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PubMedDate not supplied

From multimodality digital imaging to multimedia patient record.

The constant improvement in computer power and performance nowadays offers convenient and efficient means of manipulating images, graphics, and movies on off-the-shelf workstations. With this improvement the trend toward integration of multimodality clinical documents from patient records comes naturally. Images and graphs are certainly the most important part of the complementary information that must accompany the text and numerical data. It is, however, possible to include sounds and voice messages together with all the other modalities. In medicine that could certainly help conveying hart murmur or sounds, but could also offer a convenient way of including vocal messages and comments. These new possibilities will certainly change the way physicians use workstations for direct communication. The computer industry will soon offer means of interactive communication between remote users through computer workstations. That alone will open a completely new era in cooperative computing and remote consultation scenarios in medicine. More than the technology itself, a complete change in behavior and work habits can be expected in the medical community.

Computer Communication Networks↗
PubMed1996

[Evaluation of pediatric advise asked by telephone in emergency units].

BACKGROUND: Telephone calls for advice are common in pediatric emergency departments. This study was conducted to determine the nature of these calls and the answers provided. METHODS: From 24 April through 24 July 1994, all telephone calls requesting pediatric advice in the emergency department of the Poissy Hospital were independently analysed by two pediatricians from forms prospectively filled in for each call by the resident or the attending people who answered the call. RESULTS: Of the 239 registered calls, 186 could be analysed. They represented, in number, 15.25% of the children seen at the same emergency department during the study period. Weekend and holiday calls accounted for 35.5% of calls. 7.8% of calls were received from 0.01 am to 8.00 am, 28.7% from 8.01 am to 4.00 pm, and 63.5% from 4.01 pm to 12.00 pm. Thirty-seven percent concerned children under one year of age. The caller was one of the parents in 93% of cases. The four most frequent complaints were fever (26.5%), requests for information (17.2%), rash (12.3%), and vomiting (10.2%). The review of calls by two pediatricians determined that 67% of children did not need to be seen by a physician within six hours; 28% needed to be seen within 6 hours, and 5% needed to be seen within one hour. The advice given was followed in 88% of cases; 96% of callers were satisfied with their calls management. CONCLUSIONS: Telephone advice constitutes an important part of the activity in the pediatric emergency department. Instructional programs in telephone management are necessary for physicians. These programs should include communication skills and familiarization with protocols concerning the most frequent complaints, especially those regarding children under one year of age.

Adolescent↗
PubMed1996

[Telephonic advice by an emergency department given in a simulated pediatric case].

BACKGROUND: Emergency departments (ED) are requested everyday to dispense medical telephone advice for children. To evaluate the quality of telephone management, a mock scenario simulating a febrile 4 month-old-girl with signs compatible with septicemia was used. METHODS: One hundred randomly selected French emergency departments were called on. Half of the hospitals had a pediatric department with more than 20 beds; the other half did not have a pediatric department. A research technician called and said: "My baby has got fever and I do not know what to do". Additional information was given only on request. RESULTS: Ninety-four ED gave medical advice by telephone: 65% of the cases by a physician, 24.5% by a nurse, 9.5% by a nurse technician and 1% by a secretary. In hospitals without a pediatric department, physicians took calls in 76.5% of the cases, whereas in hospitals with a pediatric department they only took calls in 53% of the cases. The mean number of questions asked per ED was 3.1. The age of the child was requested by 87.2% of the respondents. Advice was given by 36.1% of the ED without asking either the age of the patient or grade of the fever. The advice given by the respondents was: come to the ED immediately (30.9%), see a community physician immediately (51%), come to the ED tomorrow (2.1%), see a community physician tomorrow (8.5%), and manage at home (7.5%). CONCLUSIONS: This study has shown important inadequacies in pediatric telephone advice given by some ED. It suggests that the respondents do not use a protocol to handle the calls; development of such protocols to guide the histories taken and advice given for the most common telephone queries is urged.

Attitude of Health Personnel↗
PubMedDate not supplied

Evolution of telepsychiatry to rural sites: changes over time in types of referral and in primary care providers' knowledge, skills and satisfaction.

INTRODUCTION: Rural populations remain underserved in terms of psychiatric services. This study assesses changes over time in the utilization of telepsychiatric services by individual primary care providers (PCPs) and clinics in rural areas, specifically: (a) types of referrals for telepsychiatry service; (b) PCPs' knowledge and skills related to medication dosing; and (c) PCPs' satisfaction with telepsychiatry. METHODS: Data with regard to patient demographics, diagnoses, reason for consultation, medication dosing and satisfaction were prospectively collected on the first 200 and the subsequent 200 telepsychiatric initial consultations. A number of educational interventions were implemented during the project. RESULTS: Adult patients were primarily referred for mood and anxiety disorders, particularly for diagnosis and medication treatment planning. Over time, PCPs significantly improved medication dosing and asked for more treatment planning help. PCPs' satisfaction also improved over time. DISCUSSION: Telepsychiatric consultation, in combination with specific educational interventions, appears to facilitate the enhancement of skills and knowledge of PCPs. "Developmental" steps in provider and clinic evolution, along with interventions specific to a given provider's and a given site's needs, ought to be further elucidated.

Academic Medical Centers↗
PubMed2004

Diagnostic accuracy of second-opinion diagnoses based on still images.

Second opinion of histological specimens is an important part of the daily routine in anatomic pathology practices. Today, extramural second opinion can be easily obtained by sending still images via an electronic network. The aim of this study was to examine the diagnostic accuracy of second opinion diagnosis based on still images selected from glass slides of 90 archived cases originally referred for extramural second opinion. Two pathologists together diagnosed first the still images (phase 1) and then the glass slides (phase 2). Phase 1 and phase 2 diagnoses were compared with the original second opinion diagnoses (OSODs). The pathologists achieved the same diagnostic results in phase 1 and in phase 2 measured against the OSOD, 67.8% (n = 61) and 68.9% (n = 62) complete agreement, respectively. In 29 cases in phase 1, the diagnoses were discordant with the OSOD. Three cases had incorrect benign diagnoses and 8 cases had incorrect malignant diagnoses. There were 8 false-negative diagnoses regarding malignancy, 6 false-positive diagnoses regarding malignancy, and 4 other discordant diagnoses. Eleven of the 29 discordant diagnoses could have had clinical implications. In interpreting these results, it is important to acknowledge the observer variability in diagnostic histopathology in general. In conclusion, the results support the concept of using still images to obtain second opinion diagnosis.

Diagnostic Errors↗
PubMed2004

Teleotolaryngology: a retrospective review at a military tertiary treatment facility.

OBJECTIVE/HYPOTHESIS: The use of real-time telemedicine in providing quality health-care in multiple specialties has been demonstrated in several small studies; however, a review of the literature reveals no large-scale prospective or retrospective telemedicine studies in otolaryngology. The telemedicine office at Naval Medical Center San Diego (NMCSD) acquired a large otolaryngology telemedicine patient database, and this study reviews the otolaryngology telemedicine experience at NMCSD over an 18-month period. STUDY DESIGN: We conducted a retrospective and reviewed new patient consults for the NMCSD otolaryngology telemedicine clinic from April 1, 2001, until November 6, 2002. RESULTS: During the study period, a total of 883 patients received new patient evaluations. Of 883 patients, 568 (64.3%) received a preliminary diagnosis and were treated accordingly. Telemedicine resulted in the avoidance of 22.7% consults. Only 115 (13.0%) of 883 patients required traditional face-to-face otolaryngology consultation. In addition, only 30 (4.3%) of 705 patients who underwent flexible nasopharyngoscopy, otomicroscopy, or nasal endoscopy received incomplete examinations. CONCLUSIONS: Our study demonstrates the ability of telemedicine to function in an general otolaryngology setting.

Adolescent↗
PubMed2002

Orthodontic referrals via TeleDent Southwest.

The information presented in this article must be interpreted with caution. Ideally the trial should have lasted longer because five of the seven participating dentists said they felt constrained from taking in more cases because access to TeleDent advice would cease before completion of all but the shortest of treatments. Second, the number of practitioners recruited into the trial was small, and the dentists chosen were highly selected. Third, almost all the data are based on the opinions of the participating dentists, and for three of the dentists the number of cases on which those opinions were based was small. Finally, it must be remembered that all United Kingdom NHS dentists are busy and work on a highly structured "time of service" payment system. Although the costs of hardware, software, line rental, and training were borne by the TeleDent project, there was no financial compensation for the time spent by dentists capturing images of their patient records and putting together the whiteboard and transmitting the information. There was a significant financial disincentive for using the system. Ideally, a long-term prospective randomized study of the effect of teledentistry advice on outcome of orthodontic treatment provided by general dental practitioners should be undertaken. The data collected in the current study supported the dentists' opinions that TeleDent SW enabled them to offer a better service for their patients and use specialist services more appropriately.

Computer Communication Networks↗
PubMed2002

Joint teleconsultations (virtual outreach) versus standard outpatient appointments for patients referred by their general practitioner for a specialist opinion: a randomised trial.

BACKGROUND: The current model of general practitioner referral of patients to hospital specialists in the UK is sometimes associated with unnecessary duplication of investigations and treatments. We aimed to compare joint teleconsultations between general practitioners, specialists, and patients (virtual outreach) with standard outpatient referral. METHODS: Virtual outreach services were established in London and Shrewsbury. The general practitioners referred 3170 patients, of whom 2094 consented to participate in the study and were eligible for inclusion. 1051 patients were randomly assigned virtual outreach, and 1043 standard outpatient appointments. We followed up the patients for 6 months after their index consultation. The primary outcome measure was the offer of a follow-up outpatient appointment. Analysis was by intention to treat. FINDINGS: More patients in the virtual outreach group than the standard group were offered a follow-up appointment (502 [52%] vs 400 [41%], odds ratio 1.52 [95% CI 1.27-1.82], p<0.0001). Significant differences in effects were observed between the two sites (p=0.009) and across different specialties (p<0.0001). Virtual outreach increased the offers of follow-up appointments more in Shrewsbury than in London, and more in ear, nose, and throat surgery and orthopaedics than in the other specialties. Fewer tests and investigations were ordered in the virtual outreach group by an average of 0.79 per patient (0.37-1.21, p=0.0002). Patients' satisfaction (analysed per protocol) was greater after a virtual outreach consultation than after a standard outpatient consultation (mean difference 0.33 scale points [95% CI 0.23-0.43], p<0.0001), with no heterogeneity between specialties or sites. INTERPRETATION: The trial showed that allocation of patients to virtual outreach consultations is variably associated with increased offers of follow-up appointments according to site and specialty, but leads to significant increases in patients' satisfaction and substantial reductions in tests and investigations. Efficient operation of such services will require appropriate selection of patients, significant service reorganisation, and provision of logistical support.

Ambulatory Care Facilities↗
PubMed2000

The use of telemedicine in child sexual abuse evaluations.

OBJECTIVE: To describe the advantages, disadvantages and current status of child abuse consultations conducted through telemedicine networks. METHOD: The results of a telephone survey of seven statewide telemedicine networks are reported and discussed with respect to goals, funding, technical support and expertise, infrastructure, and extent of use. Quality assurance and liability issues concerning telemedicine child abuse consultations are also reviewed. RESULTS: The goals of telemedicine networks in child abuse are to provide (1) expertise to less experienced clinicians primarily in rural areas; (2) a method for peer review and quality assurance to build consensus of opinions particularly in sexual abuse cases; and (3) support for professionals involved in an emotionally burdensome area of pediatrics. Problems encountered by existing networks include: (1) funding for equipment and reimbursement for consultation; (2) consistent technical support: (3) clinician lack of technical expertise, knowledge, or motivation; and (4) lack of network infrastructure. Legal considerations include licensure exemptions for consulting across state lines, potential for malpractice, patient confidentiality and security of images forwarded over modem lines, and liability of the equipment, consulting site, and the consultant in criminal proceedings. CONCLUSIONS: Telemedicine consultations offer a unique opportunity to raise the standard of care in child abuse evaluations, but success depends on clinician motivation, appropriate infrastructure, and ongoing funding and technical support.

Child↗
PubMed1997

An image capture and communication system for emergency computed tomography.

An image capture and communication system for emergency computed tomography (CT) is presented. The system, named ICCS, integrates CT scanners, personal computers (PC), network systems, an IBM API gateway and an IBM mainframe platform. The ICCS was implemented in the emergency unit in the Taichung Veterans General Hospital (TCVGH) and has received considerable support from the doctors, nurses and staff of the TCVGH emergency unit who have shown great interest in ICCS. This is because ICCS allows physicians in the emergency unit to examine patients' images on image viewing stations immediately after the patients are CT scanned. It also makes remote consultation possible for doctors who can stay where they are and consult with radiologists through the system and a hot line without leaving the emergency unit. This advantage greatly reduces the consultation time and saves many unnecessary trips between the emergency unit and the Department of Radiology.

Emergency Service, Hospital↗
PubMedDate not supplied

Implementing a nurse-led telephone advice system in ophthalmology.

This article describes the background research I undertook to determine the potential for a telephone advice line in this major specialist eye hospital in the United Kingdom. The information gained was used to implement a computer-based telephone assessment system with guidelines. This system enables a registered nurse with an ophthalmic qualification to offer telephone triage and general information and advice about eye problems. The help line was identified as a service that would enhance the care of patients with eye problems, their carers, and health providers. The help line, "Moorfields Direct," was given a dedicated telephone number and was officially launched in February 1999.

Eye Diseases↗
PubMed2001

The comparative impact of video-consultation on neurosurgical health services.

This study evaluated the impact of telemedicine technology on the provision of neurosurgical health services. We focused on the differences between the use of real time audio-visual teleconferencing and teleradiology versus conventional telephone consultations in the referral of neurosurgical patients from a large district general hospital. All patients requiring emergency neurosurgical consultation were included for randomization into telephone consultation only (Mode A), teleradiology and telephone consultation (Mode B) and video-consultation (Mode C). Measures of effectiveness included diagnostic accuracy and adverse events during the transfer and Glasgow Outcome Score. In a 10-month period, 327 patients were recruited and randomized into the study: the male/female ratio was 2:1 and the number of patients required to be transferred to the neurosurgical unit was 125 (38%). There was a trend towards a more favourable outcome in the video-consultation mode (44%, Mode C), versus teleradiology (31%, Mode B), versus telephone consultation (38%, Mode A). The interim data of this prospective randomized trial suggests that video-consultation may have a favourable impact on emergency neurosurgical consultations.

Emergencies↗
PubMed2004

What are the challenges faced by psychiatrists in the management of Alzheimer's disease?

Alzheimer's disease (AD) is a debilitating condition affecting millions of elderly citizens. The quality of life for AD patients significantly deteriorates in the face of worsening cognitive deficits and disabling functional declines, both contributing to manifestations of difficult behaviors. Of the estimated 4 million individuals with AD, only 60% of probable AD cases are diagnosed, with little more than half of those receiving treatment. One of the possible reasons for this problem is the large role primary care physicians (PCPs) have in diagnosing and treating AD. The barriers that PCPs confront to adequately manage these patients will be discussed. Finally, the specific challenges that geriatric psychiatrists will face in addressing these issues in an environment where there is only a limited number of trained geriatric psychiatrists will be discussed, as well as the possible role that new technology could have in finding the solution to this difficult problem.

Aged↗
PubMed2000

Referral patterns and the referral system for oral surgery care. Part 2: The referral system and telemedicine.

OBJECTIVE: To investigate GDP opinions of the current referral system and to investigate the need and demand for telemedicine in oral surgery referrals. DESIGN: Postal questionnaire. SETTING: 400 GDPs in Greater Manchester. RESULTS: 84% participation rate. 48% were not satisfied overall with the service of their current specialist oral surgery referral site. The principal reason was the length of the waiting time for consultation and treatment. Distance for patients to travel to the specialist unit was also of concern, even though most patients (89%) travelled short distances (return journey of twelve miles or less). 23% of respondents wished to improve their ability to communicate with the oral surgeon and 70% wanted involvement in the patient consultation. Both of these requirements were more likely in younger practitioners. CONCLUSION: There is a need and demand for change in the referral system for oral surgery specialist care. Telemedicine could conceivably be one way to improve access to specialist oral surgery care.

Adult↗
PubMed2005

Teledentistry for screening new patient orthodontic referrals. Part 2: GDP perception of the referral system.

OBJECTIVE: To evaluate GDP opinion about a teledentistry system to screen new patient orthodontic referrals. STUDY DESIGN: Cross-sectional questionnaire. SAMPLE: Two hundred general dental practitioners (GDPs) were approached from Stockport, Rochdale, Oldham, Bury and Bolton in Greater Manchester, and High Peak in Derbyshire. METHOD: A questionnaire about a teledentistry system for new orthodontic patients was developed, following interviews with eight GDPs participating in a teledentistry trial. The questionnaire was posted to another 200 GDPs who were asked questions on issues such as the efficiency of a teledentistry system; the usefulness of a teledentistry system from the patients' point of view; their view of a teledentistry system; and any concerns they had relating to security, confidentiality and consent. RESULTS: Seventy one per cent of GDPs thought teledentistry for orthodontic referrals would be a good idea. At least 90% of responders agreed or neither agreed nor disagreed that patients would benefit from such a system. Over half of GDPs agreed or strongly agreed that there would be implications on their surgery time, expense and equipment security. CONCLUSIONS: GDPs generally supported a teledentistry system for new patient orthodontic referrals. Although perceived patient advantages were agreed, GDPs tended to be less sure about the impact on them in terms of set-up expenses, time in the surgery and appropriate remuneration.

Attitude of Health Personnel↗
PubMed1998

Comparison of teleconsultations and face-to-face consultations: preliminary results of a United Kingdom multicentre teledermatology study.

The objective of this multicentre study was to undertake a systematic comparison of face-to-face consultations and teleconsultations performed using low-cost videoconferencing equipment. One hundred and twenty-six patients were enrolled by their general practitioners across three sites. Each patient underwent a teleconsultation with a distant dermatologist followed by a traditional face-to-face consultation with a dermatologist. The main outcome measures were diagnostic concordance rates, management plans and patient and doctor satisfaction. One hundred and fifty-five diagnoses were identified by the face-to-face consultations from the sample of 126 patients. Identical diagnoses were recorded from both types of consultation in 59% of cases. Teledermatology consultations missed a secondary diagnosis in 6% of cases and were unable to make a useful diagnosis in 11% of cases. Wrong diagnoses were made by the teledermatologist in 4% of cases. Dermatologists were able to make a definitive diagnosis by face-to-face consultations in significantly more cases than by teleconsultations (P = 0.001). Where both types of consultation resulted in a single diagnosis there was a high level of agreement (kappa = 0.96, lower 95% confidence limit 0.91-1.00). Overall follow-up rates from both types of consultation were almost identical. Fifty per cent of patients seen could have been managed using a single videoconferenced teleconsultation without any requirement for further specialist intervention. Patients reported high levels of satisfaction with the teleconsultations. General practitioners reported that 75% of the teleconsultations were of educational benefit. This study illustrates the potential of telemedicine to diagnose and manage dermatology cases referred from primary care. Once the problem of image quality has been addressed, further studies will be required to investigate the cost-effectiveness of a teledermatology service and the potential consequences for the provision of dermatological services in the U.K.

Attitude of Health Personnel↗
PubMed2001

Can we use video images to triage pigmented lesions?

BACKGROUND: Advances in telemedicine permit consultations where the doctor and patient are at different sites. OBJECTIVES: To determine whether this technology could be used to triage referrals of pigmented lesions to a dermatology out-patient clinic, and thereby assist in managing the ever increasing number of lesions being referred. METHODS: When patients attended clinic, a clinical diagnosis of their pigmented lesion was made and recorded. A still image of each lesion was subsequently taken from a video camera using a PC card, and stored. These images were subsequently viewed in conjunction with the general practitioner's referral information and designated as 'warrants referral' or 'does not warrant referral'. For each lesion this decision was compared with the clinical diagnosis made during the live consultation in the clinic (the 'gold standard'). Clinical diagnoses designated as warranting referral were malignant melanoma, basal cell carcinoma, keratoacanthoma, atypical naevus and pyogenic granuloma (due to the potential clinical confusion with amelanotic melanoma). Lesions that were not considered to warrant referral included benign melanocytic naevus, seborrhoeic keratosis, dermatofibroma, congenital naevus, solar lentigo, actinic keratosis and various other benign conditions. RESULTS: In total, 819 lesions were evaluated, resulting in a mean sensitivity of 81% and specificity of 73% for the technique. CONCLUSIONS: We feel that the overall sensitivity of 81% is encouraging as regards the use of such a technique as a triage tool, but that the inability to examine the whole patient or palpate the lesions is a major drawback in the safe triage of patients with pigmented lesions.

Adolescent↗