Systematic review of studies of patient satisfaction with telemedicine

Telerehabilitation in stroke care--a systematic review

We conducted a systematic review of telerehabilitation interventions in stroke care. The following databases were searched: Medline, Embase, DARE-NHSEED-HTA (INAHTA) and the Cochrane Library. Nine studies, all published after 2000, were included in the review. A wide variety of telemedicine interventions in post-stroke rehabilitation care was identified. Four studies had been carried out in the USA, two in the Netherlands, two in Italy and one in China. There were four randomized controlled trials and one qualitative analysis. Four studies used an observational study design/case series. Home-based telerehabilitation interventions showed promising results in improving the health of stroke patients and in supporting caregivers. Telemedicine systems based on a virtual environment for upper extremity exercise can improve the physical health of stroke patients. Health professionals and participants reported high levels of satisfaction and acceptance of telerehabilitation interventions. There was no evidence regarding the effects on resource utilization or cost-effectiveness. Most studies showed promising results, although overall, the quality of the evidence on telerehabilitation in post-stroke care was low.

Exploring public perspectives on e-health: findings from two citizen juries

BACKGROUND

Interest and investment in e-health continue to grow world-wide, but there remains relatively little engagement with the public on this subject, despite calls for more public involvement in health-care planning.

DESIGN

This study used two modified citizen juries to explore barriers and facilitators to e-health implementation and the priorities for future e-health research from the perspective of health service users and lay representatives. Citizen juries bring together a group of people to deliberate over a specific issue. They are given information and invited to 'cross-examine' witnesses during the process.

RESULTS

Jurors were very keen for lay views to be included in e-health development and embraced the citizen jury approach. They agreed unanimously that e-health should be developed and thought it was in many ways inevitable. Although there was much enthusiasm for a health-care system which offered e-health as an option, there was as much concern about what it might mean for patients if implemented inappropriately. E-health was preferred as an enhancement rather than substitute for, existing services. Lack of universal access was seen as a potential barrier to implementation but problems such as lack of computer literacy were seen as a temporary issue. Participants emphasized that e-health research needed to demonstrate both clinical and economic benefits.

CONCLUSION

There was broad support from the citizen juries for the development of e-health, although participants stressed that e-health should enhance, rather than substitute, face-to-face services. One-day citizen juries proved a practical method of public engagement on this subject.

Telehealthcare for asthma

BACKGROUND

Healthcare systems internationally need to consider new models of care to cater for the increasing numbers of people with asthma. Telehealthcare interventions are increasingly being seen by policymakers as a potential means of delivering asthma care. We defined telehealthcare as being healthcare delivered from a distance, facilitated electronically and involving the exchange of information through the personalised interaction between a healthcare professional using their skills and judgement and the patient providing information.

OBJECTIVES

To assess the effectiveness of telehealthcare interventions in people with asthma.

SEARCH STRATEGY

We searched in the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED, and PsycINFO; this was supplemented by handsearching of respiratory journals. We also searched registers of ongoing and unpublished trials.

SELECTION CRITERIA

We selected completed randomised controlled trials of telehealthcare initiatives aiming to improve asthma care.

DATA COLLECTION AND ANALYSIS

Two review authors independently appraised studies for inclusion and extracted data and performed meta-analyses. We analysed dichotomous variables to produce an odds ratio (OR) and continuous variables to produce a mean difference.

MAIN RESULTS

We included 21 trials in this review. The 21 included studies investigated a range of technologies aiming to support the provision of care from a distance. These included: telephone (n = 9); video-conferencing (n = 2); Internet (n = 2); other networked communications (n = 6); text Short Messaging Service (n = 1); or a combination of text and Internet (n = 1). Meta-analysis showed that these interventions did not result in clinically important improvements in asthma quality of life (minimum clinically important difference = 0.5): mean difference in Juniper's Asthma Quality of Life Questionnaire (AQLQ) 0.08 (95% CI 0.01 to 0.16). Telehealthcare for asthma resulted in a non-significant increase in the odds of emergency department visits over a 12-month period: OR 1.16 (95% CI 0.52 to 2.58). There was, however, a significant reduction in hospitalisations over a 12-month period: OR 0.21 (95% CI 0.07 to 0.61), the effect being most marked in people with more severe asthma managed predominantly in secondary care settings.

AUTHORS' CONCLUSIONS

Telehealthcare interventions are unlikely to result in clinically relevant improvements in health outcomes in those with relatively mild asthma, but they may have a role in those with more severe disease who are at high risk of hospital admission. Further trials evaluating the effectiveness and cost-effectiveness of a range of telehealthcare interventions are needed.

An Evidence-Based Adoption of Technology Model for Remote Monitoring of Elders' Daily Activities

What benefit will new technologies offer if they are inadequately or not used? This work presents a meta-synthesis of adoption of technology related findings from four innovative monitoring intervention research studies with older adults and their informal and/or formal caregivers. Each study employed mixed methods analyses that lead to an understanding of the key variables that influenced adoption of telephone and Internet based wireless remote monitoring technologies by elders and their caregivers. The studies were all conducted in "real world" homes ranging from solo residences to multi-story independent living residential buildings. Insights gained came from issues not found in controlled laboratory environments but in the complex interplay of family-elder-staff dynamics around balancing safety and independence. Findings resulted in an adoption of technology model for remote monitoring of elders' daily activities derived from evidence based research to advance both practical and theoretical development in the field of gerontechnology.

Relation between patient satisfaction, compliance and the clinical benefit of a teletreatment application for chronic pain

We investigated the ease of use and usefulness as a measure of patient satisfaction, compliance, clinical benefit and its mutual relationships concerning a teletreatment application for chronic pain. Fifty-two subjects with neck and shoulder pain received and completed a four-week myofeedback-based teletreatment intervention. Prior to the onset of the intervention (at baseline) and immediately after the intervention they were asked to fill in questionnaires to measure discrepancies (gap scores) between expectations and experiences with the ease of use and usefulness of the treatment, as well as pain intensity and pain disability. In addition, the actual use of the system (i.e. the volume of muscle activity data available on the server) was logged. The subjects reported a significantly higher score on ease of use after the intervention compared to baseline, suggesting that the equipment was easier to use than they expected. Compliance was associated with clinical benefit. There was no significant relation between patient satisfaction and compliance. Patient satisfaction is a key indicator of how well the telemedicine treatment met expectations and compliance is important because of its association with clinical outcomes.

Keys to a successful and sustainable telemedicine program

OBJECTIVES

The aim of this study was to determine organizational characteristics evident in successful telemedicine programs. The study proposed four research questions to identify the key organizational characteristics for successful telemedicine programs.

METHODS

Data were collected through an online survey using modified unified theory of acceptance and use of technology (UTAUT) and organizational change readiness (ORC) validated assessments.

RESULTS

Using the UTAUT instrument and the ORC assessment, themes of successful telemedicine programs emerged. Overarching themes of successful programs included being formally structured, forward thinking, seeking to improve the quality of patient care, and being financially stable.

CONCLUSIONS

This research provides a data-driven understanding of organizational issues that serve to maximize a telemedicine program's ability to achieve the overall goals and mission of a healthcare organization.

Women's experience of telehealth cancer genetic counseling

Telegenetics offers an alternative model of delivering genetic counseling to rural and outreach areas; however there is a dearth of qualitative research into the patient's experience. Twelve women who had received telemedicine genetic counseling for hereditary breast and/or ovarian cancer (HBOC) within the previous 12 months participated in a semi-structured telephone interview. The interview explored women's experience with telegenetics, satisfaction, perceived advantages and disadvantages and quality of the interaction with their genetic professionals. Overall women were highly satisfied with telegenetics. Telegenetics offered them convenience and reduced travel and associated costs. The majority of women described feeling a high degree of social presence, or rapport, with the off-site genetic clinician. One woman with a recent cancer diagnosis, reported that telemedicine was unable to meet her needs for psychosocial support. This finding highlights the need to be mindful of the psychosocial support needs of women with a recent diagnosis being seen via telegenetics. Patients attending for HBOC genetic counseling are generally highly satisfied with the technology and the interaction. Care should be taken, however, with patients with more complex psychosocial needs.

Long-term patient acceptance of and satisfaction with implanted device remote monitoring

AIMS

To evaluate patients' acceptance and satisfaction of the Home Monitoring (HM) remote control system after 1 year of follow-up by a self-made questionnaire (HM Acceptance and Satisfaction Questionnaire, HoMASQ) specifically designed for this purpose.

METHODS AND RESULTS

The HoMASQ contains 12 items designed to investigate five different aspects strictly connected to patient's acceptance and satisfaction of remote monitoring: (i) relationship with their healthcare provider, (ii) easy of use of HM technology, (iii) related psychological aspects, (iv) implications on general health, and (v) overall satisfaction. Each item was rated on a five-point scale: from 0 to 4 with favourable responses score > or =2. The theoretical maximum total score (the highest detected acceptance and satisfaction level) was 48. The HoMASQ was given to 119 patients followed by HM during the 1-year follow-up visit. Ninety-nine percent of all the administered questionnaire items were answered. The mean total score was 40.8 +/- 5.4 with a mean percentage of favourable answers of 96.3 +/- 18.8% (CI 95.2 - 97.2%). The mean scores for each of the five areas of the HoMASQ were: 3.0 +/- 0.9 for relationship, 3.4 +/- 0.6 for easy of use, 3.4 +/- 0.9 for psychological aspects, and 3.4 +/- 0.8 for clinical implication and overall satisfaction. Cronbach's alpha for reliability of the HoMASQ was 0.73.

CONCLUSION

A high level of acceptance and satisfaction after 1-year remote control by HM was detected by the five-point scale HoMASQ, which showed a good internal reliability.

Home telemonitoring in patients with chronic heart failure: a chance to improve patient care?

BACKGROUND

Telemonitoring can improve the medical care, quality of life, and prognosis of chronically ill patients. This review article summarizes the current status of health services research on telemonitoring, focusing on patients with chronic congestive heart failure.

METHOD

The Medline database was selectively searched for articles appearing from June 2001 to May 2008, with an emphasis on randomized, controlled trials.

RESULTS

The available scientific data on vital signs monitoring are limited, yet there is evidence for a positive effect on some clinical endpoints, particularly mortality. Nonetheless, any possible improvement of patient-reported outcomes, such as the quality of life, still remains to be demonstrated.

CONCLUSIONS

The data suggest that telemonitoring is effective, yet there is no evidence for superior outcomes with any particular model of care incorporating telemonitoring (i.e., monitoring of vital signs versus structured telephone monitoring). A valid criticism is that the individual components of home telemonitoring have not yet been separately tested in order to compare their individual effects.

Alternative delivery methods for pharmacy services

In many developed countries, the provision of pharmacy services is no longer restricted to the traditional “walk-in” or face-to-face approach. This paper examines whether alternative delivery methods provide patients with pharmacy services that meet their medication and related information needs, and discusses professional issues and the implications for practice. Although not appropriate for everyone, studies show that many patients do accept the alternative means of service delivery examined here. For some patients, such as those with mobility problems or who live in remote areas, technology-driven alternatives may be preferred. Health care professionals must take steps to address legitimate concerns about the protection of patient safety and confidentiality. To increase patient choice, the pharmacy profession needs to look closely at the positive aspects of these alternatives, as they can be incorporated in “traditional” pharmacy practice.

A Telemedicine system based on Internet and short message service as a new approach in the follow-up of patients with gestational diabetes

To evaluate the feasibility of a Telemedicine system based on Internet and short message service in the follow-up of patients with gestational diabetes. Compared to control group, Telemedicine group reduced 62% the number of unscheduled face-to-face visits, and 82.7% in the subgroup of insulin-treated patients, improving patient satisfaction, and achieving similar pregnancy and new born outcomes.

Patient satisfaction with physician-patient communication during telemedicine

The quality of physician-patient communication is a critical factor in treatment outcomes and patient satisfaction with care. To date, few studies have specifically conducted an in-depth evaluation of the effect of telemedicine (TM) on physician-patient communication in a medical setting. Our objective was to determine whether physical separation and technology used during TM have a negative effect on physician-patient communication. In this noninferiority randomized clinical trial, patients were randomized to receive a single consultation with one of 9 physicians, either in person (IP) or via TM. Patients (n = 221) were recruited from pulmonary, endocrine, and rheumatology clinics at a Midwestern Veterans Administration hospital. Physician-patient communication was measured using a validated self-report questionnaire consisting of 33 items measuring satisfaction with visit convenience and physician's patient-centered communication, clinical competence, and interpersonal skills. Satisfaction for physician's patient-centered communication was similar for both consultation types (TM = 3.76 versus IP = 3.61), and noninferiority of TM was confirmed (noninferiority t-test p = 0.002). Patient satisfaction with physician's clinical competence (TM = 4.63 versus IP = 4.52) and physician's interpersonal skills (TM = 4.79 versus IP = 4.74) were similar, and noninferiority of TM was confirmed (noninferiority t-test p = 0.006 and p = 0.04, respectively). Patients reported greater satisfaction with convenience for TM as compared to IP consultations (TM = 4.41 versus IP = 2.37, noninferiority t-test p < 0.001). Patients were equally satisfied with physician's ability to develop rapport, use shared decision making, and promote patient-centered communication during TM and IP consultations. Our data suggest that, despite physical separation, physician-patient communication during TM is not inferior to communication during IP consultations.

A multipoint videoconference-based telemedicine system for electrocardiogram monitoring

In this work, a system to transfer electrocardiogram image signal through videoconference is described. The approach proposed was tested in order to evaluate its performance and the quality of the signal received back from the videoconference. The performance presented good results as the system react rapidly and no losses of data were observed.

Diabetes Interactive Diary: a new telemedicine system enabling flexible diet and insulin therapy while improving quality of life: an open-label, international, multicenter, randomized study

OBJECTIVE

Widespread use of carbohydrate counting is limited by its complex education. In this study we compared a Diabetes Interactive Diary (DID) with standard carbohydrate counting in terms of metabolic and weight control, time required for education, quality of life, and treatment satisfaction.

RESEARCH DESIGN AND METHODS

Adults with type 1 diabetes were randomly assigned to DID (group A, n = 67) or standard education (group B, n = 63) and followed for 6 months. A subgroup also completed the SF-36 Health Survey (SF-36) and World Health Organization-Diabetes Treatment Satisfaction Questionnaire (WHO-DTSQ) at each visit.

RESULTS

Of 130 patients (aged 35.7 +/- 9.4 years; diabetes duration 16.5 +/- 10.5 years), 11 dropped out. Time for education was 6 h (range 2-15 h) in group A and 12 h (2.5-25 h) in group B (P = 0.07). A1C reduction was similar in both groups (group A from 8.2 +/- 0.8 to 7.8 +/- 0.8% and group B from 8.4 +/- 0.7 to 7.9 +/- 1.1%; P = 0.68). Nonsignificant differences in favor of group A were documented for fasting blood glucose and body weight. No severe hypoglycemic episode occurred. WHO-DTSQ scores increased significantly more in group A (from 26.7 +/- 4.4 to 30.3 +/- 4.5) than in group B (from 27.5 +/- 4.8 to 28.6 +/- 5.1) (P = 0.04). Role Physical, General Health, Vitality, and Role Emotional SF-36 scores improved significantly more in group A than in group B.

CONCLUSIONS

DID is at least as effective as traditional carbohydrate counting education, allowing dietary freedom for a larger proportion of type 1 diabetic patients. DID is safe, requires less time for education, and is associated with lower weight gain. DID significantly improved treatment satisfaction and several quality-of-life dimensions.

The outcomes of gestational diabetes mellitus after a telecare approach are not inferior to traditional outpatient clinic visits

Objective. To evaluate the feasibility of a telemedicine system based on Internet and a short message service in pregnancy and its influence on delivery and neonatal outcomes of women with gestational diabetes mellitus (GDM). Methods. 100 women diagnosed of GDM were randomized into two parallel groups, a control group based on traditional face-to-face outpatient clinic visits and an intervention group, which was provided with a Telemedicine system for the transmission of capillary glucose data and short text messages with weekly professional feedback. 97 women completed the study (48/49, resp.). Main Outcomes Measured. The percentage of women achieving HbA1c values <5.8%, normal vaginal delivery and having a large for-gestational-age newborn were evaluated. Results. Despite a significant reduction in outpatient clinic visits in the experimental group, particularly in insulin-treated women (2.4 versus 4.6 hours per insulin-treated woman resp.; P < .001), no significant differences were found between the experimental and traditional groups regarding HbA1c levels (all women had HbA1c <5.8% during pregnancy), normal vaginal delivery (40.8% versus 54.2%, resp.; P > .05) and large-for-gestational-age newborns (6.1% versus 8.3%, resp.; P > .05). Conclusions. The system significantly reduces the need for outpatient clinic visits and achieves similar pregnancy, delivery, and newborn outcomes.

Parental perceptions toward digital imaging and telemedicine for retinopathy of prematurity management

BACKGROUND

Telemedicine is an emerging technology with potential to improve care for retinopathy of prematurity (ROP). This study evaluates parental perceptions about digital imaging and telemedicine for ROP care.

METHODS

During a 1-year period, one parent of each infant who underwent wide-field retinal imaging for ROP was given a questionnaire designed to evaluate parental perceptions using a 5-point Likert-type scale. Five items assessed perceptions toward digital retinal imaging, and ten items assessed attitudes toward telemedicine. Construct validity of the questionnaire was examined using factor analysis. Responses were summarized using descriptive and correlational statistics.

RESULTS

Forty-two parents participated. Factor analysis extracted two factors explaining 79% of the total variance in digital retinal imaging items (Cronbach's alpha = 0.843), and three factors explaining 63% of the total variance in telemedicine items (Cronbach's alpha = 0.631). Among digital imaging items, the highest mean (+/-SD) score was for "digital pictures of my child's retinopathy should be included in the permanent medical record" (4.4 +/- 0.6), and the lowest was for "digital cameras and computers are reliable" (3.8 +/- 0.8). Among telemedicine items, the highest mean (+/-SD) score was for "technology will improve the quality of medical care for my child" (4.3 +/- 0.6), and the lowest was for "technology will make it harder for a patient and doctor to establish a good relationship" (2.6 +/- 1.1).

CONCLUSIONS

Parents reported positive perceptions about telemedical ROP diagnosis, but expressed some preference for face-to-face care. Telemedicine has potential to alter the nature of the patient-physician relationship.

Reliability associated with the Roter Interaction Analysis System (RIAS) adapted for the telemedicine context

OBJECTIVE

This study's purpose was to adapt the Roter Interaction Analysis System (RIAS) for telemedicine clinics and to investigate the adapted measure's reliability. The study also sought to better understand the volume of technology-related utterance in established telemedicine clinics and the feasibility of using the measure within the telemedicine setting. This initial evaluation is a first step before broadly using the adapted measure across technologies and raters.

METHODS

An expert panel adapted the RIAS for the telemedicine context. This involved accounting for all consultation participants (patient, provider, presenter, family) and adding technology-specific subcategories. Ten new and 36 follow-up telemedicine encounters were videotaped and double coded using the adapted RIAS. These consisted primarily of follow-up visits (78.0%) involving patients, providers, presenters, and other parties. Reliability was calculated for those categories with 15 or more utterances.

RESULTS

Traditional RIAS categories related to socioemotional and task-focused clusters had fair to excellent levels of reliability in the telemedicine setting. Although there were too few utterances to calculate the reliability of the specific technology-related subcategories, the summary technology-related category proved reliable for patients, providers, and presenters. Overall patterns seen in traditional patient-provider interactions were observed, with the number of provider utterances far exceeding patient, presenter, and family utterances, and few technology-specific utterances.

CONCLUSION

The traditional RIAS is reliable when applied across multiple participants in the telemedicine context. Reliability of technology-related subcategories could not be evaluated; however, the aggregate technology-related cluster was found to be reliable and may be especially relevant in understanding communication patterns with patients new to the telemedicine setting. Use of the RIAS instrument is encouraged to facilitate comparison between traditional, face-to-face clinics and telemedicine; among diverse consultation mediums and technologies; and across different specialties. Future research is necessary to further investigate the reliability and validity of adding technology-related subcategories to the RIAS. The limited number of technology-related utterances, however, implies a certain degree of comfort with two-way interactive video consultation among study participants.

PRACTICE IMPLICATIONS

Telemedicine continues to increase access to healthcare. The technology-related categories of the adapted RIAS were reliable when aggregated, thereby providing a tool to better understand how telemedicine affects provider-patient communication and outcomes.

Vital signs remote monitoring through multipoint videoconferencing

A system for remote monitoring of patients' vital signs using multipoint videoconferencing is proposed. A multiparametric module and a videoconference server were developed to set up a proof-of-concept where a text was streamed live as data was captured, while a third party monitored it.

An Exploratory Study of Patient Acceptance of Walk-In Telemedicine Services for Minor Conditions

Though healthcare costs continue to soar, the healthcare industry lags other service industries in applying information technology to improve customer (i.e., patient) service, improve access to healthcare services, and reduce costs. One particular area of concern is overuse and overcrowding of emergency departments for nonurgent care. Telemedicine is one potentially important application of information technology in this realm. The objective of this study is to examine the antecedents of patient acceptance of walk-in telemedicine services for minor ailments. Drawing upon theoretical models in the healthcare and technology acceptance literatures and based on salient beliefs elicited during interviews with 29 potential adopters, the authors develop a conceptual model of antecedents of patient acceptance of walk-in telemedicine services for minor conditions. While relative advantage, informational influences, and relationship with one’s physician emerged as important predictors of acceptance, media richness and e-consultation diagnosticity emerged as central concerns for potential adopters. They discuss the study’s implications for research and practice and offer suggestions for future empirical studies.

Methodology for analyzing and developing information management infrastructure to support telerehabilitation

The proliferation of advanced technologies led researchers within the Rehabilitation Engineering Research Center on Telerehabilitation (RERC-TR) to devise an integrated infrastructure for clinical services using the University of Pittsburgh (PITT) model. This model describes five required characteristics for a telerehabilitation (TR) infrastructure: openness, extensibility, scalability, cost-effectiveness, and security. The infrastructure is to deliver clinical services over distance to improve access to health services for people living in underserved or remote areas. The methodological approach to design, develop, and employ this infrastructure is explained and detailed for the remote wheelchair prescription project, a research task within the RERC-TR. The availability of this specific clinical service and personnel outside of metropolitan areas is limited due to the lack of specialty expertise and access to resources. The infrastructure is used to deliver expertise in wheeled mobility and seating through teleconsultation to remote clinics, and has been successfully deployed to five rural clinics in Western Pennsylvania.

An evaluation of patient-physician communication style during telemedicine consultations

BACKGROUND

The quality of physician-patient communication is a critical factor influencing treatment outcomes and patient satisfaction with care. To date, there is little research to document the effect of telemedicine (TM) on physician-patient communication.

OBJECTIVE

The objectives of this study are to measure and describe verbal and nonverbal communication during clinical TM consultations and to compare TM with in-person (IP) consultations in terms of the quality of physician-patient communication.

METHODS

Veteran patients (n = 19) requiring pulmonary medicine consultations were enrolled into the study. The study group included 11 patients from the Iron Mountain Veterans Affairs Hospital (VAMC) remote site. Patients had individual TM consultations with a pulmonary physician at the Milwaukee VAMC hub site. A control group of 8 patients had IP consultations with a pulmonary physician at the Milwaukee VAMC. Video recordings of medical consultations were coded for patient-physician verbal and nonverbal communication patterns using the Roter Interaction Analysis System (RIAS).

RESULTS

There were no differences in the length of TM consultations (22.2 minutes) and IP consultations (21.9 minutes). Analysis of visit dialogue indicated that the ratio of physician to patient talk was 1.45 for TM and 1.13 for IP consultations, indicating physician verbal dominance. Physicians were more likely to use orientation statements during IP consultations (P = .047). There were greater requests for repetition from patients during TM consultations (P = .034), indicating perceptual difficulties.

CONCLUSIONS

The study findings indicate differences between TM and IP consultations in terms of physician-patient communication style. Results suggest that, when comparing TM and IP consultations in terms of physician-patient communication, TM visits are more physician centered, with the physician controlling the dialogue and the patient taking a relatively passive role. Further research is needed to determine whether these differences are significant and whether they have relevance in terms of health outcomes and patient satisfaction with care.

Current Directions in Videoconferencing Tele-Mental Health Research

The provision of mental health services via videoconferencing tele-mental health has become an increasingly routine component of mental health service delivery throughout the world. Emphasizing the research literature since 2003, we examine: 1) the extent to which the field of tele-mental health has advanced the research agenda previously suggested; and 2) implications for tele-mental health care delivery for special clinical populations. Previous findings have demonstrated that tele-mental health services are satisfactory to patients, improve outcomes, and are probably cost effective. In the very small number of randomized controlled studies that have been conducted to date, tele-mental health has demonstrated equivalent efficacy compared to face-to-face care in a variety of clinical settings and with specific patient populations. However, methodologically flawed or limited research studies are the norm, and thus the research agenda for tele-mental health has not been fully maximized. Implications for future research and practice are discussed.

Current Directions in Videoconferencing Tele-Mental Health Research

The provision of mental health services via videoconferencing tele-mental health has become an increasingly routine component of mental health service delivery throughout the world. Emphasizing the research literature since 2003, we examine: 1) the extent to which the field of tele-mental health has advanced the research agenda previously suggested; and 2) implications for tele-mental health care delivery for special clinical populations. Previous findings have demonstrated that tele-mental health services are satisfactory to patients, improve outcomes, and are probably cost effective. In the very small number of randomized controlled studies that have been conducted to date, tele-mental health has demonstrated equivalent efficacy compared to face-to-face care in a variety of clinical settings and with specific patient populations. However, methodologically flawed or limited research studies are the norm, and thus the research agenda for tele-mental health has not been fully maximized. Implications for future research and practice are discussed.

Exploring the formation of patient satisfaction in rural community telepharmacies

OBJECTIVES

To apply a previously validated patient satisfaction questionnaire within rural community telepharmacies in an effort to identify the underlying factors determining satisfaction with those services and to assess whether the latent structure(s) of patient satisfaction varies depending on delivery mode or communityspecific factors.

DESIGN

Descriptive, nonexperimental, cross-sectional study.

SETTING

Eight rural community telepharmacy sites (seven in North Dakota and one in Minnesota) in fall 2005.

PATIENTS

400 potential participants in rural communities (response rate 24% [n = 96]) whose primary community pharmacy is a telepharmacy site.

INTERVENTION

PATIENTS visiting a pharmacy to have at least one prescription filled were asked to complete a survey and mail responses to the investigators. The survey contained 37 questions, the first 20 of which were adapted from a well-established, validated survey instrument.

MAIN OUTCOME MEASURE

Patient satisfaction with rural community telepharmacy services; patient responses to 20 questions in the survey were used as main outcome variables.

RESULTS

Applying factor analysis to the data yielded a single dimension of patient satisfaction.

CONCLUSION

A previous application of this instrument in a traditional community pharmacy setting yielded two interrelated latent constructs ("friendly explanation" and "managing therapy"). Our analysis suggests that the formation of patient satisfaction in rural community telepharmacies is much simpler in that patients form a single construct exhibiting high mean and median values. Anecdotal evidence from the literature suggests that the formation of a single construct reflects patients' desire to retain a point of access to health care in their communities.

Views on technology among people in need of health care at home

OBJECTIVES

The aim of this study was to describe how people in need of health care at home view technology.

STUDY DESIGN

A qualitative approach was used based on qualitative interviews, followed by qualitative content analysis.

METHODS

District nurses (DNs) from 4 health care centres in Northern Sweden had access to different kinds of distance-spanning technology with mobile devices and who used it in their health care at home. Persons in whose home the technology was being used were asked to participate in an interview. The interviewed persons were selected consecutively.

RESULTS

The results fall into 2 categories: (1) The well-known technology at hospital is new at home, (2) the new technology opens up possibilities but it also has limitations, with seven adherent subcategories.

CONCLUSIONS

The participants viewed the technology at home as something good and as something that could open up possibilities. At the same time, they placed the use of the technology in the hands of the staff which indicates some degree of dissociation from the technology. The importance of personal meetings between patient and caregiver was very clearly stressed even when distance meetings could be performed and accepted. The participants expressed immense trust in the nursing staff and considered them responsible for the new technology at home.

A systematic review of clinical outcomes, clinical process, healthcare utilization and costs associated with telerehabilitation

PURPOSE

To identify clinical outcomes, clinical process, healthcare utilization and costs associated with telerehabilitation for individuals with physical disabilities.

METHOD

Relevant databases were searched for articles on telerehabilitation published until February 2007. Reference lists were examined and key journals were hand searched. Studies that included telerehabilitation for individuals with physical impairments and used experimental or observational study designs were included in the analysis, regardless of the specific clientele or location of services. Data was extracted using a form to record methodological aspects and results relating to clinical, process, healthcare utilization and cost outcomes. Study quality of randomized clinical trials was assessed using the PEDro rating scale.

RESULTS

Some 28 articles were analysed. These dealt with rehabilitation of individuals in the community, neurological rehabilitation, cardiac rehabilitation, follow-up of individuals with spinal cord injuries, rehabilitation for speech-language impairments, and rehabilitation for varied clienteles. Clinical outcomes were generally improved following a telerehabilitation intervention and were at least similar to or better than an alternative intervention. Clinical process outcomes, such as attendance and compliance, were high with telerehabilitation although few comparisons are made to alternative interventions. Consultation time tended to be longer with telerehabilitation. Satisfaction with telerehabilitation was consistently high, although it was higher for patients than therapists. Few studies examined healthcare utilization measures and those that did reported mixed findings with respect to adverse events, use of emergency rooms and doctor visits. Only five of the studies examined costs. There is some preliminary evidence of potential cost savings for the healthcare facility.

CONCLUSION

While evidence is mounting concerning the efficacy and effectiveness of telerehabilitation, high-quality evidence regarding impact on resource allocation and costs is still needed to support clinical and policy decision-making.

Socio-technical and organizational challenges to wider e-Health implementation

Recent advances in information communication technology allow contact with patients at home through e-Health services (telemedicine, in particular). We provide insights on the state of the art of e-Health and telemedicine for possible wider future clinical use. Telemedicine opportunities are summarized as i) home telenursing, ii) electronic transfer to specialists and hospitals, iii) teleconsulting between general practitioners and specialists and iv) call centres activities and online health. At present, a priority action of the EU is the Initiative on TM for chronic disease management as home health monitoring and the future Vision for Europe 2020 is based on development of Integrated Telemedicine Services. There are pros and cons in e-Health and telemedicine. Benefits can be classified as benefits for i) citizens, patients and caregivers and ii) health care provider organizations. Institutions and individuals that play key roles in the future of e-Health are doctors, patients and hospitals, while the whole system should be improved at three crucial levels: 1) organizational, 2) regulatory and 3) technological. Quality, access and efficiency are the general key issues for the success of e-Health and telemedicine implementation. The real technology is the human resource available into the organizations. For e-Health and telemedicine to grow, it will be necessary to investigate their long-term efficacy, cost effectiveness, possible improvement in quality of life and impact on public health burden.

Satisfaction with care in post-stroke patients undergoing a telerehabilitation programme at home

We conducted a pilot telerehabilitation study with post-stroke patients with arm motor impairment. We compared the degree of satisfaction of patients undergoing a virtual reality (VR) therapy programme at home (Tele-VR group) to satisfaction experienced by those undergoing the same VR therapy in a hospital setting (VR-group). The rehabilitation equipment used a 3D motion tracking system to create a virtual environment in which the patient's movement was represented. In tele-therapy, the patient equipment was installed in their homes, connected to the hospital by four ISDN lines at a total bandwidth of 512 kbit/s. Rehabilitation data were transmitted via one line and videoconferencing via the other three. Ten patients with mild to intermediate arm motor impairment due to an ischaemic stroke, were randomized into VR or Tele-VR groups. A questionnaire was used at the end of treatment to measure each patient's degree of satisfaction. Tele-VR treated patients showed median values equal to or higher than the VR group patients in all 12 items investigated, except one. In motor performance, the Tele-VR group improved significantly (P < or = 0.05), while the VR group showed no significant change. Patients assigned to the Tele-VR group were able to engage in therapy at home and the videoconferencing system ensured a good relationship between the patient and the physical therapist whose physical proximity was not required.

Face-to-face versus remote administration of the Montgomery-Asberg Depression Rating Scale using videoconference and telephone

Although the use of telemedicine in psychiatry has a long history in providing clinical care to patients, its use in clinical trials research has not yet been commonly employed. Telemedicine allows for the remote assessment of study patients, which could be done by a centralized, highly calibrated, and impartial cohort of raters independent of the study site. This study examined the comparability of remote administration of the Montgomery-Asberg Depression Rating Scale (MADRS) by videoconference and by telephone to traditional face-to-face administration. Two parallel studies were conducted: one compared face-to-face with videoconference administration (N=35), and the other compared face-to-face with telephone administration (N=35). In each study, depressed patients were interviewed independently twice: once in the traditional face-to-face manner, and the second time by either videoconference or teleconference. A counterbalanced order was used. The mean MADRS score for interviews conducted remotely by videoconference was not significantly different from the mean MADRS scores conducted by face-to-face administration (mean difference=0.51 points), P=.388, intraclass correlation (ICC)=.94, P<0001. Similarly, the mean MADRS score for interviews conducted by telephone was not significantly different from the mean MADRS score conducted by face-to-face administration (mean difference=0.74 points), P=.270, ICC=.93, P<0001. Results of the study support the comparability of remote administration of the MADRS, by both telephone and videoconference, to face-to-face administration. Comparability of the administration mode allows for remote assessment of patients in both research and clinical applications.

Mobile diabetes intervention study: testing a personalized treatment/behavioral communication intervention for blood glucose control

BACKGROUND

National data find glycemic control is within target (A1c<7.0%) for 37% of patients with diabetes, and only 7% meet recommended glycemic, lipid, and blood pressure goals.

OBJECTIVES

To compare active interventions and usual care for glucose control in a randomized clinical trial (RCT) among persons with diabetes cared for by primary care physicians (PCPs) over the course of 1 year.

METHODS

Physician practices (n=36) in 4 geographic areas are randomly assigned to 1 of 4 study groups. The intervention is a diabetes communication system, using mobile phones and patient/physician portals to allow patient-specific treatment and communication. All physicians receive American Diabetes Association (ADA) Guidelines for diabetes care. Patients with poor diabetes control (A1c> or =7.5%) at baseline (n=260) are enrolled in study groups based on PCP randomization. All study patients receive blood glucose (BG) meters and a year's supply of testing materials. Patients in three treatment groups select one of two mobile phone models, receive one-year unlimited mobile phone data and service plan, register on the web-based individual patient portal and receive study treatment phone software based on study assignment. Control group patients receive usual care from their PCP. The primary outcome is mean change in A1c over a 12-month intervention period.

CONCLUSION

Traditional methods of disease management have not achieved adequate control for BG and other conditions important to persons with diabetes. Tools to improve communication between patients and PCPs may improve patient outcomes and be satisfactory to patients and physicians. This RCT is ongoing.

Provider utilization of telemedicine: the elephant in the room

This paper addresses the challenge of provider underutilization of telehealth which continues to surface as an ongoing problem. In addition, this essay offers a list of ideas to serve as a starting point from which to address this key issue.

The opening phase of telemedicine consultations: an analysis of interaction

This paper describes communication in the opening phases of real-time, video-mediated telemedicine consultations, using the method of conversation analysis, in three NHS settings in the UK. The literature on interaction analysis in face-to-face medical consultations indicates that physicians' capacity to determine topics in consultations is established in the opening phases of the encounter. This is because patients concede the communicative floor to physicians who claim it for themselves by using well-established patterns of interaction. Drawing on 10 teleconsultations, the analysis shows that, for health care professionals and patients, video-mediated telemedicine is unfamiliar terrain, where communication requires constant negotiation of skills and roles, this complexity being added to by the fact that more than one professional participates in the encounter. Analysis of the opening phases of teleconsultations shows them to involve 'floor negotiation' between professionals and between professionals and patients in which they experience discrepancies between suggested 'frames', a term coined by Goffman [Goffman, E. (1974). Frame analysis. New York: Harper and Row.] to indicate interpretive schemas that allow people to understand the meaning of events in interactions in which they participate. Frame attunement is achieved during floor negotiation through various interruptions, interjections and attachments that professionals produce to defend their agenda. The novelty of the setting also made participants negotiate the physical space in which the encounter took place. We make tentative suggestions for the training of participants, based on the limited evidence of this study, which requires extending by further studies based on direct observation.

Vision and challenges of Evidence-Based Health Informatics: a case study of a CPOE meta-analysis

OBJECTIVE

To discuss, taking the example of a meta-analysis on computerized physician order entry (CPOE) systems, the special challenges of Evidence-Based Health Informatics, defined as the conscientious, explicit and judicious use of current best evidence when making decisions about introduction and operation of information technology in a given health care setting.

METHODS

We conducted a case study by performing a systematic review and meta-analysis of CPOE studies. We collected and discussed the challenges we addressed and how they could be overcome.

RESULTS

Challenges comprise the correct identification of published health informatics evaluation studies, the low reporting and study quality of studies, the problem of combining evidence from heterogeneous studies, and the problem of publication bias in health informatics.

CONCLUSION

Based on our experiences while conducting the CPOE meta-analysis, we argue that we are still at the beginning of Evidence-Based Health Informatics. To overcome the discussed challenges, health informatics should strive for harmonized terminology, a study registry, reporting standards, financial or legal incentives for conducting studies, methods to combine evidence from quantitative and qualitative studies, and guidelines for conducting and publishing evaluation studies.

The effectiveness of telemental health applications: a review

OBJECTIVE

To review the evidence of benefit from use of telemental health (TMH) in studies that reported clinical or administrative outcomes.

METHOD

Relevant publications were identified through computerized literature searches using several electronic databases. Included for review were scientifically valid articles that described controlled studies, comparing TMH with a non-TMH alternative, and uncontrolled studies that had no fewer than 20 participants. Quality of the evidence was assessed with an approach that considers both study performance and study design. Judgments were made on whether further data were needed to establish each TMH application as suitable for routine clinical use.

RESULTS

Included in the review were 72 papers that described 65 clinical studies; 32 (49%) studies were of high or good quality. Quality of evidence was higher for Internet- and telephone-based interventions than for video conferencing approaches. There was evidence of success with TMH in the areas of child psychiatry, depression, dementia, schizophrenia, suicide prevention, posttraumatic stress, panic disorders, substance abuse, eating disorders, and smoking prevention. Evidence of success for general TMH programs and in the management of obsessive-compulsive disorder were less convincing. Further study was judged to be necessary or desirable in 53 (82%) of the studies.

CONCLUSION

Evidence of benefit from TMH applications is encouraging, though still limited. There is a need for more good-quality studies on the use of TMH in routine care. The emerging use of Internet-based applications is an important development that deserves further evaluation.

Attitudes toward telehealth use among rural residents: a Danish survey

CONTEXT

Rural communities tend to be underserved by medical services. Low access to medical services affects quality of life and may also affect settlement decisions. The use of telehealth has often been mentioned as an alternative way to provide health care services in remote, underserved areas. One prerequisite for successful delivery of health care by means of telehealth is the existence of positive attitudes toward telehealth solutions among the potential end beneficiaries.

PURPOSE

The purpose of this study was to examine the attitudes toward telehealth use among residents in a Danish rural area.

METHOD

A representative sample from the island of AErø (n = 1,000) was selected and attitudes toward 2 telehealth applications were examined by structured telephone interviews regarding: (1) video consultation between patient and specialist, and (2) transfer of work tasks from local hospital to a hospital outside Denmark.

FINDINGS

As many as 58% did not like the idea of having a consultation with a specialist carried out by video consultation, whereas 26% did not like the idea of having their X-rays assessed by a hospital outside Denmark. The reluctance regarding both telehealth solutions was higher among older people and people with no education beyond primary school.

CONCLUSIONS

As the rural population in Denmark, as well as in other countries, tends to be older and less educated than the national average, the introduction of telehealth services faces special challenges in rural areas.