Clinical feasibility of remote angiographic teleconsultation using a ISDN-30 communication network.
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Coronary Angiography↗
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Human factors in telesurgery: effects of time delay and asynchrony in video and control feedback with local manipulative assistance.
This paper presents the results of experiments examining the performance of a telesurgeon and an assistant local to the patient performing simulated laparoscopic tasks under a variety of time-delay conditions. Of particular interest is a comparison between the surgeon provided with audio/video and force feedbck synchronously with various time delays, and the surgeon performing asynchronously, where video is delayed relative to force feedback. These conditions are relevant since current telecommunication systems have limited bandwidth, and video signals must be compressed for efficient transmission. This produces a time lag between the video camera and the surgeon's monitor, Force feedback and position commands from a surgical teleoperator require much lower bandwidth, and can be transmitted in near-real time. In the first of two series of experiments, two laparoscopic training tasks were performed under different time-delay conditions, with force and video feedback delayed by equal amounts. In the second series, using the same tasks, the force feedback was more immediate, while the video delay lagged by the time required for compression and decompression. In both experiments, there were various role assignments in terms of whether the telesurgeon or the assistant controlled the laparoscope and/or the various surgical tools required. The three most striking results are that (1) nontrivial time delays significantly degraded the performance of the surgical tasks, (2) asynchronous force feedback resulted in significantly faster task-performance than did synchronous performance when the surgeon operated the laparoscopic tools, and (3) there was no difference between synchrony and asynchrony when the remote surgeon operated the laparoscope and gave commands while the local assistant operated the surgical tools.
Humans↗
Information acquisition from audio-video-data sources: an experimental study on remote diagnosis. The LOTAS Group.
OBJECTIVE: To determine what information sources are used during a remote diagnosis task. MATERIALS AND METHODS: Experienced trauma care providers viewed segments of videotaped initial trauma patient resuscitation and airway management. Experiment 1 collected responses from anesthesiologists to probing questions during and after the presentation of recorded video materials. Experiment 2 collected the responses from three types of care providers (anesthesiologists, nurses, and surgeons). Written and verbal responses were scored according to detection of critical events in video materials and categorized according to their content. Experiment 3 collected visual scanning data using an eyetracker during the viewing of recorded video materials from the three types of care providers. Eye-gaze data were analyzed in terms of focus on various parts of the videotaped materials. RESULTS: Care providers were found to be unable to detect several critical events. The three groups of subjects studied (anesthesiologists, nurses, and surgeons) focused on different aspects of videotaped materials. CONCLUSION: When the remote events and activities are multidisciplinary and rapidly changing, experts linked with audio-video-data connections may encounter difficulties in comprehending remote activities, and their information usage may be biased. Special training is needed for the remote decision-maker to appreciate tasks outside his or her speciality and beyond the boundaries of traditional divisions of labor.
Anesthesiology↗
Interactive telecardiology for the evaluation of heart murmurs in children.
OBJECTIVE: To study the accuracy, patient satisfaction, and cost of telecardiographic evaluations of pediatric patients. MATERIALS AND METHODS: Patients referred to a rural pediatric cardiology outreach clinic were examined in person by a pediatric cardiologist. A second pediatric cardiologist who had no knowledge of the findings of face-to-face examination reevaluated the same patients utilizing a 768-Kbps telemedicine system. Any additional testing was performed by personnel who had no knowledge of the face-to-face evaluation. The main outcome measures included the final cardiac diagnosis, frequency of additional tests such as electrocardiography, (ECG) echocardiography (ECHO), and patient satisfaction. RESULTS: The diagnosis was agreed upon in 19 of the 21 patients studied. Two patients with small ventricular septal defects were missed during the telemedicine evaluation. The utilization rates of additional studies for both the face-to-face cardiologist and the telemedicine cardiologist were not significantly different. Patient satisfaction with the telemedicine encounter was good. CONCLUSIONS: Telemedicine appears to be effective and useful for the cardiac evaluation of pediatric patients. In spite of high data-transfer rates, differences between telemedicine and face-to-face patient encounters were observed.
Child↗
Learning and understanding in virtual teams.
There are sufficient reasons to conclude that virtual education is not just hype. There are, among others, economic motivations such as bringing one learning module to a larger audience of learners, and pragmatic reasons such as achieving flexibility in time and space for learning, which is especially important for adult learners. However, from a pedagogic point of view there are some doubts. Current technologies meant for learning and working in teams are often designed for functional collaboration (e.g., sharing documents, communicating), but fail to support learning, understanding and team forming (e.g., carrying out pedagogically adequate tasks, understanding each other's work and group dynamic processes) in virtual teams. In order to understand virtual teams, we need to know how we can study learning and understanding in virtual teams. Interesting research questions are: Which concepts are important in understanding virtual teams? How can we measure those concepts, and in what type of setting (e.g., experimental study, case study)? The aim of this special issue is to provide and discuss concepts and pragmatic insights in research on learning and understanding in virtual teams. The aim of this article is to set the stage for those articles.
Adult↗
In search of reflective behavior and shared understanding in ad hoc expert teams.
The work reported on here concentrates on virtual ad hoc expert teams for the integration of learning and working, as ad hoc teams seem to be one way to cope with complexity in a knowledge-intensive society. In order to let ad hoc teams learn and work together, group members require effective communication and shared understanding among each other. Two empirical studies were conducted to study collaborative learning and shared understanding, one exploratory study and one experiment. In the first study, it was explored how virtual design teams work and learn together. Based on conceptual ideas, collaborative learning and shared understanding were observed and assessed in a design team over a period of four months. It was concluded that shared understanding was suboptimal; mainly due to the effect that hardly any questions were raised and answered. The second study elaborates on the need to encourage question-answer patterns and reflective behavior in such teams. A tool was developed that supported questioning behavior. As it was hypothesized that this tool leads to better questioning behavior, which in turn results in more reflective behavior and in increased shared understanding, an experiment was conducted. In the exploratory study, as well as in the experimental study, the perceived shared understanding increased over time. However, in both studies suboptimal questioning behavior and little reflective activity were noticed. The main results of the two empirical studies are compared and discussed.
Adult↗
Determining sociability, social space, and social presence in (a)synchronous collaborative groups.
The effectiveness of group learning in asynchronous distributed learning groups depends on the social interaction that takes place. This social interaction affects both cognitive and socioemotional processes that take place during learning, group forming, establishment of group structures, and group dynamics. Though now known to be important, this aspect is often ignored, denied or forgotten by educators and researchers who tend to concentrate on cognitive processes and on-task contexts. This "one-sided" educational focus largely determines the set of requirements in the design of computer-supported collaborative learning (CSCL) environments resulting in functional CSCL environments. In contrast, our research is aimed at the design and implementation of sociable CSCL environments which may increase the likelihood that a sound social space will emerge. We use a theoretical framework that is based upon an ecological approach to social interaction, centering on the concept of social affordances, the concept of the sociability of CSCL environments, and social presence theory. The hypothesis is that the higher the sociability, the more likely that social interaction will take place or will increase, and the more likely that this will result in an emerging sound social space. In the present research, the variables of interest are sociability, social space, and social presence. This study deals with the construction and validation of three instruments to determine sociability, social space, and social presence in (a)synchronous collaborating groups. The findings suggest that the instruments have potential to be useful as measures for the respective variables. However, it must be realized that these measures are "first steps."
Adult↗
Exploring relational regulation in computer-mediated (collaborative) learning interaction: a developmental perspective.
This article presents a qualitative analysis showing the dependency of effective collaborative argumentation on interpersonal relational aspects that develop during synchronous interaction. Four regulatory principles are proposed as propelling the interaction, and of these, autoregulation, or the conservative restraints within the existing relation, appears to be the dominant force. When using a structured dialogue system (SDS), instead of free chat, via roles and sentence-openers, the social dimension of the relation between participants disappears from the surface interaction. Even though using the SDS seems to foster a more focused and task-functional approach, argumentation appears to affect the relations between participants in a negative way, since after an argumentative sequence, repair of the relationship takes place. It might even be argued that, because of relational stress, in many cases, argumentation is momentarily suspended.
Adult↗
Tele-ophthalmology via stereoscopic digital imaging: a pilot project.
Diabetic eye disease is present in remote communities across Canada. A pilot study was designed to assess the feasibility of stereoscopic digital imaging to identify levels of diabetic retinopathy via teleophthalmology. Diabetic patients were assessed for diabetic retinopathy by seven field stereoscopic digital imaging through a dilated pupil. Images were transferred by satellite to a tertiary eye center for review by a retinal specialist. Images were viewed stereoscopically on a video monitor, with grading of all images using a modified Early Treatment Diabetic Retinopathy Study (ETDRS) classification. Patients found to have treatable diabetic retinopathy were transferred to a tertiary eye center for assessment and treatment by a retinal specialist. One hundred patients (199 eyes) had stereoscopic digital imaging of the retina. Microaneurysms were identified in 70 eyes, hard exudates in 31 eyes. Two eyes were identified with neovascularization of the disc (NVD) and 15 eyes with clinically significant macular edema (CSME). All eyes identified by stereoscopic digital imaging with treatable disease were confirmed by clinical examination with contact lens biomicroscopy. Stereoscopic digital imaging of the retina enables the identification of diabetic retinopathy. Further research is needed to delineate the sensitivity and specificity of stereoscopic digital imaging when compared to slide film and clinical examination.
Alberta↗
Computer-based remote diabetes education for school personnel.
Teachers are expected to respond quickly and accurately to any diabetes incident that may occur to children in the school setting. Access to diabetes information is crucial for student safety, health, academic achievement, and social competence. This paper describes a technique to provide Web-based diabetes information using computer audio and video to enrich a text-based training experience. Two groups of teachers were presented with diabetes training material via either paper or a Web-based computer system. Both groups were then evaluated for diabetes knowledge and satisfaction. Subjects using the Web-based system had significantly (t = 2.22; p < 0.033) higher knowledge scores (72.5% versus 66.4% correct) and were significantly (t = 3.9; p < 0.001) more satisfied with the training session (4.2 versus 3.1 on a five-point scale) than subjects who used paper documents traditionally used for teacher training. With the advantages in learning and the reduced cost of a Web-based system, diabetes distance education is a viable and desirable alternative to paper-based diabetes education.
Adult↗
Evaluation of an asynchronous teleconsultation system for diagnosis of skin cancer and other skin diseases.
We wished to assess both diagnostic accuracy and concordance among dermatologists when evaluating digital images of skin disease presented using a low-cost asynchronous (store-and-forward) format. Each of eight board-certified dermatologists reviewed 50 clinical cases presented in digital format on a 15-inch computer monitor. For each case, the teleconsultants made a primary diagnosis and differential diagnosis and indicated whether or not a biopsy should be performed both before and after reviewing a brief history of each case. Diagnostic accuracy was calculated for each teleconsultant on the basis of biopsy, culture, or wet mount results. Concordance was determined by comparing primary and differential diagnoses made by the teleconsultants on all 50 cases with those made by the dermatologists who originally examined the patients in person. For eight skin cancers, the diagnostic accuracy for the inperson dermatologist was 88% versus 90% (range, 75-100%) for the teleconsultants. For the 25 cases (including the 8 skin cancers) confirmed by either biopsy (20), culture (1), or wet mount (4), the in-person accuracy was 84% compared to 73% (range, 65-88%) for the teleconsultants. The concordance between the in-person and teleconsultant diagnoses were in agreement 77% of the time (90% if differential diagnoses were included). After evaluating the accompanying history, teleconsultants changed their primary diagnosis in 11% of the cases (range, 2-22%). Biopsy rates were not significantly different between teleconsultants (45%) and in-person dermatologists (40%). An asynchronous software application can provide levels of diagnostic accuracy and concordance equivalent to those reported using live teleconsultation.
Biopsy↗
Financial analysis of telecardiology used in a correctional setting.
The aim of this study is to evaluate the cost savings of 3 years of telecardiology used in a prison. This study compares the cost per visit of providing cardiology services by telemedicine (telecardiology) to patients at Powhatan Correctional Center of the Virginia Department of Corrections (PCC) and the cost of providing traditional cardiology services at the cardiology clinic of the Medical College of Virginia Campus of Virginia Commonwealth University (MCV Campus). During 1996 to 1998, telecardiology visits increased from 24 per year to 86. In this study, lower use of telecardiology services in 1996 resulted in higher cost per visit of $189. This was $45 more than the cost of traditional cardiology in the cardiology clinic at the MCV Campus. In 1997 and 1998, however, higher utilization of telecardiology services decreased the cost per visit to $135 and $132, respectively. This resulted in a cost saving with telecardiology of $15 per visit in 1997 and $46 per visit in 1998. Because the vast proportion of telemedicine operating costs are fixed, increased utilization causes reduced cost per visit and results in a cost saving compared with providing these services via a non-telemedicine program.
Cardiology↗
Telephone management in substance abuse treatment.
The purpose of this article is to describe the results of a clinical trial in which telephonic case management was evaluated as a supplement to substance abuse treatment. An interactive voice response system (IVR) was developed by the research team for use in the case management of randomly assigned participants in a clinical trial research project. The features of the software program facilitated a double caseload for the case manager as well as real-time data capture. At intake, no significant differences were found between participants in the telecommunication condition and the general project. Thus, the effectiveness of random assignment was supported. An IVR was useful for case management services, was less costly, and showed acceptability to clients. A reduction in time expenditure by using telecommunication occurred within three activity areas. Telecommunication facilitated client interaction and the use of case management, and it reduced provider time expenditure. As an alternative strategy, telecommunication case management can enhance cost effectiveness improvements.
Adult↗
Suggested principles of professional ethics for the online provision of mental health services.
The goal of this project was to suggest principles of professional ethics for the online provision of clinical mental health services that could guide clinicians who provide and patients who receive such services. A joint committee of the International Society for Mental Health Online (ISMHO) and the Psychiatric Society for Informatics (PSI) was formed. Discussion and development of these principles took place online. A set of principles was produced and endorsed by ISMHO on January 9, 2000, and by PSI on May 13, 2000. The principles involve informed consent (about the process, the clinician, the potential risks and benefits, safeguards, and alternatives), standard operating procedure (competence, legal requirements, the structure of the services, evaluation, multiple treatment providers, confidentiality, records, and existing guidelines), and emergencies (procedures and local backup). This project demonstrates that traditional principles of professional ethics can be extended to online services, that comprehensive ethical principles can be developed by groups that cross disciplinary and national boundaries, and that productive collaboration can take place entirely online; and suggest that online clinicians have the potential to regulate themselves.
Clinical Competence↗
A comparative cost analysis of an integrated military telemental health-care service.
The National Naval Medical Center, Bethesda, Maryland, integrated telemental health care into its primary behavioral health-care outreach service in 1998. To date, there have been over 1,800 telemental health visits, and the service encounters approximately 100 visits per month at this time. The objective of this study was to compare and contrast the costs to the beneficiary, the medical system, and the military organization as a whole via one of the four methods currently employed to access mental health care from remotely located military medical clinics. The four methods include local access via the military's civilian health maintenance organization (HMO) network, patient travel to the military treatment facility, military mental health specialists' travel to the remote clinic (circuit riding) and TeleMental Healthcare (TMH). Interactive video conferencing, phone, electronic mail, and facsimile were used to provide telemental health care from a military treatment facility to a remote military medical clinic. The costs of health-care services, equipment, patient travel, lost work time, and communications were tabulated and evaluated. While the purpose of providing telemental healthcare services was to improve access to mental health care for our beneficiaries at remote military medical clinics, it became apparent that this could be done at comparable or reduced costs.
Cost-Benefit Analysis↗
Public information services in the field of communication disorders: comparison between teleservice and E-service.
This study evaluates the use of information services in the field of communication disorders by monitoring two communication disorders information services operated in Israel over 8-10 months. One was an E-service and the other was a teleservice. More women than men used the services. Approximately 85% of referrals were judged as appropriate and relevant to the field, and the majority of problems could be treated sufficiently through the service.
Adolescent↗
Toward an understanding of diagnostic teleconsultations and their impact on diagnostic confidence.
This paper describes a four-stage model of the medical diagnostic process, and provides the results of an initial test of this emerging knowledge management theory. A study of the diagnostic teleconsultations between primary care physicians located in remote communities and specialists at the Medical College of Georgia was conducted. The study involved an analysis of the video recordings of teleconsultations and postteleconsultation telephone interviews with the specialists and physicians conducting diagnostic teleconsultations. The study revealed that the number of hypotheses generated by specialists, the overall duration of teleconsultations, and physicians' change in diagnostic confidence depended on the diagnostic stage of the specialty teleconsultation. This study demonstrated that the diagnostic stages have different behavioral and cognitive characteristics. Designers of telemedicine programs can complement these characteristics to increase the productivity of health care providers.
Clinical Competence↗
Teleconsultation practice guidelines: report from G8 Global Health Applications Subproject 4.
This report presents a series of recommendations derived from deliberations of the G8 countries Subproject 4 Group (SP4 Group) of the Global Health Care Applications Project entitled, A Teleconsultation Practice Guideline. The recommendations provide an initial step toward developing a general guideline platform for the practice of telemedicine/teleconsultation.
Computer Security↗