A review of the first year's experience with an automatic message-routing system for low-cost telemedicine

The Swinfen Charitable Trust has used email for some years as a low-cost telemedicine medium to provide consultant support for doctors in developing countries. A scalable, automatic message-routing system was constructed which automates many of the tasks involved in message handling. During the first 12 months of its use, 1510 messages were processed automatically. There were 128 referrals from 18 hospitals in nine countries. Of these 128 queries, 89 (70%) were replied to within 72 h; the median delay was 1.1 day. The 39 unanswered queries were sent to backup specialists for reply and 36 of them (92%) were replied to within 72 h. In the remaining three cases, a second-line (backup) specialist was required. The referrals were handled by 54 volunteer specialists from a panel of over 70. Two system operators, located 10 time zones apart, managed the system. The median time from receipt of a new referral to its allocation to a specialist was 0.2 days (interquartile range, IQR, 0.1-0.8). The median interval between receipt of a new referral and first reply was 2.6 days (IQR 0.8-5.9). Automatic message handling solves many of the problems of manual email telemedicine systems and represents a potentially scalable way of doing low-cost telemedicine in the developing world.

Isoform specific changes in calcium transporters in colon and breast cancer cell lines

Calcium transporters play vital roles in the transport of calcium ions across cells of the mammary gland and the intestine. One such transporter is the plasma membrane Ca2+-ATPase (PMCA), of which there are 4 different genes (PMCA1-4). In these studies we investigated the hypothesis that the expression of PMCA is altered in HT-29 colon cancer cells during sodium butyrate and post-confluence mediated differentiation. We also investigated if PMCA expression is altered in breast cancer cell lines in an isofrom specific manner. Our results indicate isoform specific changes in PMCA mRNA and protein levels in HT-29 cells during differentiation, using real time RT-PCR and western blotting, respectively. We also observed pronounced alterations in the mRNA levels of the PMCA isoform linked to lactation (PMCA2) in a bank of breast cancer cell lines compared to normal cell lines. Changes in other isoforms were less pronounced. To further study the role of specific calcium transporters we have optimised conditions for the reverse transfection of MCF-7 breast cancer cells using NeoFX (Ambion). Using real time RT-PCR we have confirmed gene knockdown for specific isoforms and have studied the time course of knockdown over 96 hours. We see approximately 68 % inhibition at 24 hours increasing to 84 % 96 hours post-reverse transfection. Our studies suggest that the expression of specific calcium transporter isoforms can be significantly altered in cancer cell lines and that isoform specific inhibition of calcium transporters is possible using reverse transfection of siRNA

Government relations, government regulations: Jumping through the hoops

Over the last decade, telehealth in Australia has been primarily facilitated and driven by government funding. The government now has a major policy initiative in online health. However, in pursuing the broad initiative there is a danger that some of the smaller components can get lost, and this is probably what has happened to telehealth. There appear to be a number of steps required if telehealth in Australia is to keep up the pace of development that occurred in the 1990s, as we move into what is now being called the era of e-health, involving broadband Internet health service delivery. This area is changing extremely rapidly and is increasingly migrating away from the public sector in Australia, where most of the developmental work has occurred, and into the private sector. Many of the issues that require consideration within the domain of e-health in Australia are also relevant to other countries. E-health will significantly change the way that health-care is practised in future, and it is clear that it is the human factors that are more difficult to overcome, rather than the technological ones.

Developing a protocol for the use of telenursing in community health in Australia

As the first step in developing a protocol for the use of video-phones in community health, we carried out a feasibility study among clients with a range of health needs. Clients were equipped with a commercially available video-phone connected using the client's home telephone line. A hands-free speaker-phone and a miniature video-camera (for close-up views) were connected to the video-phone. Ten clients participated: five required wound care, two palliative care, two long-term therapy monitoring and one was a rural client. All but two were aged 75 years or more. Each client had a video-phone for an average of two to three weeks. During the six months of the study, 43 client calls were made, of which 36 (84%) were converted to video-calls. The speaker-phone was used on 24 occasions (56%) and the close-up camera on 23 occasions (53%). Both clients and nurses rated the equipment as satisfactory or better in questionnaires. None of the nurses felt that the equipment was difficult to use, including unpacking it and setting it up; only one client found it difficult. Taking into account the clients' responses, including their free-text comments, a judgement was made as to whether the video-phone had been useful to their nursing care. In seven cases it was felt to be unhelpful and in three cases it was judged helpful. Although the study sample was small, the results suggest that home telenursing is likely to be useful for rural clients in Australia, unsurprisingly, because of the distances involved.

A comparison of telepaediatric activity at two regional hospitals in Queensland

We conducted a 15-month feasibility study of telepaediatrics. A novel service was offered to two hospitals in Queensland (Mackay and Hervey Bay). We used data from all other hospitals throughout the state as the control group. Although both intervention hospitals were provided with the same service, the telepaediatric activity generated and the effect on admissions and outpatient activity were markedly different. There was a significant decrease in the number of patient admissions to Brisbane from the Mackay region. In addition, there was an increase in the number of Mackay patients treated locally (as outpatients). In contrast, little change was observed in Hervey Bay. We assessed whether the observed differences between the two hospitals were due to various factors which influenced the use of the telepaediatric service. These factors included the method of screening patients before transfer to the tertiary centre and the physical distance between each facility and the tertiary centre. We believe that the screening method used for patient referrals was the most important determinant of the use of the telepaediatric service.

Child development services: a multidisciplinary approach to professional education via videoconference

We have piloted a monthly series of multidisciplinary case discussions via videoconference in the area of child development. The project provided a forum for clinical discussion of complex cases, peer review, professional development and networking for allied health professionals and paediatricians. Six sites in Queensland participated in the project; each site presented at least one case for discussion. The videoconferences ran for 90 min each and were attended by an average of 26 health professionals. The response rate for a questionnaire survey was 71%. The respondents rated the effectiveness of case summaries and the follow-up newsletter very positively. Despite some early difficulties with the technical aspects of videoconferencing, the evaluation demonstrated the participants' satisfaction with the project and its relevance to their everyday practice.

Logistical aspects of large telemedicine networks. 2: Measurement of network activity

We carried out a retrospective review of the videoconference activity records in a university-run hospital telemedicine studio. Usage records describing videoconferencing activity in the telemedicine studio were compared with the billing records provided by the telecommunications company. During a seven-month period there were 211 entries in the studio log: 108 calls made from the studio and 103 calls made from a far-end location. We found that 103 calls from a total of 195 calls reported by the telecommunications company were recorded in the usage log. The remaining 92 calls were not recorded, probably for one of several reasons, including: failed calls-a large number of unrecorded calls (57%) lasted for less than 2 min (median 1.6 min); origin of videoconference calls-calls may have been recorded incorrectly in the usage diary (i.e. as being initiated from the far end, when actually initiated from the studio); and human error. Our study showed that manual recording of videoconference activity may not accurately reflect the actual activity taking place. Those responsible for recording and analysing videoconference activity, particularly in large telemedicine networks, should do so with care.

User satisfaction with allied health services delivered to residential facilities via videoconferencing

We have investigated the role of videoconferencing in allied health service provision to high-care clients in rural residential facilities. Videoconferencing equipment was set up at a rural aged-care facility and a metropolitan allied health centre; ISDN transmission at 384 kbit/s was used to link the equipment. Twelve residents were assessed by both videoconference and face to face across five allied health disciplines (a total of 120 assessments). User satisfaction was measured using questionnaires and focus groups. Face-to-face assessment took significantly longer than videoconferencing assessment. However, the mean satisfaction ratings for face-to-face assessments were higher than for videoconferencing and the majority of the staff preferred the face-to-face format. Videoconferencing was particularly useful for consultations and the initial stages of the assessment process. A number of issues relating to the videoconferencing equipment, to the environment in which assessments were performed and to the clients themselves need to be addressed in order for this form of service delivery to be effective.

Enhancing experiential learning via virtual environments

Research indicates Virtual Reality (VR) is delivering on it's promised potential to provide enhanced training and education outcomes. A significant research project, at the University of Queensland, has constructed a number of virtual contexts in which the phenomena experienced by patients who have psychosis are reproduced for use in psychiatry education. Symptoms of psychosis reproduced include delusions, hallucinations and thought disorder. The new software enables psychiatry students to experience the inner world of a patient with psychosis. Lecturers in psychiatry report VR has the potential to enhance student's abilities to actually 'feel' the types of emotions and physiological reactions a hallucination precipitates in a patient. The current work of the project and stages of software development will be demonstrated. The virtual environments provide a new method of delivering experiential learning opportunities to higher education classrooms.