David A Fleming

University of Missouri, Columbia, Missouri, United States

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Publications (19)24.18 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Abstract Background: The body of research is rapidly growing regarding the use of telemedicine in patient care, including cost-effectiveness, patient access, patient outcomes, etc. Less has been done describing physician communication during different aspects of the clinical visit (i.e., education, assessment, treatment, etc.) during actual versus virtual patient visits. The purpose of this study was to evaluate dermatology healthcare providers' communication via both modalities with regard to content and style. Subjects and Methods: In-person and teledermatology patient visits were observed, audio-recorded, and transcribed over an 8-month period. A content analysis was performed. Results: The Wilcoxon rank sum test was used to compare the content differences between visit modalities for each category. A p value of 0.05 was considered as significant for all tests. There were no statistically significant differences between modalities in the average number of physician words in seven of eight communication categories: small talk, clinical assessment, psychosocial issues, patient education, patient compliance, patient treatment, and administrative issues (p value range, 0.16-0.91). As well, the same communication themes occurred in each modality to essentially the same degree. For instance, assessment and discussion of treatment occurred in 100% of in-person and teledermatology visits, as did small talk. Conclusions: This research indicates that physician providers communicate with similar style and content whether using teledermatology or in-person.
    Telemedicine and e-Health 05/2013; · 1.40 Impact Factor
  • Dominic E Sanford, David A Fleming
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    ABSTRACT: This essay explores the unique perspective of medical students regarding the ethical challenges of providing full disclosure to patients and their families when medical mistakes are made, especially when such mistakes lead to tragic outcomes. This narrative underscores core precepts of the healing profession, challenging the health care team to be open and truthful, even when doing so is uncomfortable. This account also reminds us that nonabandonment is an obligation that assumes accountability for one's actions in the healing relationship and that apologizing for mistakes can serve to heal. It argues that even medical students have an obligation to speak up when actions violate their moral beliefs, even if this means confronting a superior. Ethical principles cannot be abandoned in fear of adverse evaluation or failure to conform. Healthcare workers have an obligation to address mistakes made around the time of a patient's death with the patient's family. This responsibility trumps any selfish desire to avoid unpleasant feelings of guilt or regret. Such events often bring closure to already anguished relatives and spouses, and may help to facilitate the grieving process. This includes pressing forward the need to apologize to patients and/or their families when mistakes are made and when decisions are made that lead to poor outcomes for the patient, even when benevolently intended.
    HEC Forum 06/2010; 22(2):159-69.
  • David A Fleming, Karen E Edison, Hon Pak
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    ABSTRACT: The ethical implications of telehealth go well beyond providers' obligations to ensure privacy and confidentiality. The ethical conundrum of telehealth realizes the uniquely positive impact that telehealth can have on patients, providers, and clinical outcomes, as well as the potential for harm and abuse that may ensue. This article explores telehealth as one of many evolving information technologies that have ethical questions extending well beyond the confines of privacy and confidentiality. Providers and systems who utilize telehealth should also consider how it influences relationships with patients, access to healthcare, capacity for equitable treatment, cost, and quality of life. The ability to respond to these concerns will be important to the future development and deployment of this important technology as one means by which to improve access and quality of healthcare for all members of our society.
    Telemedicine and e-Health 09/2009; 15(8):797-803. · 1.40 Impact Factor
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    Lanis L Hicks, David A Fleming, Adam Desaulnier
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    ABSTRACT: The objective of this study was to evaluate the impact of remote monitoring home telehealth on client and provider satisfaction, clinical outcomes, and cost. The project design was a pragmatic evaluation of the technology in a real-world setting at an operational scale rather than a controlled clinical trial. Patients receiving monitoring were selected by the home health agency, and a random sample of other agency clients was selected for comparative purposes. Data were collected on additional costs and benefits associated with home telehealth monitoring. Quantitative and qualitative data suggest that when remote monitoring telehealth technology was utilized in the home-care setting, both clients and providers were very satisfied with services; they felt it was easy to communicate, and that the technology was convenient and user friendly. Clients also felt that home telehealth technology had a very positive impact on the provider-client relationship and improved care. The study also suggests that home care monitoring reduces hospitalizations and decreases personnel expenses. This preliminary study provides evidence as to the value of remote monitoring home telehealth in the delivery of services to home care populations. It also provides evidence as to the positive impact that this form of technology may have on healthcare systems, provider and client satisfaction, and on the relationships that form between providers and clients.
    Telemedicine and e-Health 09/2009; 15(7):664-71. · 1.40 Impact Factor
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    ABSTRACT: Research is yet to fully examine the utility and effectiveness of telehealth in primary care resident ambulatory training. This study examined the attitudes of preceptors, residents, and nurses on (1) the impact of telehealth on healthcare; (2) the impact of telehealth on the work activity of resident clinics; (3) the impact of telehealth on resident training in the outpatient setting; and (4) the impact of telehealth on relationships. There were three focus groups, one each of preceptors (N = 5), residents (N = 10), nurses (N = 7). Eight focus group themes evolved regarding the use of telehealth in the resident clinic: (1) impact on patient/provider relationships; (2) consistent with the values of those using telehealth; (3) logistics; (4) reduces patient transfers; (5) appropriate level of care; (6) reimbursement concerns; (7) psychological risk; and (8) impact on resident/attending relationships. Though as yet not generalizable, results of this pilot study suggest that there is general acceptability of telehealth in ambulatory resident training settings, but there is concern about the impact that telehealth may have on relationships, logistics, finances, and the need to see patients face-to-face when there is greater complexity.
    Telemedicine and e-Health 05/2009; 15(3):277-82. · 1.40 Impact Factor
  • Don Reynolds, David A Fleming
    The American Journal of Bioethics 03/2009; 9(2):16-7. · 4.00 Impact Factor
  • David A Fleming, Don Reynolds
    The American Journal of Bioethics 12/2008; 8(11):21-2. · 4.00 Impact Factor
  • David A Fleming, Don Reynolds
    The American Journal of Bioethics 04/2008; 8(3):24-5; discussion W4-6. · 4.00 Impact Factor
  • David A Fleming
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    ABSTRACT: Late one night you are called to the room of an elderly nursing home patient who has been febrile for three days and is now short of breath, coughing, and tachycardic. She has already received three days of oral antibiotics. The patient was treated for pneumonia a year ago in the nursing home and has a history of hypertension and early dementia but has otherwise been healthy. Though mildly confused at times, presently she is alert and oriented and appears to understand her circumstances. Her respiratory status is quickly deteriorating, however. You and the other nursing staff are concerned about impending respiratory failure. There is no Do-Not-Resuscitate order in the chart. You feel hospitalization may improve her chances for survival and that short-term intubation with ventilator support may even be indicated in order to stabilize her medical condition. She has a living will indicating “no life support if terminal conditions” and the patient has recently refused hospitalization, yet her family is telling you that “she really doesn’t mean it” under these circumstances because she is sick and confused and has agreed to being hospitalized before. It’s time to act—what to do? Making decisions within the complexities of modern health care is not easy. This is especially true in long term care situations where the preferences of often chronically debilitated patients may not be known and for whom hospitalization or other intervention may increase their risk of death, suffering, and further impairment. Ethical dilemmas often present themselves in this context, and having a mechanism available to effectively address complex ethical issues in a timely fashion is critical to the quality and safety of patient care. One of the most common ethical challenges occurs when the patient has questionable capacity to make decisions and it is unclear as to what they would want us to do, and whether the burden of treatment is worth the expected benefit and expense. Not uncommonly in
    HEC Forum 10/2007; 19(3):245-59.
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    ABSTRACT: This study explored the association between perceptions of health care quality and quality of life in patients with advanced metastatic cancer and their informal caregivers (n=39). Patients' and caregivers' perceptions of health care quality, mental health, health-related quality of life, symptoms, and burden were measured. The key findings included the following: 1) patients' mental health and depression scores correlated with those of caregivers, suggesting that the mental health of patients and their caregivers are associated; 2) patients and caregivers shared similar perceptions regarding health care quality; 3) the presence of depression in caregivers correlated with caregivers being less satisfied with the health care being given to their patients (this correlation did not exist for patients, a finding that may be due in part to the protective buffering effect that caregivers provide their patients as illness progresses); and 4) a modified Primary Care Assessment Survey, originally designed for primary care patients, was a useful measure of health care assessment for both patients and caregivers. These data suggest that patients with advanced disease and their caregivers share similar perceptions and evolve as a "unit of care," and caregivers, as unique and important members of the patient's health care team, are also in need of care. When depressed, caregivers may unilaterally lose trust by becoming less satisfied with the quality of health care being provided to their patients.
    Journal of Pain and Symptom Management 06/2006; 31(5):407-20. · 2.60 Impact Factor
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    David A Fleming
    HEC Forum 01/2006; 17(4):260-75.
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    ABSTRACT: Telemedicine, defined as the use of advanced telecommunication technologies to bridge geographic distance and improve delivery of care, is perceived by many as a way to eliminate barriers to quality care at the end of life. The use of telemedicine in hospice, known as telehospice, is a novel approach to such care, and few pilot studies have investigated its feasibility. The purpose of this study was to assess hospice providers 'perceptions of telehospice. A focus group session was conducted with 10 staff members from five hospice agencies in Missouri. Participants included administrators, nurses, and social workers. Overall, providers had a positive perception of telehospice and found that the use of videophone technology enhanced care by enabling providers, patients, and family members a means to communicate. However, they emphasized that it was an additional tool and not a substitute for actual visits. Issues of privacy and usability were also raised.
    American Journal of Hospice and Palliative Medicine 01/2004; 21(5):343-7. · 1.23 Impact Factor
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    ABSTRACT: A key aspect of the role of clinicians caring for patients in the setting of advanced illness focuses on attending to the needs of informal caregivers during the end-of-life period. The purpose of this study was twofold: (1) to complement and enrich existing quantitative findings regarding caregiver burden near the end of life, and (2) to identify potential solutions to caregivers' unmet needs in an effort to assist clinicians in the development of clinical interventions. This qualitative study, using focus groups and content analysis of transcripts, was conducted in a comprehensive cancer center in Washington, DC. Seven focus groups were held: three with recently bereaved caregivers and four with active caregivers of patients with metastatic cancer and an expected survival of 6 to 12 months. Data were stratified into two broad categories: (1) general problems and (2) behaviors/activities that were helpful/would have been helpful in alleviating these problems. Within each of these two categories, five subcategories emerged: medical care (including provision of information, coordination of care, bedside manner, satisfaction with care), quality of life (including well-being, role adjustments), help from others (including practical assistance, social support), positives of caregiving, and unsolicited themes (including job flexibility, impact of the disease on the family, informational needs, relationship with patient). Results suggest caregivers may benefit from more information about patient prognosis and hospice, attention to quality-of-life issues, and enhanced, direct communication with clinicians. Although information of this nature is likely to be known to palliative care clinicians, the specific details and verbal insights provided by caregivers give an important voice to existing quantitative data and may provide more detailed information to assist palliative care clinicians seeking to develop interventions to meet caregiver needs during the period near the end of life.
    Palliative and Supportive Care 10/2003; 1(3):247-59. · 0.98 Impact Factor
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    ABSTRACT: Hospice care focuses on palliation and the relief of suffering aiming to improve the quality of patients' last days. Telemedicine is considered to be a tool that can address challenges such as staff shortage, funding limitations and limited access to services in rural areas. Hospice services via telemedicine can be delivered directly into a patient's home by utilizing videoconferencing technology. The Missouri Telehospice Project aims to investigate the impact of a telehospice model on satisfaction with delivered care, caregiver burden, crisis prevention rates and overall cost of delivered care. Five urban and rural hospice agencies in Missouri are participating. A needs assessment study was conducted where hospice staff members responded to a set of questions within focus group and interview sessions providing feedback about the design, type of technology, frequency of usage and perceived impact on quality of hospice care.
    AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium 02/2003;
  • David A Fleming
    The Journal of clinical ethics 02/2002; 13(4):316-23. · 0.47 Impact Factor
  • Cheryl Rathert, David A Fleming
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    ABSTRACT: Health care delivery teams have received much attention in recent years from researchers and practitioners. Recent empirical research has demonstrated that objective and subjective outcomes tend to be improved when care teams function smoothly and efficiently. However, little is known about how the work environment, or care context, influences team processes that lead to better outcomes. The purposes of this study were to explore acute care staff's perceptions of how two components of the work environment, the ethical climate and continuous quality improvement leadership, influence teamwork and to begin to identify actionable approaches for improving teamwork. Although ethical climate influences have been studied in several sectors, research is lacking in health care. A cross-sectional field study explored how the ethical climate impacted teamwork in an acute care setting and how continuous quality improvement leadership behaviors moderated the relationship between the ethical climate and teamwork. Results indicated that clinicians who perceived the ethical climate to be benevolent were significantly more likely to say that teamwork was better. Furthermore, we found that continuous quality improvement leadership styles moderated the relationship between the ethical climate and teamwork. Although a benevolent ethical climate appears to be associated with effective teamwork, it appears that the proximate continuous quality improvement behaviors exhibited by leaders have a significant impact as well, above and beyond the climate. Implications for research and practice are discussed.
    Health care management review 33(4):323-31. · 1.30 Impact Factor
  • Win Phillips, David A Fleming
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    ABSTRACT: One might argue that beneficence entails a moral obligation for health care providers and systems to adopt electronic medical records (EMR). But this argument is thwarted because EMR systems are currently not required to meet existing standards of care for health care services. Yet using EMR systems may still be prudent if benefits of adoption significantly outweigh burdens. Future moral questions regarding EMR systems will shift from obligations of adoption to that of proper use.
    Missouri medicine 107(4):234-9.
  • Win Phillips, David Fleming
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    ABSTRACT: The use of electronic medical record systems raises important ethical concerns about patient privacy and confidentiality, medical errors, expectations of structured data entry by clinicians, documentation integrity, and provider-patient interaction. Clinicians and health care organizations need to define best practices and policies in the use of EMR systems to improve quality and maintain clinician efficiency without compromising patient welfare and safety.
    Missouri medicine 106(5):328-33.
  • David Fleming
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    ABSTRACT: Ethical dilemmas are encountered frequently in long term facilities, encompassing a myriad of concerns related to end of life care, rehospitalization, artificial hydration and nutrition, capacity for decision making, use of sedation, and dealing with conflict that may arise amongst those caring for and about the patient. Having a formalized means of sorting through difficult cases is often not readily available in long term care facilities that have limited staffing and are often a remote distance from tertiary care centers where clinical ethicists tend to live professionally. A method is proposed to provide patients, families, and staff a means by which to systematically work through ethical dilemmas when formal ethics consultation is not available.
    Missouri medicine 104(5):387-91.

Publication Stats

88 Citations
24.18 Total Impact Points


  • 2002–2010
    • University of Missouri
      • • Department of Internal Medicine
      • • Department of Health Management and Informatics
      Columbia, Missouri, United States
  • 2006
    • Georgetown University
      • Center for Clinical Bioethics
      Washington, D. C., DC, United States