bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of payment method on behaviour of primary care physicians: a systematic review
Authors: Gosden Toby , Forland Frode , Kristiansen Ivar Sonbo , Sutton Matthew , Leese Brenda , Giuffrida Antonio , Sergison Michelle , Pedersen Lone
Published: October 2002

Objective: To review the impact of payment systems on the behaviour of primary care physicians.

Methods: All randomised trials, controlled before and after studies, and interrupted time series studies that compared capitation, salary, fee-for-service or target payments (mixed or separately) that were identified by computerised searches of the literature. Methodological quality assessment and data extraction were undertaken independently by two reviewers using a data checklist. Study results were qualitatively analysed.

Results: Six studies met the inclusion criteria. There was considerable variation in the quality of reporting, study setting and the range of outcomes measured. Fee-for-service resulted in a higher quantity of primary care services provided compared with capitation but the evidence of the impact on the quantity of secondary care services was mixed. Fee-for-service resulted in more patient visits, greater continuity of care, higher compliance with a recommended number of visits, but lower patient satisfaction with access to a physician compared with salary payment. The evidence of the impact of target payment on immunisation rates was inconclusive.

Conclusions: There is some evidence to suggest that how a primary care physician is paid does affect his/her behaviour but the generalisability of these studies is unknown. Most policy changes in the area of payment systems are inadequately informed by research. Future changes to doctor payment systems need to be rigorously evaluated.
Assessing the value of hospital-in-the-home: lessons from Australia
Authors: Viney Rosalie , Haas Marion , Shanahan Marian , Cameron Ian
Published: October 2002

Objectives: To identify factors that influence the cost-effectiveness of hospital-in-the-home (HITH) and to discuss the impact of funding arrangements in creating incentives or disincentives for the establishment of HITH services.

Methods: A review of HITH services in Australia was undertaken. Based on the review, factors affecting the relative costs of HITH and conventional care were identified, in particular, the effect of funding and organisational arrangements on the incentives for managers and providers to choose between HITH and conventional care.

Results: The review of HITH services identified a wide range of models of HITH in Australia. Factors identified as important to the success of HITH included demographic and location issues, referral mechanisms, the choice of staffing and the management of the programme. However, it was clear that the structure of the programme often related to funding arrangements. Issues such as 'incentive funding', establishment costs and opportunity for costshifting were identified as being relevant to incentives for the efficient provision of HITH.

Conclusions: Evaluations are essential to inform decisions about whether HITH is likely to be a viable and costeffective alternative to inpatient care. However, the relative costs of HITH and conventional care will depend on local factors. From the point of view of the decision-maker, these will be affected by funding and organisational arrangements. Funders must be aware that complex financial incentives may mask the true costs of HITH services relative to hospital services. They need to ensure that the incentives created by funding arrangements are transparent.
Explicit and implicit rationing: taking responsibility and avoiding blame for health care choices
Authors: Ham Chris , Coulter Angela
Published: October 2002

Rationing health care in publicly funded health care systems is becoming more challenging because of the growing gap between the possibility of effective medical intervention and limited resources. This poses both an economic challenge and a political puzzle. On the basis of experience in those systems that have adopted a systematic approach to rationing, it can be suggested that the dilemmas involved should be addressed by strengthening both the information base to support decisions and the institutional framework in which decisions are taken. The contribution both of experts and of lay people is needed to inform decision-making, and the processes adopted need to allow for this as well as being transparent and accountable. In practice, rationing is likely to combine explicit and implicit decision-making and to result in the exclusion of services at the margins and the development of guidelines in the mainstream. The politics of rationing may favour muddling through and the evasion of responsibility but this will be difficult to sustain in an environment in which public awareness of decision-making in health care is growing.
Statistical heterogeneity in systematic reviews of clinical trials: a critical appraisal of guidelines and practice
Authors: Higgins Julian , Thompson Simon , Deeks Jonathan , Altman Douglas
Published: October 2002

Objective: Heterogeneity between study results can be a problem in any systematic review or meta-analysis of clinical trials. Identifying its presence, investigating its cause and correctly accounting for it in analyses all involve difficult decisions for the researcher. Our objectives were: to collate recommendations on the subject of dealing with heterogeneity in systematic reviews of clinical trials; to investigate current practice in addressing heterogeneity in Cochrane reviews; and to compare current practice with recommendations.

Methods: We review guidelines for those undertaking systematic reviews and examine how heterogeneity is addressed in practice in a sample of systematic reviews, and their protocols, from the Cochrane Database of Systematic Reviews.

Results: Advice to reviewers is on the whole consistent and sensible. However, examination of a sample of Cochrane protocols and reviews demonstrates that the advice is difficult to follow given the small numbers of studies identified in many systematic reviews, the difficulty of pre-specifying important effect modifiers for subgroup analysis or meta-regression and the unresolved debate concerning fixed versus random effects metaanalyses. There was disagreement between protocols and reviews, often either regarding choice of important potential effect modifiers or due to the review identifying too few studies to perform planned analyses.

Conclusion: Guidelines that address practical issues are required to reduce the risk of spurious findings from investigations of heterogeneity. This may involve discouraging statistical investigations such as subgroup analyses and meta-regression, rather than simply adopting a cautious approach to their interpretation, unless a large number of studies is available. The notion of a priori specification of potential effect modifiers for a retrospective review of studies is ill-defined, and the appropriateness of using a statistical test for heterogeneity to decide between analysis strategies is suspect.
Impediments to change in an Australian trial of coordinated care
Authors: Gardner Karen , Sibthorpe Beverly
Published: October 2002

Objectives

To identify impediments to change at the local level in an Australian trial of coordinated care.

Methods

Qualitative data were collected from in-depth interviews with key stakeholders, analysis of policy and other documents and the observation of trial processes. We developed an analytical framework that included four domains: agreeing trial goals and objectives; overcoming the financial barriers to producing effective care; reducing costs; and improving continuity of care. In each of these domains, we examined the strategies and processes adopted by the trial as well as the perceptions, actions and reactions of the various stakeholders to the evolving model.

Results

The trial had mixed success in implementing its key strategies in each of the four domains. Stakeholders did not fully endorse the trial&s key goals and strategies, general practitioners were unable to become effective purchasers, increased gatekeeping was never fully realised, cost-saving strategies were not taken up and improvements in continuity of care were impeded by limited provider networks and general practitioner reluctance to collaborate with other providers. Thus the system had some key features of a coordinated care model but none of the qualities that were needed to operationalise them.

Conclusions

The trial&s approach to coordinating care and its use of market mechanisms to remove the financial barriers to effective care were insufficient for motivating behaviour change in the context of a system that is structured by powerful social processes and relationships.
Cost of medical injury in New Zealand: A retrospective cohort study
Authors: Brown Paul , Mcarthur Colin , Newby Lynette , Lay-Yee Roy , Davis Peter , Briant Robin
Published: October 2002

Objective

To estimate the cost of treating medical injury associated with hospital admissions in New Zealand and the patient characteristics of costly adverse events.

Methods

As part of the New Zealand Quality in Healthcare Study (NZQHS), a retrospective examination of medical records in 13 public hospitals identified the occurrence of clinical procedures and hospital bed days attributable to adverse events. The prices charged to foreign patients were used to estimate the cost of the health care resources used.

Results

850 adverse events were identified in the NZQHS which cost an average of $NZ 10 264 per patient. For New Zealand, adverse events are estimated to cost the medical system $NZ 870 million, of which $NZ 590 million went toward treating preventable adverse events. The results suggest that up to 30% of public hospital expenditure goes toward treating an adverse event. The results also suggest that older patients, neonates and those with moderately serious co-morbidity tended to have more costly adverse events.

Conclusions

Adverse events lead to a significant use of health care resources in New Zealand. These findings suggest that substantial resources could be saved by eliminating preventable adverse events.
Telemedicine and decision support in emergency ambulances in Uppsala
Authors: Karlsten R , Sjoqvist B A
Published: October 2002

In Sweden, as in many other countries, paramedics or nurses constitute the majority of prehospital personnel. If tasks usually performed by doctors are to be performed by these personnel, there is a need for guidelines and triage in the handling of medical emergencies. We describe an information management system used in ambulances for data communication, documentation, triaging and presentation of checklists. In most cases, data are input while the patient is being cared for. The information is collected and stored together with data automatically received from the dispatch centre. The latter data are transferred by a mobile radio network to the ambulance. Medical data (e.g. electrocardiograms) are transferred from the ambulance over the data network to the receiving medical facility. All transferred data are finally collected in a database for statistical analysis and follow-up.
Interactive television for an urban adult mental health service: The Guy's psychiatric intensive care unit telepsychiatry project
Authors: Haslam Richard , Mclaren Paul
Published: October 2002

We carried out a feasibility study of an interactive television (IATV) system to enhance the provision of psychiatric intensive care services to a remote adult acute psychiatric ward in the same National Health Service mental health trust. The system used videoconferencing equipment connected by ISDN at 128 kbit/s. The system was used for patient referral, assessment and monitoring by staff at the remote site 8 km away.
Results of a meta-analysis of cost–benefit research: Is this a question worth asking?
Authors: Whitten Pamela , Kingsley Charles , Grigsby Jim
Published: October 2002

We attempted a meta-analysis of telemedicine research studies of the costs associated with telemedicine. First, we performed a search of six well known databases with a variety of relevant keywords. After discarding non-English publications, books and duplicate publications resulting from the same study, we were left with 551 articles for analysis. Our second step was to separate the articles into two groups: those with and those without quantitative cost data. Only 38 articles contained any type of real data. Because many of these 38 studies proved to be inadequately designed or conducted, we were unable to peform a traditional meta-analysis. Furthermore, there were a number of disturbing features common to these studies, including the omission of the number of consultations or patients, almost non-existent longitudinal data collection and lack of uniformity in cost analyses. We conclude that it is premature for any statements to be made, either positive or negative, regarding the cost-effectiveness of telemedicine in general.
Contracting with health-care customers and specialists for the provision of telemedicine services across European borders: The TEN– Telemed legal project
Authors: Stanberry Ben , Rossignol Guy , Menke Phillippe
Published: October 2002

Two generic contract models have been developed to resolve the legal and ethical issues that arise when contracting for telemedicine services across Europe. Model 1 relates to the risks and responsibilities of the expert providing the specialist opinion and the telemedicine service organization, while model 2 outlines the risks and responsibilities from the perspective of the client seeking the advice and (again) the telemedicine service organization. These contracts express the legal rights and responsibilities of each of the parties involved.
How do teleconsultations for remote trauma management change over a period of time?
Authors: Tachakra Sapal , Dutton Diana , Newson Roger , Hayes Jesus , Sivakumar Alganandan , Jaye Peter , Bak Julie
Published: October 2002

We obtained follow-up information about the new patients seen at a minor accident and treatment service (MATS) staffed by emergency nurse practitioners (ENPs). A previous study, of 150 teleconsultations in a six-month period starting in April 1996, was used for comparison. In the present series, 150 teleconsultations occurring in a four-month period starting in April 1999 were studied; the patients constituted 5.6% of the 2658 new attenders or 3.8% of the 3936 total attenders. In comparison with the study three years before, falling teleconsultation rates were partly offset by increasing numbers of attenders and an extension of the ENPs’ roles and skills. Teleconsultation rates rose when the number of consultant-run clinics was curtailed and ENP-run clinics replaced some of them. Eligibility to request and report more radiographs reduced the need for teleconsultations, and subsequently teleconsultations for help with interpretation of radiographs fell as the ENPs became more experienced. Specialty residents trusted ENP judgement and accepted telephoned direct admission of cases to their wards. Fewer teleconsultations were required for soft-tissue injuries. Telemedicine is an excellent educational tool.
Multidimensional telecare strategies for rural residents with brain injury
Authors: Schopp Laura H , Johnstone Brick R , Merveille Octave C
Published: October 2002

Rural residents with brain injury have difficulty in accessing care from qualified psychologists for consequent cognitive, emotional and behavioural symptoms. We examined high-quality videoconferencing to enhance care for persons with brain injury in three areas: cognitive assessment, psychotherapy and rural mental health training. The assessment study evaluated 52 outpatients seen for diagnostic visits over videoconferencing, and compared their experiences with those of 52 age- and diagnosis-matched controls seen in person. Persons seen via telemedicine were more likely than controls to want to repeat their experience and more satisfied than were the neuropsychologists who examined them. In the psychotherapy study, neurorehabilitation patients were seen via videoconferencing for therapy related to brain injury or stroke. Persons receiving psychotherapy were less likely than persons receiving assessment services to want to repeat their experience. In the training study, 39 rural mental health providers were trained via videoconferencing, and trainees demonstrated significant improvement on tests of knowledge about brain injury. Trainees formed a network of mental health provider referrals for persons with brain injury in a wide geographic area. Given adequate training and ongoing support, rural clinicians can treat many brain-injury adjustment issues locally, reserving specialist consultation for emergency or complex problems.
Global medicine and licensing
Authors: Nohr Leif Erik
Published: October 2002

Telemedicine embraces the concept of global health-care. In order to realize the internationalization of the practice of medicine, licensing issues need to be addressed. Most countries have their own regulations on licensing to protect the patient and ensure high-quality care. International licensing regulations are likely to result in the standardization of medical practice.
Teledermatology - the requirements of dermatologists in private practice
Authors: Glaessl A , Schiffner R , Walther T , Landthaler M , Stolz W
Published: October 2002

Eighty-four dermatologists in private practice in Bavaria were surveyed by postal questionnaire. Of the 45 who responded (a 54% response rate), 96% used a computer in their private practice. Fifty-seven per cent of respondents owned systems with Pentium processors, while 23% were still using 386 or 486 processors. Most of them used the Windows 95, UNIX or Apple operating system. Of the respondents who had a modem, 74% used ISDN. There were few modems connected to the ordinary telephone network. Of all respondents, 56% used email regularly. Several possible teledermatology applications were proposed in the survey (i.e. teleconsultation, on-line off-line videoconferencing, email attachments). Fifty-six per cent of respondents said that they would perform teleconsultations with dermatology clinics, 40% preferred a teleconsultation via telephone and computer, and 42% sending files via email. The survey demonstrated that a high proportion of dermatologists in private practice would use a teledermatology service.
Telerehabilitation at the University of Alberta
Authors: Liu Lili , Miyazaki Masako
Published: October 2002

We established a telerehabilitation system to link staff at the University of Alberta with clinicians and students located in Two Hills, a rural community approximately 180km east of Edmonton. From February 1996 to March 1999, the Faculty of Rehabilitation Medicine conducted a total of 254 telehealth sessions, most of which involved participants in the rehabilitation discipline. Of these connections, only 11 were unsuccessful owing to technical or telecommunication problems (i.e. 96% were successful). The average duration of a session was 1h 15min. There were benefits to the Faculty in the areas of clinical supervision of students, clinical consultation, undergraduate and graduate education as well as professional development. The future benefits of such an initiative will depend on how well we address challenges pertaining to training, human resource and infrastructure.
A qualitative study of the organizational consequences of telemedicine
Authors: Aas I H Monrad
Published: October 2002

The organizational consequences of telemedicine have frequently been mentioned in the telemedicine community, but there are few empirical studies. A study was therefore carried out of what happens in organizations when telemedicine is implemented. Qualitative interviews were undertaken with 30 persons working in teledermatology, telepsychiatry, a telepathology frozen-section service and tele-otolaryngology. Almost all respondents reported numerous organizational changes, some important. Changes in work processes were the most common. Examples of the organizational consequences of telemedicine were organizational restructuring, new organizational units, changed mechanisms for internal coordination, different flows of patients through the health-care system, improved coordination of care, new job descriptions, relocation of the place of work, employment of personnel living far away from the workplace, effects on employees not directly involved in telemedicine, sharing of experiences, minor staffing changes, clinical teamwork independent of co-location, administrative meetings arranged by telemedicine, merger of organizations independent of location, less travel by staff (and patients), a possible beneficial effect on the quality of care, and limited opposition to the adoption of the technology. Telemedicine may be important in the future organization of the disciplines studied and in health-care generally. The infrastructure of electronic networks may play an important role for organizations as the volume of telemedicine activity increases and economies of scale are realized.
A prospective satisfaction study and cost analysis of a pilot child telepsychiatry service in Newfoundland
Authors: Elford D R , White H , St John K , Maddigan B , Ghandi M , Bowering R
Published: October 2002

We evaluated user satisfaction with a PC-based videoconferencing system used for child psychiatry assessments and performed a cost analysis. Thirty patients (aged 5-16 years), accompanied by a parent, completed a psychiatric assessment using the videoconferencing system. One of five child psychiatrists was randomly assigned to each assessment. Satisfaction questionnaires were completed after each assessment by the psychiatrist, patient and parent. Parents also completed a cost questionnaire. The telecommunications bandwidth was 336 kbit/s. The psychiatrists stated that they were either 'very satisfied' or 'satisfied' with the telepsychiatry assessments. On a five-point Likert scale (1 = lowest, 5 = highest), 28 of the 30 parents (93%) rated their satisfaction level as 5; the other two rated it 4. All 30 parents (100%) stated that they 'liked' the telepsychiatry assessment and would use the system again. Twenty-nine parents (97%) indicated that they would prefer to use the telepsychiatry system to travelling to see a child psychiatrist in person. Eleven children (aged 5-12) participated and all (100%) said they 'liked' using the telepsychiatry system. Five out of nine children (56%) stated they liked the 'television doctor' better than the 'real' doctor; four said they had no preference. Nineteen adolescents (aged 13-16 years) participated and most were very satisfied or satisfied with the system. Seventeen of the 19 adolescents (89%) said they would prefer to see the psychiatrist on the videoconferencing system to travelling for an assessment, and the same number said that they would use telepsychiatry again. The estimated total travel cost for the 30 patients was $12,849, an average of $428 per patient. The total cost of the telepsychiatry service for the three-month pilot was $12,575, or $419 per patient.
Changes in the workplace with telemedicine
Authors: Tachakra Sapal , El Habashy Ashraf , Dawood Mary
Published: October 2002

The opinions of 110 emergency nurse practitioners (ENPs) practising telemedicine in 11 British minor injury units were sought using a questionnaire. There were 90 respondents (82%). The respondents thought that, since telemedicine had been introduced, they had become more open to change (96%) and more ready to grasp opportunities (93%). They considered that they were more keen to learn new things (99%) and were better disposed to teaching others (90%). They adopted a more advisory and supportive role (80%), found the work environment more varied (83%) and were well disposed to teamwork (64%). The power balance with doctors had changed (86%) and doctors indulged in dialogue rather than direction (69%). The results suggest that although changes have started in the workplace, they have not been as dramatic as a previous study of patients had predicted.
Telemedicine in the Michigan Upper Peninsula region: an evaluation of the first five years
Authors: Whitten Pamela , Eastin Matthew S , Davis Sally
Published: October 2002

A telemedicine network has operated in the Upper Peninsula (UP) region of Michigan since 1995. The Marquette General Health System (MGHS) is the tertiary hospital that provides telemedicine services to 14 surrounding rural health facilities and another seven clinics. In order to assess the state of telemedicine in the UP region and its potential for development, three main factors were assessed: organizational development, telemedicine activity and perceptions of the key players. Data were collected through interviews with five MGHS telemedicine staff, 10 physicians (five from the MGHS and five from surrounding rural areas), 13 of the 14 chief executive officers (CEOs) of the remote telemedicine sites and a survey of 21 telemedicine site coordinators. This information was analysed in order to outline job roles and responsibilities; to document the process of doing telemedicine; and to understand current policies and procedures. Telemedicine activity from 1995 to 1999 was analysed in terms of the purpose of the session. In 1999, a total of 515 telemedicine sessions were conducted, 323 being non-educational and 192 being educational. Most CEOs of the rural hospitals were interested in furthering their use of clinical telemedicine applications. The data also indicated a great need for education, particularly of the rural physicians. The overall view of those surveyed about MGHS's telemedicine programme was positive. Respondents were quick to compliment the staff whenever possible. New telemedicine staff have been employed, which will allow responsibilities to be reassigned in such a way as to create a more efficient system.
Online orthodontic advice: a protocol for a pilot teledentistry system
Authors: Cook J , Mullings C , Vowles R , Ireland R , Stephens C
Published: October 2002

A prototype teledentistry service was established that incorporated a PC-based expert system designed to assist in orthodontic cases. It guided the general dental practitioner (GDP) through the assessment of a patient's malocclusion and helped ensure that all relevant clinical observations were made and details recorded. The resulting data file, containing radiographic images and clinical data, was then transferred via the Internet to a dental specialist. The specialist's recommendations were returned by the same route or, where appropriate, a realtime videoconference was conducted. During an eight-month trial, six GDPs referred 158 cases through the teledentistry system; another 24 cases were referred directly to a local consultant. The protocol used during the trial worked satisfactorily. The GDPs found that it was straightforward and covered all aspects of the cases they submitted.
Dentists' opinions of an online orthodontic advice service
Authors: Cook Julian , Edwards John , Mullings Christine , Stephens Chris
Published: October 2002

An online teledentistry service was tested for eight months to determine whether it could help to reduce the high level of inappropriate orthodontic referrals to consultants and provide general dental practitioners (GDPs) with quick access to advice that would enable them to tackle a wider range of cases themselves. Six GDPs took part in the trial and were interviewed after it had been running for four months. The most important conclusions from the interviews were that the process of sending cases was quite straightforward, that teledentistry was a good way of getting advice and that it was popular with both patients and their parents. The GDPs enjoyed the experience and felt that there had been significant benefits, especially in educational terms.
Progress in Australian teledermatology
Authors: Lim Adrian C , See Adrian C , Shumack Stephen P
Published: October 2002

Because of their remoteness, the majority of rural towns in Australia are disadvantaged in terms of access to dermatological services. Telemedicine offers one solution. Since the mid-1990s, Australian dermatologists have experimented with tele-medicine as an adjunct to clinical practice. The technical viability of teledermatology was first demonstrated in 1997. In 1999, the accuracy and reliability of teledermatology were demonstrated in a real-life urban setting. In 2001, Broken Hill (in western New South Wales), a location remote from dermatology services, served as a trial site for the institution of tele-dermatology as the primary method of accessing dermatological services. High patient and general practitioner acceptability and positive medical outcomes were demonstrated, but the study also revealed unexpected barriers and pitfalls in the effective operation of rural teledermatology.
Online eye care in prisons in Western Australia
Authors: Yogesan K , Henderson C , Barry C J , Constable I J
Published: October 2002

In prisons, prison medical officers provide general medical care. However, if specialist care is needed then the prisoner is transported to a specialist medical centre. This is a costly procedure and prison escapes occur during transportation. We have tested our Internet-based eye care system in prisons in Western Australia. Medical and ophthalmic history, visual acuity and intraocular pressure were stored in a browser-based multimedia database. Digital images of the retina and the external eye were recorded and transmitted to a central server. Based on the medical data and the digital images, the specialist ophthalmologist could provide a diagnosis within 24 h. Eleven patients (mean age 48, range 30–82 years) were reviewed during two separate visits to a maximum-security prison in Western Australia. Our main aim was to train prison medical officers and nurses to operate the portable ophthalmic imaging instruments and to use the Internet-based eye care system. The outcome of the pilot study indicated that considerable savings could be made in transport costs and the security risk could be reduced. The Ministry of Justice in Western Australia has decided to implement telemedicine services to provide regular ophthalmic consultation to its prisons.
Online consulting. The experience of a commercial service
Authors: Leslie Simon
Published: October 2002

Doctor Global Ltd began online consulting in April 1999. It was one of the first online medical consulting services in the world. Doctor Global does not derive a significant portion of its income from providing or supervising online consultations via its Website, although experience with enabling them has been important for the development of its core product, a consumer-oriented Web-based electronic medical record.
Continuing education in physical rehabilitation using Internet-based modules
Authors: Lemaire E D , Greene G
Published: October 2002

A rehabilitation outreach team created evidence-based and peer-reviewed educational modules using standard desktop presentation software. Eighteen modules on various topics in physical rehabilitation were published in several formats, including Web pages, directly from the presentation file, for the benefit of health-care providers in eastern and north-eastern Ontario. An online evaluation form could be completed by anyone visiting the Website; the people responsible for community rehabilitation services were asked to encourage their staff to complete the forms. A total of 174 forms were received. The module 'Principles of transfers for health-care workers' accounted for 18% of the evaluations and the module 'Assisted range-of-motion exercises for arms and legs to maintain joint flexibility' accounted for 14%. Thirty-nine per cent of respondents were registered nurses, 13% were physiotherapists and 26% were people with disabilities. Thirty per cent of the participants had limited or no experience with online learning. In the evaluation, high ratings were given for satisfaction and usefulness. From an educator's perspective, multimedia content could be created and distributed without a substantial investment in equipment, software, training and publication time; this represents a 'write once, publish everywhere' approach.
Learning in organizations working with telemedicine
Authors: Aas I H Monrad
Published: October 2002

To investigate learning in telemedicine, qualitative interviews were conducted with 30 people working with telepsychiatry, teledermatology, a telepathology frozen-section service and tele-otolaryngology. More than 80% of the respondents said that they had learnt something new by using telemedicine. Most frequently the participants improved their knowledge of the specialty in which they were involved, but this was not the only way in which they learnt. The learning did not necessarily change behaviour, as two-thirds of the respondents felt that the learning had not permitted them to perform tasks for which they had previously needed assistance (although this varied somewhat with the type of telemedical work that respondents were engaged in). Two-thirds of respondents thought that something more could be done in telemedical work to promote their own learning, which shows the clear potential for learning by telemedicine. Learning could be promoted further by extending the use of the technology to other applications. To start working with telemedicine, initial instruction seems to be sufficient—a more extensive training programme appears unnecessary. In future, as many applications of telemedicine are implemented, health-care organizations may become important arenas for learning and leaders will have to focus on learning. The results of the present study clearly showed that working with telemedicine produces learning.
Teleradiology services for a rural hospital: a case study
Authors: Franken E A , Whitten P , Smith W L
Published: October 2002

We investigated the perceived quality of teleradiology services offered at a rural hospital in comparison with radiology provided by three other methods: circuit riding', an on-site radiologist, and a hybrid arrangement. The research design was a case study, with interviews of administrators, technologists and physicians at the rural hospital, followed by a structured survey of all staff physicians. Responses were analysed both qualitatively and quantitatively. Both interviews and the survey indicated that teleradiology was perceived to be as accurate as on-site film interpretation. All other aspects of the service- efficiency, reports, communications and the overall contribution to patient care-were judged to be poorer than on-site radiology. We conclude that the provision of acceptable teleradiology requires considerable attention to all aspects of the radiology service, with attention to differences in institutional culture and mission, and to communication.
Telepsychiatry, the satellite system and family consultation
Authors: Paul Norman L
Published: October 2002

A pilot telepsychiatry session was conducted with the US Department of Defense Satellite Communication System. The subjects were a family incompletely divorced many years before. There were two satellite interviews with this family. Bringing together all members of the original family so that questions could be addressed as to what happened when the children were very young unblocked a 13-year-old communication problem.
A cost analysis of a tele-oncology practice
Authors: Doolittle G C , Harmon A , Williams A , Allen A , Boysen C D , Wittman C , Mair F , Carlson E
Published: October 2002

Costs were monitored for three different types of oncology practice: a telemedicine clinic and a fly-in outreach clinic, both held in rural areas, and a traditional clinic held in a city hospital. Total expenses were calculated over the year May 1995 to April 1996. The average cost per telemedicine visit was $812. The average cost per out reach clinic visit was $897. Flying in oncology support for this practice was therefore about 10% more costly than telemedicine. While the outreach cost may have been inappropriately high due to as low start-up phase, it was still less expensive during this period to be seen via telemedicine. For comparison, the average cost per traditional oncology clinic visit was $149. However, this figure does not take into account the costs of access to a city-based service by rural patients.
Distributed clinical neurophysiology
Authors: Loula P , Rauhala E , Erkinjuntti M , Raty E , Hirvonen K , Hakkinen V
Published: October 2002

We have developed a consultation forum for clinical neurophysiology in Finland. The system connects local digital electroencephalography EEG recording and analysing networks using a high-speed asynchronous transfer mode ATM network. Clinicians can obtain a second opinion using interactive data and video consultations or using data-only consultations. In addition, the system can be used for off-line review of prerecorded data. During a one-month evaluation, 66 EEG recordings were made altogether in Satakunta Central Hospital and consultations were required on 12 occasions. Nine of them were data-only consultations and three were data and video consultations. A data consultation lasted 15-20 min and a data and video consultation 35-45 min. Clinically, there were numerous benefits for the hospitals. The system established a link to a centre of excellence for second opinions or continuing education. It also helped with on-duty arrangements and enabled the construction of national data banks.
The legal and ethical aspects of telemedicine. 1: Confidentiality and the patient's rights of access
Authors: Stanberry Ben
Published: October 2002

This paper reviews the principle of confidentiality and the rights of access by patients to their medical records. Confidentiality has been germane to the ethics of medical practice since the time of Hippocrates but the nature of the legal obligation of confidence does not have such a clear pedigree. The introduction of crossborder telemedical consultations presents a very real danger to maintaining the confidentiality of medical data. While both the common law and statute law can be used to prevent the unauthorized interception and disclosure of medical data and protect the patient's rights of access and ownership in the UK, it is the harmonization regime of the European Union that will bring comprehensive regulation and legal clarity to the protection of patients' rights within an increasingly international medical super-specialty'.
The legal and ethical aspects of telemedicine. 2: Data protection, security and European law
Authors: Stanberry Ben
Published: October 2002

The electronic record may be subject to abuses that can be carried out on a large scale and cause great damage. A wide range of data protection and information security measures will need to be taken to ensure the quality and integrity of such records. A European Union directive was formally adopted in 1995 which sets the obligations of those responsible for data processing as well as a number of important rights for individuals. The responsible teleconsultant or medical officer, as the data controller, must make sure these measures are enforced. In the case of the transmission of medical records to another location, the original data controller may remain liable for abuses. But as different elements of the records are spread throughout the different departments of a hospital or across different geographical locations, it may become difficult to ascertain who is responsible for protecting and controlling what. To this end, the designation of liability by contractual means, between the hospitals and remote users of a telemedicine network, would be the clearest and most straightforward way of achieving uniformity and predictability in terms of the distribution of responsibility for data protection and security.
Pathologists' attitudes to implementing telepathology
Authors: Mairinger Thomas , Netzer Thomas Taro , Schoner Wolfgang , Gschwendtner Andreas
Published: October 2002

If pathologists will benefit so much from using telepathology, why is it taking so long to be introduced? This question has been discussed between experts, but the potential users are rarely asked for their opinions. A questionnaire was sent to the 256 members of the Austrian Society of Pathology; this addressed general aspects of telemedicine, telepathology in frozen-section services and expert consultation, videoconferencing technologies, teleteaching and teletraining. The response rate was 46 . In general, the pathologists thought that telemedicine could become valuable in their daily routine. However, pathologists were most afraid of sampling errors in remote diagnosis and would not readily accept an alternative to the conventional method of looking at a sample. This is only possible using realtime, remotely controlled microscopes. Telepathology systems providing only still images would not be acceptable to most respondents. There was interest in the use of videoconferencing for clinicopathological conferences. Teleteaching and teletraining were seen as welcome additional techniques, but were nevertheless judged unable to replace classical methods of teaching and training.
The clinical and economic advantages of remote, community-based physiological assessment
Authors: Johnson Paul
Published: October 2002

A prospective study documented the nutritional intakes of a large cohort of pregnant women living in Portsmouth and investigated the independent relationships of smoking, dietary intake and other maternal socio-economic factors on outcome and cardiorespiratory function of the child during sleep at home at three weeks and three months of age. Unattended overnight cardiorespiratory recording was performed and the data stored in local memory before transmission on demand via modem to Oxford next morning. The telemetry of the physiological data, entirely managed by part-time community nurses in Portsmouth, was very successful. Despite some losses, which included transmission failures, electrode or lead disconnection, and monitor malfunction, 92% of the physiological data were analysed at Oxford. Personalized physiological monitoring in the community provides an opportunity for new evidence bases that will enable a new level of individualized care.
Continuous assessment of the risk of falling using telecare
Authors: Doughty Kevin , Cameron Keith
Published: October 2002

The prevention of falls in the elderly could be based on risk assessment and the prediction of when an individual is likely to sustain an injury. A telecare system should allow the dynamic assessment of risk to be produced by a control centre computer, based on data transmitted from local sensors in the elderly person's home. A fall risk index could be calculated from mobility, activities of daily living and medication. However, substantial data-sets will be required before such fall risk indices attain statistical significance. As they are developed, fall prediction algorithms could be constantly reviewed and modified in order to reach the point where an acceptable level of accuracy is reached.
A cost measurement study for a tele-oncology practice
Authors: Doolittle G C , Williams A , Harmon A , Allen A , Boysen C D , Wittman C , Mair F , Carlson E
Published: October 2002

Summary The costs of providing oncology services in three different ways were measured. Services were provided to a peripheral hospital by: conventional clinics, in which the oncologist worked at the hospital concerned; outreach clinics, in which an oncologist was flown in periodically from a central hospital; and telemedicine clinics, in which the oncologist at the central hospital practised via a video-link. During a one-year study period, 2400 patients were seen in conventional clinics, 81 in outreach clinics and 103 in telemedicine clinics. At these workloads the average costs per patient were 149, 897 and 812, respectively. However, the average costs cannot be compared directly without further information about the shape of the unit cost curves.
Evaluation of telemedical support to a free-standing minor accident and treatment service
Authors: Tachakra Sapal , Wiley Camilla , Dawood Mary , Sivakumar Alganandan , Dutton Diana , Hayes Jesus
Published: October 2002

We studied all patients attending a free-standing minor accident and treatment service MATS run by emergency nurse practitioners ENPs . In a six-month period, 5563 patients were seen in the MATS, of whom 2843 51 were new attenders. A teleconsultation was carried out with 150 of these patients 2.7 of all cases . The most common reason 39 was to discuss a radiograph with an accident and emergency consultant. The accuracy of the telemedicine-assisted radiographic diagnosis was checked subsequently by a review panel. The ENPs' working diagnoses made by viewing the films had a sensitivity of 90 and a specificity of 96 ; this was improved by telemedicine assistance to 97 and 99 , respectively. The telemedicine patients were also surveyed several months after being seen in the MATS; their replies indicated that the telemedicine diagnoses had been correct.
Telemedical experiences at an Antarctic station
Authors: Hyer Randall N
Published: October 2002

Wintering-over in Antarctica represents a physician's most remote and inaccessible scenario, apart from a space station. Because of the harsh and unpredictable winter weather, Antarctic stations are typically inaccessible for over six months of the year. Telephone and fax communication, and recently other forms of telemedicine, have provided vital links to specialists. The author was the sole physician for more than 250 people wintering-over during the 1995 austral winter at McMurdo Station. There were several instances of serious or life-threatening illness where the author relied on teleconsultation. These cases included new-onset coronary artery disease, posterior hip dislocation, complicated Colles’ fracture and acute appendicitis. There were also numerous consultations for non-emergency clinical presentations normally managed by specialists. Telemedicine was a crucial link to specialists from the remote and inaccessible environment of Antarctica.
Digitized mammograms: a preliminary clinical evaluation and the potential for telemammography
Authors: Murphy J M , O'Hare N J , Wheat D , Mccarthy P A , Dowling A , Hayes R , Bowmer H , Wilson G F , Molloy M P
Published: October 2002

We performed a preliminary clinical evaluation of digitized mammograms to assess whether digital images suitable for telemammography could be obtained. Thirty mammograms were digitized at a resolution of 4000x4000 pixels and 12 bit/pixel. The series contained 17 carcinomas in 16 patients. Five consultant radiologists reported both the original mammograms and the digitized images. There was agreement between the reports of the mammograms and the digitized images in relation to whether a suspicious lesion was present or not in 95% of cases. No study considered benign on viewing the film images was interpreted as malignant on reporting the digitized images. This suggests that film digitizers may allow a digital image of a mammogram of acceptable quality for telemammography to be obtained in the absence of a purpose-built digital mammography system.
User satisfaction with realtime teleneurology
Authors: Craig John , Russell Clive , Patterson Victor , Wootton Richard
Published: October 2002

User satisfaction (i.e. that of patients, medical staff at a remote hospital and medical staff at a neurological centre) with realtime teleneurology consultations was studied prospectively. Twenty-five patients with neurological problems admitted to a hospital without permanent neurological cover were assessed from a neurological centre by specialist neurologists using realtime video-links transmitting at 384 kbit/s. All users reported high levels of satisfaction with the technical aspects of the consultations. Patients, almost universally, reported confidence in teleneurology as a means of dealing with their presenting complaints. Similarly, medical staff at either site felt confident in managing patients using teleneurology and almost always felt that a telephone consultation would not have achieved as good an outcome. No major organizational problems were identified. These findings suggest overall user satisfaction with realtime teleneurology for managing patients with neurological problems admitted to hospitals that do not have resident neurologists.