Health care in remote areas

Biosymbiotic platform for chronic long-range monitoring of biosignals in limited resource settings

Remote patient monitoring is a critical component of digital medicine, and the COVID-19 pandemic has further highlighted its importance. Wearable sensors aimed at noninvasive extraction and transmission of high-fidelity physiological data provide an avenue toward at-home diagnostics and therapeutics; however, the infrastructure requirements for such devices limit their use to areas with well-established connectivity. This accentuates the socioeconomic and geopolitical gap in digital health technology and points toward a need to provide access in areas that have limited resources. Low-power wide area network (LPWAN) protocols, such as LoRa, may provide an avenue toward connectivity in these settings; however, there has been limited work on realizing wearable devices with this functionality because of power and electromagnetic constraints. In this work, we introduce wearables with electromagnetic, electronic, and mechanical features provided by a biosymbiotic platform to realize high-fidelity biosignals transmission of 15 miles without the need for satellite infrastructure. The platform implements wireless power transfer for interaction-free recharging, enabling long-term and uninterrupted use over weeks without the need for the user to interact with the devices. This work presents demonstration of a continuously wearable device with this long-range capability that has the potential to serve resource-constrained and remote areas, providing equitable access to digital health.

Diagnosis of Middle Ear Disease using Tympanograms and Digital Imaging

OBJECTIVE: The study investigates the ability of physicians with different levels of training to accurately identify middle ear (ME) pathology using tympanograms and tympanic membrane (TM) digital photographs.

STUDY DESIGN AND SETTING: Groups of medical students, internal medicine residents, and attending and resident otolaryngologists were presented with a set of 50 matched tympanograms and photographs of TMs. The physicians were asked to differentiate between a normal and an abnormal-appearing TM. The sensitivity and specificity of diagnosis of ME pathology by physicians were compared with the gold standard, examining the ME cavity for pathology during myringotomy.

RESULTS: The sensitivity did not vary among physicians with different levels of training; however, specificity improved with an increase in physician experience.

CONCLUSIONS AND SIGNIFICANCE: This study establishes a baseline for accuracy of diagnosis of ME pathology using tympanograms and photographs of TMs as compared with binocular otomicroscopy and the gold standard, myringotomy. EBM rating: B-2.

Home telehealth--current state and future trends

OBJECTIVE

The purpose of this paper is to give an overview about the state of the art in research on home telehealth in an international perspective.

METHOD

The study is based on a review of the scientific literature published between 1990 and 2003 and retrieved via Medline in January/February 2004. All together, the abstracts of 578 publications have been analyzed.

RESULTS

The majority of publications (44%) comes from the United States, followed by UK and Japan. Most publications deal with vital sign parameter (VSP) measurement and audio/video consultations ("virtual visits"). Publications about IT tools for improved information access and communication as well as decision support for staff, patients and relatives are relatively sparse. Clinical application domains are mainly chronic diseases, the elderly population and paediatrics.

CONCLUSIONS

Internationally, we observe a trend towards tools and services not only for professionals but also for patients and citizens. However, their impact on the patient-provider relationship and their design for special user groups, such as elderly and/or disabled needs to be further explored. In general, evaluation studies are rare and further research is critical to determine the impacts and benefits, and limitations, of potential solutions and to overcome a number of hinders and restrictions, such as - the lack of standards to combine incompatible information systems; - the lack of an evaluation framework considering legal, ethical, organisational, clinical, usability and technical aspects; - the lack of proper guidelines for practical implementation of home telehealth solutions.

Information technology in the future of health care

Technology advances have changed the face of health care. This paradigm shift blurred the boundaries between public health, acute care, and prevention. Technology's role in the diagnosis, treatment assignment, follow-ups, and prevention will be reviewed and future impact projected. The understanding of shift in our expectation for each aspect of health care is critical so that levels of success are understood. Technology advances in health care delivery will be discussed. Specific applications are presented and explained and future trends discussed. Four applications are defined, and related to categories of technologies and their attributes.

Experience in the application of Java Technologies in telemedicine

Java language has been demonstrated to be an effective tool in supporting medical image viewing in Russia. This evaluation was completed by obtaining a maximum of 20 images, depending on the client's computer workstation from one patient using a commercially available computer tomography (CT) scanner. The images were compared against standard CT images that were viewed at the site of capture. There was no appreciable difference. The client side is a lightweight component that provides an intuitive interface for end users. Each image is loaded in its own thread and the user can begin work after the first image has been loaded. This feature is especially useful on slow connection speed, 9.6 Kbps for example. The server side, which is implemented by the Java Servlet Engine works more effective than common gateway interface (CGI) programs do. Advantages of the Java Technology place this program on the next level of application development. This paper presents a unique application of Java in telemedicine.

Internet and technology transfer in acute care hospitals in the United States: survey-2000

This paper provides the results of the survey-2000 measuring technology transfer and, specifically, Internet usage. The purpose of the survey was to measure the levels of Internet and Intranet existence and usage in acute care hospitals. The depth of the survey includes e-commerce for both business-to-business and customers. These results are compared with responses to the same questions in survey-1997. Changes in response are noted and discussed. This information will provide benchmarks for hospitals to plan their network technology position and to set goals. This is the third of three articles based upon the results of the survey-2000. Readers are referred to prior articles by the author, which discuss the survey design and provide a tutorial on technology transfer in acute care hospitals. (1) Thefirst article based upon the survey results discusses technology transfer, system design approaches, user involvement, and decision-making purposes. (2)

Telemedicine in the sleep laboratory: feasibility and economic advantages of polysomnograms transferred online

The costs for polysomnography (PSG) and alternative diagnostic procedures for sleep-disordered breathing are challenging public health care systems. We wanted to determine if a telemedicine protocol with online transfer of PSGs from a remote site could be cost-effective and clinically useful while improving patient access to full PSG. Fifty-nine PSGs were performed in 54 pulmonary patients with suspected sleep-disordered breathing at a remote hospital. The data were transferred by File Transfer Protocol (FTP) via the Internet to Walter Reed Army Medical Center (WRAMC) for scoring and interpretation. The results were faxed back to the remote hospital. Clinical utility was assessed by evaluating the reasons for patient referral and the resulting diagnoses. The economic benefits were calculated by comparing direct expenses of the telemedicine protocol with costs for contracting PSGs at outside sleep laboratories. A total of 93% (55) of all PSGs were transferred successfully online. Of the 54 patients, 47 had PSGs performed for diagnosis (including three split-night studies), 8 underwent treatment titration, and 1 patient had both overnight studies. Diagnoses were obstructive sleep apnea in 43 patients, central sleep apnea in 2, and upper airway resistance syndrome in 2. The disease conditions were defined as severe in 27 patients, moderate in 12 patients, and mild in 8 patients. Each PSG cost $700 (including costs for lost transmissions) compared to $1,250 for referral to a private sleep laboratory. A savings of $550 per study was realized with the telemedicine protocol. The online transfer of PSGs from a remote site to a centralized sleep laboratory is technically feasible and clinically useful. Telemedicine offers an effective alternative for cost reduction in sleep medicine while improving patient access to specialized care in remote areas.

Implementation and evaluation of a telemedicine course for physician assistants

Clinical telemedicine uses interactive video technologies and telecommunications networks to deliver medical consultations to distant patients and their primary care providers. Telemedicine provides real-time access to specialists whose services might not otherwise be available in rural or medically underserved areas. While recently there has been dramatic growth in the use of telemedicine, there is little evidence that telemedicine as a patient care delivery system has been incorporated into the medical school curriculum. The authors describe the current status of telemedicine in medical curricula and report on efforts at the University of Iowa to incorporate telemedicine into the curriculum of its Physician Assistant Program.

Tutorial on technology transfer and survey design and data collection for measuring Internet and Intranet existence, usage, and impact (survey-2000) in acute care hospitals in the United States

This paper provides a tutorial of technology transfer for management information systems in health care. Additionally it describes the process for a national survey of acute care hospitals using a random sample of 813 hospitals. The purpose of the survey was to measure the levels of Internet and Intranet existence and usage in acute care hospitals. The depth of the survey includes e-commerce for both business to business and with customers. The relationships with systems approaches, user involvement, user satisfaction and decision-making will be studied. Changes with results of a prior survey conducted in 1997 can be studied and enabling and inhabiting factors identified. This information will provide benchmarks for hospitals to plan their network technology position and to set goals.

Problems and our solutions for implementing telemedicine systems

There are several problems on the practical use of telemedicine, for example, the difficulties involved in promoting communication between medical facilities, uncooperative clinicians, and the absence of high-speed circuits and high-resolution CRT. From the Japanese point of view, we suggest ways to resolve these problems. We will analyze and propose scenarios for realizing successful communications among medical institutions, medical communication and its characteristics, barriers to the promotion of communications among medical institutions, second-opinion centers, and separate satellites and separate circuits. We also mention the World Wide Web for teleconsultation, provision of assistance to people with data handicaps via a communications satellite, and assistance to programs designed for training telemedicine specialists. Using a communication satellite, we offer programs that explain preventive medicine, support activities for nursing at home, explain the risks of fast food, and support activities for the handicapped and women in a simple manner to computer illiterates.

The relationship between business process re-engineering and Internet usage: survey of acute care hospitals in the United States

The data from a national survey of acute care hospitals was used for analysis. Hatcher discusses the complete questionnaire, data collection procedure, and sample selection. The relationship between business process re-engineering, total quality management, innovation system approaches, and Internet usage and potential usage will be reported and discussed.

The effectiveness of videophones in home healthcare for the elderly

OBJECTIVES

This study evaluates the effectiveness of telecare, the use of videophones in healthcare for the elderly in communities, and proposes an effective application of telecare in home healthcare.

METHODS

An intervention study design was applied to evaluate the add-on benefits to home healthcare from a videophone system using Integrated Services Digital Network (ISDN) installed in individual homes of clients and service providers. An intervention group of home healthcare cases were provided with videophones (VHHC group), and it was compared to a reference group of regular healthcare cases (HHC group). Persons from the 2 groups were individually matched according to sex, age, and their independence in activities of daily living. The functional independence of the individuals in the 2 groups was assessed before and 3 months after home healthcare was started, with and without videophones. The effectiveness of videophones was assessed by analyzing the improvements in functional independence using a paired t test.

RESULTS

Improvements in functional independence of 5 pairs of males and 11 pairs of females were analyzed. Improvements in ADL, communication, and social cognition independence of the VHHC group over the 3-month trial period measured by the Functional Independence Measure were 1.5 points, 0.7 points, and 1.9 points, respectively; statistically, these were significantly greater than those of the HHC group (individually P < 0.05).

CONCLUSIONS

The effectiveness of the videophones in home healthcare service was found to be significant. This evidence supports the use of videophones in home healthcare to improve the quality of service.

Internet usage and potential impact for acute care hospitals: survey in the United States

These survey results are from a national survey of acute care hospitals. A random sample of 813 hospitals was selected with 115 responding and 33 incorrect addresses resulting in a 15% response rate. The purpose of the study was to measure the extent of information systems integration in the financial, medical, and administrative systems of the hospitals. Internet usage including homepages and advertising was measured. Other selected telecommunication applications are analyzed. As demonstration projects from the literature are compared to the survey results, the potential for hospitals is tremendous. Resulting cost savings could be equally impressive. This information will provide a benchmark for hospitals to determine their position relative to Internet technology and to set goals.

Low-bandwidth telemedicine for remote orthotic assessment

A model for performing remote orthotic assessments using low-bandwidth computer communication technology (video conferencing) was developed, tested, and evaluated. System evaluation involved comparing a series of remote assessments with on-site assessments. While most on-site and on-line results were similar, discrepancies which occurred were attributed to between-clinician differences, measurement technique differences, technical and learning obstacles at the start of the project, and within subject variations during the day. On-line assessment efficiency improved with each on-line session and corresponded with increased confidence in the system, easier system use, and better overall satisfaction. An on-line debriefing session was held with all project clinicians. These clinicians supported continued use of the communication system for rehabilitation consultation and education. Clinically. preliminary face-to-face meetings and a regular practice schedule were recommended. Technically, the system was considered good; however, suggested improvements included using a high quality speaker-phone system, streamlining the video capture process, and providing more reliable telecommunication connections.

The future of robotics can be ours

As the use of robotic aides increases the possibility of telesurgery, the perioperative scope of practice could include using patients' homes or other nontraditional settings as surgical sites. Even mobile surgical vans could be used. To perform telesurgery, the health care industry actively must define the role of the health care professional with the patient who can make an incision and insert a laparoscope. This may create an opportune time to promote the RN first assistant (RNFA) role--a goal that will involve expanding our state nurse practice acts to allow RNFAs to perform various functions for true advanced practice in nontraditional settings. Additionally, it will mean defining what functions and personnel must be available in these new creative settings. Current experiments have focused on using nonlicensed assistants, which can lead to legal and moral concerns. Legal and moral concerns include not only appropriate personnel, but also patient privacy. In telesurgery, patient information would be transmitted over communication lines, possibly seriously jeopardizing patient privacy. Perioperative nurses must be vigilant regarding patient privacy and continue to be patient advocates. Additional concerns relate to the possible complications or emergencies that can occur in any procedure, such as bleeding, cardiac arrest, or malignant hyperthermia. As this field is being developed, these concerns must be addressed, and possible complications and emergencies must be prepared for. All patients deserve highly trained individuals to care for them. It is a concern that unlicensed personnel are being considered to manage these potentially serious situations. It is now more important than ever that perioperative nurses stay on top of technologic advances. One surgeon stated that perioperative nurses are at a point in history in which they can make a difference--a potentially lifesaving difference. Nurses will have to be comfortable with new technology, know when it is working well, and be able to assess the patient's status critically. The use of robotic aides can decrease the amount of physical work that nurses do; however, they also have the capability to denigrate nurses' positions. If not careful, nurses could lose their focus on the caring aspect of the nursing profession. Although computers remain machines programmed by humans, it seems they more often are masters of information. Today, procedures can be performed in cyberspace as if surgeons were present at the surgical sites. Could robotic aides and computers do a better job than physicians and nurses, causing these health care providers to become extinct? Probably not. Although robots and computers may be able to replicate the knowledge and skill of physicians, patients require human interaction that computers cannot provide. This involves feelings and human communication beyond current technology, despite robotic engineers' continuing attempts to replicate this. The ultimate use of robotics remains uncertain; however, the human touch will not soon, if ever, be replaced by robotic technology. It is now of utmost urgency that all perioperative nurses refine and hone the caring skills that Florence Nightingale instilled to ensure their professional future. Robotics is a new and challenging aspect being added to nursing care. Nurses must take an active role, embrace this technology, and work to maximize their position with it.

Telemedicine. Present applications and future prospects

Information technology has enabled much of the business community to function in a time and place-independent manner. Health care has lagged in adopting this technology because of tradition, concern for patient security and confidentiality, liability, and licensure issues. This article reviews the current state of telemedicine technology, its applications, and opportunities for further development. Urology is identified as a specialty that stands to benefit from advances in technologies applicable to remote diagnosis, monitoring and care of patients, physician training, and record keeping.

Telemedicine for airline passengers, seafarers and islanders

Airline passengers, seafarers and islanders are three different examples of people who can benefit from telemedicine. However, the peculiar characteristics of each group require different applications. In 60 years of activity, the CIRM has assisted more than 37,000 patients. In the 10 years from 1986 to 1996 the Centre provided radio medical assistance to 7647 patients, of whom 6981 (91.3%) were sailors, 642 (8.4%) were people living in isolated areas (small italian islands) with few medical facilities, while only 24 patients (0.3%) were airline passengers. In the same period, the telecommunication service received or transmitted almost 80,000 medical messages.