Description

Telemedicine' has been defined in general terms to be 'medicine practised at a distance' and as such it encompasses both diagnosis and treatment, as well as medical education. During the last decade certain telemedicine applications, such as videoconsulting and teleradiology, have matured to become essential health care services. Others, such as telepathology, remain the subject of intensive research effort. The Journal of Telemedicine and Telecare publishes peer-reviewed papers on all aspects of both telemedicine and telecare - the latter covering distance nursing and community support. It is relevant to both the primary and secondary medical sectors, as well as having application to the veterinary field, and includes papers on all aspects of these emerging fields. In addition to original articles, the journal publishes preliminary communications, commissioned review articles, case reports, letters to the Editor and book reviews.

Publications in this journal

• Telemedicine support for the developing world.

  Authors: Richard Wootton

  Journal of telemedicine and telecare. 14(3):109-14.

  Telemedicine has been used for some years in the industrialized world, albeit with rather mixed success. There is also a considerable literature on the potential use of telemedicine for theTelemedicine has been used for some years in the industrialized world, albeit with rather mixed success. There is also a considerable literature on the potential use of telemedicine for the developing world. However, there are few reports of the actual use of telemedicine there. A review identified five telemedicine networks providing second opinions; each network had been in operation for over five years. Although they have different aims and methods of operation, they exhibit some common features. In particular, none of them appear to be dealing with markedly increasing referral rates. Rough calculations suggest that only about 0.1% of the potential telemedicine demand from the developing world is being met. Possible reasons include the referrers being too busy and a perceived loss of control. If this analysis is correct, then the right strategy for future telemedicine in developing countries will be to concentrate on the construction of within-country networks that demonstrably alter health outcomes, can be shown to be cost-effective and sustainable, and will provide a model for other countries to copy.

• PROSAFE-extended, a telemedicine platform to contribute to medical diagnosis.

  Authors: Sylvain Bonhomme, Eric Campo, Daniel Estève, Joëlle Guennec

  Journal of telemedicine and telecare. 14(3):116-9.

  A single elderly, dependent subject was monitored for a period of three months. Data were collected from 12 sensors in his apartment. We investigated new criteria for diagnosing abnormal events withA single elderly, dependent subject was monitored for a period of three months. Data were collected from 12 sensors in his apartment. We investigated new criteria for diagnosing abnormal events with more reliability. Initial results suggested that six diagnostic functions could be achieved using only presence sensors. These were: immobility detection; the level of agitation; the speed of motion in chosen areas; the distance covered; the time spent in given areas of the apartment; and the activities of getting up, going to bed and going to the toilet. The analysis was based on calculation of thresholds from past behaviour of the user for automatically defined temporal bands. Any variation in these criteria may represent a change in the subject's physical abilities and may thus allow the remote identification of potential risk.

• Early experience in using telemonitoring for the management of chronic disease in primary care.

  Authors: Joanna Fursse, Malcolm Clarke, Russell Jones, Sneh Khemka, Genevieve Findlay

  Journal of telemedicine and telecare. 14(3):122-4.

  We have investigated the use of telemonitoring in three long-term conditions: chronic heart failure (CHF), type 2 diabetes and essential hypertension. Participants were provided with a homeWe have investigated the use of telemonitoring in three long-term conditions: chronic heart failure (CHF), type 2 diabetes and essential hypertension. Participants were provided with a home telemonitoring unit for a 12-week period and entered physiological data each day. The data were sent automatically via the participant's telephone line to a server and could be viewed via a web browser. An intervention algorithm was developed to improve the accuracy with which patients requiring intervention were recognized compared to existing systems based on a simple threshold. Thirty patients completed the 12-week trial. One patient dropped out, giving data on 29 patients (mean age 70 years, 17 women). The algorithm prompted a clinical intervention in 11 patients (38%). The average time that elapsed before the first intervention was 47 days (SD 21). Primarily the interventions (72%) resulted in changes to medication and health advice. The results suggest that four weeks is sufficient time in which to recognize the need to intervene clinically and that in 12 weeks it is possible to effect a change towards a target.

• Feasibility of a telemedicine 'booth' for supporting remote care in Scotland.

  Authors: Fiona Mair, Gordon Peterkin, Angus Laing, James Ferguson, Susan Fraser

  Journal of telemedicine and telecare. 14(3):127-9.

  Access to health care in remote settings is becoming increasingly difficult in Scotland. We have investigated the feasibility of a telemedicine 'booth'. Two telemedicine booths were constructed forAccess to health care in remote settings is becoming increasingly difficult in Scotland. We have investigated the feasibility of a telemedicine 'booth'. Two telemedicine booths were constructed for display at the Royal Highland Show in Edinburgh. One was equipped for patient use and one for the doctor. The booths contained videoconferencing and physiological monitoring equipment connected via an IP link at a bandwidth of 1.1 Mbit/s. The picture resolution was 4CIF (704 x 576 pixels). A total of 238 members of the public used the booth for a teleconsultation with a doctor. Ninety-three percent completed questionnaires. Of the 221 respondents, 75% saw the booth as an opportunity to access specialist advice; 84% felt that the booth would save them attending a hospital or clinic; 60% felt that it would improve the way they looked after their own health. The concept of a telemedicine booth appears both feasible and acceptable to the public.

• More patients with minor injuries could be seen by telemedicine.

  Authors: Fiona Mair, James Ferguson

  Journal of telemedicine and telecare. 14(3):132-4.

  The Grampian Minor Injuries Telemedicine Service has been operating since 2001 supporting 15 minor injury units (MIUs) in community hospitals. Currently over 120 new patients are seen each month. WeThe Grampian Minor Injuries Telemedicine Service has been operating since 2001 supporting 15 minor injury units (MIUs) in community hospitals. Currently over 120 new patients are seen each month. We conducted a retrospective review to estimate the number of patients who were sent to the main hospital emergency department (ED) who would have been suitable for telemedicine treatment instead. All attendances at three MIUs and onward referrals to the ED during the months January and July 2006 were identified from a database. A total of 112 patients were referred from the three MIUs during the study period. MIU C, which utilized teleconsultations the most, referred the lowest proportion of its patients (2%). MIU B, which had all X-rays reviewed by a general practitioner, referred the most (85%). At MIU B, 80-85% of patients referred to the ED without having a teleconsultation could have been managed by telemedicine. Telemedicine for MIUs has been repeatedly reported in the medical literature as being successful, but widespread usage of this technique remains to be achieved.

• Diagnosis of congenital heart disease in neonates by videoconferencing: an eight-year experience.

  Authors: Brian A McCrossan, Brian Grant, Gareth J Morgan, Andrew J Sands, Brian Craig, Frank A Casey

  Journal of telemedicine and telecare. 14(3):137-40.

  Over an eight-year period, echocardiograms were transmitted by ISDN at 384 kbit/s for a total of 132 patients suspected of having congenital heart disease (CHD). Five transmitted scans wereOver an eight-year period, echocardiograms were transmitted by ISDN at 384 kbit/s for a total of 132 patients suspected of having congenital heart disease (CHD). Five transmitted scans were inadequate. Hands-on echocardiograms were performed subsequently on 116 of the remaining 127 cases (91%). Major CHD was diagnosed in 42 of the 116 infants (36%) and minor CHD in 49 (42%). The telemedicine diagnosis was accurate in 97% of the cases (kappa = 0.90). There were four diagnostic errors. Transfer to the regional unit was avoided in 95 patients (72%). The present study shows that high diagnostic accuracy is possible using a telemedicine link to transmit images obtained with the assistance of real-time guidance by a paediatric cardiologist. The results also demonstrate the importance of an expert interpreting the echocardiographic images, since the accuracy of diagnosis was considerably improved (the kappa coefficient increased from 0.14 to 0.90).

• The delivery of a minor injuries telemedicine service by Emergency Nurse Practitioners.

  Authors: David R Miller, Khyber Alam, Susan Fraser, James Ferguson

  Journal of telemedicine and telecare. 14(3):143-4.

  We conducted a retrospective review to assess the potential for Emergency Nurse Practitioners (ENPs) to deliver telemedicine advice for minor injuries. Over a one-year study period, 835 patients fromWe conducted a retrospective review to assess the potential for Emergency Nurse Practitioners (ENPs) to deliver telemedicine advice for minor injuries. Over a one-year study period, 835 patients from 15 minor injury units in community hospitals presented to the minor injuries telemedicine service and were seen via videoconferencing by a doctor at the Aberdeen emergency department. A case review showed that overall, ENPs were considered capable of treating 470 of 788 new presentations (60%). If children under 14 years of age and shoulder injuries were excluded, this figure rose to 84%. Assessment of all minor injuries via a telemedicine network by medical staff is unnecessary. An ENP-led service offers a realistic and attractive alternative.

• Clinical validation of a wearable system for emotional recognition based on biosignals.

  Authors: Laura Pastor Sanz, Cecilia Vera-Munoz, Giuseppe Fico, María Teresa Arredondo

  Journal of telemedicine and telecare. 14(3):152-4.

  The AUBADE system can be trained to classify a subject's feelings into six different emotional classes, derived from three of the basic emotions (happiness, disgust and fear). The performance ofThe AUBADE system can be trained to classify a subject's feelings into six different emotional classes, derived from three of the basic emotions (happiness, disgust and fear). The performance of different classifiers was examined. Biosignals were recorded from 24 healthy subjects who viewed pictures designed to invoke different emotional responses. A psychologist evaluated the emotional status of the subjects by looking at their faces. During the training stage, information from 15 subjects was used to teach the system how to discriminate the emotional status of the subject based on the biosignals provided as input. A subset of the data was used for comparing the performance of four different classifiers. They were evaluated using three different metrics: sensitivity, positive predictive accuracy and accuracy. Using the SVM classifier, the AUBADE system provided sensitivities in the range 63-81%. The positive predictive accuracy was in the range 71-95%. The accuracy was in the range 63-83%, depending on the emotional class considered. The work paves the way for remote telemonitoring of patients suffering from neurological diseases.

• A five-year review of ground-to-air emergency medical advice.

  Authors: Alastair Urwin, James Ferguson, Roderick McDonald, Susan Fraser

  Journal of telemedicine and telecare. 14(3):157-9.

  We reviewed five years' experience of providing ground-to-air medical advice for commercial passenger aircraft. A total of 273 events occurred in-flight where further advice was sought. The mostWe reviewed five years' experience of providing ground-to-air medical advice for commercial passenger aircraft. A total of 273 events occurred in-flight where further advice was sought. The most common age group resulting in calls were from those aged 21-30 years, who generated 38 calls (16%). The 273 cases included gastrointestinal conditions (26%), neurological (22%) and cardiovascular events (14%). Most incidents were managed conservatively in-flight with oxygen and/or other medications. Aircraft diversion occurred on 9% of occasions; cardiovascular and neurological emergencies were the major cause of this. Collaboration between aviation providers should be considered to develop a common database of in-flight emergencies so that contents of medical kits can be standardized in order to improve the quality of care in the air.

• A low-cost decision support network for electrocardiograph transmission from oil rigs in the North Sea.

  Authors: Karyn Webster, Susan Fraser, Fiona Mair, James Ferguson

  Journal of telemedicine and telecare. 14(3):162-4.

  A telemedicine service consisting of electrocardiogram (ECG) interpretation and advice on the management of chest pain offshore was offered to oil rig installations in the North Sea. A total of 14A telemedicine service consisting of electrocardiogram (ECG) interpretation and advice on the management of chest pain offshore was offered to oil rig installations in the North Sea. A total of 14 subscribing oil rigs were supplied with thrombolytic drugs and rig paramedics were trained in their delivery. Electrocardiographs could be recorded using a standard ECG machine and then digitized using a scanner for transmission as an email attachment. Several oil companies invested in ECG equipment which allowed direct recording of the patient's ECG in electronic form for transmission by email. Uptake of the telemedicine service was very rapid. The majority of rig medics found the system very easy to use. During a 36-month study period from August 2004, 47 cases of chest pain were dealt with by telemedicine. Of these 47 cases, only six patients (13%) were airlifted to shore. The 41 remaining ECGs did not to have acute changes requiring immediate evacuation. The use of email for ECG transmission proved to be highly effective in managing chest pain offshore.

• The JTT at 100.

  Authors: Richard Wootton, Elizabeth Krupinski

  Journal of telemedicine and telecare. 14(1):1.

• An evaluation of second and third generation telecare services in older people's housing.

  Authors: Simon Brownsell, Steven Blackburn, Mark S Hawley

  Journal of telemedicine and telecare. 14(1):8-12.

  In a controlled study of older people living in sheltered housing (retirement housing), 24 people provided with telecare were compared with a control group of 28 people. The intervention consisted ofIn a controlled study of older people living in sheltered housing (retirement housing), 24 people provided with telecare were compared with a control group of 28 people. The intervention consisted of second generation telecare equipment, such as automatic flood or falls detectors, a third generation lifestyle reassurance system and an Internet café. After a 12-month monitoring period, there was no noticeable change in the fear of falling. There was no significant difference for eight of the nine SF-36 domains. However, the Social Functioning domain showed a significant difference (P = 0.049), with scores 8% higher in the intervention group, suggesting a beneficial effect of telecare. Positive trends were also evident in areas such as an increase in the length of time spent out of the home, improved feelings of safety during the day and night, and a reduction in the fear of crime. The Internet café was used by 25% of people for at least 20 min per week. The results suggest that second generation telecare systems and Internet facilities could be more widely used in service delivery, but that lifestyle reassurance requires further development.

• The TeleGuard trial of additional telemedicine care in CAD patients. 1 Utilization of the system.

  Authors: Alexander Katalinic, Annika Waldmann, Bernhard Schwaab, Gert Richardt, Abdolhamid Sheikhzadeh, Heiner Raspe

  Journal of telemedicine and telecare. 14(1):17-21.

  Patients with established coronary artery disease (CAD) were recruited in 11 hospitals and randomized to an intervention (telemedicine system; n = 752) or a control group (usual medical care; n =Patients with established coronary artery disease (CAD) were recruited in 11 hospitals and randomized to an intervention (telemedicine system; n = 752) or a control group (usual medical care; n = 748). On the day before discharge, patients in the intervention group were equipped with a 12-lead event recorder and trained to use the device. Whenever they had symptoms, they could contact the call centre, transmit an ECG (without redialling) and consult a physician. During a 12-month study, 171 patients (23%) in the intervention group contacted the call centre, a total of 269 times. The main reasons for calling were chest pain and radiating pain. Pathological changes were seen in 24% of the transmitted ECGs. Only 23% of the calls were made in the first hour after onset of symptoms and a further 12% in the subsequent hour, suggesting that patients should be encouraged to use ECG transmission at an earlier stage. At follow-up, 157 patients (21%) had had at least one recurrent cardiac event (myocardial infarction, cardiac hospital stay, re-vascularization). The proportion was significantly higher in telemedicine users (35%) than in non-users (17%), P < 0.001. Regardless of utilization, the majority of the intervention patients considered that the telemedicine system was helpful (users = 93%, non-users = 89%; P = 0.095).

• The potential of digital monochrome images versus colour slides in telescreening for diabetic retinopathy.

  Authors: Monika Alise Johansen, Kristian Fossen, Jan Norum, Terje Christoffersen, Håkon Oritsland, Daniel Haga, Per Hasvold, Johan Gustav Bellika, Undine Knarvik, Steinar Pedersen

  Journal of telemedicine and telecare. 14(1):27-31.

  We explored the potential of digital monochrome images as an alternative to colour slides in screening for diabetic retinopathy. Twenty-eight patients with diabetes were recruited for the study andWe explored the potential of digital monochrome images as an alternative to colour slides in screening for diabetic retinopathy. Twenty-eight patients with diabetes were recruited for the study and 20 actually participated. Using a fundus camera (Nikon 505AF) one set of three digital images and one set of three colour slides were taken per eye. Two independent ophthalmologists graded the colour slides and the digital images for diabetic retinopathy. The ophthalmologists spent about two minutes grading each set of images, suggesting that specialists could potentially screen a large number of patients. The agreement between the two screening methods was 0.95 and 0.89, with respect to disease or no disease. The agreement (kappa) between the two ophthalmologists for grade of retinopathy was 0.47 when colour slides were employed and 0.61 when digital monochrome images were employed. The results indicate that digital red-free monochrome images represent a superior screening tool for diabetic retinopathy. Tele-screening may be beneficial when patients have to travel substantial distances to visit an ophthalmologist.

• A review of ICT systems for HIV/AIDS and anti-retroviral treatment management in South Africa.

  Authors: Tove Sørensen, Ulrike Rivett, Jill Fortuin

  Journal of telemedicine and telecare. 14(1):37-41.

  Telemedicine and e-health systems have been proposed as a support tool, to monitor and evaluate HIV/AIDS management strategies. The aim of the present study was to provide an overview of telemedicineTelemedicine and e-health systems have been proposed as a support tool, to monitor and evaluate HIV/AIDS management strategies. The aim of the present study was to provide an overview of telemedicine and e-health systems for HIV/AIDS in South Africa as a basis for developing an e-health toolkit for anti-retroviral treatment (ART). An initial literature review and a subsequent interactive networking approach were chosen to identify telemedicine and e-health systems, projects and services for HIV/AIDS and ART facilities in low-resource settings and under-served areas. The literature review produced little useful information. In contrast, the face-to-face interviews and the focus group discussions provided useful information about projects and systems which had not been published. The meetings involved 1 - 5 people per session, about 30 people in total. The review showed that there were some plans for telemedicine and e-health implementation in South Africa. However, there was no all-inclusive ICT-based system in place for AIDS treatment there. With the exception of the major health information systems and electronic patient record systems, none of the telemedicine and e-health systems identified in the review were ready to be deployed across the country as a whole.

• Memorable telemedicine experiences.

  Authors: Richard Wooton, Elizabeth Krupinski, David Hailey, Victor Patterson, Richard Scott, John Whited, Pamela Whitten, Sun Yoo, Elsie Hui, James Ferguson, Jasper Van der Westhuyzen, Klaus Kayser, Maurice Mars, Melinda Martin-Khan, Sapal Tachakra, Simonetta Scalvini, Stephen Shumack, Anthony Smith, H. Peter Soyer, Max Stachura

  Journal of telemedicine and telecare. 14(1):50-4.

• Decoding CODECs.

  Authors: Rex E Gantenbein, Barbara J Robinson

  Journal of telemedicine and telecare. 14(2):59-61.

  A codec is the mechanism by which video and audio signals are compressed to conserve bandwidth before transmission across a telecommunication network. It may be implemented either in hardware orA codec is the mechanism by which video and audio signals are compressed to conserve bandwidth before transmission across a telecommunication network. It may be implemented either in hardware or software. In the past, manufacturers sometimes used proprietary codecs that were incompatible with those from other manufacturers. As network usage became more widespread, however, it became clear that standards were needed to permit interoperability between equipment from different manufacturers. Regardless of the coding standards employed, the primary concerns for the user of a codec system are the quality of the audio and video transmitted. How does one decide what kind of codec to use? For telehealth applications, good quality is important, so it is best to look at products from established manufacturers. Ultimately, the choice of a codec for telehealth depends primarily on the trade-offs between quality, cost, bandwidth requirements and interoperability required by the application(s) for the system, and the environment in which it will be used.

• Teleradiology in neurosurgery: experience in 1024 cases.

  Authors: Juergen Kreutzer, Hiroyoshi Akutsu, Rudolf Fahlbusch, Michael Buchfelder, Christopher Nimsky

  Journal of telemedicine and telecare. 14(2):67-70.

  Between June 1995 and June 2000 teleradiology was performed in 1024 neurosurgical cases (945 patients). An analogue image transfer system was used for presentation of computed tomography (CT) andBetween June 1995 and June 2000 teleradiology was performed in 1024 neurosurgical cases (945 patients). An analogue image transfer system was used for presentation of computed tomography (CT) and magnetic resonance imaging (MRI) scans from seven referring hospitals in southern Germany. The system used a 19,200 baud modem connection via the ordinary telephone network. The diagnoses on presentation were intracerebral haematoma (50%), trauma (27%), subarachnoid haemorrhage (4%), stroke (5%) and others (14%). Retrospective analysis showed that in 67% of cases admission and therefore ground-based transportation of the patients to our neurosurgical centre was not necessary for different reasons (moribund status, no surgical intervention required or no neurosurgical problem at all). If each patient had been transferred, then the potential savings for ground transportation were euro339.93 per case (with accompanying physician of the affiliated hospital) or euro373.96 per case (with accompanying experienced ICU physician), respectively (euro1 is US$1.4). The total cost of the image transfer system for all eight hospitals was euro96,000; this was amortised after 282 teleconsultations, which occurred after 15 months of usage. A simple teleradiology system in neurosurgery enables rapid and reliable telephone consultations, mainly on patients with trauma, stroke and intracerebral haematoma at low cost.

• Use of telemedicine for haemodialysis: perceptions of patients and health-care providers, and clinical effects.

  Authors: Pamela Whitten, Lorraine Buis

  Journal of telemedicine and telecare. 14(2):75-8.

  In Michigan, the use of telemedicine for dialysis patients began in three centres in 2005. A total of 747 clinical consultations was conducted in the following 22 months. Telephone surveys wereIn Michigan, the use of telemedicine for dialysis patients began in three centres in 2005. A total of 747 clinical consultations was conducted in the following 22 months. Telephone surveys were conducted with 34 patients and four providers. The patients and providers all had positive perceptions of the telemedicine system and the care that was delivered. Most of the clinical measures of the patients met or exceeded the recommendations made by Renal Network 11. In addition to the clinical work, the telemedicine equipment was used for educational events. Twenty-six professional educational events were provided with a total audience of 105 individuals, and 35 administrative meetings were provided with 286 staff members in attendance. The study showed that patients and providers could participate in educational events that might not be available locally. Despite the success of dialysis telemedicine, the Marquette General Health System discontinued its use in 2007 when the Center for Medicare and Medicaid Services re-affirmed that dialysis centres were not approved sites for telemedicine.

• Pre-admission orthopaedic occupational therapy home visits conducted using the Internet.

  Authors: Tammy Hoffmann, Trevor Russell

  Journal of telemedicine and telecare. 14(2):83-7.

  We evaluated the feasibility and accuracy of conducting occupational therapy home visits using the Internet. Studies were conducted at the homes of 40 patients who were scheduled to undergo a totalWe evaluated the feasibility and accuracy of conducting occupational therapy home visits using the Internet. Studies were conducted at the homes of 40 patients who were scheduled to undergo a total hip or knee replacement: home visits were conducted, on the same day, by both a face-to-face therapist and an online therapist. The online therapist conducted the visit via a low-speed, dial-up Internet connection using a specially developed telerehabilitation system. This system combines real-time videoconferencing (320 x 240 pixel resolution) with a suite of calibrated assessment tools which the operator can use to measure real-scale angular displacement/velocity and linear distances during the videoconference. Both therapists completed a home environment questionnaire, assessed patients' transfer ability and measured the heights of six objects/pieces of furniture. For the questionnaire items which related to variables in the home environment, the mean percentage exact agreement was 98.9% (SD 2.6; range 90-100), while there was 100% agreement on the items related to transfers. The mean absolute difference in measured heights between the two therapists ranged from 0.1-3.3 cm. The results suggest that conducting pre-admission orthopaedic occupational therapy home visits via the Internet is both feasible and accurate.

• Use of telemedicine for pre-implant dental assessment - a comparative study.

  Authors: Hans-Joachim Nickenig, Manfred Wichmann, Andreas Schlegel, Stephan Eitner

  Journal of telemedicine and telecare. 14(2):93-7.

  We evaluated real-time telemedicine for exchanging expert opinions in the area of pre-implant dental assessment. From 2003 to 2005, every tenth patient at the armed forces' dental clinic inWe evaluated real-time telemedicine for exchanging expert opinions in the area of pre-implant dental assessment. From 2003 to 2005, every tenth patient at the armed forces' dental clinic in Cologne-Wahn seeking implant counselling was discussed via videoconference (intervention group, n = 85). Indications, prosthodontic options, the required number of implants and implant positions were determined. The mean time required for the videoconferences was 3.5 min (range 1.0-9.5). In the control group (n = 772), the implant consultation was performed based on existing records, without using telemedicine. In three cases (3%), a basic change in the prosthodontic concept was required as compared to the telemedicine plan; in the control group, the concept changed in 7% of cases. The changes in the number and position of implants during therapy were also similar in the two groups. The results showed that telemedicine permitted satisfactory preoperative evaluation of the implantation operation.

• International multipoint videoconferencing for paediatric burns research.

  Authors: Niall Higgins, Roy Kimble

  Journal of telemedicine and telecare. 14(2):107-8.

• Human factors in primary care telemedicine encounters.

  Authors: Robert J Bulik

  Journal of telemedicine and telecare. 14(4):169-72.

  Traditional delivery of primary care takes place in a face-to-face transaction between provider and patient. In telemedicine, however, the transaction is 'filtered' by the distance and technology.Traditional delivery of primary care takes place in a face-to-face transaction between provider and patient. In telemedicine, however, the transaction is 'filtered' by the distance and technology. The potential problem of filtered communication in a telemedicine encounter was examined from a human factors perspective. Patients with and without experience of telemedicine, and providers who had experience of telemedicine, were asked about patient-provider relationships in interviews and focus groups. Seven themes emerged: initial impressions, style of questions, field of view, physical interaction, social talk, control of encounter and ancillary services. This suggests that communication can be improved and better patient-provider relationships can be developed in a primary care telemedicine encounter if attention is paid to four areas of the interaction: verbal, non-verbal, relational and actions/transactional. The human factors dimension of telemedicine is an important element in delivery of health care at a distance - and is one of few factors over which the provider has direct control.

• Utilization of telemedicine by heart disease patients following hospitalization.

  Authors: Andreas J Morguet, Paul Kühnelt, Antje Kallel, Ursula Rauch, Heinz-Peter Schultheiss

  Journal of telemedicine and telecare. 14(4):178-81.

  NYHA class III and IV chronic heart failure has been established as a potential indication for telemedical care and monitoring already. We conducted a prospective study to assess the utilization ofNYHA class III and IV chronic heart failure has been established as a potential indication for telemedical care and monitoring already. We conducted a prospective study to assess the utilization of telemedical services by cardiac patients in order to identify further indications. A total of 540 patients (mean age 59 years) with various heart diseases participated for at least 30 days in a home-based telemedicine service programme. The two primary outcome measures were the rates of symptom-driven telephone calls (A) and ECG transmissions (B) per patient-year. The total follow-up was 68,649 days, with a median of 93 days. Symptomatic patients placed 713 calls and transmitted 221 ECGs. Poisson regression analysis with subset selection yielded four significant (P < 0.05) independent positive predictors of the use of the telemedicine service: (1) recent repeat (at least one previous) percutaneous coronary intervention (A, P = 0.010; B, P = 0.001); (2) recent cardioversion for atrial fibrillation or flutter (A, P < 0.0001; B, P < 0.0001); (3) ejection fraction (A, P = 0.012; B, P > 0.05); and (4) reciprocal of age (A, P < 0.0001; B, P > 0.05). These data suggest that telemedicine may benefit patients following repeat percutaneous coronary intervention or cardioversion for atrial fibrillation. Since patients availed themselves of telemedicine service less with deteriorating ejection fraction and increasing age, individuals with chronic heart failure will need dedicated programmes, especially when they are older.

• Communicating textual health information to the mobile phones of visually-impaired users.

  Authors: Per Egil Kummervold, Halgeir Holthe

  Journal of telemedicine and telecare. 14(4):186-9.

  We investigated how short messages communicating health information would best be distributed to people with vision difficulties using mobile phones. Twelve visually-impaired persons who were unableWe investigated how short messages communicating health information would best be distributed to people with vision difficulties using mobile phones. Twelve visually-impaired persons who were unable to read short message service (SMS) messages directly compared three methods of presenting text messages as speech: (1) ordinary SMS messages were sent to the users and converted into speech by the mobile phone; (2) multimedia messages were sent to the users with prerecorded speech-synthesized information; and (3) mobile phone calls were placed to the users and prerecorded speech-synthesized messages were streamed to them. The latter two approaches used server-generated sound files. Over a three-month trial period, we sent a total of 88 SMS messages to the subjects, 111 multimedia messaging service (MMS) messages and 104 telephone calls. All of the SMS messages, 88% of the MMS messages and 69% of the telephone calls were received. In subsequent interviews, we asked the users which presentation method they preferred. SMS scored significantly better than both MMS (P = 0.033) and telephones (P = 0.006). All three methods had serious drawbacks. However, the study suggests that it might be possible to develop suitable technology for communicating with people with vision difficulties by mobile phone.

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