The importance of setting and evaluating standards of telemedicine training

The importance of appropriate training in the use of videoconferencing equipment for clinical purposes is often underestimated when telemedicine projects are established. We developed a user training programme which was delivered via videoconferencing to a group of 130 nurses. Training was delivered on a one-to-one basis. A questionnaire was developed to evaluate user satisfaction and the effectiveness of training. One hundred and two fully completed questionnaires were returned (a 79% response rate). High levels of satisfaction were obtained but the level of user competence reached 100% only when training was supported by a training manual and at least weekly practice. Before establishing a telemedicine service, the following steps appear to be important: identify the required training competencies; deliver a 'hands on' training programme based on the required training competencies; back up the training programme with an instruction booklet; ensure that trainees have at least weekly practice; measure the level of user competence.

Is there a role for telemedicine in adult allergy services?

Telemedicine refers to the application of telecommunication and information technology (IT) in the delivery of health and clinical care at a distance or remotely and can be broadly considered in two modalities: store-and-forward and real-time interactive services. Preliminary studies have shown promising results in radiology, dermatology, intensive care, diabetes, rheumatology and primary care. However, the evidence is limited and hampered by small sample sizes, paucity of randomised controlled studies and lack of data relating to cost-effectiveness, health related quality of life and patient and clinician satisfaction. This review appraises the evidence from studies that have employed telemedicine tools in other disciplines and makes suggestions for its potential applications in specific clinical scenarios in adult allergy services. Possible examples include: triaging patients to determine the need for allergy tests; pre-assessment for specialised treatments such as allergen immunotherapy; follow up to assess treatment response and side effects; and education in self-management plan including training updates for self-injectable adrenaline and nasal spray use. This approach might improve access for those with limited mobility or living far away from regional centres, as well as bringing convenience and cost savings for the patient and service provider. These potential benefits need to be carefully weighed against evidence of service safety and quality. Keys to success include delineation of appropriate clinical scenarios, patient selection, training, IT support and robust information governance framework. Well-designed prospective studies are needed to evaluate its role. This article is protected by copyright. All rights reserved.

Moving tele-monitoring and tele-treatment from promise to practice : a business model approach for a chronic lower back pain application

The availability of new information and communication technologies creates opportunities for new, mobile tele-health services. While many promising tele-health projects deliver working R&D prototypes, they often do not result in actual deployment. We aim to identify critical issues than can increase our understanding and enhance the viability of the mobile tele-health services beyond the R&D phase by developing a business model. The present study describes the systematic development and evaluation of a service-oriented business model for tele-monitoring and -treatment of chronic lower back pain patients based on a mobile technology prototype. We address challenges of multi-sector collaboration and disruptive innovation.

The Chronic Heart-Failure Assistance by Telephone (CHAT) Study: Assessment of Telephone Support for Vulnerable Patients with Chronic Disease

Aim: To determine whether telephone support using an evidence-based protocol for chronic heart failure (CHF) management will improve patient outcomes and will reduce hospital readmission rates in patients without access to hospital-based management programs. Methods: The rationale and protocol for a cluster-design randomised controlled trial (RCT) of a semi-automated telephone intervention for the management of CHF, the Chronic Heart-failure Assistance by Telephone (CHAT) Study is described. Care is coordinated by trained cardiac nurses located in Heartline, the national call center of the National Heart Foundation of Australia in partnership with patients’ general practitioners (GPs). Conclusions: The CHAT Study model represents a potentially cost-effective and accessible model for the Australian health system in caring for CHF patients in rural and remote areas. The system of care could also be readily adapted for a range of chronic diseases and health systems. Key words: chronic disease management; chronic heart failure; integrated health care systems; nursing care, rural health services; telemedicine; telenursing

[Letter to the Editor] Telemonitoring in Patients with Heart Failure

To the Editor: Chaudhry et al. suggest that enhanced support in the use of a telephone-based interactive voice-response system for patients recently discharged after worsening heart failure does not improve outcomes. This finding is broadly consistent with previous systematic reviews of telephone support1 and contrasts with the substantial effect observed with home telemonitoring of vital signs in similar populations.1 The treatment of patients in the control group was excellent, but unrepresentative of usual clinical care and not inferior to the treatment of patients receiving enhanced support. Monitoring alone is unlikely to improve outcomes but may do so when it improves prescription of or adherence to lifesaving treatments. Given enough resources, traditional methods for delivering care may render an interactive voice-response system or a home telemonitoring system ineffective. Nonetheless, there may be more cost-efficient approaches to ensuring quality care.2 Informal post hoc addition of these data to our recent meta-analysis of telephone support1 does not substantially alter the point estimates for death from any cause or heart-failure−related hospitalizations, but it does nullify the small benefit in hospitalizations for any cause, which may not be reduced by a heart-failure−focused intervention.1 Original article: Telemonitoring in Patients with Heart Failure NEJM. December 9, 2010 | S.I. Chaudhry and Others

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 (P0) and the weighted kappa statistic with linear weight (Kw) 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 (P0= 0.71; Kw = 0.52; P < .0001) and agreement for the Standard Practice group (P0= 0.70; Kw = 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.

A secure telehealth system for ubiquitous health environment

U-Healthcare means that it provides healthcare services "at anytime and anywhere" using wired, wireless and ubiquitous sensor network technologies. As a main field of U-healthcare, Telehealth has been developed as an enhancement of Telemedicine. This system includes two-way interactive web-video communications, sensor technology, and health informatics. With these components, it will assist patients to receive their first initial diagnosis. Futhermore, Telehealth will help doctors diagnose patient's diseases at early stages and recommend treatments to patients. However, this system has a few limitations such as privacy issues, interruption of real-time service and a wrong ordering from remote diagnosis. To deal with those flaws, security procedures such as authorised access should be applied to as an indispensible component in medical environment. As a consequence, Telehealth system with these protection procedures in clinical services will cope with anticipated vulnerabilities of U-Healthcare services and security issues involved.

Personalised electronic messages to improve sun protection in young adults

The incidence of all skin cancers, including melanoma, continues to rise. It is well known that ultraviolet (UV) radiation is the main environmental risk factor for skin cancer, and excessive exposure at a young age increases the risk of developing skin cancer. The aim of this study was to determine the acceptability and feasibility of delivering sun protection messages via electronic media such as short message services (SMS) to people 18-40 years, and explore factors associated with their acceptability. Overall, 80% of participants agreed that they would like to receive some form of sun protection advice; of these, 20% prefer to receive it via SMS and 42% via email. Willingness to receive electronic messages about the UV index was associated with being unsure about whether a suntanned person would look healthy and greater use of sun protection in the past. Careful attention to message framing and timing of message delivery and focus on short-term effects of sun exposure such as sunburn and skin ageing should increase the acceptability of such messages to young people. We conclude that sun protection messages delivered to young adults via electronic media appear feasible and acceptable.

Telehealth for nursing homes: the utilization of specialist services for residential care

Specialist care consultations were identified by two research nurses using documentation in patient records, appointment diaries, electronic billing services and on-site observations at a 441-bed long term care facility. Over a six-month period there were 3333 consultations (a rate of 1511 consultations per year per 100 beds). Most consultations were for general practice (n = 2589, 78%); these consultations were mainly on site (99%), with only 27 taking place off site. There were 744 consultations for specialities other than general practice. A total of 146 events related to an emergency or unplanned hospital admission. The remaining medical consultations (n = 598, 18%) related to 23 medical specialities. The largest number of consultations were for surgery (n = 106), podiatry (n = 100), nursing services including wound care (n = 74), imaging (n = 41) and ophthalmology (n = 40). Many services which are currently being provided on site to metropolitan long-term care facilities could be provided by telehealth in both urban and rural facilities.

Emerging work practice with a telehealth stethoscope

We investigated the collaboration of ten doctor-nurse pairs with a prototype digital telehealth stethoscope. Doctors could see and hear the patient but could not touch them or the stethoscope. The nurse in each pair controlled the stethoscope. For ethical reasons, an experimenter stood in for a patient. Each of the ten interactions was video recorded and analysed to understand the interaction and collaboration between the doctor and nurse. The video recordings were coded and transformed into maps of interaction that were analysed for patterns of activity. The analysis showed that as doctors and nurses became more experienced at using the telehealth stethoscope their collaboration was more effective. The main measure of effectiveness was the number of corrections in stethoscope placement required by the doctor. In early collaborations, the doctors gave many corrections. After several trials, each doctor and nurse had reduced corrections and all pairs reduced their corrections. The significance of this research is the identification of the qualities of effective collaboration in the use of the telehealth stethoscope and telehealth systems more generally.