of 512 MByte. The file was compressed to 2, 5 and 10 MByte. The recordings were viewed by a panel of four experienced observers who were blinded to the compression ratio used. Using a simple seven-point scoring system, the observers rated the quality of the clip on 17 items. The maximum compression ratio that was considered clinically acceptable was found to be 1:50-1:100. This produced final file sizes of 5-10 MByte, corresponding to a screen size of 320 x 240 pixels, running at 15 frames/s. This study expands the possibilities for providing tertiary perinatal services to the wider community.

Realtime fetal ultrasound by telemedicine in Queensland. A successful venture?

We have established a realtime fetal tele-ultrasound consultation service in Queensland, which has been integrated into our routine clinical practice, The service, which uses ISDN transmission at 384 kbit/s, allows patients in Townsville to be examined by subspecialists in Brisbane, 1500 km away. For the 90 tele-ultrasound consultations performed for the first 71 patients, 90% of the babies have been delivered, and outcome data have been received on all the pregnancies. All significant anomalies and diagnoses have been confirmed. The referring clinicians would have physically referred 24 of the 71 patients to Brisbane in the absence of telemedicine. A crude cost-benefit calculation suggests that the tele-ultrasound service resulted in a net saving of A$6340, and at the same time enabled almost four times the number of consultations to be carried out.

Research into telehealth applications in speech-language pathology

A literature review was conducted to investigate the extent to which telehealth has been researched within the domain of speech-language pathology and the outcomes of this research. A total of 13 studies were identified. Three early studies demonstrated that telehealth was feasible, although there was no discussion of the cost-effectiveness of this process in terms of patient outcomes. The majority of the subsequent studies indicated positive or encouraging outcomes resulting from telehealth. However, there were a number of shortcomings in the research, including a lack of cost-benefit information, failure to evaluate the technology itself, an absence of studies of the educational and informational aspects of telehealth in relation to speech-language pathology, and the use of telehealth in a limited range of communication disorders. Future research into the application of telehealth to speech-language pathology services must adopt a scientific approach, and have a well defined development and evaluation framework that addresses the effectiveness of the technique, patient outcomes and satisfaction, and the cost-benefit relationship.

Barriers to effective cancer pain management: A survey of hospitalized cancer patients in Australia

The purpose of this study was to examine attitudinal barriers to effective pain management in a consecutively recruited cohort of 114 cancer patients from four Australian hospitals. When surveyed, 48% of this sample reported experiencing pain within the previous 24 hours. Of these, 56% reported this pain to be distressing, horrible or excruciating, with large proportions indicating that this pain had affected their movement, sleep and emotional well-being. Three factors were identified as potentially impacting on patients responses to pain-poor levels of patient knowledge about pain, low perceived control over pain, and a deficit in communication about pain. A trend for older patients to experience more severe pain was also identified. These older patients reported being more willing to tolerate pain and perceive less control over their pain. Suggestions are made for developing patient education programs and farther research using concepts drawn from broader social and behavioral models. J Pain Symptom Manage 2002:23:393-405. (C) U.S. Cancer Pain Relief Committee, 2002.

Physical outcome measurements via the Internet: reliability at two Internet speeds

We have developed a software application to enable interactive rehabilitation via the Internet. The reliability of the telemedicine application was examined by comparing it with face-to-face assessment. The physical outcome measures assessed were knee range of motion, quadriceps muscle strength, limb girth and an assessment of gait. One therapist performed both in-person and Internet-based measurements of all outcome measures on 20 normal subjects. There was good agreement between the two techniques (the 95% limits of agreement included zero for all the variables studied). Internet assessments were conducted at two bandwidths: ISDN at 128 kbit/s and the telephone network at 17 kbit/s. Bandwidth had no significant influence on any of the measures. This study suggests that Internet-based physiotherapy interventions delivered to the home are suitable for further development.

Assessing clinical reasoning: a method to monitor its development in a PBL curriculum

The aim of this study was to develop and trial a method to monitor the evolution of clinical reasoning in a PBL curriculum that is suitable for use in a large medical school. Termed Clinical Reasoning Problems (CRPs), it is based on the notion that clinical reasoning is dependent on the identification and correct interpretation of certain critical clinical features. Each problem consists of a clinical scenario comprising presentation, history and physical examination. Based on this information, subjects are asked to nominate the two most likely diagnoses and to list the clinical features that they considered in formulating their diagnoses, indicating whether these features supported or opposed the nominated diagnoses. Students at different levels of medical training completed a set of 10 CRPs as well as the Diagnostic Thinking Inventory, a self-reporting questionnaire designed to assess reasoning style. Responses were scored against those of a reference group of general practitioners. Results indicate that the CRPs are an easily administered, reliable and valid assessment of clinical reasoning, able to successfully monitor its development throughout medical training. Consequently, they can be employed to assess clinical reasoning skill in individual students and to evaluate the success of undergraduate medical schools in providing effective tuition in clinical reasoning.

Telemedicine for new neurological outpatients: putting a randomized controlled trial in the context of everyday practice

In a retrospective review, the telemedical management of 65 outpatients from a randomized controlled trial (RCT) of telemedicine for non-urgent referrals to a consultant neurologist was compared with the management of 76 patients seen face to face in the same trial, with that of 150 outpatients seen in the neurology clinics of district general hospitals and with that of 102 neurological outpatients seen by general physicians. Outcome measures were the numbers of investigations and of patient reviews. The telemedicine group did not differ significantly from the 150 patients seen face to face by neurologists in hospital clinics in terms of either the number of investigations or the number of reviews they received. Patients from the RCT seen face to face had significantly fewer investigations but a similar number of reviews to the other 150 patients seen face to face by neurologists (the disparity in the number of investigations may explain the negative result for telemedicine in that RCT). Patients with neurological symptoms assessed by general physicians had significantly more investigations and were reviewed significantly more often than all the other groups. Patients from the RCT seen by telemedicine were not managed significantly differently from those seen face to face by neurologists in hospital clinics but had significantly fewer investigations and follow-ups than those patients managed by general physicians. The results suggest that management of new neurological outpatients by neurologists using telemedicine is similar to that by neurologists using a face-to-face consultation, and is more efficient than management by general physicians.

A review of guidelines and standards for telemedicine

We conducted a review to establish the range and scope of current telemedicine guidelines and standards. Published guidelines were identified by searching the Medline and Telemedicine Information Exchange (TIE) databases, and by performing a Google search using the term 'telemedicine guidelines'. Three types of guidelines were identified, namely clinical, operational and technical. Clinical guidelines included those for teleradiology, telepsychiatry, home telenursing, minor injuries telemedicine, surgical telemedicine, teledermatology and telepathology. Operational guidelines included those for email communication, Internet access and videoconferencing. Technical guidelines included those from the American Telemedicine Association and the US Office for the Advancement of Telehealth. The main standards relevant to telemedicine include those of the International Telecommunication Union and the DICOM standard. The scarcity of guidelines and standards suggests that telemedicine is not yet near to routine use. If an international telemedicine organization were to take responsibility for defining guidelines, under the direction of clinicians with appropriate telemedicine experience, this might speed up their development.

Terminally ill cancer patients' wish to hasten death

This exploratory study investigated factors associated with the wish to hasten death among a sample of terminally ill cancer patients. Semi-structured interviews conducted on a total of 72 hospice and home palliative care patients were subjected to qualitative analysis using QSR-NUDIST. The main themes to emerge suggested that patients with a high wish to hasten death had greater concerns with physical symptoms and psychological suffering, perceived themselves to be more of a burden to others, and experienced higher levels of demoralization, while also reporting less confidence in symptom control, fewer social supports, less satisfaction with life experiences and fewer religious beliefs when compared with patients who had a moderate or no wish to hasten death. The implications of these findings will be discussed.

Randomized comparison of the quality of realtime fetal ultrasound images transmitted by ISDN and by IP videoconferencing

We compared the quality of realtime fetal ultrasound images transmitted using ISDN and IP networks. Four experienced obstetric ultrasound specialists viewed standard recordings in a randomized trial and rated the appearance of 30 fetal anatomical landmarks, each on a seven-point scale. A total of 12 evaluations were performed for various combinations of bandwidths (128, 384 or 768 kbit/s) and networks (ISDN or IF). The intraobserver coefficient of variation was 2.9%, 5.0%, 12.7% and 14.7% for the four observers. The mean overall ratings by each of the four observers were 4.6, 4.8, 5.0 and 5.3, respectively (a rating of 4 indicated satisfactory visualization and 7 indicated as good as the original recording). Analysis of variance showed that there were no significant interobserver variations nor significant differences in the mean scores for the different types of videoconferencing machines used. The most significant variable affecting the mean score was the bandwidth used. For ISDN, the mean score was 3.7 at 128 kbit/s, which was significantly worse than the mean score of 4.9 at 384 kbit/s, which was in turn significantly worse than the mean score of 5.9 at 768 kbit/s. The mean score for transmission using IP was about 0.5 points lower than that using ISDN across all the different bandwidths, but the differences were not significant. It appears that IP transmission in a private (non-shared) network is an acceptable alternative to ISDN for fetal tele-ultrasound and one deserving further study.

The family costs of attending hospital outpatient appointments via videoconference and in person

We compared the costs incurred by families attending outpatient appointments at the Royal Children's Hospital (RCH) in Brisbane with those incurred by families who had a consultation via videoconference in their regional area. In each category 200 families were interviewed. The median time spent travelling for videoconferences was 30 min compared with 80 min for face-to-face appointments. Families interviewed in the outpatient department had travelled a median distance of 70 km, while those who had a videoconference at the local hospital had travelled only 20 km. It cost these families much more to attend an appointment at the RCH than to attend a videoconference. Ninety-six per cent of families (193) reported at least one of the following types of expense: 150 families had expenses related to parking (median A$10), 156 had fuel expenses (median A$10) and 122 reported costs related to meals purchased at the RCH (median A$10). Only 21 families who had their appointment via local videoconference reported any additional costs. Specialist appointments via videoconference were a more convenient and cheaper option for families living in regional areas of Queensland than the conventional method of attending outpatient appointments at the specialist hospital in Brisbane.

The diagnostic reliability of Internet-based observational kinematic gait analysis

We investigated the accuracy and reliability of observational kinematic gait assessments performed via a low-bandwidth Internet link (118 kbit/s) and a higher-speed Internet link (128 kbit/s). Twenty-four subjects were randomized to either bandwidth group. Gait was assessed with the Gait Assessment Rating Scale (GARS) in the traditional manner, which is from video-recordings, and with repeated measurements via the online method. Online assessment was found to provide as accurate a measure of gait performance as the traditional assessment (limits of agreement