Telemedicine/telehealth: an international perspective. Clinical applications in telemedicine/telehealth

Telehealth and Health Equity in Older Adults With Heart Failure: A Scientific Statement From the American Heart Association

Enhancing access to care using telehealth is a priority for improving outcomes among older adults with heart failure, increasing quality of care, and decreasing costs. Telehealth has the potential to increase access to care for patients who live in underresourced geographic regions, have physical disabilities or poor access to transportation, and may not otherwise have access to cardiologists with expertise in heart failure. During the COVID-19 pandemic, access to telehealth expanded, and yet barriers to access, including broadband inequality, low digital literacy, and structural barriers, prevented many of the disadvantaged patients from getting equitable access. Using a health equity lens, this scientific statement reviews the literature on telehealth for older adults with heart failure; provides an overview of structural, organizational, and personal barriers to telehealth; and presents novel interventions that pair telemedicine with in-person services to mitigate existing barriers and structural inequities.

Opening up disruptive ways of management in cancer pain: the concept of multimorphic pain

PURPOSE

Following a series of articles reviewing the basics of cancer pain management, in this article, we develop the guiding principle of our philosophy: the concept of multimorphic pain and how to integrate it as the innovative cornerstone of supportive care in cancer.

METHOD

Critical reflection based on literature analysis and clinical practice.

RESULTS

This model aims to break with standard approaches, offering a more dynamic and exhaustive vision of cancer pain as a singular clinical entity, taking into account its multimorphic characteristics (cancer pain experience can and will change during cancer: aetiology, physiopathology, clinical presentation and consequences of pain) and the disruptive elements that can occur to influence its evolution (cancer evolution, concomitant treatments, pain from associated diseases, comorbidities and complications, or modifications in the environment). Our model establishes the main key stages for interdisciplinary management of cancer pain: Early, personalised management that is targeted and multimodal; Identification, including in advance, of potential disruptive elements throughout the care pathway, using an exhaustive approach to all the factors influencing pain, leading to patient and caregiver education; Optimal analgesic balance throughout the care pathway; Integration of this concept into a systemic early supportive care model from the cancer diagnosis.

CONCLUSIONS

Given the difficulties still present in the management of pain in cancer, and whilst cancer is often considered as a chronic condition, the concept of multimorphic pain proposes a practical, optimised and innovative approach for clinicians and, ultimately, for patients experiencing pain.

A clinical approach to the management of cancer-related pain in emergency situations

PURPOSE

Most cancer patients experience many pain episodes depending on disruptive elements, leading them to the emergency room. The objective of the article is to describe common pitfalls that need to be avoided, as well as opportunities to be seized for repositioning patients back on their care pathway.

METHODS

Critical reflection based on literature analysis and clinical practice.

RESULTS

Most forms of cancer are now chronic, evolving diseases, and patients are treated with high-technology targeted therapies with iatrogenic effects. Moreover, the multimorphic nature of cancer-related pain requires dynamic, interdisciplinary assessments addressing its etiology, its pathophysiology, its dimensions (sensory-discriminatory, cognitive, emotional, and behavioral), and the patient's perception of it, in order to propose the most adapted therapies. However, for most patients, cancer pain remains underestimated, poorly assessed, and under-treated. In this context, the key steps in emergency cancer pain management are as follows: • Quick relief of uncontrolled cancer pain: after eliminating potential medical or surgical emergencies revealed by pain, a brief questioning will make the use of carefully titrated morphine in most situations possible. • Assessment and re-assessment of the pain and the patient, screening specific elements, to better understand the situation and its consequences. • Identification of disruptive elements leading to uncontrolled pain, with an interdisciplinary confrontation to find a mid to long-term approach, involving the appropriate pharmaceutical and/or non-pharmaceutical strategies, possibly including interventions.

CONCLUSIONS

Pain emergencies should be part of the cancer care pathway and, through supportive care, provide an opportunity to help cancer patients both maintain their physical, psychological, and social balance and anticipate further painful episodes.

The Influence of Telepathology on Coordination Practices

BACKGROUND

Coordination between physicians and allied professionals is essential to the effective delivery of care services and is associated with positive patient outcomes. As information technology can radically transform how professionals collaborate, both researchers and healthcare accreditation bodies are devoting a growing interest to the means of achieving better coordination.

INTRODUCTION

The primary aim of this study is to explain the extent to which and how coordination practices between pathologists, technologists, and surgeons are transformed when telepathology is being implemented.

MATERIALS AND METHODS

An interpretive case study was conducted. A total of 60 semistructured interviews with key participants were conducted, in addition to several days of direct observation of telepathology-based intraoperative consultations (IOCs).

RESULTS

Three major kinds of transformation of coordination practices were observed. First, the telepathology system itself constrains and disrupts coordination routines, such as the presentation of slides. Second, anticipating IOC, proactively performed by the laboratory personnel in traditional settings, requires more formal requests in a telepathology context. Third, local technologists become more autonomous in performing complex macroscopy manipulations and managing the laboratory tasks traditionally performed by pathologists.

CONCLUSIONS

Successful coordination of work in a telepathology-based IOC context requires that significant transformations be anticipated and accounted for. Project managers need to formalize new work processes, support the transformations in professional roles, and mitigate the major hindrances that small material changes may have on work routines.

Patient Satisfaction With an Early Smartphone-Based Cosmetic Surgery Postoperative Follow-Up

BACKGROUND

While prevalent in everyday life, smartphones are also finding increasing use as a medical care adjunct. The use of smartphone technology as a postoperative cosmetic surgery adjunct for care has received little attention in the literature.

OBJECTIVES

The purpose of this effort was to assess the potential efficacy of a smartphone-based cosmetic surgery early postoperative follow-up program. Specifically, could smartphone photography provided by the patient to the plastic surgeon in the first few days after surgery allay patient's concerns, improve the postoperative experience and, possibly, detect early complications?

METHODS

From August 2015 to March 2016 a smartphone-based postoperative protocol was established for patients undergoing cosmetic procedures. At the time of discharge, the plastic surgeon sent a text to the patient with instructions for the patient to forward a postoperative photograph of the operated area within 48 to 72 hours. The plastic surgeon then made a return call/text that same day to review the patient's progress. A postoperative questionnaire evaluated the patients' postoperative experience and satisfaction with the program.

RESULTS

A total of 57 patients were included in the study. Fifty-two patients responded to the survey. A total of 50 (96.2%) patients reported that the process improved the quality of their postoperative experience. The protocol allowed to detect early complications in 3 cases. The physician was able to address and treat the complications the following day prior to the scheduled clinic follow up.

CONCLUSIONS

The smartphone can be effectively utilized by the surgeon to both enhance the patient's postoperative experience and alert the surgeon to early postoperative problems.

LEVEL OF EVIDENCE

4.

Training Residents in the Use of Telepsychiatry: Review of the Literature and a Proposed Elective

Many regions in the United States are deficient in mental health services, especially those in rural areas. As a result of these deficiencies, many patients in need of psychiatric services are often left untreated. Although it is clear that telepsychiatry has great potential in improving patient access to mental health care in areas where psychiatric services are deficient, the lack of familiarity with the technology and inadequate training are current barriers to expanding the use of telepsychiatry. A review of telepsychiatry, its clinical applications, and evidence-based literature regarding competencies in graduate medical education related to telepsychiatry are provided. An approach to implementing telepsychiatry into a curriculum is suggested. We also propose an elective clinical experience with resources for didactics or independent study that will enable residents to develop a knowledge base and competence in the practice of telepsychiatry.

Telehealth in Western Australia: The challenge of evaluation

Between 1996 and 2003, a network of 85 telehealth videoconference sites was implemented in Western Australia (WA), together with 19 teleradiology facilities. Telehealth services have been growing steadily, and in 2002 there were over 30,000 teleradiology transmissions and 1250 clinical occasions of service via videoconference. The funding bodies, and in particular the WA Department of Health, need to know whether the aims of the project have been achieved. They must also decide whether investment should continue. A process of progressive evaluation has been implemented to identify progress to date, the benefits achieved and the potential for further development. However, it is difficult to evaluate a broad range of programmes in rural and remote locations for such an embryonic service. These difficulties are compounded by the lack of a strategy at national level to ensure consistency and compatibility not only of infrastructure, equipment and standards but also of data capture and evaluation methodologies for telehealth. This would allow comparisons across regions and states, which in turn would provide opportunities to learn from others and thus improve health-care nationally.

Telemedicine: A Reliable Tool to Assess the Severity of Respiratory Distress in Children

BACKGROUND AND OBJECTIVES

Remote assessment of respiratory distress using telemedicine enabled audio-video conferencing (TM) is of value for medical decision-making. Our goal was to evaluate the interobserver reliability (IOR) of TM compared with face-to-face (FTF) assessment of respiratory distress in children.

METHODS

A prospective, cohort study was performed in pediatric emergency department from July 2012 to February 2013. Children (aged 0-18 years) who presented with signs of respiratory distress were included in the study. The respiratory score is a 4-item, 12-point scale (respiratory rate [1-3], retractions [0-3], dyspnea [0-3], and wheezing [0-3]) that assesses the severity of a child's respiratory distress. Each child was evaluated by a pair of observers from a pool of 25 observers. The first observer evaluated the patient FTF, and the second observer simultaneously and independently evaluated remotely via TM. The overall respiratory distress severity is based on the respiratory scale and reported as nonsevere (≤8) and severe (≥9) respiratory distress. The IOR reliability between FTF and TM assessment was measured using a 2-way mixed model, absolute agreement and average measure intraclass correlation coefficient (ICC).

RESULTS

Forty-eight patients and 135 paired observations were recorded. IOR between the FTF and TM groups for total respiratory score had an ICC of 0.95 (confidence interval 0.93-0.96) and for subscores, the ICC range was as follows: respiratory rate = 0.92, retractions = 0.85, dyspnea = 0.94, and wheezing = 0.77.

CONCLUSIONS

TM is a reliable tool to assess the severity of respiratory distress in children.

A prospective comparison of telemedicine versus in-person delivery of an interprofessional education program for adults with inflammatory arthritis

Introduction We evaluated two modes of delivery of an inflammatory arthritis education program ("Prescription for Education" (RxEd)) in improving arthritis self-efficacy and other secondary outcomes. Methods We used a non-randomized, pre-post design to compare videoconferencing (R, remote using telemedicine) versus local (I, in-person) delivery of the program. Data were collected at baseline (T₁), immediately following RxEd (T₂), and at six months (T₃). Self-report questionnaires served as the data collection tool. Measures included demographics, disorder-related, Arthritis Self-Efficacy Scale (SE), previous knowledge (Arthritis Community Research and Evaluation Unit (ACREU) rheumatoid arthritis knowledge questionnaire), coping efficacy, Illness Intrusiveness, and Effective Consumer Scale. Analysis included: baseline comparisons and longitudinal trends (R vs I groups); direct between-group comparisons; and Generalized Estimating Equations (GEE) analysis. Results A total of 123 persons attended the program (I: n = 36; R: n = 87) and 111 completed the baseline questionnaire (T₁), with follow-up completed by 95% ( n = 117) at T₂ and 62% ( n = 76) at T₃. No significant baseline differences were found across patient characteristics and outcome measures. Both groups (R and I) showed immediate effect (improved arthritis SE, mean change (95% confidence interval (CI)): R 1.07 (0.67, 1.48); I 1.48 (0.74, 2.23)) after the program that diminished over six months (mean change (95% CI): R 0.45 (-0.1, 0.1); I 0.73 (-0.25, 1.7)). For each of the secondary outcomes, both groups showed similar trends for improvement (mean change scores (95% CI)) over time. GEE analysis did not show any meaningful differences between groups (R vs I) over time. Discussion Improvements in arthritis self-efficacy and secondary outcomes displayed similar trends for I and R participant groups.

Telemedicine in Cleft Care: Reliability and Predictability in Regional and International Practice Settings

BACKGROUND

Regional and international cleft care providers are challenged in their ability to deliver reliable, comprehensive care. Our institution utilizes video teleconferencing to facilitate initial evaluation and postoperative cleft care. This study describes our experience using telemedicine, generates a perioperative treatment algorithm using this technology, and compares cost-utility of telemedicine to in-person ambulatory visits when regional practices are involved.

METHODS

A 5-year retrospective review of all cleft patients evaluated in an ambulatory setting was conducted. Patient demographics and location, number, and type of telemedicine visits were recorded. Specific treatment algorithms utilizing telemedicine for perioperative care for primary and secondary cleft lip and nasal repair, palatoplasty, and operation for velopharyngeal insufficiency are described. A cost-utility analysis was performed comparing distances between patient homes and primary hub versus telemedicine clinic sites.

RESULTS

Five hundred nineteen patients were identified; 18.1% attended at least 1 teleconferencing visit. Postoperative follow-up was 100%. The majority of screening, preoperative, and postoperative care was provided using telemedicine. In-person evaluations were performed when intraoral assessments were necessary. Telemedicine visits were associated with an average savings of 239 miles per visit in the United States and 578 miles per visit in Mexico.

CONCLUSIONS

Video teleconferencing can be used to provide comprehensive regional and international cleft care to facilitate initial evaluations and consistent follow-up. This technology can alleviate the travel burden on families and cleft care providers practicing over a large geographic radius.

Telemedicine Applications for the Pediatric Emergency Medicine: A Review of the Current Literature

OBJECTIVE

The aim of this study was to review current literature relating to telemedicine in pediatric emergency medicine including its clinical applications and challenges associated with its implementation.

METHODS

We reviewed the literature using standard search methods in accordance with preferred reporting items for systematic reviews and meta-analysis. We included the studies done in emergency settings for all age groups and narrowed our search to the articles that are relevant to "impact on quality of care" and "patient outcome." We also described current telemedicine uses, software, hardware, and other requirements needed for pediatric emergency applications.

RESULTS

Telemedicine has a potential role in pediatric emergency medicine for real-time decision making to improve quality of care for children. Logistic and legal challenges exist for pediatric emergency medicine applications similar to its uses in other settings.

CONCLUSIONS

Current frameworks exist in the use of telemedicine for pediatric emergency medicine. Research is still needed to see whether clinical outcomes are improved with pediatric emergency telemedicine solutions. Practical issues regarding training, accessibility, and resource allocation should be explored as pediatric emergency telemedicine evolves.

Use of Telepsychiatry in Psychodynamic Psychiatry

This article reviews the organization, infrastructure basics, applications, effectiveness, outreach, and implementation barriers related to telepsychiatry. We highlight the tremendous potential and promise that this technology holds and also discuss the importance that telepsychiatry may play in the field of psychodynamic psychiatry. Given the growing effectiveness evidence base for therapy delivered over the Internet, telepsychiatry holds a large unexplored territory to help psychodynamically minded patients connect with psychodynamically oriented psychiatrists. This economically advantageous medium can be utilized to deliver psychodynamically guided approaches to the patient, alone or in combination with pharmacological and other psychosocial interventions. We hope, this article will help psychodynamically trained psychiatrists to consider bridging the gap with the remotely located, chronically mentally ill population which oftentimes has scarcity of resources.

The assessment of telemedicine to support outpatient palliative care in advanced cancer

Objective:

We aimed to examine telemedicine as a form of home and additional support for traditional outpatient care as a way to remotely monitor and manage the symptoms of patients with advanced cancer.

Method:

In total, 12 patients were monitored through monthly consultations with a multidisciplinary healthcare team and weekly web conferences. To evaluate and treat pain and other symptoms, the Edmonton Symptom Assessment System (ESAS) was applied during all remote or in-person interviews.

Results:

During monitoring, the team contacted the patients on 305 occasions: there were 89 consultations at the hospital, 19 in-person assistances to the family (without the patient), 77 web conferences, 38 telephone calls, 80 emails, and 2 home visits. The mean monitoring time until death was 195 ± 175.1 days. Eight patients who completed the ESAS in all interviews had lower mean distress symptom scores according to web conferences than in person.

Significance of results:

Telemedicine allowed greater access to the healthcare system, reduced the need to employ emergency services, improved assessment/control of symptoms, and provided greater orientation and confidence in the care given by family members through early and proactive interventions. Web conferencing proved to be a good adjuvant to home monitoring of symptoms, complementing in-person assistance.

Predictive factors of telemedicine service acceptance and behavioral intention of physicians

PURPOSE

Despite the proliferation of telemedicine technology, telemedicine service acceptance has been slow in actual healthcare settings. The purpose of this research is to develop a theoretical model for explaining the predictive factors influencing physicians' willingness to use telemedicine technology to provide healthcare services.

METHODS

We developed the Telemedicine Service Acceptance model based on the technology acceptance model (TAM) with the inclusion of three predictive constructs from the previously published telemedicine literature: (1) accessibility of medical records and of patients as clinical factors, (2) self-efficacy as an individual factor and (3) perceived incentives as regulatory factors. A survey was conducted, and structural equation modeling was applied to evaluate the empirical validity of the model and causal relationships within the model using the data collected from 183 physicians.

RESULTS

Our results confirmed the validity of the original TAM constructs: the perceived usefulness of telemedicine directly impacted the behavioral intention to use it, and the perceived ease of use directly impacted both the perceived usefulness and the behavioral intention to use it. In addition, new predictive constructs were found to have ramifications on TAM variables: the accessibility of medical records and of patients directly impacted the perceived usefulness of telemedicine, self-efficacy had a significant positive effect on both the perceived ease of use and the perceived usefulness of telemedicine, and perceived incentives were found to be important with respect to the intention to use telemedicine technology.

CONCLUSIONS

This study demonstrated that the Telemedicine Service Acceptance model was feasible and could explain the acceptance of telemedicine services by physicians. These results identified important factors for increasing the involvement of physicians in telemedicine practice.

The 60 most highly cited articles published in the Journal of Telemedicine and Telecare and Telemedicine Journal and E-health

Summary

We analysed the most highly cited articles in two specialist telemedicine journals, the Journal of Telemedicine and Telecare (JTT) and Telemedicine Journal and E-health (TJEH). Articles were extracted from the Science Citation Index Expanded in September 2012. A total of 1810 articles were listed for the JTT and 1550 for TJEH. In the JTT, the mean number of citations was 43 (SD 13); in TJEH the mean number of citations was 30 (SD 11). The average number of citations for the JTT was significantly higher than for TJEH ( P < 0.001). In each journal, the 60 articles which had the most citations were identified as highly cited publications (HCPs). The 60 HCPs in the JTT originated from 16 countries; the 60 HCPs in TJEH originated from 10 countries. Considering both journals together, the majority of HCPs came from the US, UK, Australia and Canada. In the JTT, the mean number of authors for each HCP was 4.6 (SD = 3.1); in TJEH, the mean number of authors for each HCP was 4.5 (SD = 2.3). There was no difference between the two journals ( P = 0.84) and the characteristics of the HCPs published in the JTT and TJEH were broadly similar. Although HCPs are not a direct method of measuring quality, they are an indicator of the scientific impact of the articles.

Image quality in real-time teleultrasound of infant hip exam over low-bandwidth internet links: a transatlantic feasibility study

Evolution of communication systems, especially internet-based technologies, has probably affected Radiology more than any other medical specialty. Tremendous increase in internet bandwidth has enabled a true revolution in image transmission and easy remote viewing of the static images and real-time video stream. Previous reports of real-time telesonography, such as the ones developed for emergency situations and humanitarian work, rely on high compressions of images utilized by remote sonologist to guide and supervise the unexperienced examiner. We believe that remote sonology could be also utilized in teleultrasound exam of infant hip. We tested feasibility of a low-cost teleultrasound system for infant hip and performed data analysis on the transmitted and original images. Transmission of data was accomplished with Remote Ultrasound (RU), a software package specifically designed for teleultrasound transmission through limited internet bandwidth. While image analysis of image pairs revealed statistically significant loss of information, panel evaluation failed to recognize any clinical difference between the original saved and transmitted still images.

Telehealth trends and the challenge for infrastructure

BACKGROUND

As telehealth takes advantage of improved networks, there is a growing need to understand the infrastructure needs of future telehealth developments. This work aims to predict such needs based on current trends and research.

MATERIALS AND METHODS

We conducted a literature review of telehealth with a focus on advanced network infrastructure. We drew inferences from our previous demonstrator projects in advanced telehealth, but the most important findings emerged from interviews with a panel of thought leaders.

RESULTS

Our results show that there will be simultaneous and coupled evolution of telehealth through the space spanned by three axes: care models, clinical applications, and technology. We also consider a two-dimensional model of reach and complexity to describe future applications. Universal access to advanced networks will drive fundamental changes in healthcare deliver. The biggest change will be seen in home and mobile health care delivery, forming part of a trend toward patient-centric models. Other aspects of decentralization in healthcare systems will include networks of caregivers. Besides this reach trend, the complexity trend will include integrating multiple-channel applications and seamlessly moving large datasets in real time among hospitals, other medical facilities, and homes. There is a need to provide infrastructure that does not have an upper limit on quality of service and allows telehealth to address mobility, usability, interoperability, intelligence, and adaptability in a systematic way.

Using technology in the delivery of mental health and substance abuse treatment in rural communities: a review

Rural communities face tremendous challenges in accessing mental health and substance abuse treatment services. Some of the most promising advancements in the delivery of rural health care services have been in the area of telecommunication technology. These applications have the potential to reduce the disparities in the delivery of substance abuse and mental health services between urban and rural communities. The purpose of this inquiry was to explore the advances and uses of telecommunications technology, and related issues, in the delivery of mental health and substance abuse treatment services within rural areas. A review of the academic literature and other relevant works was conducted and the content was organized into four major themes: (a) advantages of telehealth and applications to rural practice, (b) barriers to implementation in rural practice, (c) utilization in rural areas, and (d) areas for further research.

Telehealth for nursing homes: the utilization of specialist services for residential care

Specialist care consultations were identified by two research nurses using documentation in patient records, appointment diaries, electronic billing services and on-site observations at a 441-bed long term care facility. Over a six-month period there were 3333 consultations (a rate of 1511 consultations per year per 100 beds). Most consultations were for general practice (n = 2589, 78%); these consultations were mainly on site (99%), with only 27 taking place off site. There were 744 consultations for specialities other than general practice. A total of 146 events related to an emergency or unplanned hospital admission. The remaining medical consultations (n = 598, 18%) related to 23 medical specialities. The largest number of consultations were for surgery (n = 106), podiatry (n = 100), nursing services including wound care (n = 74), imaging (n = 41) and ophthalmology (n = 40). Many services which are currently being provided on site to metropolitan long-term care facilities could be provided by telehealth in both urban and rural facilities.

Telehealth approaches to obsessive-compulsive related disorders

Recently, a major new category classification of disorders, the obsessive-compulsive related disorders (OCRDs), has been proposed (Hollander, Braun, & Simeon, 2008). The proposed disorders that would fall in this category are associated with efficacious treatments, but have not been widely disseminated. Recent developments in telehealth have made treatment available to a wider range of clients with putative OCRDs. This paper evaluates the efficacy of these treatments when delivered using telehealth methodologies. While the evidence is preliminary, the early results are encouraging for the delivery of cognitive-behavior therapy for a wide range of OCRDs. Additional research directions are suggested in light of these emerging technologies for treatment delivery.

Current perspectives in medical image perception

Medical images constitute a core portion of the information a physician utilizes to render diagnostic and treatment decisions. At a fundamental level, this diagnostic process involves two basic processes: visually inspecting the image (visual perception) and rendering an interpretation (cognition). The likelihood of error in the interpretation of medical images is, unfortunately, not negligible. Errors do occur, and patients' lives are impacted, underscoring our need to understand how physicians interact with the information in an image during the interpretation process. With improved understanding, we can develop ways to further improve decision making and, thus, to improve patient care. The science of medical image perception is dedicated to understanding and improving the clinical interpretation process.

Angelcare mobile system: homecare patient monitoring using bluetooth and GPRS

The quick progress in technology has brought new paradigms to the computing area, bringing with them many benefits to society. The paradigm of ubiquitous computing brings innovations applying computing in people's daily life without being noticed. For this, it has used the combination of several existing technologies like wireless communications and sensors. Several of the benefits have reached the medical area, bringing new methods of surgery, appointments and examinations. This work presents telemedicine software that adds the idea of ubiquity to the medical area, innovating the relation between doctor and patient. It also brings security and confidence to a patient being monitored in homecare.

Image analysis for retinopathy of prematurity diagnosis

PURPOSE

To review findings from the authors' published studies involving telemedicine and image analysis for retinopathy of prematurity (ROP) diagnosis.

METHODS

Twenty-two ROP experts interpreted a set of 34 wide-angle retinal images for presence of plus disease. For each image, a reference standard diagnosis was defined from expert consensus. A computer-based system was used to measure individual and linear combinations of image parameters for arteries and veins: integrated curvature (IC), diameter, and tortuosity index (TI). Sensitivity, specificity, and receiver operating characteristic areas under the curve (AUC) for plus disease diagnosis were determined for each expert. Sensitivity and specificity curves were calculated for the computer-based system by varying the diagnostic cutoffs for arterial IC and venous diameter. Individual vessels from the original 34 images were identified with particular diagnostic cutoffs, and combined into composite wide-angle images using graphics editing software.

RESULTS

For plus disease diagnosis, expert sensitivity ranged from 0.308-1.000, specificity from 0.571-1.000, and AUC from 0.784 to 1.000. Among computer system parameters, one linear combination had AUC 0.967, which was greater than that of 18 of 22 (81.8%) experts. Composite computer-generated images were produced using the arterial IC and venous diameter values associated with 75% under-diagnosis of plus disease (ie, 25% sensitivity cutoff), 50% under-diagnosis of plus disease (ie, 50% sensitivity cutoff), and 25% under-diagnosis of plus disease (ie, 75% sensitivity cutoff).

CONCLUSIONS

Computer-based image analysis has the potential to diagnose severe ROP with comparable or better accuracy than experts, and could provide added value to telemedicine systems. Future quantitative definitions of plus disease might improve diagnostic objectivity.

Telerehabilitation clinical and vocational applications for assistive technology: research, opportunities, and challenges

Rehabilitation service providers in rural or underserved areas are often challenged in meeting the needs of their complex patients due to limited resources in their geographical area. Recruitment and retention of the rural clinical workforce are beset by the ongoing problems associated with limited continuing education opportunities, professional isolation, and the challenges inherent in coordinating rural community healthcare. People with disabilities who live in rural communities also face challenges accessing healthcare. Traveling long distances to a specialty clinic for necessary expertise may be troublesome due to inadequate or unavailable transportation, disability specific limitations, and financial limitations. Distance and lack of access are just two threats to quality of care that now being addressed by the use of videoconferencing, information exchange, and other telecommunication technologies that facilitate telerehabilitation. This white paper illustrates and summarizes clinical and vocational applications of telerehabilitation. We provide definitions related to the fields of telemedicine, telehealth, and telerehabilitation, and consider the impetus for telerehabilitation. We review the telerehabilitation literature for assistive technology applications; pressure ulcer prevention; virtual reality applications; speech-language pathology applications; seating and wheeled mobility applications; vocational rehabilitation applications; and cost-effectiveness. We then discuss external telerehabilitation influencers, such as the positions of professional organizations. Finally, we summarize clinical and policy issues in a limited context appropriate to the scope of this paper.

Telemedicine for retinopathy of prematurity diagnosis: evaluation and challenges

Retinopathy of prematurity (ROP) is a vasoproliferative disorder affecting low birth weight infants. Although timely diagnosis and treatment can significantly reduce the risk of severe complications, ROP remains a leading cause of childhood blindness worldwide. Limitations of current disease management strategies include extensive travel and logistical coordination requirements for ophthalmologists and neonatologists, decreasing availability of adequately trained ophthalmologists at the point of care, variability in how retinal findings are diagnosed and documented, and a growing need for ROP care worldwide. Store-and-forward telemedicine is an emerging technology by which medical data are captured for subsequent interpretation by a remote expert. This has potential to improve accessibility, quality, and cost of ROP management. In this article, we summarize the current evaluation data on applications of telemedicine for ROP, particularly involving the diagnostic accuracy and reliability of remote image interpretation by experts. We also address challenges such as the cost-effectiveness of telemedicine, and highlight potential barriers to implementation of these systems. Understanding these principles is essential to determine future directions in research and development of telemedicine systems for ROP, as well as for other ophthalmic diseases.

Empirical evidence on the use and effectiveness of telepsychiatry via videoconferencing: implications for forensic and correctional psychiatry

A growing body of literature now suggests that use of telepsychiatry to provide mental health services has the potential to solve the workforce shortage problem that directly affects access to care, especially in remote and underserved areas. Live interactive two-way audio-video communication-videoconferencing-is the modality most applicable to psychiatry and has become synonymous with telepsychiatry involving patient care, distance education, and administration. This article reviews empirical evidence on the use and effectiveness of videoconferencing in providing diagnostic and treatment services in mental health settings that serve child, adolescent, and adult populations. Descriptive reports, case studies, research articles, and randomized controlled trials related to clinical outcomes were identified and reviewed independently by two authors. Articles related to cost-effectiveness, technological issues, or legal or ethical aspects of telepsychiatry were excluded. The review of the evidence broadly covers mental health service provision in all settings, including forensic settings. Given the sparse literature on telepsychiatry in forensic settings, we discuss implications for mental health care across settings and populations and comment on future directions and potential uses in forensic or correctional psychiatry.

What is the business case for improving care for patients with complex conditions?

INTRODUCTION

Patients with complex conditions account for a disproportionate share of health care spending. Although evidence indicates that care for these patients could be provided more efficiently, the financial impact of mechanisms to improve the care they receive is unclear.

DESIGN/METHODS

Numerous mechanisms-emphasizing patient self-management, care coordination, and evidence-based guidelines-aim to improve the quality of care and outcomes for patients with complex conditions. Assessing the overall "business case" for these mechanisms requires carefully estimating all relevant costs and financial benefits, then comparing them in present value terms. Mechanisms that are not cost-saving may still be implemented if they are cost-effective. We reviewed articles in peer-reviewed journals, as well as reports available on publicly accessible websites, which contained data about the business case for mechanisms to improve care for patients with complex conditions.

MAIN RESULTS

Published studies do not provide clear evidence that current mechanisms are cost saving. This literature also has several major methodological shortcomings with respect to providing an understanding of the business case for these mechanisms.

CONCLUSIONS

Further research using standardized methodologies is needed to understand the business case for mechanisms to improve care for patients with complex conditions. Implications for VA business case analyses include the necessity of establishing appropriate time horizons, scope of services, and target populations, as well as considering the impact of existing VA systems.

Maturity of teledermatology evaluation research: a systematic literature review

BACKGROUND

There is a growing interest in teledermatology in today's clinical practice, but the maturity of the evaluation research of this technology is still unclear.

OBJECTIVES

This systematic review describes the maturity of teledermatology evaluation research over time and explores what kind of teledermatology outcome measures have been evaluated.

METHODS

Systematic review of literature found in Medline database (1966 up to April 2006). A telemedicine evaluation strategy consisting of four consecutive research phases (parallel to drug and diagnostics evaluation research) extended with a fifth postimplementation phase was used to classify all included studies by two independent reviewers. In addition, main characteristics (store-and-forward or real-time, study design, outcome measures) were registered.

RESULTS

Three hundred and forty-five papers were systematically selected from Medline, and 244 papers were excluded. For two randomized controlled trials (RCTs), multiple papers in phase III were found. After correcting for this, 99 studies remained included (11 phase I, 72 phase II, two phase III, six phase IV, eight postimplementation phase). The number of phase II studies is the largest and still growing, while other phases are much less represented. Diagnostic accuracy was the most often used outcome measure and was found in phase I, II and IV. Store-and-forward teledermatology has been evaluated more since 2001, but most phase IV studies (RCTs, including cost aspects) are on real-time teledermatology.

CONCLUSIONS

Most teledermatology evaluation studies are classified as feasibility studies (phase II). The number of phase III and IV studies remains low through the years. Compared with other specialties in telemedicine (i.e. telesurgery, telepaediatrics), teledermatology seems to be a mature application. However, more evaluation studies with a focus on clinical outcomes such as preventable referrals or time to recovery are needed to prove that teledermatology indeed is a promising and cost-saving technology.

Detection of tumours using a computational tactile sensing approach

BACKGROUND

A new method is presented for determining the existence of an embedded object in biological tissue.

METHODS

We propose a method for modelling tissue containing a simulated tumour. Indications of the existence of a tumour that appear on the surface of the tissue were also determined. FEM provided properties such as the shape, size, depth and location of tumour.

RESULTS

A number of different cases were created and solved by the software and tactile images and stress graphs were extracted. These results clearly showed the existence of the tumour in the tissue. Maximum stresses were used to create tactile maps. Simulation results demonstrated good agreements with other studies.

CONCLUSIONS

Three-dimensional analysis leads to a novel method of predicting the characteristics of a tumour and can be directly applied to the incorporation of tactile sensing in artificial palpation, helping surgeons in non-invasive procedures.

E-dermatology: emails about dermatological diseases on the Internet

Today, it is very easy to access information for both doctors and patients thanks to the Internet. The number of websites including health information is increasing day by day. This study was targeted to retrospectively investigate the dermatological questions received by the free consultation page of the health site for IsNet customers. The patients were assessed on the aspects of age and sex. The diseases were classified by the subject of the questions emailed and on what the patient would like to learn. It was also assessed whether the patient had seen a doctor before sending the email. The responses of the dermatologist were also classified as information on the disease and the treatment. A total of 607 questions were examined. One hundred and thirteen male and 69 female patients disclosed their sexes. Also, only 208 patients stated their age and the mean age was 29.3 years. Four hundred and sixty questions were related to the emailer. The questions usually asked were about treatment and requests for comprehensive information about the disease. The diseases most frequently asked about were: acne, hair diseases, pruritus, eczema, seborrheic dermatitis, psoriasis, superficial mycoses and vitiligo. Most responses were related to general information on diagnosis and treatment options. The Internet is frequently preferred for its speed; therefore, users do not give detailed information because it is not required. These results show there are differences in the intentions of our Internet users and the aims of our health website. In order to conduct these kinds of services more efficiently, preparing special forms would be useful. These data can be beneficial in the development of e-medicine programs.

The diffusion of a medical innovation: where teleradiology is and where it is going

Teleradiology is one of the more successful applications of telemedicine as measured by a bibliometric analysis of teleradiology research publications. The organizational diffusion of innovation framework is helpful in understanding the diffusion of teleradiology. Teleradiology had become part of the practices of two-thirds of radiologists who responded to the American College of Radiology survey in 1999. It is clear that teleradiology has become routinized even though quantitative data are hard to find. Telecardiology may be the next successfully diffused form of telemedicine. The potential cloud on the horizon for telediagnostics is political pressure to avoid outsourcing to foreign countries, particularly those to which US information technology jobs have already been transferred. How the outsourcing issue is resolved will have a significant effect on teleradiology specifically, and, perhaps, telemedicine generally.

Human tactile perception as a standard for artificial tactile sensing—a review

In this paper, we examine the most important features of human skin tactile properties with special emphasis on the characteristics which are vital in the design of artificial systems. Contrary to the visual and auditory senses, the touch signal is not a well-defined quantity. As a result, the researchers of this field are still dealing with the basics of collecting the most relevant data. Following this, mimicking the sense of touch by producing artificial tactile skin is a challenging process. Although the sense of touch is widely distributed all over the human body, the tactile perception in the human hand is of great importance in terms of surgical and medical robotics applications. In this study, the role of various mechanoreceptors in the human hand, such as, RA, SA I, SA II, and PC units are discussed in relation to the stimuli like force, position, softness, and surface texture. Taking human hand as a suitable tactile model, the necessary engineering features of an artificial tactile sensor, such as, spatial and temporal resolutions, force sensitivity, and linearity, are being reviewed. In this work, we also report on the current and possible future applications of tactile sensors in various surgical procedures.

High-volume teleradiology service: focus on radiologist satisfaction

In 1998 we surveyed our radiologists on teleradiology satisfaction. Results were generally positive. In 2002 we experienced a sevenfold case increase in teleradiology volume. The present study surveyed the radiologists again. The hypothesis was that, with increased case volume and radiologist experience with the system, ratings would increase. Image quality was excellent/good, although plain film and ultra sound (US) had more fair/poor ratings. Monitors, navigation, image processing, and Web-based reporting were rated as excellent/good. The voice-recognition system was rated poorly. Diagnostic confidence was about the same as for film. Exceptions were magnetic resonance imaging (MRI) US, and plain film. Up to 10% of cases are unreadable because of poor image quality, not enough images, or inadequate patient history. Overall, the radiologists are satisfied, although some improvements can be made.

TIMTEM project: our experience in a remote area

We report our experience, begun in 1998 on a small island in the Dodecanese area of Greece, which has been called TIMTEM. The aim of this project was to improve care for people living on islands, creating a model exportable to other rural areas. The operative setting of the TIMTEM project is the island of Tilos (Greece); local authorities take part in it under the guidance of the only physician available on the island. The University of Pisa-Italy (Department of Surgery, Post-graduate School of Emergency Surgery) manages the scientific and organizational part of the project. Tilos is a rocky Mediterranean island with a surface of 64 km(2) and a population of about 500 inhabitants (with a peak of 2,000 tourists in July and August). A physician and a nurse are responsible for the only medical care on the island, and they also dispense drugs. The project was implemented on three phases. During the first phase, a campaign was held to encourage the population to cooperate with clinical data collection; a temporary telemedicine station was established, and a complete screening of the population was performed. The second phase was focused on the application of telesonography. During the third phase, a telematic and/or direct participation for reference hospital physicians (Regional Medical Society-Dodecanese) and for Greek physicians was planned. As well, a fully equipped central telemedicine station in the reference hospital was established under the local jurisdiction. The results of the third phase are still incomplete; the data presented here are preliminary. But all indicators show that the project is exportable to remote areas elsewhere.

Treating childhood depression over videoconferencing

Effective cognitive-behavioral treatments for childhood depression have developed over the last decade, but many families face barriers to such care. Telemedicine increases access to psychological interventions by linking the child and the clinician using videoconferencing (VC). The current study evaluated an 8-week, cognitive-behavioral therapy (CBT) intervention for childhood depression either face-to-face (F2F) or over VC. The telemedicine setup included two PC-based PictureTel systems at 128 kilibits per second (kbps). Success was defined by (1) decreasing depressive symptoms at similar rates in both the VC group and the F2F group and (2) demonstrating the feasibility of a randomized controlled trial in telemental health. Children were assessed for childhood depression using the mood section of the Schedule for Affective Disorders and Schizophrenia for School Age Children-Present Episode (K-SADS-P). Twenty-eight children were randomized to either F2F or VC treatment. The participants completed the K-SADS-P and the Children's Depression Inventory (CDI) at pre- and post-treatment. The CBT treatment across the two conditions was effective. The overall response rate based on post-evaluation with the K-SADS-P was 82%. For the CDI total score, both the Time and the Group by Time effects were significant (p < 0.05). The interaction effect reflected a faster rate of decline in the CDI total score for the VC group. The study serves as a model for building on past research to implement a randomized controlled trial. This information provides persuasive research data concerning treatment effectiveness for clinicians, families, and funders.

Telemedicine in otolaryngology

More research is needed in otolaryngology telemedicine, but it would be a mistake to stop at only determining if telemedicine is as good as an in-person exam. The digital image recorded in a telemedicine encounter can be manipulated to increase diagnostic information not currently available. Radiologists currently take a chest radiograph in which a chest mass or the tip of an nasogastric tube is difficult to visualize, and by inverting the gray scale or viewing other digital manipulations of that image, the mass or tube tip becomes obvious. Examples in otolaryngology might include images of the larynx manipulated to better demonstrate the inflamed tissue of reflux, or images of the tympanic membrane manipulated to better demonstrate early retraction. Despite dramatic and likely continued decreases, equipment cost is still an issue. Current research points to good consumer acceptance, and certainly with each new generation the technology is more readily accepted. As Nesbitt [4] points out, it is certainly not difficult to look to the future and see ubiquitous broadband with video as common as telephone, or even extreme broadband enabling robotics and virtual reality TV with three-dimensional touch. Robotics and genomics will eventually play a greater role in telemedicine and our lives in general. Applications for remote diagnosis in biologic warfare defense and homeland security are currently raising interest in telemedicine. Telemedicine will be combined with new technological advances such as virtual "fly-through" computerized axial tomography examinations. Instead of performing an exploratory tympanotomy, surgeons will use computer programs to "fly through" and examine all aspects of a patient's middle or even inner ear. Spectral imaging of the eardrum, larynx, or oropharynx will immediately identify bacteria without cultures, or gram stain, and potential malignancy without biopsy. By measuring fluorescence emitted from an oropharynx illuminated with a specific visible or nonvisible light spectrum, spectral imaging will be able to provide instant identification of bacteria or evidence of malignant changes. The underlying principles of a successful business model must continue to be applied, with the most critical ingredient for telemedicine's success being the filling of specific health care needs. As long as the need is there, telemedicine in otolaryngology will advance.