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PubMed2005

Telepediatric surgery: capturing clinical outcomes.

PURPOSE: The aim of this study is to compare outcomes and patient characteristics of telehealth vs in-person contacts in pediatric surgery ambulatory care patients. METHODS: All non-Winnipeg telehealth patients (group 1), non-Winnipeg in-person patients (group 2), and a convenience sample of Winnipeg in-person patients (group 3) seen in the pediatric ambulatory surgical clinic and day surgery by one pediatric surgeon in a tertiary urban (Winnipeg, Manitoba) hospital between April 2002 and June 2003 were analyzed. RESULTS: There were 118, 205, and 120 (total, 443) patients and 153, 427, and 246 (total, 826) patient contacts in groups 1, 2, and 3, respectively. Of 826 patient contacts, 272 were day surgery procedures and 554 were consults and follow-ups, of which 27% (n = 152) were seen via telehealth. Of the non-Winnipeg contacts, 33.4% of consults and 51.5% of follow-ups used telehealth. Variations were seen between the telehealth and the 2 in-person groups on average age at contact, patient no-show rates, intraoperative complication rates, and postoperative complication rates. The interval to consult by telehealth decreased significantly during the course of the study. CONCLUSIONS: This is the first comparative analysis of telehealth outcomes in a population of pediatric surgery ambulatory care patients. Telehealth improves access to pediatric surgical services without untoward clinical outcomes.

Age Factors↗
PubMed1999

Web-based teledermatology consult system: preliminary results from the first 100 cases.

The TRICARE Region 1 Teledermatology Consortium has developed a secure web-based "store and forward" consult system designed to allow medical treatment facilities throughout the region to submit dermatology consults. Realizing that there is very little objective data on teledermatology, we have begun to evaluate our system through the integration of questionnaires for patients, referring physicians, and consultants in addition to telephonic patient follow up. We report the preliminary data from the first 100 cases received in the first two months since partly deploying the web based teledermatology consult system in the Tricare Region I (Northeast United States). We primarily address system effectiveness (percentage of cases that required follow up to dermatology and/or primary care physicians, adequacy of evaluating pigmented lesions) diagnostic agreement, acceptance, effect on access to care, and educational value to the primary care physicians.

Attitude of Health Personnel↗
PubMed2005

Telemedicine in maxillofacial trauma: a 2-year clinical experience.

PURPOSE: The authors report the 2-year experience of use of the PATATRAC telemedicine system in managing maxillofacial trauma. MATERIALS AND METHODS: Thirty-five regional hospitals on-line with PATATRAC in the period from January 2002-January 2004 have sent 18 consultations (11 men and 7 women) to the Maxillofacial Surgery Division of San Giovanni Battista Hospital in Turin for telemedicine evaluation of patients with maxillofacial trauma. RESULTS: Only 50% of the consultations (9 patients) sent via PATATRAC indicated maxillofacial treatment, and only one case resulted in immediate transfer. Of the remaining 8 transfers, 2 patients were transferred after treatment of associated lesions in the receiving hospital, and the other 6 patients were transferred as scheduled based on the availability of beds in the specialist center. CONCLUSIONS: The results obtained, despite the poor number of telemedicine maxillofacial consultations, have mainly proved the usefulness of PATATRAC in drastically reducing expensive and unnecessary transfers of maxillofacial patients, without indications for either immediate or deferred treatment, thus also avoiding discomfort to the patient with other injuries.

Adolescent↗
PubMed1997

Rural applications of telemedicine.

OBJECTIVES: To describe the status of telemedicine in rural America, the characteristics of health care facilities using telemedicine technologies to serve rural patients, the volume and scope of services delivered, the costs associated with this care, and the funding sources. METHODS: A screening survey was mailed to all 2472 nonfederal U.S. hospitals located outside metropolitan areas. Nonrespondents were interviewed by telephone. Those who reported some form of telemedicine capability, and all the telemedicine affiliates they named, became the sample for a detailed follow-up survey (N = 558) in January 1996. RESULTS: Ninety-six per cent of all rural hospitals responded to the screener survey, and 89% of the 558 identified telemedicine facilities responded to the detailed follow-up survey (total respondents = 499). In this cross-sectional study, two thirds of the telemedicine respondents (340) were using only teleradiology. Of the 159 telemedicine programs pursuing other clinical applications, 67% had been using telemedicine for 2 years or less. Telemedicine facilities have tried many clinical specialty applications, the most common being radiology, cardiology, and orthopedics. At this early stage of technology diffusion, reported utilization of the telemedicine systems for both clinical and nonclinical applications was very low, and the unit costs of equipment acquisition and operating expenses were corresponding high. Programs most commonly used hospital financial resources and federal grants and contracts for support. Telemedicine networks planned to grow from an average of nine facilities to an average of 13 facilities during 1996. CONCLUSIONS: Investment has been rapid in telemedicine, and the installed base reported in this survey was large, sophisticated, and growing rapidly. Nonclinical uses of the technology (e.g., meetings, training sessions, continuing medical education) were more common than clinical consultations, although the volumes of both were quite low. Investment and expansion to new sites were occurring in the absence of a favorable payor reimbursement environment and in spite of low volume at most operating sites, demonstrating optimism about the future of telemedicine and the potential for nonclinical applications.

Cost-Benefit Analysis↗
PubMed2001

Telepsychiatry as a routine service--the perspective of the patient.

Patient perspectives were examined as part of an assessment of a routine telepsychiatry service in rural Alberta. Information was gathered through self-report questionnaires and telephone interviews. Of 379 questionnaires distributed to patients, 230 (61%) were returned. Of the patients who completed questionnaires, 89% reported being satisfied with the service and 96-99% were satisfied with the equipment and the room. Twenty-nine of 31 patients who were interviewed by telephone preferred telepsychiatry to waiting for a consultation, were willing to use the service again and would recommend telepsychiatry to a friend. While 25 of these 31 patients preferred telepsychiatry to travelling to a consultation, 15 indicated that they would prefer a face-to-face interview to telepsychiatry and a further seven were unsure. Twenty-three of the 31 patients interviewed would have had to miss time from work or pay for child care in order to travel to a conventional psychiatric consultation. The availability of telepsychiatry led to an estimated cost saving of $210 per consultation for patients who would otherwise have had to travel. From the patient's perspective, telepsychiatry was an acceptable technique in the management of mental health difficulties that both increased access to services and produced cost savings.

Adolescent↗
PubMed2002

Professional's Information Link (PiL): a web-based asynchronous consultation service.

Despite the massive growth of on-line information resources, many clinicians still prefer to obtain information from other clinicians, particularly those to whom they refer patients. Based on this notion and an information needs assessment, we developed the Professional's Information Link (PiL), a Web-based asynchronous consultation service to facilitate question answering between rural clinicians and an academic medical center. The system aims to provide answers to questions within two working days. It also includes patient handouts and continuing medical education resources. Our preliminary evaluation demonstrates modest but enthusiastic use of the system.

Academic Medical Centers↗
PubMed1998

Primary-care delivery for sickle cell patients in rural Georgia using telemedicine.

BACKGROUND: Advances in newborn screening and pediatric management of sickle cell disease have resulted in patients living well into adulthood. For adults, preventive care and medication monitoring are crucial for optimal health maintenance. The Medical College of Georgia (MCG) in Augusta provides consultative services and comprehensive medical care to about 1200 sickle cell patients residing in middle and southern Georgia. An increase in the demand for clinical services in this patient population has resulted in expansion of sickle cell outreach efforts throughout the state. OBJECTIVE: A telemedicine clinic for adult sickle cell patients was established in order to meet the growing clinical demands. METHODS: An on-site outreach clinic was introduced in the target area. After 10 months of operation, a monthly telemedicine clinic was offered to patients as an option for routine medical follow-up. A clinic model was used, with scheduled appointments and a public health nurse assisting at the remote site. Phlebotomy and laboratory services enhanced the telemedicine encounter. RESULTS: Over a 12-month period, 52 encounters for 28 patients from 17 medically underserved counties were completed. All patients were African-American, and 89. 3% had Medicaid or Medicare insurance coverage or both. The clinic encounter time was 24 +/- 7.9 minutes (mean +/- SD), comparable to that for all telemedicine clinic encounters during the same period. CONCLUSIONS: The adult sickle cell population in rural Georgia accepts innovative health care delivery using telemedicine. Thus, the telemedicine sickle cell clinic has increased access to care for rural patients in underserved areas. For providers, it has allowed greater clinical productivity and diminished travel time to outreach clinics.

Adult↗
PubMed2006

Changing availability and cost of Internet physician consultations and prescription medications.

INTRODUCTION: Internet use by the public to obtain medical information and services continues to grow. In 1999, we found cost of general physician visits was 15% higher, and cost of medications was 10% greater via the Internet than from community providers. The goal of this study was to re-examine changes in product availability and costs to consumers four years later. DESIGN: We searched multiple websites 1 June 2003 - 31 August 2004, offering physician consultations and prescription medications. We compared mean cost of Internet physician visits and price per pill to costs of community-based general physicians and pharmacies in the Philadelphia region. RESULTS: We found 144 sites worldwide providing physician services and prescription medications. Mean charge for an Internet physician consultation was 55 dollars, 8.3% lower than for a comparable visit to a community practitioner. Mean cost per pill across 204 available medications was 36.7% higher at Internet sites than at local pharmacies. Shipping and handling (S&H) added a mean of 15.40 dollars. Total cost to Internet consumers was similar whether or not Internet sites charged for a physician consultation and/or S&H. Obtaining physician visits and medications over the Internet was about 40% more costly than in the local community. CONCLUSION: The Internet continues to hold great promise for provision of health and medical care services by expanding access. However, increased access to physician care and medications entails higher cost, and quality of physician services and pharmaceuticals provided remain controversial.

Health Expenditures↗
PubMed1999

Patient cost-benefit analysis of teledermatology measured in a randomized control trial.

A randomized controlled trial of the costs and benefits of teledermatology consultations compared with traditional hospital consultations was carried out. Over a nine-month period, 197 patients were referred from general practice for a dermatological opinion, 98 for a teledermatology consultation and 99 for a hospital consultation. Eighty patients required an additional subsequent hospital appointment. Patients were asked to complete an economic questionnaire after each consultation, and 164 questionnaires were returned: 62% of those randomized to the teledermatology consultation responded compared with 58% of those randomized to the hospital consultation. Patients seen by teledermatology at their own health centre had shorter distances to travel and spent less time overall attending the appointment compared with those seen at the hospital. However, the teledermatology consultations were more time-consuming for the general practitioner and dermatologist. These findings indicate that teledermatology has more benefits for the patient than for the health-care delivery team.

Adolescent↗
PubMed1999

Are dermatologists in private practice interested in teledermatological services?

Diagnosing dermatologic skin conditions can be difficult, especially in pigmented skin lesions. Therefore, the consultation of an expert via teledermatology could prove vital. For this purpose, a rapid transfer of medical data including high resolution images is essential. This transfer can be performed with a variety of modern telecommunication technologies, including ISDN, highspeed-ISDN, Internet, and Intranet. As the levels of both communication software and camera-systems can be quite different, our survey investigated the equipment of 84 dermatologists in private practice. A questionnaire was distributed on computer equipment, operating system software, and any image documentation systems used, as well as required telecommunications equipment and possible applications of tele-dermatology. This survey showed a response rate of 54% and proves that dermatologists in private practice are interested in telemedicine services. Most dermatologists surveyed use Windows 95 operating software and 74% have access to modern ISDN modems or PC-cards. Dermatologists currently prefer applications with low-tech communication hardware and software requirements. Consultation of dermatological centers was the favored application with 59%. Our survey clearly demonstrates that a high percentage of dermatologists in private practice would use tele-dermatology. In our experience, for the excellence of this service an image documentation system is essential to provide the tele-dermatological expert with standardized images with constant illumination.

Dermatology↗
PubMed2004

Use of information technology to improve quality of healthcare: Kosova's telemedicine project and international virtual e-hospital as an example.

The idea to create the Telemedicine Project of Kosova and the International Virtual e-Hospital Network of Kosova, was presented at G8-Meeting, in Berlin May 4-5, 2000, by the senior author (RL) then Assistant Professor of Surgery at Virginia Commonwealth University, in Richmond, Virginia during the presentation, the "The anatomy of war and destruction of Kosova: The alumni view on reconstruction of heath in Kosova". Following wide spread acceptance by many countries and institutions around the world of the idea of creating a virtual e-hospital in Kosova,, became a reality. To ensure the creation of a telemedicine center and realization of the project in Kosova, the Telemedicine Association of Kosova was created in Prishtina, September 30, 2000. On February 2, 2001 a Memorandum of Understanding (MOU) for the implementation of TPK was signed between all stakeholders in health in Kosova. After extensive preparation, with the funding from the European Agency for Reconstruction, the Telemedicine Center of Kosova (TCK) was inaugurated on December 10, 2002, making way for the official beginning of the first phase of development of the TPK. This historical moment for Kosova and for the Balkan countries received extensive media coverage locally and abroad. Currently we are at the second year and phase of TPK realization. The Telemedicine Center of Kosova (TCK) is a state-of-the-art telemedicine center, the best in the Balkan and southeastern Europe. As such TCK is providing basic foundations for development of educational medical programs within the Kosova's medical system; as well it is establishing the standards of regional and international consultations and collaboration in the Balkan Peninsula. Furthermore, it is providing a solid basis for creation of human capacity that will lead and implement telemedicine program in the nine regional telemedicine centers of Kosova, for many years and decades to come.

Computer Simulation↗
PubMed1997

[Our experience with a 24-hour on-call program in Nihon University Hospitals].

We must recognize that undergraduate clinical training is insufficient in Japan and that we need to improve the role of the laboratory medicine, especially in the area of communication. Therefore, postgraduate training in clinical pathology/laboratory medicine should include; 1. Basic clinical skills (Communication skills, physical examination and common laboratory procedures such as Gram's stain, Wright-Giemsa stain, etc.), 2. Principles, instrumentation and techniques of each discipline of this broad scientific field, 3. How laboratory information is used in a medical setting, 4. The role of the clinical pathologist/laboratory physician in interacting with laboratory staff, physicians and patients. There is an increasing gap between the clinic and the laboratory. Current needs require us to make a major attempt to bridge this gap. This effort will require new and resourceful means of communication and interaction. A 24-hour on-call program was established to enrich the training of the clinical pathology residents in the USA. Each resident in the program is responsible for being on call, which entails learning the day-to-day operation of the laboratory and being available to interpret laboratory data when the need arises. Residents are expected to refer to the appropriate staff member those situations that he or she feels unable to handle. A review of all on-call problems with staff provides to be a valuable education tool, both for the residents and the staff. This learning strategy was adopted from UCSF Hospital and introduced to Nihon University Itabashi Hospital by K. Kumasaka MD in 1984. And that after 12 years of actual experience, we conclude the training program provides a readily available consultative service for the house staff, and facilitates patient care. In addition, we should make rounds with physicians and go to conferences in areas of interest and responsibilities. We could be mainly responsible for a number of problem-solving areas within the laboratory that would be directly responsive to patient problems encountered by physicians.

Clinical Competence↗
PubMed2002

The North Lewisham telepsychiatry project: beyond the pilot phase.

The integration of a telepsychiatry application into an inner-city community mental health service was evaluated over 10 months. ISDN videoconferencing at 128 kbit/s was employed for psychiatric consultation between a primary care centre and a community mental health centre. A convenience sample of patients and referrals seen by videoconferencing was compared with a sample seen face to face. During the study period 19 patients were managed by videoconferencing and 12 face to face. There were 162 consultations, comprising 81 prearranged teleconsultations and 81 prearranged face-to-face consultations. There was no significant difference in attendance between videoconferencing and face-to-face consultations. Nine of the videoconferencing new referrals had not completed their treatment at the end of the study period, compared with only three in the face-to-face group. This implies that it takes longer to complete treatment for new referrals managed by videoconferencing.

Adult↗
PubMed2000

Practicing dentistry in the age of telemedicine.

BACKGROUND: This article examines teledentistry and some of its current legal issues. Topics include licensure, malpractice, technology and ethics. General recommendations for the dental practitioner are included. The literature review includes state and federal laws, the Telemedicine Report to Congress and numerous articles (both printed and electronic) associated with the topic. Sources were selected for timeliness and relevance to legal issues and implications of telemedicine/teledentistry for the dental practitioner. CONCLUSIONS: Numerous issues require resolution before telemedicine and teledentistry will truly realize their enormous potential to increase access to health care while decreasing health care costs. These issues include interstate licensure, jurisdiction and malpractice, as well as technological, security and ethical questions. PRACTICE IMPLICATIONS: Telemedicine and teledentistry are relatively new to the dental field. Many of the legal issues reviewed have yet to be resolved by the legislature or the courts. Furthermore, technology has not yet progressed to the point where the practitioner can be certain that no technological failure will occur during a teledental consultation. In spite of these problems, the potential of telemedicine and teledentistry is tremendous. Improvement in accessibility of health care and lowered health care costs are only two of the many advantages that will emerge as telemedicine and teledentistry become integrated with, and fundamentally change, the practice of medicine and dentistry.

Computer Graphics↗
PubMed2005

A tele-ultrasound needs analysis in Queensland.

A tele-ultrasound survey was distributed to clinicians and sonographers in regional and rural sites throughout Queensland. In all, 28 centres were invited to complete a profile questionnaire, and 27 centres were invited to complete a case-log. Twenty-five of the 28 questionnaires were returned (89% response rate). Twenty-two of the 27 case-logs were returned (81% response rate). Obstetric ultrasound was the most frequently performed ultrasound examination, accounting for 846 (35%) of the 2,410 recorded during the two-week survey period. The respondents considered that 182 cases would have benefited from further consultation: 79% for diagnostic advice, 13% for patient management advice and 8% for advice on examination technique. Six hospitals appeared to have the greatest need for a tele-ultrasound service. There was a strong preference for the store-and-forward transmission of static images: 70% preferred this modality, in comparison with 19% who preferred realtime transmission and 11% who preferred store-and-forward transmission of video clips.

Female↗
PubMed2003

Mystery shopping in health service evaluation.

BACKGROUND: Over the last 5 years, primary care telephone triage systems have been introduced in the United Kingdom, United States, Australia, and most recently in New Zealand. Evaluation of the clinical safety of such systems poses a challenge for health planners and researchers. AIM: To evaluate the use of simulated patients in the assessment of aspects of clinical safety in a pilot New Zealand primary care telephone triage service. DESIGN OF STUDY: 'Mystery shopping', an evaluation strategy commonly used in market research, was adapted by using simulated patients for telephone triage service evaluation. SETTING: New Zealand. METHODS: Four scripted clinical scenarios were developed by academic general practitioners, validated in student teaching situations, and then used by simulated patients to make 101 telephone calls. The scenarios were designed to necessitate a referral to a medical practitioner for further investigation. The documentation kept by the callers was compared with the call records from the telephone triage company, and both were analysed for capture and handling of the clinical safety features of each scenario. In cases where the endpoint was not a medical assessment, possible reasons for this were explored. RESULTS: Records were retrieved for 85 telephone calls. Considerable triage variability was discovered. There were discrepancies between expected and actual triage outcomes with 51% of analysed calls resulting in a self-care recommendation. A number of reasons were identified both for the triage variability and the unpredicted outcomes. Audiotaping of consultations would have enhanced the credibility of the evaluation but it would have carried ethical constraints. CONCLUSION: Simulated patients can be used to evaluate the limitations of health services and to identify areas that could be addressed to improve patient safety. Evaluation of patient satisfaction with services is not sufficient alone to evaluate safety.

Adult↗
PubMed2001

Teledermatology in New Zealand.

BACKGROUND: Teledermatology is the delivery of specialist dermatological services at a distance. It has become possible because of technological advances in digital imaging and telecommunications. Consultations may be "interactive" using video-conferencing equipment or "store-and-forward" using prerecorded text and images. The best method to deliver teledermatology services is unknown. OBJECTIVE: Studies were designed to determine (a) if it was possible to diagnose and manage skin diseases using video-conferencing equipment, (b) if teledermatology was acceptable to patients and medical practitioners, and (c) whether it offered any economic advantages. We have also compared interactive and store-and-forward techniques. METHOD: The trials were conducted in collaboration with the Institute of Telemedicine & Telecare, Queen's University, Belfast, as part of the UK Teledermatology Trials. RESULTS: The trials have involved more than 300 teledermatology consultations. Having established that a diagnosis can be made in more than two-thirds of the cases, the majority of video consultations have resulted in satisfactory management, with only small numbers of patients requiring face-to-face review. Teledermatology is generally popular with patients and can save them considerable time and money. Routine clinics continue in three centers. We have found that effective store-and-forward teledermatology requires very good images and comprehensive historical referral data.

Attitude of Health Personnel↗
PubMed1998

Shared care for diabetes: supporting communication between primary and secondary care.

As health care becomes more complex, interest in the benefits of coordination of care has increased. Especially patients that are being treated jointly by more than one physician (shared care), are vulnerable to adverse effects resulting from inadequate coordination and communication. We describe a study in which care providers support shared care by using computer-based patient records for data storage, and structured electronic data interchange (EDI) as a means of communication. The study showed that the electronic communication network for exchanging consultation outcomes significantly increased frequency of communication and the availability of data to the general practitioner on diagnostic procedures performed in the hospital, thus providing more complete information about the care that patients are receiving.

Computer Communication Networks↗