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PubMed2004

Delivering cognitive-behavior therapy for panic disorder with agoraphobia in videoconference.

Delivering psychotherapy by videoconference could significantly increase the accessibility of empirically validated treatments. The aim of this study was to compare the effectiveness of cognitive-behavior therapy (CBT) for panic disorder with agoraphobia (PDA) when the therapy is delivered either face-to-face or by videoconference. A sample of 21 participants was treated either face-to-face or by videoconference. Results showed that CBT delivered by videoconference was as effective as CBT delivered face-to-face. There was a statistically significant reduction in all measures, and the number of panic-free participants among those receiving CBT by videoconference was 81% at post-treatment and 91% at the 6-month follow-up. None of the comparisons with face-to-face psychotherapy suggested that CBT delivered by videoconference was less effective. These results were confirmed by analyses of effect size. The participants reported the development of an excellent therapeutic alliance in videoconference as early as the first therapy session. The importance of these results for treatment accessibility is discussed. Hypotheses are proposed to explain the rapid creation of strong therapeutic alliances in videoconferencing.

Adult↗
PubMed2004

Telemedicine in oral surgery and maxillofacial trauma: a descriptive account.

Trauma patients presenting to emergency rooms (ER) in rural or remote locations have significantly less access to oral and maxillo-facial surgery (OMFS) specialists. In this case, OMFS services at four hospitals were rearranged to concentrate expertise, inpatients, and 24/7 cover on a single site. A Federation (managed clinical network) model was used that improved the management of inpatients and made better use of a small team of junior medical staff. New government standards limiting the on-call burden for U.K. junior doctors (The New deal) were met under this service model. Despite the success of the Federation, the loss of on-site OMFS support to the three peripheral ER departments was problematic. Sites that do not have OMFS support used a simple telephone referral to transfer patients to the OMFS center. The degree to which referrals were considered inappropriate led to operational and patient satisfaction difficulties. The introduction of an OMFS telemedicine system linking the three peripheral/"spoke" ER departments to the OMFS center/"hub" succeeded in increasing the appropriateness of patient transfers, developed the skills of the ER medical staff, and was believed to have led to an overall improvement in the early-stage management of this group of patients. The telemedicine system augmented the overall success of the Federation model. New uses for telemedicine within the OMFS service soon developed.

Emergency Service, Hospital↗
PubMed2004

Telehomecare: a comparison of three Canadian models.

The delivery of health care is often segmented into sectors. In Canada, hospital care has traditionally been distinct from community care, and thus the transition of patients across sectors has been challenging. This paper focuses on the systematic development of an integrated model of care for children, for the purpose of smoothing the transition from hospital to home. The new service model uses emerging telecommunications technology to link hospital care providers to patients at home and is termed "telehomecare" (THC). Independent models of THC were developed for three sites across Canada through semistructured interviews and focus groups. Participants included health care providers and administrators from the hospital and community, and patient families. The resulting models were compared using content analysis to determine whether there was a core model of THC that was generalisable across Canada. A core model of THC was identified that includes the use of videoconferencing to enable the integration of hospital- and community-based care to support patients during the initial stages of the transition to home. Each site also articulated unique characteristics in their service model that were related to the nature of their health care delivery system and patient population. This paper describes the core model of transitional care, presents a synopsis of each of the three models, and compares the models. THC provides opportunities to address limitations in the current system and to improve upon equity of access to quality care for children making the transition from hospital to home.

Aftercare↗
PubMed2005

An empirical examination of client attitudes towards online counseling.

Trends over the past decade have shown that online counseling has grown in terms of popularity among consumers and clinicians alike; however, little, if any empirical evidence exists that examines client attitudes towards online counseling as alternative to traditional face-to-face therapy. Therefore, this study investigated client attitudes towards online counseling. Data was collected from 48 e-clients who received online counseling at the Center for Online Addiction. Variables such as client perceptions and concerns about using online counseling, clients' reasons for seeking online counseling over in-office treatment, and demographic profiles of e-clients were assessed. Results suggested that Caucasian, middle-aged males, with at least a four-year bachelors degree were most likely to use online counseling and anonymity, convenience, and counselor credentials were the most cited reasons they sought online counseling over in-office treatment. The lack of perceived privacy and security during online chat sessions and the fear of being caught while conducting online sessions were the main concerns reported by e-clients. A better understanding of client motives and perceptions towards online counseling helps to guide treatment in using the Internet as a clinical tool, especially as the Internet becomes increasingly more available in previously remote markets and the field of online counseling continues to grow.

Adult↗
PubMed2006

Usability of the remote console for virtual reality telerehabilitation: formative evaluation.

The Remote Console (ReCon) is a telerehabilitation application that allows therapists to remotely communicate with patients while monitoring and controlling their virtual rehabilitation exercises. It provides therapists visual feedback of patients' movements, their exercise simulations replicated in real time and with tools to conduct training without a face-to-face session. The Recon underwent a formative evaluation (a type of usability engineering methodology) used to refine its design. Five physical therapists from different practice settings acted as representative users. During the evaluation, these users made errors related to manipulation and finding and understanding controls. Technical issues with the server and audio communication were identified. These findings were used to fine-tune the ReCon system.

Computer Simulation↗
PubMed2006

The Jerusalem TeleRehabilitation System, a new low-cost, haptic rehabilitation approach.

Survivors of brain injury or stroke can improve movement ability with intensive, supervised practice. Since the hours of supervised therapy with a physical or occupational therapist are limited, telerehabilitation will enable patients to greatly expand the hours that they practice therapeutic exercises. The Jerusalem TeleRehabilitation System (JTRS) consists of patient and therapist systems plus a central server and database connected via the internet. The system can work in two modes: (1) a cooperative mode in which the therapist and patient are online at the same time, and (2) a stand-alone mode in which the patient uses the system on his own. In both cases, the system will monitor the status and progress of the patient and various parameters of his movement abilities, and prepare reports for the patient and for the therapist. From the clinic, the therapist will be able to change the screen seen by the patient and change the level and types of tasks, as needed. Compared to existing systems, our system will have the following advantages: (1) inexpensive and easy to use; (2) remote monitoring and control of the patient's computer by the therapist in the clinic; (3) more detailed analysis of patient status and progress; (4) a "smart" system which self-adapts to the patient's capabilities in real time, increasing or decreasing the difficulty of the exercise as needed; and (5) a central, international database which, by gathering data on many patients over time, will provide the basis for "smart" therapy and will also facilitate coordinated multicenter research studies.

Computer Simulation↗
PubMedDate not supplied

Wireless teleradiology for renal colic and renal trauma.

BACKGROUND PURPOSE: Image transmission is an integral part of telemedicine, allowing evaluation of patients at remote sites. We developed a simple method of wireless transmission of digital images to a hand-held computer (PDA) and evaluated its feasibility and diagnostic accuracy in patients with acute renal colic or renal trauma. MATERIALS AND METHODS: The CT images from 11 patients with suspected renal colic and one patient with renal trauma were transmitted using a cellular telephone with a wireless modem link to a PDA (Sony Clie 615C). A diagnostic interpretation was recorded for the presence/absence of an upper-tract stone, stone location, estimated stone size, and signs of upper-tract obstruction. Radiologic staging of trauma was provided in the patient with a renal injury. Comparison was made with the final dictated report of a staff radiologist. RESULTS: Ten CT sets of patients with renal colic were used for comparison, the remaining one being excluded because of ambiguity in the final radiology report. An average of 5.9+/-1.6 images, average size 32.2+/-5.2 kb (range 21-42 kb) for each patient were sent at an average speed of 1 kb/sec. Interpretation correctly identified stone presence in 80%, hydronephrosis in 100%, and perinephric stranding in 80% and stone size within 1+/-1 mm. A stage-3 renal trauma was correctly identified and staged. CONCLUSION: Wireless teleradiology to PDA units provides image quality sufficient for diagnostic interpretation. Anticipated improvements in wireless transmission and PDA screen image resolution will enhance the speed, quality, and quantity of images transmitted. Wireless teleradiology may facilitate convenient rapid evaluation of patients at remote sites.

Abdominal Injuries↗
PubMed1995

Evaluation of remote stethoscopy for pediatric telecardiology.

OBJECTIVE: To investigate the interobserver reliability and diagnostic validity of a commercial electronic stethoscope for pediatric telecardiology. MATERIALS AND METHODS: Pairs of blinded pediatric cardiologists made independent diagnoses, recommendations concerning follow-up echocardiography, and specific judgments regarding heart sounds, murmurs, and congenital heart disease using an electronic (ES) or an acoustic (AS) stethoscope on 78 pediatric cardiology outpatients and at a distance of 450 km (280 miles) with 38 telemedicine cardiology outpatients. The kappa statistic (K) indexed the instruments' interexaminer reliabilities. The validity of ES was measured by K for ES versus AS and by the percentage of cases where the findings for ES and AS differed sufficiently to suggest an important ES screening error. RESULTS: For heart disease, AS, ES, and tele-ES reliabilities were satisfactory (K = 0.80, 0.67, and 0.80, respectively), as were AS agreement with hands-on ES (K = 0.65) and with tele-ES (K = 0.64). The AS and ES reliabilities and ES/AS agreement were also satisfactory for systolic regurgitant and diastolic pulmonic murmurs (K = 0.63-0.78) but were unsatisfactory for evaluable heart sounds and other murmurs (K = 0.16-0.60). The ES yielded clinically important disagreements with AS in 5.4% of the clinic cases and 10.5% of the telemedicine cases (P = 0.67). In determining the need for additional work-up (echocardiography) or follow-up appointments, hands-on ES and tele-ES had a combined accuracy of 92%, with a sensitivity of 88% and a specificity of 97%. CONCLUSIONS: Hands-on ES provided reliable and valid screening for congenital heart disease. Tele-ES was highly reliable but had reduced diagnostic validity. Examiner blinding, bandwidth limitations, and artificial restrictions on the remote assistant may have contributed to this reduced performance. As these factors are easily correctable, we regard the ES as a highly promising tool for pediatric telecardiology.

Child↗
PubMed1995

MDTV Telemedicine Project: technical considerations in videoconferencing for medical applications.

In spite of the many advances in technology, complex problems must be addressed in establishing and maintaining a telemedicine system. Although most such systems are built around interactive videoconferencing (IAVC) equipment, clinical requirements dictate that these systems offer more than traditional IAVC systems. Input from system users should be obtained early in the design process to ensure the functionality necessary to achieve maximum utilization. Surprisingly, audio, rather than video, signals may present the greatest challenge to achieving consistent, high-quality videoconferencing encounters. Audio technical problems can be frustrating for patients and providers alike and can undermine user confidence in IAVC as a vehicle for healthcare delivery. A capability for remote access and control of components at distant sites seems essential to providing cost-effective and technically reliable service.

Humans↗
PubMed1996

Telemedicine in Micronesia.

Distance and isolation profoundly affect the delivery of health care in the islands of Micronesia. The lack of specialty services on most of the islands has led to a costly off-island referral system that strains health care budgets. Care providers there have incorporated advances in telecommunications to create a telemedicine network amongst themselves and with a tertiary care hospital in Hawaii. They developed an interactive video conferencing system, a still-image transmission network, and a data transfer network for use principally in patient care and continuing education. Patients now receive earlier evaluation by off-island specialists as part of an effort to improve the appropriateness of off-island referrals. Regularly scheduled medical lectures are broadcast from Pohnpei, a main island, to physicians in several more remote locations. Transmission costs are kept low by using, when possible, preexisting public-service satellites, such as the PEACESAT system that serves the entire Pacific basin. The telemedicine system is evolving, and its success depends greatly on the cooperative relationships among the partners.

Education, Medical↗
PubMed1996

Experimenting with feasibility of telemedicine in Alaska: successes and lessons learned.

Alaska may be ideally suited as a test site for telemedicine. It is by far the nation's largest state, with a population of only 550,000 clustered around a few cities and towns or widely spread across an area almost two and a half times as large as Texas. Its ratio of doctors to patients is the second lowest in the nation, and the cost of medical care exceeds that in the lower 48 states by 90%. Almost half of its residents are affiliated with the federal government in some way. Active duty and retired members of the military and their families (including children) represent 70,000 of the state's residents, and another 160,000 are affiliated with the Coast Guard, the Indian Health Service, and the Department of Veteran Affairs. In 1995, a telemedicine initiative was launched under the auspices of the 3rd Medical Center at Elmendorf Air Force Base. Its mission was to integrate video conferencing and store-and-forward technology into patient care. Brief but well-documented efforts yielded many valuable lessons on how relatively simple, low-bandwidth technology can be effectively used and its limitations. In addition, unexpected changes were observed in the way health care was delivered. This experience should provide valuable lessons for those embarking on this path to health care delivery.

Alaska↗
PubMed1996

Transmission of full-length echocardiographic images over ISDN for diagnosing congenital heart disease.

OBJECTIVES: To study the feasibility of transmitting full-length diagnostic-quality echocardiograms with video conferencing systems linked by ISDN. METHODS: Forty-three previously video-recorded full-length echocardiograms (22 complete two-dimensional Doppler studies, 21 separate M-mode studies) were transmitted from a site 30 miles distant using desktop video conferencing systems linked with one ISDN line (128 kbps). Blinded interpretations of the original recorded and transmitted studies were made by two pediatric cardiologists (two-dimensional Doppler) and a pediatric sonographer (M-mode). RESULTS: Diagnoses of normal (N = 12) and abnormal (N = 10) conditions were made from the original tapes; the same interpretations were made from the transmitted studies. Twenty-one specific abnormalities in the 10 abnormal studies were seen on both original and transmitted videotapes. These abnormalities ranged from simple congenital heart defects, including ventricular septal defect, atrial septal defect, and patent ductus arteriosus, to complex ones, such as coronary artery fistula, double-outlet right ventricle, and complete atrioventricular canal. Qualitatively, there was mild degradation in gray scale, brightness, and contrast of the images. Six M-mode variables from the transmitted images had excellent concordance with the original tracings (P = 0.506 to 0.838; r = 0.86 to 0.97). CONCLUSIONS: Although our sample size was small, this preliminary experience indicates that video conferencing equipment utilizing ISDN technology is a reliable method for transmitting full-length diagnostic-quality echocardiographic studies from remote sites. This technology may have a significant impact on the management of pediatric patients with suspected heart disease. Further evaluation is warranted.

Child↗
PubMed1996

Accuracy of interpretation of microscopic images of cytologic, hematologic, and histologic specimens using a low-resolution desktop video conferencing system.

OBJECTIVE: To determine the accuracy of interpretation of microscopic images for pathologic study transmitted over Switched-56 lines using a desktop interactive video conferencing system. MATERIALS AND METHODS: In subjective studies, two systems were connected using null-modem cables, which allowed evaluation of different bandwidths from 56 kbps to 384 kbps. Objective studies were done with two systems connected at distant sites via paired Switched-56 lines that produced an effective bandwidth of 112 kbps. A video camera mounted on a microscope was attached to the sending system. The resolution of the video image on the video conferencing system was 352 x 288 lines. Cases for cytology, hematology, and histopathology studies were selected from archives; one pathologist transmitted microscopic images, and a second pathologist made interpretations. The three pathologists were Board certified with similar experience that ranged from 20 to 35 years. Categories of interpretations or observations were predetermined for each study to allow the data on agreement between the direct microscopic interpretation or observation and that recorded by the receiving pathologist to be corrected for agreement attributable to chance alone. The results were analyzed using the kappa statistic. RESULTS: In the subjective studies, image degradation prevented interpretation while the microscope stage was moved. This problem occurred at all bandwidths tested. Image quality limited microscopic details. Organisms < 1 micron in diameter could not be seen reliably. In objective cytologic studies, overall agreement was recorded on 89 of 99 observations. In the four categories of specimens, observed agreement ranged from 0.778 to 0.958, and kappa was 0.704 to 0.948. For hematology specimens, overall agreement was found on 69 of 80 observations; observed agreement on eight types of nucleated blood cells ranged from 0.5 to 1.0, and kappa was 0.429 to 1.0. Poorer color definition and image quality prevented accurate identification of lymphoblasts and eosinophils in particular. For histologic specimens, overall agreement was obtained on 56 of 66 observations, observed agreement on four categories of histologic change ranged from 0.73 to 0.93, and kappa was 0.47 to 0.9. CONCLUSIONS: The desktop interactive video conferencing system, as configured in this study, was unsuitable for making definitive diagnoses from transmitted microscopic images.

Cell Biology↗
PubMed1997

Telemedicine in trauma care: description of 100 trauma teleconsults.

OBJECTIVE: To study the role of telemedicine in the delivery of trauma care to rural providers on a telemedicine network. METHODS: A descriptive analysis of 100 trauma teleconsults over a private telemedicine network from February 1, 1995, through July 31, 1996. RESULTS: Of 354 clinical teleconsults during the study period, 100 (28%) concerned trauma. The largest number of trauma teleconsults (54) were provided by orthopedic surgeons. Emergency physicians provided 33 teleconsults, radiologists 8, and neurosurgeons 5. The most common reasons for trauma teleconsults (94%) were diagnosis and treatment of extremity and pelvic injuries. The document camera was used for all teleconsults, primarily to transmit radiographs. The mean age of the patients was 32.3 years. Sixty-one of the teleconsults were categorized as urgent, 32 were emergency, and 7 were scheduled. The mean duration of the emergency teleconsults was 4.3 minutes, and the overall mean duration of all teleconsults was 8.6 minutes. Ninety of the trauma teleconsults occurred during regular week days, Monday through Friday. Radiologists reviewed all hardcopy radiographs and computed tomography films, and hard-copy interpretations were compared with interpretations at the time of the teleconsult. No significant discrepancies between the two modes of interpretation were noted. Of the 100 patients involved in trauma teleconsults, 68 stayed in the rural community. No significant adverse outcomes were observed among patients involved in teleconsults. CONCLUSION: This analysis confirms the clinical effectiveness of telemedicine technology in the evaluation and treatment of extremity and pelvic injuries.

Adult↗
PubMed1998

Telemicrobiology: feasibility study.

BACKGROUND: Rural hospitals generally lack staffing with infectious disease specialists or pathologists. Without on-site pathologists, the range of microbiology services offered by clinical laboratories may be limited as well. OBJECTIVE: To study the feasibility of using static-image telepathology to evaluate Gram stains of microbiologic preparations. MATERIALS AND METHODS: In this retrospective feasibility study, three pathologists evaluated Gram stains of slides from 50 cases by two viewing modalities: static-image telepathology and conventional light microscopy. Digital video images of slides were captured at two magnifications (using 40x and 100x objective lenses) at 1024 x 768 x 24-bit color and transmitted over standard telephone lines at 14,400 kbps. Pathology reports and culture results served as "truth diagnoses." Categories of interpretations were correct, minor discrepancy, or major discrepancy with regard to the implications for patient care. RESULTS: The diagnostic accuracy of video image readings and conventional light microscopy readings were nearly identical, with no statistically significant differences in the performances of specialty and nonspecialty pathologists (P > 0.05). The mean accuracies of readings of the video images and light microscopy images were 95.3% and 95.4%, respectively. Taking into account the time required by a referring pathologist to capture video digital images, telemicrobiology was somewhat less efficient than conventional light microscopy. CONCLUSIONS: Pathologists can accurately evaluate digital video images of preselected fields on Gram-stained slides. In clinical practice, however, a limiting factor may be the availability of local personnel qualified to select the microscopic fields for evaluation by telepathologists. The adequacy of the video images suggests that telepathology may also be used for remote supervision of quality assurance programs in microbiology laboratories, as well as for remote proficiency training of laboratory personnel.

Arizona↗
PubMed1998

Simulation methodology for estimating financial effects of telemedicine in West Virginia.

Understanding the full financial effects of telemedicine systems on payers, providers, and patients has been hampered by the lack of data from full-fidelity systems operating at a steady state. The vast majority of telemedicine systems in the United States have yet to achieve their full potential in serving their target populations and are operating well below capacity. The purposes of this research are two-fold: (1) to develop a methodology that compensates for the limited availability of empirical data on the financial effects of telemedicine; and (2) to test this methodology in a comprehensive telemedicine system in West Virginia. The proposed methodology utilizes simulation modeling techniques for evaluating the financial performance of a mature telemedicine system. It is particularly suitable for analyzing large, complex systems that have not yet achieved steady-state operation. Although complex, the methodology can be described simply as consisting of two major steps. The first is the identification of all of the relevant variables and parameters for modeling. The second consists of simulating "real world" decision situations involving all relevant variables and parameters. The relation among the variables and parameters are described in terms of mathematical equations. The ability of the researcher to estimate the financial effects of a given telemedicine system is a function of the extent to which the resulting model approximates conditions of the real world; i.e., the fit between model and reality.

Algorithms↗
PubMed1998

Accuracy of orthognathic evaluation using telemedicine technology.

OBJECTIVE: Telemedicine technology has the ability to project highly specialized medical and dental expertise anywhere in the world. This is particularly important to many small, isolated communities that do not have access to medical and dental specialists. Telemedicine also has the potential to reduce unnecessary travel, time away from work, and unneeded hospital admissions. For this technology to be successful, however, clinicians need to have confidence in its capabilities. This study was conducted to determine the accuracy of an orthognathic evaluation using telemedicine. MATERIALS AND METHODS: Thirteen patients were randomly selected for review by two surgeons each using telemedicine and clinical examinations. Clinically acceptable differences were established, and the results of the two examination methods were compared. RESULTS: A main effect of the examination method was observed in 7 of the 18 continuous measurements taken. Examination of the absolute value of the within-subject difference between the two examination methods demonstrated that the mean absolute difference was statistically different from zero for 13 of 18 measurements taken. CONCLUSIONS: These data demonstrate that a relatively accurate orthognathic examination can be performed with this technology. With this in mind, clinicians may feel comfortable using this technology for other clinical applications.

Adult↗