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PubMed2004

Neurosurgical teleconsultations in northern Norway.

We carried out a prospective study of the effect of neurosurgical teleconsultations on patient management in northern Norway. The total number of teleradiology image transfers during an eight-month study period was 723. We recorded data on 99 (14%) of these teleconsultations, which concerned 92 patients; the remainder were transfers to other departments at our hospital and transfers of routine examinations from a small community hospital that did not have a radiologist. The neurosurgeon on call noted the clinical condition and response time for each consultation. The consequences of the teleconsultation and the eventual benefits of the image transfer were evaluated. All 10 referring hospitals in the region used the service. The median response time was 3 hours (range 1-21 hours) in emergency cases and 1 day (range 1-7 days) in ordinary consultations. The response time was significantly shorter for patients with head injuries (median 3 hours) than for those with intracranial tumours (median 24 hours). Image transfer was considered beneficial for the patient in 93% of the cases. Avoidance of unnecessary patient transfer, changes of treatment at the referring hospital on the advice of the neurosurgeon and initiation of emergency transfer occurred in 34%, 42% and 13% of cases, respectively. The results confirm that teleconsultations between referring hospitals and a regional neurosurgical service influence patient management and reduce the frequency of patient transfer.

Aged↗
PubMed2002

Teleconsultations: who uses them and how?

A literature survey was carried out to identify papers describing teleconsulting applications. From 1259 potentially relevant articles identified through Medline, 128 articles were selected for review. The majority of these had been published in the Journal of Telemedicine and Telecare (50 articles, or 39%). We analysed different user groups, equipment and implementation issues, and the type of connections. In 101 studies (79%) the teleconsultations were between doctors, in 11 they were between patient and doctor, in seven between patient and nurse, and in nine between nurse and doctor. Studies of consultations between patients and health-care professionals were thus quite rare. Surgery was the most common specialty in which teleconsultation was described. The teleconsultations were realtime or mainly realtime in 72% of articles. In 39% of studies the primary focus was on videoconferencing. The most common means of connection was by ISDN digital lines (38%). There were very few mentions of how to ensure data protection or to maintain patient confidentiality. We conclude that, for the majority of teleconsultation needs, asynchronous communication is the most flexible and cost-effective approach. Realtime videoconferencing can be justified only in particular circumstances.

Humans↗
PubMed2006

Economic evaluation of a tertiary telepsychiatry service to an island.

The island of Jersey is located 160 km south of Britain and 23 km from northwest France. The island has well-established primary and secondary mental health services, but tertiary services have to be purchased from UK mainland service providers. A pilot study of telepsychiatry was conducted, using videoconferencing to access tertiary mental health services from the UK. During a six-month study period, five patient consultations and six specialist presentations were carried out. The total cost of using videoconferencing to deliver tertiary mental health services not ordinarily available in Jersey was 3483.06 pounds. The costs of using the traditional model instead would have been 12,975.00 pounds. The threshold at which videoconferencing became cheaper than travel was between five and six telemedicine episodes per year; the actual workload during the pilot study was 22 episodes per year. The study suggests that telemedicine is cost-effective for providing tertiary mental health services not ordinarily available in Jersey.

Channel Islands↗
PubMed2004

The safety and effectiveness of minor injuries telemedicine.

OBJECTIVES: To determine the safety of minor injuries telemedicine compared with on-site specialist care, current practice, and a robust gold standard, and to assess the clinical effectiveness of this new technique. METHODS: Patients presenting to a peripheral hospital within 10 days of injury were separately assessed by each of: an emergency medicine specialist based at a district general hospital using telemedicine, a second on-site emergency medicine specialist, and an on-site general practitioner (representing current practice). The primary outcome measure was discrepancies between these three medical assessments and a gold standard. All patients were subsequently randomised to follow one of the independent treatment plans generated by the above assessments. Secondary outcomes were recovery and further use of healthcare services measured seven days after recruitment, and consultation duration. RESULTS: 600 patients were recruited over a 12 month period. Overall, 73 discrepancies were identified, with 12 important over-treatments and 11 important under-treatments. No consultation modality was clearly superior to any other, and there were no statistically significant differences in the secondary outcomes of clinical effectiveness measured at seven days. The mean duration of a telemedicine consultation (6.0 min) was almost twice as long as an on-site specialist (3.1 min) or on-site general practitioner consultation (3.4 min) (p<0.0001 in both cases). CONCLUSIONS: Minor injuries telemedicine is safe and clinically effective, providing care that is equivalent to specialist on-site assessment and the current practice of treatment by a general practitioner. There is no evidence that telemedicine provides superior care, and there are a number of process issues that may impede successful implementation of this new technique.

Adolescent↗
PubMed1998

Telekid Care: bringing health care into schools.

BACKGROUND: Telekid Care is a project that attempts to overcome the health and educational barriers faced by children in urban Kansas City, Kansas. Telemedicine units were placed in school nurses' offices and linked to physicians at the University of Kansas Medical Center (KUMC). This paper describes the development of this project, presents utilization data, and discuss the lessons learned from the application of telemedicine in a school setting. RESULTS: Project developers spent 11 months designing the protocol and procedures for a pilot test. Four elementary schools participated, and 187 consultations were conducted. The most common reason for consultation was ear, nose, and throat (ENT) problems, making up 28% of all consults. Mandatory school physical examinations and dermatology problems combined to make up an additional 40% of the consults. The average time that elapsed between the request for a consult and confirmation of an appointment was 23 minutes. When immediate service was requested, 85% of the consults occurred the day of the request. These results strongly demonstrate telemedicine's ability to offer immediate service to children in need. CONCLUSION: Telemedicine enabled underserved inner-city children to gain access to health services. This service was most effective when it was integrated into the delivery system. Furthermore, community groups strongly favored the project, positively influencing its acceptance as an innovative health care delivery system.

Appointments and Schedules↗
PubMed1998

The effect of a neonatal telecardiology system on respiratory therapy in very low birthweight infants.

Factors in the U.S. healthcare system have shifted the site of care of many newborns to hospitals where subspecialty services are unavailable. This study examines whether a more rapid turn-around of echocardiogram interpretations and availability of interactive video during neonatal consultations reduces the morbidity of very low birthweight (VLBW) infants. The two groups (n = 21 and n = 28) were similar on the basis of known risk factors. A composite index of respiratory therapy intensivity and duration was used to measure the utilization of respiratory therapies. The index was similar in both groups, 89.6 +/- 12.6 before versus 89.5 +/- 13.0 with telemedicine. These results show little evidence of a reduction in RT utilization.

Cardiology↗
PubMed1997

[The digital image archive--its clinical applications and importance in cardiology consulting by telemedicine].

The revolution in digital technology is rapidly changing the world of telecommunications. Its applications to Medicine, and in particular to Cardiology, offer enormous benefits since communication is an essential part of medical practice. The need to improve the management of medical information is critical because of the explosion of medical knowledge, and the need to provide comprehensive documentation on patient care. The availability of a network offers many possibilities for clinical, research and teaching activities. Relevant, up-to-date scientific information is instantly available for analysis and interaction. The authors review the issue of digital communications as well as its potential application to Telemedicine, and present their preliminary experience with digital analysis and storage of echocardiographic images.

Cardiology↗
PubMedDate not supplied

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

OBJECTIVE: To assess the effects on information exchange of electronic communication between physicians co-treating diabetic patients. DESIGN: Comparison of traditional paper-based communication for reporting and electronic communication. SETTING: General practitioners and an internal medicine outpatient clinic of an urban public hospital. SUBJECTS: A total of 275 diabetic patients, and the 32 general practitioners and one internal medicine consultant who cared for them. INTERVENTION: An electronic communication network, linking up the computer-based patient records of the physicians, thus enabling electronic data interchange. MAIN OUTCOME MEASURES: Number of letters sent and received per year by the general practitioners, the number of diabetes-related parameters (e.g. results of laboratory tests) in the patient records, and HBA1C levels. RESULTS: INTERVENTION GPs received more messages per year (1.6 per patient) than control GPs (0.5 per patient, P<0.05). Significant higher availability (P<0.05) was achieved for data on HBA1C levels, fructosamine levels, blood pressure measurements, cholesterol levels, triglyceride levels and weight measurements. INTERVENTION patients showed a slight but significant decrease of HBA1C levels in the second semester of 1994 (from 7.0 to 6.8, P = 0.03), control patients also showed a slightly decreased group mean, but this change was not significant (from 6.6 to 6.5, P = 0.52). The magnitudes of these mean differences, however, were not significantly different (intervention group: 0.21; control group: 0.12, P = 0.68). CONCLUSIONS: 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. A large-scale experiment over a longer period of time is needed to assess the effects of improved communication on quality of care.

Adult↗
PubMed2000

Could a low-cost audio-visual link be useful in rheumatology?

We have investigated prospectively the diagnostic accuracy, specialist satisfaction and patient-specialist rapport of a low-cost audio-visual link between a junior doctor with a patient and a consultant rheumatologist. Using a telephone link and subsequently a video-phone link, 20 patients, with various rheumatological problems, were presented by a junior doctor to the consultant rheumatologist for provisional diagnosis. All patients were then seen face to face by the consultant, when a final diagnosis was made. An independent consultant rheumatologist made a 'gold standard' diagnosis. Thirty-five per cent of diagnoses were made correctly over the telephone and 40% over the video-phone--there was no significant difference in the diagnostic accuracy between these two methods of communication. Rapport over the video-phone was universally poor. Where it was important, clinical signs could not be visualized over the video-phone and in more than 85% of cases small joint swellings could not be seen clearly.

Adolescent↗
PubMed2004

The status of telepsychiatry services in Canada: a national survey.

A survey of Canadian telepsychiatry programmes was undertaken to provide information for future health services. Fourteen programmes were identified. They used a variety of service models and administrative arrangements. The average number of clinical consultations per programme per year was 238, which corresponds to 107 psychiatric teleconsultations per million persons served by the programmes. The rate for children's telepsychiatry services was higher, at 194 per million. Comparison with some telepsychiatry programmes in the USA revealed similar patterns of activity. While the development of telepsychiatry services in Canada is promising, there is nevertheless concern regarding the viability and activity levels of these programmes over the long term. This survey demonstrates that programmes from across a large country can respond to a standardized questionnaire and provide comparable information.

Adult↗
PubMed2006

A pilot study of nurse-led, home monitoring for patients with chronic respiratory failure and with mechanical ventilation assistance.

We assessed the feasibility of telemedicine for home monitoring of 45 patients with chronic respiratory failure (CRF) discharged from hospital. The patients transmitted pulsed arterial saturation (pSat) data via a telephone modem to a receiving station where a nurse was available for a teleconsultation. A respiratory physician was also available. Scheduled and ad hoc appointments were conducted. Thirty-five patients were on home mechanical ventilation, 13 with invasive and 22 with non-invasive devices. The main diagnosis was chronic obstructive pulmonary disease (COPD). The follow-up period was 176 days (SD 69). In all, 376 calls for scheduled consultations were received and 83 ad hoc consultations were requested by the patients. The actions taken were: 55 therapy modifications, 19 hospitalizations in a respiratory department for decompensated CRF, three hospitalizations in an intensive care unit (ICU), 22 requests for further investigations, 25 contacts with the general practitioner (GP), 66 demands for respiratory consultations and 10 calls for the emergency department. The mean time recorded for the 459 calls was 16 min/patient/week. In 82% of calls, a pSat recording was received successfully. The nurse time required to train the users in the operation of the pSat instrument was high (mean time 30 min). However, the results showed that home monitoring was feasible, and useful for titration of oxygen, mechanical ventilation setting and stabilization of relapses.

Chronic Disease↗
PubMed1997

[Telesurgery: standards--consultations--continuing education].

The aim of the TESUS project is to bring together several European university hospitals in a federation as well as a certain number of clinical centers in a network, the purpose of which is the online and offline transmission of surgical procedure imaging and advice. The innovation is threefold: It provides the surgeon with online information, diagnostic and therapeutic tools and expert advice, the need for which might come up before and during surgical procedures, as well as the same services in the context of teaching and training through regular staff. The developed services will be a major contribution to EU-wide standardisation of health care procedures and therapeutic approaches.

Computer Communication Networks↗
PubMed2004

A pilot study of nurse-led, home-based telecardiology for patients with chronic heart failure.

We assessed the feasibility of home-based telecardiology for patients with chronic heart failure (CHF). Seventy-four CHF patients were enrolled into a programme of telephone follow-up and single-lead electrocardiography (ECG) monitoring. The patients transmitted their ECG data by fixed telephone line to a receiving station, where a nurse was available for an interactive teleconsultation. Patients were followed up for a mean (SD) of 307 (108) days; 1467 calls were analysed (213 ad hoc consultations and 1254 scheduled consultations). A total of 124 cardiovascular events were recorded. Modifications to therapy were suggested in response to 119 calls; hospital admissions were suggested for 13 patients, further investigations for 7 and a consultation with the patient's general practitioner for 13. No action was taken after 1330 calls. Twenty-two ECG abnormalities were recorded. In 63 patients receiving the beta-blocker carvedilol, the mean dosage increased from 36 to 42 mg. In the previous year there were 1.8 hospitalizations per patient, while in the follow-up period there were 0.2 hospitalizations per patient. Following up CHF patients using a nurse-led telecardiology programme seems to be feasible and useful.

Aged↗
PubMed1996

Teleconsultation: a new neurosurgical image transfer system for daily routine and emergency cases--a four-year study.

In January 1991, an image transfer unit was developed and installed in the neurosurgical department of the University in Mainz. The system provides an image transfer of patient data via fibreoptic cable networks (VBN), ISDN, and public telephone line. In the following 4 years, 432 consultations were recorded. Nine departments were linked within this system. They provided an emergency out-patient department for primary treatment and radiology. The lack of a neurosurgical department in these clinics was made up for by the image transfer system. In these rural medical departments, teleconsultation improves the care of daily routine neurosurgical cases, as well as in emergency cases. There is also a decrease of costs due to teleconsultation. The image transfer via simple public telephone line was sufficient.

Adolescent↗
PubMed2002

Four years' experience of telemedicine support of a minor accident and treatment service.

In 1996 we studied patients attending a minor accident and treatment service in London, some of whom were the subjects of teleconsultations with a main hospital emergency department. In the subsequent four years, 56,139 patients were seen at the minor accident and treatment service unit. Teleconsultations were performed in 2032 cases (3.6%). Most of the teleconsultations (58%) concerned patients with fractures. The main reason for teleconsultation was to review and discuss radiographs (46%). In comparison with the 1996 study, both the emergency nurse practitioners and the consultant had improved the accuracy of their teleradiology diagnosis, although the difference was not significant. Most of the telemedicine patients (90%) did not need a transfer to the main department. Thus telemedicine allowed local decision making in the majority of cases. In the 1996 survey, 75% of patients were sent to their general practitioner or to the main hospital department; in the present survey, this proportion had halved, to 38%. The present study showed that teleconsultations are an effective way of preventing patients being transferred unnecessarily from a minor accident and treatment service to the main hospital accident and emergency department.

Emergency Service, Hospital↗
PubMed2005

The use of random effects models to allow for clustering in individually randomized trials.

BACKGROUND: We describe different forms of clustering that may occur in individually randomized trials, where the observed outcomes for different individuals cannot be regarded as independent. We propose random effects models to allow for such clustering, across a range of contexts and trial designs, and investigate their effect on estimation and interpretation of the treatment effect. METHODS: We apply our proposed models to two individually randomized trials with potential for clustering, a trial of teleconsultation in hospital referral (the main outcome being offer of a further hospital appointment) and a trial of exercise therapy delivered by physiotherapists for low back pain (the outcome being a back pain score). Extensions to the methods include the possibility of explaining heterogeneity between clusters using cluster level characteristics and the potential dilution of cluster effects due to noncompliance. RESULTS: In the teleconsultation trial, the odds ratio was significant (1.52, 95% CI 1.27 to 1.82) when clustering was ignored, but smaller and nonsignificant (1.36, 95% CI 0.85 to 2.13) when clustering by hospital consultant was taken into account. The 95% range of estimated treatment effects across consultants was from 0.21 to 8.76. This variability was only partially explained by the specialty of the consultant. In the back pain trial, although there was an overall benefit of exercise (change of - 0.51 points on the back pain score) and little evidence of clustering, the estimated treatment effects for different physiotherapists ranged from -1.26 to +0.26 points. CONCLUSIONS: Clustering is an important issue in many individually randomized trials. Ignoring it can lead to underestimates of the uncertainty and too extreme P-values. Even when there is little apparent heterogeneity across clusters, it can still have a large impact on the estimation and interpretation of the treatment effect.

Back Pain↗
PubMed2001

Telepathology overview: from concept to implementation.

Telepathology is the practice of pathology at a distance by using video imaging and telecommunications. Significant progress has been made in telepathology. To date, 12 classes of telepathology systems have been engineered. Rapid and ultrarapid virtual slide processors may further expand the range of telepathology applications. Next-generation digital imaging light microscopes, such as miniaturized microscope arrays (MMA), may make virtual slide processing a routine laboratory tool. Diagnostic accuracy of telepathology is comparable with that of conventional light microscopy for most diagnoses. Current telepathology applications include intraoperative frozen sections services, routine surgical pathology services, second opinions, and subspecialty consultations. Three telepathology practice models are discussed: the subspecialty practice (SSP) model; the case triage practice (CTP) model; and the virtual group practice (VGP) model. Human factors influence performance with telepathology. Experience with 500 telepathology cases from multiple organs significantly reduces the video viewing time per case (P < .01). Many technology innovations can be represented as S-curves. After long incubation periods, technology use and/or efficiency may accelerate. Telepathology appears to be following an S-curve for a technical innovation.

Diffusion of Innovation↗
PubMed2005

Telecardiology: one-lead electrocardiogram monitoring and nurse triage in chronic heart failure.

We investigated a home-based intervention based on telecardiology in patients with chronic heart failure (CHF). Two hundred and thirty CHF patients, aged 59 years (SD 9), in stable condition and with optimized therapy were enrolled. The programme consisted of trans-telephonic follow-up and electrocardiogram (ECG) monitoring followed by visits from a paramedical and medical team. The patient could call the centre when required (tele-assistance), while the team could call the patient at prescheduled times (telemonitoring). During the first 12 months, there were 3767 calls (873 ad hoc and 2894 scheduled calls). There were 648 events, including 126 episodes of asymptomatic hypotension and 168 episodes which were not due to cardiological symptoms. No actions were taken by the nurse after 2417 calls (64%). A change in therapy was suggested after 418 calls, hospital admission in 62 patients, further investigations for 243 patients and a consultation with the general practitioner in 41 patients. A total of 2303 one-lead ECG recordings were received (10 per patient); 126 recordings (6%) were diagnosed as pathological in comparison with the baseline one. The one-lead ECG recording was used for titration of beta-blockers in 79 patients (mean dosage 38 mg vs 42 mg, P<0.01). Home telenursing could be an important application of telemedicine and single-lead ECG recording seems to offer additional benefit in comparison with telephone follow-up alone.

Cardiac Output, Low↗