# Treatment of Diabetic Foot Ulcers in the Home: Video Consultations as an Alternative to Outpatient  Hospital Care

Authors: Jane Clemensen; Simon B. Larsen; Marit Kirkevold; Niels Ejskjaer
Journal: International Journal of Telemedicine and Applications
 (2008)

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## Abstract

The aim of this study was to investigate whether video consultations in the home can support a viable alternative to visits to the hospital outpatient clinic for patients with diabetic foot ulcers. And furthermore whether patients, relatives, visiting nurses, and experts at the hospital will experience satisfaction and increased confidence with this new course of treatment. Participatory design methods were applied as well as field observations, semistructured interviews, focus groups, and qualitative analysis of transcriptions of telemedical consultations conducted during a pilot test. This study shows that it is possible for experts at the hospital to conduct clinical examinations and decision making at a distance, in close cooperation with the visiting nurse and the patient. The visiting nurse experienced increased confidence with the treatment of the foot ulcer and characterized the consultations as a learning situation. All patients expressed satisfaction and felt confidence with this new way of working.


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## Body

## 1. Introduction

Diabetes,
late complications hereof, and diabetic foot ulcers in particular present
increasing challenges in terms of amputations, sick leaves, reduced functioning,
and escalating financial costs [1]. The patients' quality of life
decreases dramatically with the occurrence of diabetic foot ulcers. Currently,
most treatment is carried out by nonexperts such as visiting nurses and general
practitioners [2, 3] despite the fact that studies
demonstrate the importance of specialized knowledge in the treatment of chronic
wounds [3, 4]. To enable the experts to monitor
an increasing number of patients more regularly, telemedicine (telemedicine, in
its broadest sense, means “delivery of healthcare and the exchange of
healthcare information across distances” [5]) has been suggested as a way of
creating alternative treatment methods [6].Previous
studies have documented coherence between expert assessments of ulcers based on
digital images versus live assessment [7, 8]. Even low-resolution images may
sometimes be sufficient [9, 10]. Digital photographs have also
proven valuable in learning situations, for example, when giving directions for
wound care [11]. Only a preliminary set of
experiences exists in using the emerging UMTS (universal mobile telephony system) technology
for telemedicine, for example, for teleconsultations from a moving ambulance [12], but so far the results are
promising.Conclusions
from other studies demonstrate that expert-guided treatment makes nurses use
more advanced wound care remedies with better healing outcomes as a result [2, 3] and it leads to increased patient satisfaction through less travel and reduced waiting time [13–15]. Dansky and Bowles have even
suggested that communicating with the expert over a distance facilitates a more
optimal dialog, which empowers the patients who participate more actively in
their care planning. This new communication form creates a new bond—a relationship based on partnership.Furthermore, Dansky and Bowles found a significant learning curve for nurses
and expect that the nurses will become increasingly comfortable and efficient
as the technology becomes pervasive [16–18]. Another outcome of the Kaiser
Permanente Tele-Home Health Research Project was that the patients became more
actively involved in attending their own health care needs and the remote
visits were characterized as convenient because the patients felt comfortable
with discussing personal problems and in receiving care at home [14]. Treatment of diabetic ulcers has
turned out to be applicable to both synchronous [19] and asynchronous telemedicines [20]. Willbright found that telemedicine
made the specialist nurse more empowered and enabled to independently develop
treatment plans [19].Most of
these studies have utilized a static installation in the patient's home or a
store-and-forward solution for enabling the visiting nurse to receive advice
from experts. Thus, the telemedical solutions have either connected the patient
with the visiting nurse, or the visiting nurse with the expert. To a large
extent, the treatment can be perceived as collaboration between these three
stakeholders (the patient, the visiting nurse, and the expert). For this
reason, enabling the three partners to be simultaneously engaged in the
communication taking place may increase the extent to which the expert
knowledge can be utilized directly in the treatment. Furthermore, a direct
dialog between people with different perspectives may enable a more holistic
view and thereby result in a more tailored treatment.To pursue
this goal, we investigated the technological possibilities for supporting a new
organization of the treatment where the expert, the visiting nurse, and the
patient in collaboration could discuss the situation and plan the treatment.In this
article, we present the results of a pilot test, the aim of which was to
investigate the possibility of having the expert participating in the home
consultations by the use of technology and in cooperation with the visiting
nurse and the patient. In this article, we define “experts” as either a nurse
or a doctor specialized in treatment of diabetic foot ulcers in our study
located at Aarhus Hospital, Denmark. The visiting nurses referred to in this article are associated with local community
centers in the residential area of the respective patients and they were nonexperts
in diabetic foot ulcers.We explore
the subjective satisfaction of patients and healthcare professionals to test
the hypothesis that a telemedical consultation can be a viable alternative to a
visit to the outpatient clinic. In order for a telemedical consultation to be
characterized as a viable alternative to a visit to the outpatient clinic, all
participants must experience the telemedical treatment as satisfactory in terms
of (1) the clinicians being provided with sufficient clinical information for
clinical assessments and decisions to be made accurately, (2) the visiting
nurses feeling supported and secured during the sessions, and (3) the patient
being satisfied with the consultations. In the following, the findings related
to these three issues are presented.


## 2. Methods

During a
2-year process of participatory design, initial problems and potential
solutions in the field of treatment of diabetic foot ulcers were investigated.
Participatory design (PD) is a research approach, derived from action-based research
that is applied to the development of technological and organizational
solutions to real-world problems [21, 22]. PD is a qualitative study, in
which the aim is to have close cooperation with the users during the process in
order to ensure that the (technological) result can be understood and handled
in practice by the users [23]. In our study, the group of
participants consisted of hospital doctors and nurses specialized in diabetic
foot ulcers, visiting nurses, patients, and relatives. The PD process contained
field studies, workshops with the users, experiments in both laboratories and hospitals, and specification of an electronic ulcer record. The details of the methodology are
described in another article [24]. The PD process resulted in the
creation of a telemedical system for supporting the pilot test carried out
during summer 2005. This article reports the results of the test.


### 2.1. Setup for the Pilot Test Intervention

Five
patients who were all mentally well functioning and following a course of
treatment in the outpatient clinic were selected for inclusion by the experts—the same hospital clinicians who had
participated in the PD process (1 doctor and 3 nurses). After the patients gave
informed consent (including permission to film the video consultations), we
contacted the management of the patient's local center to inform about the
study and to obtain permission to involve the patient's visiting nurse. After
that, we informed the visiting nurse in more detail and a meeting was set up
for demonstration of the technology. The project was approved by the Regional Ethics Committee.The
patients were offered 3 consecutive video consultations to substitute 3 visits
to the outpatient clinic all conducted by the same team of clinicians. A
telemedical course of treatment was initiated by an intensive consultation in
the outpatient clinic, where the experts created the patient file in the online
ulcer record and uploaded high-resolution images of the ulcer as well as
obtaining measurements such as peripheral blood pressure, blood sugar. Furthermore, the first of the three telemedical consultations was prescheduled
by the researchers with both the visiting nurse, the patient and the hospital
experts.The
telemedical setup consisted of UMTS video telephones (Motorola A920) and a
custom designed online ulcer record. Prior to the consultations, the visiting
nurse used the video phone to take pictures of the ulcer and transmit them to
the ulcer record. As the video phones currently available on the market may not
yet provide a sufficient image quality, the images from the phone were
supplemented with images from a standard digital camera (Nikon CoolPix5400).
These high-resolution images were uploaded to the ulcer record upon return to
the office and therefore not available during the online consultations, but
they were used as a safety precaution. (The experts were able to view those
pictures later in cases of uncertainty. No changes were made to the assessment
or the treatment on the background of these images, however.) At the agreed
time of consultation, the visiting nurse made a video call from the home to the
doctor and to an expert nurse at the hospital. The experts used (1) the still images and the video
stream from the video phones, (2) images from the previous consultation, and (3) the cooperation of the visiting nurse in order to evaluate the ulcer and to
prescribe further treatment. After the consultation, the experts wrote their
summary of the consultation in the online web-based record. Figure1 shows two
photographs from one of the consultations.A video consultation from the pilot test.
(a) The doctor and expert nurse at the hospital. (b) The visiting nurse
and the patient at the home. The pictures originate from an article in a Danish
newspaper (Morgenavisen JyllandsPosten, 10th May 2005) describing the project
and the patient in picture on
the right has given permission to its publication.
(a)(b)


### 2.2. Data Collection

Each
consultation was video filmed by the researchers both in the patient's home and
at the hospital and transcribed afterwards. After completion of the telemedical
experiments, the researchers conducted semistructured interviews of one-hour
duration with each of the 5 visiting nurses at their local center and with the
patients in their homes (which also involved a relative in 3 out of the 5 cases). Furthermore, we conducted a focus group interview with the 3 expert nurses to
gain a guided discussion (all expert nurses had been informally interviewed
individually after each consultation) and one individual semistructured
interview with the doctor. As a final measure to circumvent amicable bias due
to the personal presence of the researchers in the interviews, all participants
were asked to indicate their satisfaction with every consultation in a
questionnaire.The total data
material consisted of transcripts of field studies, workshops, experiments,
interviews, and video consultations as well as the questionnaires and a
specification of the electronic ulcer record. The material was analyzed
systematically where data were categorized in themes arising during the
analysis, both concerning the participants’ satisfaction, as described in this
article as well as themes described in other articles elsewhere.


## 2.1. Setup for the Pilot Test Intervention

Five
patients who were all mentally well functioning and following a course of
treatment in the outpatient clinic were selected for inclusion by the experts—the same hospital clinicians who had
participated in the PD process (1 doctor and 3 nurses). After the patients gave
informed consent (including permission to film the video consultations), we
contacted the management of the patient's local center to inform about the
study and to obtain permission to involve the patient's visiting nurse. After
that, we informed the visiting nurse in more detail and a meeting was set up
for demonstration of the technology. The project was approved by the Regional Ethics Committee.The
patients were offered 3 consecutive video consultations to substitute 3 visits
to the outpatient clinic all conducted by the same team of clinicians. A
telemedical course of treatment was initiated by an intensive consultation in
the outpatient clinic, where the experts created the patient file in the online
ulcer record and uploaded high-resolution images of the ulcer as well as
obtaining measurements such as peripheral blood pressure, blood sugar. Furthermore, the first of the three telemedical consultations was prescheduled
by the researchers with both the visiting nurse, the patient and the hospital
experts.The
telemedical setup consisted of UMTS video telephones (Motorola A920) and a
custom designed online ulcer record. Prior to the consultations, the visiting
nurse used the video phone to take pictures of the ulcer and transmit them to
the ulcer record. As the video phones currently available on the market may not
yet provide a sufficient image quality, the images from the phone were
supplemented with images from a standard digital camera (Nikon CoolPix5400).
These high-resolution images were uploaded to the ulcer record upon return to
the office and therefore not available during the online consultations, but
they were used as a safety precaution. (The experts were able to view those
pictures later in cases of uncertainty. No changes were made to the assessment
or the treatment on the background of these images, however.) At the agreed
time of consultation, the visiting nurse made a video call from the home to the
doctor and to an expert nurse at the hospital. The experts used (1) the still images and the video
stream from the video phones, (2) images from the previous consultation, and (3) the cooperation of the visiting nurse in order to evaluate the ulcer and to
prescribe further treatment. After the consultation, the experts wrote their
summary of the consultation in the online web-based record. Figure1 shows two
photographs from one of the consultations.A video consultation from the pilot test.
(a) The doctor and expert nurse at the hospital. (b) The visiting nurse
and the patient at the home. The pictures originate from an article in a Danish
newspaper (Morgenavisen JyllandsPosten, 10th May 2005) describing the project
and the patient in picture on
the right has given permission to its publication.
(a)(b)


## 2.2. Data Collection

Each
consultation was video filmed by the researchers both in the patient's home and
at the hospital and transcribed afterwards. After completion of the telemedical
experiments, the researchers conducted semistructured interviews of one-hour
duration with each of the 5 visiting nurses at their local center and with the
patients in their homes (which also involved a relative in 3 out of the 5 cases). Furthermore, we conducted a focus group interview with the 3 expert nurses to
gain a guided discussion (all expert nurses had been informally interviewed
individually after each consultation) and one individual semistructured
interview with the doctor. As a final measure to circumvent amicable bias due
to the personal presence of the researchers in the interviews, all participants
were asked to indicate their satisfaction with every consultation in a
questionnaire.The total data
material consisted of transcripts of field studies, workshops, experiments,
interviews, and video consultations as well as the questionnaires and a
specification of the electronic ulcer record. The material was analyzed
systematically where data were categorized in themes arising during the
analysis, both concerning the participants’ satisfaction, as described in this
article as well as themes described in other articles elsewhere.


## 3. Results

The 15 consultations
were performed as planned. Using UMTS for telemedicine was a challenge. Various
technical difficulties arose as described in another article [25]. The technical difficulties did not, however,
prevent the pilot test to be carried out as planned, and the clinical results
of the test are presented in this article. A wide range of clinical situations
were encountered ranging from a noncritical healing ulcer to more complicated
ulcers, and at one consultation the decision was a hospital admission. In
another case, a patient was referred to the outpatient clinic for face-to-face
specialist evaluation; however, the clinical conclusion based on the
telemedical consultation remained unchanged. The consultations lasted from 5 to 18 minutes, including the dialogs between nurses and patients and also including scheduling a time for the ensuing video consultation. The course of 3 following consultations for each patient lasted from 2 weeks to 6 weeks.The overall results
from the study demonstrate that the alternate course of treatment proved satisfactory
from the viewpoint of all 3 stakeholders. The experts were both satisfied with
the new course of treatment and they felt secure in being responsible for the
treatment performed on a distance. The visiting nurses were satisfied and felt
supported in carrying out the treatment. The patients (and relatives) felt
secure and characterized the treatment as an improvement because they were able
to remain at home.


### 3.1. Expert’s Basis for Making Decisions at a Distance

After the
consultations, the experts expressed satisfaction with the clinical basis for
their decision making. Both the information provided in the form of pictures
and communication with the patient and the cooperation with the visiting nurse
constituted important basis for the experts' decision making. “The presence of
the visiting nurse in the patient’s home compensates in full for not having the
patient in front of you,” the doctor said in the interview.By cooperating with
the visiting nurse and being precise when asking questions, the experts were
able to gather the information they would normally observe themselves,
including the color, temperature, and smell of the foot ulcer. The high-resolution
images from the digital camera were “even better than the human eye as they
compared in quality to using a magnifying glass,” explained the doctor in the
interview. However, as these pictures were uploaded following each
consultation, the experts had only access to high-resolution images from the
previous consultations at the time of the consultation. For this reason, the
less optimal images from the video phones provided the main basis for the
decisions, and if these images were not optimal in terms of, for example,
lightning or sharpness, the visiting nurse observations were particularly
useful. The possibility of comparing pictures of an ulcer from one visit to the
next also supported the assessment of healing progress.An important decision
to make for the experts was how much responsibility could be delegated to the
visiting nurse. The expert nurses had the possibility to get a feeling of the
visiting nurses skills and if extra help was needed in carrying out the
prescribed treatment. The expert nurse noted that she could value the visiting
nurses level of competences just by looking at the way she handled the
instruments. These observations lead the expert nurse towards what kind of
instruction the visiting nurses needed or what she was able to ask from her.
The doctor also assessed the competence of the visiting nurse, and described it
in this way: “I’m used to asking 3 questions and then I can almost grade them
(the visiting nurses).”In the beginning of
the pilot test, the roles of the participants in the telemedical consultations
were not defined prior to each consultation. During the pilot tests, a firmer
structure for the consultation gradually evolved. For instance, the experts
became more aware of the fact that they had to combine their own views with
that of the visiting nurse, and that the consultations were most efficient if
one person took the lead. For these reasons, the experts made it a practice to hold a preconsultation to coordinate their impression before hearing the visiting nurse. They were conscious, however, not to put forward their impression at the actual consultation until they had heard what the visiting nurse had to say in order to be able to combine their own impression from the images with the subjective opinion of the visiting nurse. Furthermore, the ongoing dialog—once connected—brings forth issues that have an impact on the
decisions, for instance, aspects of the patient’s daily living. The direct
dialog with the visiting nurse provides the expert with a more detailed
knowledge about the patient and the capabilities of the patient’s surroundings (e.g., the service levels at the local center). These issues would have been
more difficult to pursue in a hospital setting, where the knowledge of the
visiting nurse is absent. Consequently, in terms of the expert’s basis for
decisions, the video consultation provided a feasible alternative to a visit in
the outpatient clinic; and in some cases, the decision basis may even be more
holistic.


### 3.2. Support and Satisfaction for the Visiting Nurses

The visiting nurses
were all positive towards the video consultations, which is in line with
previous studies (see, e.g., [26]). They felt professionally supported in
carrying out the treatment. Four out of five visiting nurses emphasized that
participating in the project had increased their professional skills, by
receiving information and instructions from the hospital. In contrast to the
situation today, the direct contact with the experts means that a treatment
plan may be decided and any discrepancies sorted out immediately. The visiting
nurse is also instructed about new treatments which he/she understands more
readily on the basis of expert reflections and explanations.In this way, the
dialog facilitates a decision process based on mutual understanding rather than
the expert giving direct instructions. This ensures that the visiting nurse can
relate to the treatment plan, which promotes satisfaction with the cooperation.
In the interview, this particular visiting nurse was asked, if she at times
took offence by receiving instructions on her professional field. She answered: “No, I think there has been room for me to express my opinions … If I had had a
different opinion I would have had the possibility for discussing it. I feel
there was two-way communication.”The visiting nurses
also agreed that the treatment procedures would improve when working in a team
with the experts. As one nurse explained: “When I work on my own, I sometimes
doubt if the treatment is sufficient, or if a doctor should see the ulcer. To
be on the safe side I sometimes send the patient to the hospital, but when the
patient returns, it is still the same treatment that was prescribed in the
first place. This means that I misjudged the situation—that would not happen with this set-up.” The
visiting nurse became the central coordinating actor combining the two roles as
the “patient’s advocate” and the expert’s “prolonged arm.” One nurse quoted: “With the doctor I
find out which treatment is necessary, and with the patient I find out if that
is what we need …. It (her role) is more “here and now,” more present. It is a
good role to have.” The collaboration facilitated a synergetic combination of
the actors’ individual competences. “What they need on the hospital is what the
visiting nurse can see in the home” (quote VN). Furthermore, the nurses
expressed that the knowledge attained through the cooperation with the experts
would also benefit their other patients. In this sense, the telemedical organization
could enable more tailored treatment for the individual patient, which
ultimately may increase the quality of the treatment.


### 3.3. Patient Satisfaction

The patients expressed
that being able to stay at home during treatment was a great advantage. In consistency
with other studies [13, 27], patients complain about spending many hours
waiting for transportation to the hospital, waiting in the outpatient clinic,
and again waiting for transportation home.The video consultation
focused not just on the ulcer, but included the patient as well. When the
consultation is performed in the patient’s home, patients are more
self-confident and more apt to ask about personal issues, such as sleeping
problems, pain, medication [17].  One
patient quoted: “I find it reassuring—it is not always that you get to ask
the questions you have when you go up there (to the hospital)—it is easier
when you are in your home.” Another patient described the consultation in the
following way: “The contact between the visiting nurse and the experts is good. They work as a team.” By having access to the expert and the visiting nurse at
the same time, the patients are able to receive immediate answers to their
questions and at the same time follow the visiting nurse getting instructions
from the expert.The online dialog was
accepted by the patients: “It is easier to make contact, when there is a
picture, in which you can see the person instead of only a phone. I felt safe.
I think the doctor cared for me as a person, he showed interest in me.” The
patients and relatives felt both satisfied and secured by being treated at a
distance.In a few situations,
the patients were surprised about how serious problems were taken. For
instance, during one consultation a patient had signed up for a Midsummer Eve arrangement,
but the experts found it necessary to rest the foot as much as possible and
suggested a wheel chair. In the interview, the patient said that if he had not
talked to the expert, “I would just have walked to the party.” A similar
statement was given by the visiting nurse in the interview: “I would not have
reacted towards the newly arisen blister and, furthermore, I would have treated
the blister in a very different way than the one prescribed by the expert
nurse.”


## 3.1. Expert’s Basis for Making Decisions at a Distance

After the
consultations, the experts expressed satisfaction with the clinical basis for
their decision making. Both the information provided in the form of pictures
and communication with the patient and the cooperation with the visiting nurse
constituted important basis for the experts' decision making. “The presence of
the visiting nurse in the patient’s home compensates in full for not having the
patient in front of you,” the doctor said in the interview.By cooperating with
the visiting nurse and being precise when asking questions, the experts were
able to gather the information they would normally observe themselves,
including the color, temperature, and smell of the foot ulcer. The high-resolution
images from the digital camera were “even better than the human eye as they
compared in quality to using a magnifying glass,” explained the doctor in the
interview. However, as these pictures were uploaded following each
consultation, the experts had only access to high-resolution images from the
previous consultations at the time of the consultation. For this reason, the
less optimal images from the video phones provided the main basis for the
decisions, and if these images were not optimal in terms of, for example,
lightning or sharpness, the visiting nurse observations were particularly
useful. The possibility of comparing pictures of an ulcer from one visit to the
next also supported the assessment of healing progress.An important decision
to make for the experts was how much responsibility could be delegated to the
visiting nurse. The expert nurses had the possibility to get a feeling of the
visiting nurses skills and if extra help was needed in carrying out the
prescribed treatment. The expert nurse noted that she could value the visiting
nurses level of competences just by looking at the way she handled the
instruments. These observations lead the expert nurse towards what kind of
instruction the visiting nurses needed or what she was able to ask from her.
The doctor also assessed the competence of the visiting nurse, and described it
in this way: “I’m used to asking 3 questions and then I can almost grade them
(the visiting nurses).”In the beginning of
the pilot test, the roles of the participants in the telemedical consultations
were not defined prior to each consultation. During the pilot tests, a firmer
structure for the consultation gradually evolved. For instance, the experts
became more aware of the fact that they had to combine their own views with
that of the visiting nurse, and that the consultations were most efficient if
one person took the lead. For these reasons, the experts made it a practice to hold a preconsultation to coordinate their impression before hearing the visiting nurse. They were conscious, however, not to put forward their impression at the actual consultation until they had heard what the visiting nurse had to say in order to be able to combine their own impression from the images with the subjective opinion of the visiting nurse. Furthermore, the ongoing dialog—once connected—brings forth issues that have an impact on the
decisions, for instance, aspects of the patient’s daily living. The direct
dialog with the visiting nurse provides the expert with a more detailed
knowledge about the patient and the capabilities of the patient’s surroundings (e.g., the service levels at the local center). These issues would have been
more difficult to pursue in a hospital setting, where the knowledge of the
visiting nurse is absent. Consequently, in terms of the expert’s basis for
decisions, the video consultation provided a feasible alternative to a visit in
the outpatient clinic; and in some cases, the decision basis may even be more
holistic.


## 3.2. Support and Satisfaction for the Visiting Nurses

The visiting nurses
were all positive towards the video consultations, which is in line with
previous studies (see, e.g., [26]). They felt professionally supported in
carrying out the treatment. Four out of five visiting nurses emphasized that
participating in the project had increased their professional skills, by
receiving information and instructions from the hospital. In contrast to the
situation today, the direct contact with the experts means that a treatment
plan may be decided and any discrepancies sorted out immediately. The visiting
nurse is also instructed about new treatments which he/she understands more
readily on the basis of expert reflections and explanations.In this way, the
dialog facilitates a decision process based on mutual understanding rather than
the expert giving direct instructions. This ensures that the visiting nurse can
relate to the treatment plan, which promotes satisfaction with the cooperation.
In the interview, this particular visiting nurse was asked, if she at times
took offence by receiving instructions on her professional field. She answered: “No, I think there has been room for me to express my opinions … If I had had a
different opinion I would have had the possibility for discussing it. I feel
there was two-way communication.”The visiting nurses
also agreed that the treatment procedures would improve when working in a team
with the experts. As one nurse explained: “When I work on my own, I sometimes
doubt if the treatment is sufficient, or if a doctor should see the ulcer. To
be on the safe side I sometimes send the patient to the hospital, but when the
patient returns, it is still the same treatment that was prescribed in the
first place. This means that I misjudged the situation—that would not happen with this set-up.” The
visiting nurse became the central coordinating actor combining the two roles as
the “patient’s advocate” and the expert’s “prolonged arm.” One nurse quoted: “With the doctor I
find out which treatment is necessary, and with the patient I find out if that
is what we need …. It (her role) is more “here and now,” more present. It is a
good role to have.” The collaboration facilitated a synergetic combination of
the actors’ individual competences. “What they need on the hospital is what the
visiting nurse can see in the home” (quote VN). Furthermore, the nurses
expressed that the knowledge attained through the cooperation with the experts
would also benefit their other patients. In this sense, the telemedical organization
could enable more tailored treatment for the individual patient, which
ultimately may increase the quality of the treatment.


## 3.3. Patient Satisfaction

The patients expressed
that being able to stay at home during treatment was a great advantage. In consistency
with other studies [13, 27], patients complain about spending many hours
waiting for transportation to the hospital, waiting in the outpatient clinic,
and again waiting for transportation home.The video consultation
focused not just on the ulcer, but included the patient as well. When the
consultation is performed in the patient’s home, patients are more
self-confident and more apt to ask about personal issues, such as sleeping
problems, pain, medication [17].  One
patient quoted: “I find it reassuring—it is not always that you get to ask
the questions you have when you go up there (to the hospital)—it is easier
when you are in your home.” Another patient described the consultation in the
following way: “The contact between the visiting nurse and the experts is good. They work as a team.” By having access to the expert and the visiting nurse at
the same time, the patients are able to receive immediate answers to their
questions and at the same time follow the visiting nurse getting instructions
from the expert.The online dialog was
accepted by the patients: “It is easier to make contact, when there is a
picture, in which you can see the person instead of only a phone. I felt safe.
I think the doctor cared for me as a person, he showed interest in me.” The
patients and relatives felt both satisfied and secured by being treated at a
distance.In a few situations,
the patients were surprised about how serious problems were taken. For
instance, during one consultation a patient had signed up for a Midsummer Eve arrangement,
but the experts found it necessary to rest the foot as much as possible and
suggested a wheel chair. In the interview, the patient said that if he had not
talked to the expert, “I would just have walked to the party.” A similar
statement was given by the visiting nurse in the interview: “I would not have
reacted towards the newly arisen blister and, furthermore, I would have treated
the blister in a very different way than the one prescribed by the expert
nurse.”


## 4. Discussion

Our study indicates
that treatment of diabetic ulcers in the home can be effectively supported by
means of telemedicine. From the point of view of all three stakeholders
(patient, visiting nurse, and expert), the simultaneous dialog facilitates
satisfactory means for handling the cooperation and treatment.To the experts, the
communication with the patient in his own home environment brings to light
personal issues enabling a better and more individual treatment. This may also
have preventive effects as demonstrated in the case of the person attending the
Midsummer Eve party. Contrasting indirect telemedical solutions, where digital
images are obtained and forwarded to the expert by email (store-and-forward),
our setup allows the participants to informally discuss, reflect upon, and
solve discrepancies immediately in order for the treatment decision to be
initiated straight away. Furthermore, the mobile setup makes it unnecessary to
install and maintain equipment in the patient’s home.While the studies by,
for instance, Bowles and Dansky [16] investigate online connections between patient
and expert directly, without the attendance of the visiting nurse who has the
responsibility for carrying out the treatment between the expert consultations,
our setup allows both the expert and the visiting nurse to participate actively
in the expert consultations. This forges
a synergetic combination of the different stakeholders’ competences. At the
same time, the web-based online ulcer record facilitates a more traditional
store-and-forward setup, and this study shows that the combination of these two
methods is valuable in that the doctor and expert nurse could use the record
for obtaining an overview of the situation and history, while at the same time
collaborating with the visiting nurse and patient about the present situation.As reported by others [8, 28], an important spinoff effect is that the
competence of the visiting nurse may increase during this telemedical
consultation facilitating the spread of knowledge from expert to the community.In our study, the same
team of clinicians conducted all 3 consultations with each patient, especially the
patients experienced this to be a major advantage. This will not always be
possible in a large-scale implementation. Thus, an important question to be
investigated in future studies is the challenge of enabling experts to follow
up on the basis of other persons’ descriptions and examinations.It is also of vital
importance that the initial visit to the outpatient clinic prior to the
telemedical course of treatment should serve to get to know the patient in
terms of the patient’s ability to participate in a course of treatment built on
video consultations, which involves a thorough examination of the patient
including measures such as peripheral blood pressure. Thereby, the patient
obtains high quality and continuity in the treatment.Both expert nurses and
visiting nurses gained new roles in the telemedical setup. From the beginning
of the study, the expert nurses were worried about not having the patient face to
face and not having “the finger in the ulcer,” whereas the expert doctor tended
to be more open to the concept, possibly because doctors are more used to
delegating work tasks to others. The final focus group interview after the
pilot test revealed that also the expert nurses were now confident with the new
role as a consultant working through another nurse.Communication through
video phones puts constraints to the natural flow of the conversation in terms
of delays and difficulties to interpret nonverbal cues and expressions. For
this reason, all participants had to be conscious about their expressions and
we recommend attention and training in this way of communication before
implementing similar telemedical services.The visiting nurse was
invited into the experts’ reflections, which meant that her role went from
carrying out the prescribed treatment on her own and without formal influence
to be a fully fledged member of a collaborating team. Working through guidance
from the experts, the visiting nurses became more engaged, secure, and
responsible in carrying out the treatment. The competences and skills of the
visiting nurse are likely to increase from each consultation, resulting in
increased job satisfaction and qualifications.


## 5. Conclusion

In all consultations
performed during our pilot test, the three criteria for the consultation to be
characterized as a viable alternative to a visit in the outpatient clinic were
met. The experts expressed satisfaction with their basis for decisions, the
visiting nurses felt supported, and the patients experienced the new way of
receiving treatment as an advantage. Furthermore, the simultaneous
communication between expert, visiting nurse, and patient enabled the
clinicians to provide a more holistic and tailor-made treatment, indicating that the
telemedical consultations are a viable way of performing the treatment.



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*Source: 132890-2008-02-13.xml*