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Teleconsultation Practice Guidelines: Report from G8 Global Health Applications Subproject 4

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Abstract

This report presents a series of recommendations derived from deliberations of the G8 countries Subproject 4 Group (SP4 Group) of the Global Health Care Applications Project entitled, A Teleconsultation Practice Guideline. The recommendations provide an initial step toward developing a general guideline platform for the practice of telemedicine/teleconsultation.

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... 4,5 Teleconsultation can be described as a second opinion system that allows an information exchange between health professionals in order to discuss a clinical case when a specialist is not locally available. 6 It can be real time (with simultaneous interaction) or store and forward (in a timeindependent basis). Low-cost technology and low bandwidth make store-and-forward teleconsultation the most frequent form of telehealth used in developing countries. ...
... Low-cost technology and low bandwidth make store-and-forward teleconsultation the most frequent form of telehealth used in developing countries. 6 With a territorial size of 586,278 km 2 and a population of 19 million inhabitants living in 853 cities (60% with less than 10,000 inhabitants), Minas Gerais is a Brazilian state with large social, economic, cultural, geographical, and infrastructural contrasts. Within this context, telehealth could improve the public healthcare system, bringing better medical care to the population living in remote municipalities. ...
... Factors related to use of the teleconsultation system: Although these factors can be related to the telehealth center, to the operational system, or to the remote sites, in this study the questionnaire was applied only to professionals in remote sites, even though it included questions about their evaluation of factors related to the center and system. The questionnaire consisted of 27 questions about factors grouped into seven categories: institutional, 14 organizational, [15][16][17] infrastructure, 6,14,18 technical, 6,19,20 socioeconomic, [19][20][21][22] human, 17,23,24 and educational. 25 Answers were given in a 4-or 5-point scale. ...
Article
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The Telehealth Network of Minas Gerais (TNMG) is a public telehealth service that provides support to primary healthcare in Minas Gerais, Brazil, performing teleconsultation and tele-electrocardiography. The aim of this study was to assess teleconsultation requests received by the TNMG and to investigate the factors associated with low teleconsultation utilization in most municipalities. A cross-sectional study was carried out including 214 municipalities. Indicators were defined to analyze teleconsultation requests. A structured questionnaire was used to investigate factors associated with teleconsultation utilization, which were analyzed by multivariate analysis through a decision tree algorithm (chi-squared automatic interaction detector) to the entire population of the study and logistic regression for municipalities that had used the system during the analyzed period. From May to September 2009, 1,954 teleconsultations were performed. The average number (±standard deviation) of teleconsultations per municipality was 1.71 (±1.50) per month. The majority of the users were located in remote regions with a low Human Development Index. The decision tree showed "conduction of sufficient training" (p=0.0015) as the factor with the greatest positive impact on teleconsultation utilization, followed by "ability to discuss clinical cases outside the teleconsultation system" (p=0.0192). Logistic regression analysis revealed two factors associated with increased use of the system: "complexity of the system" (odds ratio=3.35; 95% confidence interval [CI], 1.58-7.09) and whether they considered that the "service helps to solve everyday problems" (odds ratio=4.37; 95% CI, 1.14-16.69). The study of factors associated with the low use of the teleconsultation system of the TNMG may help policy makers define strategies to improve the use of teleconsultation services.
... In the patient care plan, the health care professional can register nonpharmacological interventions, complementary examinations requested, specialist referral and drug prescription (the last 2 functionalities are available only to doctors), and the date for the next consultation. It is also possible to request teleconsultation, defined as a second opinion system that allows an information exchange between distant and local health care professionals, in order to discuss a clinical case when a specialist is not locally available [33]. For this project, it was possible to forward doubts straight to a family physician and an endocrinologist, who were exclusively available for this project, or to other medical and nonmedical specialties, following the workflow of the Telehealth Network of Minas Gerais, a large public Telehealth service which assists 816 municipalities in the state of Minas Gerais [34]. ...
... female, median age 34 [IQR[31][32][33][34][35][36][37][38][39], ranging from 24 to 69 years). With regard to the difficulties dealing with the technology, the majority of participants reported some difficulties in the first days using the software, but no problems afterward. ...
Article
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Background The low levels of control of hypertension and diabetes mellitus are a challenge that requires innovative strategies to surpass barriers of low sources, distance, and quality of health care. Objective The aim of this study is to develop a clinical decision support system (CDSS) for diabetes and hypertension management in primary care, to implement it in a resource-constrained region, and to evaluate its usability and health care practitioner satisfaction. Methods This mixed methods study is a substudy of HealthRise Brazil Project, a multinational study designed to implement pilot programs to improve screening, diagnosis, management, and control of hypertension and diabetes among underserved communities. Following the identification of gaps in usual care, a team of clinicians established the software functional requirements. Recommendations from evidence-based guidelines were reviewed and organized into a decision algorithm, which bases the CDSS reminders and suggestions. Following pretesting and expert panel assessment, pilot testing was conducted in a quasi-experimental study, which included 34 primary care units of 10 municipalities in a resource-constrained area in Brazil. A Likert-scale questionnaire evaluating perceived feasibility, usability, and utility of the application and professionals’ satisfaction was applied after 6 months. In the end-line assessment, 2 focus groups with primary care physicians and nurses were performed. Results A total of 159 reminders and suggestions were created and implemented for the CDSS. At the 6-month assessment, there were 1939 patients registered in the application database and 2160 consultations were performed by primary care teams. Of the 96 health care professionals who were invited for the usability assessment, 26% (25/96) were physicians, 46% (44/96) were nurses, and 28% (27/96) were other health professionals. The questionnaire included 24 items on impressions of feasibility, usability, utility, and satisfaction, and presented global Cronbach α of .93. As for feasibility, all professionals agreed (median scores of 4 or 5) that the application could be used in primary care settings and it could be easily incorporated in work routines, but physicians claimed that the application might have caused significant delays in daily routines. As for usability, overall evaluation was good and it was claimed that the application was easy to understand and use. All professionals agreed that the application was useful (score 4 or 5) to promote prevention, assist treatment, and might improve patient care, and they were overall satisfied with the application (median scores between 4 and 5). In the end-line assessment, there were 4211 patients (94.82% [3993/4211] with hypertension and 24.41% [1028/4211] with diabetes) registered in the application’s database and 7960 consultations were performed by primary health care teams. The 17 participants of the focus groups were consistent to affirm they were very satisfied with the CDSS. Conclusions The CDSS was applicable in the context of primary health care settings in low-income regions, with good user satisfaction and potential to improve adherence to evidence-based practices.
... In the patient care plan, the health care professional can register nonpharmacological interventions, complementary examinations requested, specialist referral and drug prescription (the last 2 functionalities are available only to doctors), and the date for the next consultation. It is also possible to request teleconsultation, defined as a second opinion system that allows an information exchange between distant and local health care professionals, in order to discuss a clinical case when a specialist is not locally available [33]. For this project, it was possible to forward doubts straight to a family physician and an endocrinologist, who were exclusively available for this project, or to other medical and nonmedical specialties, following the workflow of the Telehealth Network of Minas Gerais, a large public Telehealth service which assists 816 municipalities in the state of Minas Gerais [34]. ...
... female, median age 34 [IQR[31][32][33][34][35][36][37][38][39], ranging from 24 to 69 years). With regard to the difficulties dealing with the technology, the majority of participants reported some difficulties in the first days using the software, but no problems afterward. ...
Preprint
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BACKGROUND The low levels of control of hypertension and diabetes mellitus are a challenge that requires innovative strategies to surpass barriers of low sources, distance and quality of healthcare. OBJECTIVE To develop a clinical decision support system (CDSS) for diabetes and hypertension management in primary care, to implement it in a resource-constrained region, and to evaluate its usability and healthcare practitioner satisfaction. METHODS This mixed-methods study is a substudy of HealthRise Brazil Project, a multinational study designed to implement pilot programs to improve screening, diagnosis, management, and control of hypertension and diabetes among underserved communities. Following the identification of gaps in usual care, a team of clinicians established the software functional requirements. Recommendations from evidence-based guidelines were reviewed and organized into a decision algorithm, which bases the messages. Following pre-testing and expert panel assessment, pilot testing was conducted in a quasi-experimental study, which included 34 primary care units of ten municipalities in a resource-constrained area in Brazil. A Likert-scale questionnaire evaluating perceived feasibility, usability and utility of the application and professionals’ satisfaction was applied after six months. In the endline assessment, two focus groups with primary care physicians and nurses were performed. RESULTS A total of 159 reminders and suggestions was created and implemented for the CDSS. At the six-month assessment, there were 1939 patients registered in the application database and 2160 consultations were performed by primary care teams. Of the 96 healthcare professionals who were invited for the usability assessment, 26.0% were physicians, 45.8% were nurses and 28.1% were from other health professionals. The questionnaire composed by 24 items about impressions of feasibility, usability, utility and satisfaction, presented global Cronbach's alpha of 0.93. As for feasibility, all professionals agreed (median scores from 4 to 5) that the application can be used in primary care setting and it can be easily incorporated in work routine, but physicians claimed that the application might have caused significant delays on daily routine. As for usability, overall evaluation was good and it was claimed that the application was easy to understand and use. All professionals agreed that the application was useful (score 4-5) to promote prevention, assist to treat and might improve patient care, and they were overall satisfied with the application (median scores between 4 and 5). In the endline assessment, there were 4211 patients (94,8% with hypertension and 24,4% with diabetes) registered in the application’s database and 7960 consultations were performed by primary healthcare teams. The 17 participants of the focus groups were consistent to affirm they were very with the CDSS. CONCLUSIONS The CDSS was applicable in the context of primary health care setting in a low income region, with good user’s satisfaction and potential to improve adherence to evidence-based practices.
... 1,2 A component of telemedicine is teleconsultation between professionals, supported by the exchange of clinical information and videoconferencing, provided in rural areas where medical expertise is limited with access to specialized care. 3,4 Moreover, the use of teleconsultation application as a learning resource is described in several experiences in the literature. 5,6 This telemedicine application is a useful teaching methodology for developing practicebased learning and clinical skills for the writing of case studies at all stages (students, graduates, and specialists). ...
... An exhaustive study of requirements contributes to optimal application performance, information reliability, usability, and user satisfaction. 4,17,18 Identifying requirements. We visited three HPs which had participated in the Tutupaly project. ...
Article
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Background: Telemedicine is becoming increasingly important in Ecuador, especially in areas such as rural primary healthcare and medical education. Rural telemedicine programs in the country need to be strengthened by means of a technological platform adapted to local surroundings and offering advantages such as access to specialized care, continuing education, and so on, combined with modest investment requirements. Introduction: This present article presents the design of a Telemedicine Platform (TMP) for rural healthcare services in Ecuador and a preliminary technical validation with medical students and teachers. Materials and methods: An initial field study was designed to capture the requirements of the TMP. In a second phase, the TMP was validated in an academic environment along three consecutive academic courses. Assessment was by means of user polls and analyzing user interactions as registered automatically by the platform. The TMP was developed using Web-based technology and open code software. Results: One hundred twenty-four students and 6 specialized faculty members participated in the study, conducting a total of 262 teleconsultations of clinical cases and 226 responses, respectively. Conclusion: The validation results show that the TMP is a useful communication tool for the documentation and discussion of clinical cases. Moreover, its usage may be recommended as a teaching methodology, to strengthen the skills of medical undergraduates. The results indicate that implementing the system in rural healthcare services in Ecuador would be feasible.
... Finally, prior to being operational, one needs to elicit specific guidelines for the offered services (e.g. CAR, 1999; Nerlich et al., 2002). There have been many attempts in the literature where telemedicine guidelines are actually listed. ...
Book
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This book constitutes the proceedings of the 4th International Conference on Information Communication Technologies in Health (ICICTH), held in Samos, Greece, in July 2006.
... 6 If teleconsultation is established correctly, good outcomes can be obtained: timely access to correct medical information, quality improvement in the diagnosis and treatment process, increased physician trust, and significant improvement in overall quality of healthcare. 7 In the neurological field, teleconsultation is increasingly used for emergency care of patients who had a stroke between hospitals with and without specialised stroke units. [8][9][10][11][12] However, one disadvantage of this concept is the very specific focus on one medical condition. ...
Article
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Introduction The COVID-19 pandemic compelled health systems to protect patients and medical personnel during transit in hospitals by minimising transfers, prompting the use of telehealth systems. In the field of neurology, telemedicine has been used in emergency settings for acute stroke management between spoke and hub hospital networks, where good outcomes have been achieved. However, data on the use of telemedicine in non-stroke acute neurological conditions accessing the emergency department (ED) are currently missing. Methods and analyses This is an interventional, open-label trial on the use of teleconsultation in the ED for neurological diseases other than stroke. The study aims to develop a remote consultancy system (TeleNeurological Evaluation and Support, TeleNS) for patients with acute neurological symptoms referred to hospital facilities without a 24-hour availability of a neurologist consultant (spoke hospitals). The study population will include 100 ED patients referred to two spoke hospitals in 6 months, who will be asked to perform teleconsultation instead of inperson visits. As a control group, retrospectively available data from patients admitted to the ED of spoke hospitals during the same time period over the last 2 years will be evaluated. The primary objective is to assess whether a TeleNS for the ED guarantees a faster but qualitatively non-inferior diagnostic/therapeutic work-up if compared with inperson examination, assuring the availability of all the necessary examinations and treatments with consistent time-saving. Ethics and dissemination The trial was designed following the national guidelines on clinical investigation on telemedicine provided by the Italian Ministry of Health and according to the Standard Protocol Items for Randomized Trials statement guidelines. This research protocol was approved by Comitato Etico Area Vasta Emilia Nord in September 2020 (number/identification: 942/2020/DISP/AOUMO SIRER ID 805) and was written without patient involvement. Patients’ associations will be involved in the dissemination of study design and results. The results of the study will be presented during scientific symposia or published in scientific journals. Trial registration number NCT04611295 .
... Physicians spend a relatively considerable amount of time consulting with each other and name counseling as an important and integral component of their performance (20). However, it should be noted that during the consultation between two physicians, the resident or attending physician should provide sufficient and correct information to the consultant specialist (21). Since consultation between physicians with different levels of expertise and skill about a particular patient or disease can provide excellent learning experiences for both consultees and consultant (22), which in turn contributes to the quality of the residency education. ...
Article
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Background: Specialized and sub-specialized medical education, considering the special role of residents in the educational and medical system of universities, is of key importance in the higher education system of Iran. The aim of the present study was to investigate the factors affecting the quality of residency education from the perspective of professors and pediatric residents. Materials and Methods: In this cross-sectional study, sample size consists of pediatric residents and faculty members who were working in the pediatric wards of training hospitals affiliated with Mashhad University of Medical Sciences, Mashhad, Iran in 2020. The individuals have been selected through convenience sampling. The samples then filled a researcher made questionnaire (about the quality of Resident Education in clinical fields), and the obtained data were analyzed using SPSS software version 16.0. Results: A total of 10 faculty members and 35 pediatric residents participated in this study. Findings showed that professors assigned higher mean scores to the effect of individual and environmental factors on the residency education as compared to pediatric residents (p <0.05). The results showed a significant difference between professors and residents in terms of the mean scores given to the educational quality in items 14 and 13 and items 18 to 23. In other words, professors had more positive attitude towards quality of clinical education than pediatric residents (P <0.05). Conclusion: Faculty members and pediatric residents did not have the same views on the quality of residency education and professors had more positive assessment of the effect of individual and environmental factors on the clinical field as compared to pediatric residents.
... In 2002, the task force developed a recommendation for teleconsultations in clinical routine. 22 This was the first step to developing general guidelines for telemedicine/teleconsultations. The researchers in Regensburg were very experienced in telemedicine and played a leading role in the International Society for Telemedicine & eHealth (ISfTeH) right from the start. ...
Article
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Today telemedicine, or eHealth, is an important tool in everyday medical life. In all areas, from the preclinical to aftercare, significant improvements in communication structures have been seen in various eHealth options, which have had significant, positive effects on the quality of patient care in orthopedics and trauma surgery. Initially, there were several isolated solutions and many small individual projects; however, there was a lack of interdisciplinary and comprehensive systems in all healthcare fields. The German Trauma Society (DGU) together with the AUC GmbH took the lead and paved the way for a modulated, comprehensive, interface-compatible teleradiology system. Nevertheless, there are still deficits across all sectors which, in the future, will need to be optimized by eHealth methods and systems. Overall, there is an effort towards patient-centered solutions (patient empowerment). In Germany, telemedicine has gradually gained acceptance in various sectors and is being used nationwide. Telemedicine has proven itself, especially in trauma networks.
... Teleconsultation may be defined as 'consultation (…) between distant healthcare professionals with local healthcare professionals concerning a patient's diagnosis and treatment, using telecommunication and information technology to bridge the spatial and functional distance between the participants'. 11 Exclusion criteria were as follows: (1) studies regarding automatic ECG interpretation without transmission for remote evaluation; (2) studies on chronic coronary disease; (3) studies in which the telemedicine intervention was used after patient discharge; (4) duplicate publications or substudies of included studies. In the final case, the publication with the largest sample and longer follow-up was chosen, unless the publications referred to different follow-up times. ...
Article
Background Despite the promise of telemedicine to improve care for ischaemic heart disease, there are significant obstacles to implementation. Demonstrating improvement in patient-centred outcomes is important to support development of these innovative strategies. Objective To assess the impact of telemedicine interventions on mortality after acute myocardial infarction (AMI). Methods Articles were searched in MEDLINE, Cochrane Central Register of Controlled Trials, Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Base de Dados de Enfermagem (BDENF), Indice Bibliográfico Español en Ciencias de la Salud (IBECs), Web of Science, Scopus and Google Scholar, from January 2004 to January 2018. Study selection and data extraction were performed by two independent reviewers. In-hospital mortality (primary outcome), and door-to-balloon (DTB) time, 30-day mortality and long-term mortality (secondary outcomes) were assessed. Random effects models were applied to estimate pooled results. Results Thirty non-randomised controlled and seven quasi-experimental studies were included (16 960 patients). They were classified as moderate or serious risk of bias by ROBINS-I (Risk Of Bias In Non-randomized Studies–of Interventions tool). In 31 studies, the intervention was prehospital ECG transmission. Telemedicine was associated with reduced in-hospital mortality compared with usual care (relative risk (RR) 0.63(95% confidence interval[CI] 0.55 to 0.72); I ² <0.001%). DTB time was consistently reduced (mean difference −28 (95% CI −35 to –20) min), but showed large heterogeneity (I ² =94%). Thirty-day mortality (RR 0.62;95% CI 0.43 to 0.85) and long-term mortality (RR 0.61(95% CI 0.40 to 0.92)) were also reduced, with moderate heterogeneity (I ² =52%). Conclusions There is moderate-quality evidence that telemedicine strategies, in particular ECG transmission, combined with the usual care for AMI are associated with reduced in-hospital mortality and very-low quality evidence that they reduce DTB time, 30-day mortality and long-term mortality.
... Entre as diversas modalidades da telessaúde, a teleconsultoria e os serviços de telediagnóstico são as modalidades com maior aplicação nos países em desenvolvimento, por serem de baixo custo, exigirem menor infraestrutura de comunicação e propiciarem real economia para o sistema de saúde 6 A análise estatística foi realizada por meio do programa Statistical Package for the Social Sciences (SPSS), versão 20.0 (SPSS for Windows, Chicago, EUA). A associação entre variáveis relacionadas ao município e ao gestor de saúde e a não utilização do serviço de teleconsultoria pelos médicos da APS foi investigada por meio do teste qui-quadrado ou teste exato de Fisher. ...
Article
Este artigo objetiva descrever o cenário e identificar fatores associados à não utilização da teleconsultoria pelos médicos da atenção primária na macrorregião Norte de Minas Gerais. Trata-se de um estudo transversal. Para a coleta de dados, foi direcionado um questionário autoaplicado, previamente testado, aos gestores municipais de todos os municípios dessa área. Após análises bivariadas para identificação dos fatores associados à não utilização da teleconsultoria, foi empregada regressão de Poisson com variância robusta. Participaram do estudo 86 gestores municipais de saúde. Importantes barreiras estruturais à implementação da teleconsultoria foram identificadas: falta de computadores com acesso à internet nas unidades básicas de saúde (76,7%) e a qualidade insatisfatória de conexão da internet (16,3%). Na análise múltipla dos fatores associados, apenas a falta de estratégias de motivação por parte dos gestores mostrouse associada (p<0,007; RP=2,19; IC-95%:1,24-3,86) à não utilização da teleconsultoria. Os resultados reforçam o papel do gestor de saúde na promoção do uso do serviço de teleconsultoria na atenção primária.
... The first step towards developing a TM application is to define its functional specifications, including hardware and software architecture specifications, taking into account organizational aspects, user profiles and expectations. An exhaustive study of requirements contributes to optimal application performance, information reliability, usability and user satisfaction [36][37][38]. In this work, a field study [21] was designed to permit the adaptation of technologies to environments such as the medical careers as well as the ORHS program. ...
... If teleconsultation is established cor-rectly, good outcomes like timely access to correct medical information, quality improvement of the diagnosis and treatment process, increased physician trust, and significant improvement in the total quality of health care will result. Similar to every other type of consultation, the requesting physician, who is present at the patient's location, must collect sufficient and correct information for the remote consultant physician (11). Good and optimum communication between these physicians consists of exchanging related clinical information as well as patient preferences and values (12). ...
Article
Full-text available
Background: The goal of teleconsultation is to omit geographical and functional distance between two or more geographically separated health care providers. The purpose of present study is to review and analyze physician-physician teleconsultations. Method: The PubMed electronic database was searched. The primary search was done on January 2015 and was updated on December 2015. A fetch and tag plan was designed by the researchers using an online Zotero library. Results: 174 full-text articles of 1702 records met inclusion criteria. Teleconsultation for pediatric patients accounts for 14.36 percent of accepted articles. Surgery and general medicine were the most prevalent medical fields in the adults and pediatrics, respectively. Most teleconsultations were inland experiences (no=135), and the USA, Italy and Australia were the three top countries in this group. Non-specialists health care providers/centers were the dominant group who requested teleconsultation (no=130). Real time, store and forward, and hybrid technologies were used in 50, 31, and 16.7 percent of articles, respectively. The teleconsultation were reported to result in change in treatment plan, referral or evacuation rate, change in diagnosis, educational effects, and rapid decision making. Use of structured or semi-structured template had been noticed only in a very few articles. Conclusion: The present study focused on the recent ten years of published articles on physician-physician teleconsultations. Our findings showed that although there are positive impacts of teleconsultation as improving patient management, still have gaps that need to be repaired.
... O termo " telessaúde " tem o mesmo princípio, porém é mais abrangente e multidisciplinar, envolvendo todas as outras áreas relacionadas com a saúde, por exemplo, enfermagem, odontologia, psicologia, fisioterapia e fonoaudiologia. A telessaúde tem diversas modalidades, como a teleconsultoria, definida como uma troca de informações entre profissionais da saúde remotos e locais para se discutir um caso clínico ou obter segunda opinião, quando há necessidade de uma expertise inexistente no local (NERLICH et al., 2002; PAIM et al., 2011); e os serviços de telediagnóstico, com realização de exames complementares para análise à distância. Essas são as modalidades com maior aplicação nos países em desenvolvimento por serem de baixo custo, exigirem menor infraestrutura de comunicação e propiciarem real economia para o sistema de saúde (NERLICH; BALAS et al., 2002). ...
... The described situation is not merely typical for the USA but is extendible to most of the European countries as well (Nerlich 2002). ...
Article
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The introduction of Information and Communication Technology (ICT) in the health scenario is instrumental for the development of sustainable services of direct benefit for the European citizen. The setting up of satellite-based applications will enhance rapidly the decentralisation and the enrichment of the European territory driving it towards a homogenous environment for healthcare. Specific benefits obtained from the developments of eHealth and Telemedicine via Satellite services will essentially be: • To support the take-up of broadband services in rural areas; de facto contributing to the bridging of the digital divide. • To enable public authorities to contain service costs and improve prevention strategies. • Through the provision of healthcare services on moving platforms eHealth and Telemedicine via Satellite services will ubiquitously enhance the safety for European citizens. • The only way to provide a European Early Warning System capable of predicting health threats and alerting populations in a timely fashion. • The most robust way to provide healthcare emergency services in disaster situations. • To enhance the provision of ubiquitous medical education services of direct benefit for the patient and the overall medical community. • Due to its intrinsic capability of aggregating the demand, eHealth and Telemedicine via Satellite services will encourage the generation of European standards, legal and regulatory frameworks. The relevance of the above-mentioned benefits demands a coherent programmatic effort at European level. In this frame the European Space Agency has deemed necessary to set up a working group formed by representatives of different eHealth and Telemedicine user domains – i.e. the members of the telemedicine working group – in order to define key thematic areas where the programmatic actions should develop. This publication describes the results of this eHealth and Telemedicine via Satellite Working Group. It covers needs and demands, problems to be solved, and both challenges of and opportunities for different areas in eHealth and Telemedicine. The issue is to improve health systems across Europe through the use of eHealth and Telemedicine via Satellite. Europe, in this context, follows the definition of the United Nations Europe (UN Europe) which consists of 52 member states. This poses great challenges of and opportunities for the use of satellites to improve information and communication within and across countries and therefore to support health and population development.
... Web-based teleradiology management systems have been developed for patient transfers from one facility to another transferring images from PACS to PACS [20]. Many countries have developed guidelines for the use of teleradiology2122232425. However, laws and regulations governing the practice of medicine and data security were commonly enacted before the recent developments in sophisticated technology. ...
Article
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The purpose of this study was to obtain a survey about the present situation including the usage pattern, technical characteristics and the anticipated future of teleradiology in Switzerland. An internet-based questionnaire was made available to all members of the Swiss Society of Radiology. Questions concerning current teleradiology usage, the type of transmitted modalities, the technology employed, security, billing issues and the anticipated future of teleradiology were addressed. One hundred and two (22.67%) of 450 radiologists responded to the survey. Of the total, 41.2% (42) were teleradiology users, 35.3% (36) planned to use teleradiology in the near future and 24.5% (25) did not use or plan to use teleradiology. The mean number of examinations transmitted per month was 198 (range 1-2,000) and the mean distance was 33 km (range 1,250 km). An emergency service was considered the most important purpose (mean score 6.90; minimum 1, maximum 10) for the use of teleradiology, followed by image distribution (mean 6.74) and expert consultation (mean 6.61). The most commonly transmitted modality was computed tomography (mean 8.80), followed by conventional X-rays (8.40) and magnetic resonance imaging (8.32). The most commonly transmitted format was Digital Imaging and Communications in Medicine (DICOM) (66.7%), followed by bitmap/Joint Photographic Experts Group (jpg) (38.1%), using the DICOM send/receive protocol (52.4%), followed by the hypertext transfer protocol (26.2%) and e-mail (21.4%). For security a secure connection (54.8%) followed by encryption (14.3%) and anonymization (9.5%) was used. For the future, image distribution was rated the most important aspect of teleradiology (7.88), followed by emergency (7.22) and expert consultation (6.53). Development of legal regulations is considered most important (8.17), followed by data security guidelines (8.15). Most radiologists believe that insurance companies should pay for the costs of teleradiology (37.3%), followed by the radiologist (33.3%). In conclusion, in Switzerland a wide spectrum of teleradiology applications and technologies is in use. Guidelines and reimbursement issues remain to be solved.
... It is this possibility that Kassirer (2004) regards as having the potential to induce cultural changes in the delivery of care more revolutionary than any restructuring of the medical care system. Anticipating such changes, the report of the Institute of Medicine, Crossing the Quality Chasm, includes provision of patient care not only by face-to-face visits, but also by other means, including the Internet (Nerlich et al., 2002). Whether e-mail use between patients and their physicians will revolutionize medicine is yet unclear; however, its impact is already evident. ...
Article
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This study explores the extent to which e-mail messages between patients and physicians mimic the communication dynamics of traditional medical dialogue and its fulfillment of communication functions. Eight volunteers drawn from a larger study of e-mail users agreed to supply copies of their last 5 e-mail messages with their physicians and the physician replies. Seventy-four e-mail messages (40 patient and 34 physician) were provided and coded using the Roter Interactive Analysis System. The study found that physicians' e-mails are shorter and more direct than those of patients, averaging half the number of statements (7 vs. 14; p < .02) and words (62 vs. 121; p < .02). Whereas 72% of physician and 59% of patient statements were devoted to information exchange, the remaining communication is characterized as expressing and responding to emotions and acting to build a therapeutic partnership. Comparisons between e-mail and with face-to-face communication show many similarities in the address of these tasks. The authors concluded that e-mail accomplishes informational tasks but is also a vehicle for emotional support and partnership. The patterns of e-mail exchange appear similar to those of in-person visits and can be used by physicians in a patient-centered manner. E-mail has the potential to support the doctor-patient relationship by providing a medium through which patients can express worries and concerns and physicians can be patient-centered in response.
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p class="ZNstreszczenie" xss=removed> Pandemia COVID-19 w zdecydowany sposób wpłynęła na rozwój telemedycyny na świecie, a także w Polsce oraz uczyniła z niej podstawowe narzędzie świadczenia usług medycznych. Wynika to z faktu coraz szerszego stosowania opieki zdalnej w warunkach obecnej pandemii, a nie z jej upowszechniania z konieczności stosowania różnorodnych narzędzi i technik komunikacji z pacjentami. Telemedycyna jest stosunkowo nowym podejściem w Polsce, natomiast od lat jest stosowana praktycznie szczególnie w Stanach Zjednoczonych, USA, Kanadzie czy Australii. Celem naukowym artykułu jest ocena czynników satysfakcji pacjentów z telekonsultacji w kontekście doświadczenia z systemem w okresie pandemii COVID-19. W publikacji zastosowano następujące metody i techniki badawcze: analizę literatury przedmiotu oraz analizę wyników badań własnych realizowanych w Polsce w 2021 roku. Przedstawione w artykule zagadnienia mają zarówno walor poznawczy, jak i praktyczny. </p
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Telecardiology is one of the fastest-growing fields in telemedicine. In primary care, teleconsultations, telediagnosis, and tele-education, applied in an integrated manner, possibly associated with tools such as computer decision support systems, may improve the quality of care for cardiovascular diseases, especially hypertension, atrial fibrillation, heart failure, and acute myocardial infarction (AMI). In specialized care, there is extensive literature on the use of telemonitoring among patients with heart failure (HF), with evidence of reduced number of hospitalizations and all-cause mortality, as well promotion of patient empowerment. Several studies have demonstrated that hypertension telemonitoring strategies have a beneficial short- and medium-term impact on blood pressure control. Telecardiology has also different applications in emergency services, including electrocardiogram transmission, which can be associated with synchronous teleconsultation, to assist the early diagnosis and management of patients with acute coronary syndrome (ACS), with evidence of reduced AMI short- and long-term mortality. Decision support systems could also to aid in the diagnosis, management, and prediction of cardiac complications in patients with ACS, prehospital bedside ultrasound image transmission, and image transmission and support in the diagnosis and management of patients with stroke. Telehealth interventions aimed at enabling remote rehabilitation programs can overcome barriers to access while preserving clinical supervision and individualized exercise prescription. Remote monitoring using implantable devices has mixed results in clinical outcomes. Cost and quality in a telecardiology service are strictly related to the monitoring and management of the process.
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Background: There is a lack of evidence regarding audits or quality analysis of telehealth strategies in clinical practice. Our aim is to develop and implement a methodology for quality assessment of asynchronous teleconsultations. Materials and Methods: A random sample of asynchronous teleconsultations performed by the specialists from the Telehealth Network of Minas Gerais (TNMG), a public telehealth service in Brazil, was selected. The responses were evaluated regarding size, objectivity, quality, ethics, courtesy, and grammar, and received a score for each category: 1 = fair, 2 = moderate, and 3 = good. As each domain has a different importance in rating the overall quality of teleconsultation, each one was assigned a different weight, and a final score was calculated. Results: A total of 576 teleconsultations were assessed. Overall, the scores were good or moderate for all items. Only a few cases were classified as fair. Among medical specialties, pediatrics was the one that proportionally received the highest number of fair classifications, and the item "quality of the answers" was the one with highest number of worse classifications for this specialty. Corrective actions were implemented. With regard to the nonmedical specialties, the majority of the items were classified as good or moderate, and in rare cases some items received the fair rating. Conclusion: The methodology showed to be useful to evaluate the teleconsultation service. We established six domains that we considered important components to be assessed. This assessment was essential to identify the priority areas to receive correct actions. It may be easily replicated in other services worldwide.
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Introduction: The quality of clinical decisions made by on-call physician is totally dependent on the quality of medical information received from resident. Some factors such as type, number, format, quality and also the volume of such information may highly affect the quality of remote consultations. Therefore, developing a trusted standard model for such clinical communication seems to be necessary. This study was conducted with aim to design a clinical archetype (structure data) for remote decision making in high-risk pregnancies. Methods: This multi-stage cross-sectional study was conducted by using Delphi technique for identifying of the most common high-risk pregnancies to design a archetype for clinical decision making in three obstetrics and gynecology departments of educational hospitals, Mashhad. Results: There were 5 common high-risk pregnancies (leading to delivery) including hypertension, third trimester hemorrhage, PROM, pre-term and post-term delivery. 161 clinically-important groups / items were extracted from scientific References and then hand-filtered to 158 items by the participating gynecology and obstetrics experts. The final items were categorized into five classes including general information, chief complaint / current problem, medical history, clinical examination, and paraclinic results. Conclusion: Our findings showed that close interaction between clinicians and specialists in medical informatics may facilitate the improvement process of medical teleconsultations. © 2017, Mashhad University of Medical Sciences. All rights reserved.
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Teleconsultation is a method of providing services using remote technology. In rural areas it can be the solution to close the gap in service provision. In this paper, we detailed the technical factors that individuals who are attempting to engage in teleconsultation should consider. In addition, we provided some recommendations based on current trends and best practices and discussed implications for future use of such technologies.
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Introduction Both the demands and the options for patients to communicate with health care providers utilizing eHealth solutions are increasing. Some patients, or relatives to patients, want to consult another health care provider than the regular one, merely in text. Objective To improve text-based medical consultation by learning from long-term experiences. Materials and methods Physicians with comprehensive experience of answering free-text medical inquiries at an official health portal in Sweden were interviewed. The interviews were analyzed using a grounded theory approach. Results Over time, the interviewed physicians developed strategies on how to formulate the answer to a medical inquiry from a previously unknown inquirer. The answering physicians experienced their primary role as providers of medical information and as mediators between an inquirer and the regular health care provider. Many of the answering physicians experienced a personal development with improved communication skills, also in face-to-face meetings with patients. Conclusion Text-based medical consultation is part of an expanding area in eHealth. The development of strategies, guidelines, ethical considerations as well as educational efforts are needed to optimize the skills of asynchronous text-based health consultation.
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Purpose: to analyze the profile of Speech, Language and Hearing Sciences teleconsultations of a large scale public telehealth service in Minas Gerais, Brazil. Methods: all Speech-Language Pathology teleconsultations performed from February 2011 to May 2014 were assessed and classified according to the type of questions, professional who sent the solicitation and the speech-language pathologist area of expertise. Results: the 259 teleconsultations performed during the study period were originated from 81 cities. The majority of the solicitations were originated from speech-language pathologists (64.5%), followed by nurses (27.0%) and physicians (5.0%), and were related to patients' assistance (81%). Among these, 35% were about diagnosis and 65% about discussion of procedures and therapeutic approaches. There was no difference with regards to the type of solicitation and healthcare practitioner, whether speech-language pathologist or not (65.7% vs. 64.9%, p=1.00). The majority of the questions were about language (47%), followed by oral motor functions (29%), voice (20%), audiology (18%), dysphagia (10%) and public health (3%). Conclusion: in this study, the majority of the solicitations to a Speech, Language and Hearing Sciences teleconsultation service were about language, although there was demand for all fields. Although the use of teleconsultations in Speech-Language Pathology, is still in its early stages there is great potential for using this tool in clinical practice.
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Benchmarked guidelines, standards and quality management procedures for practicing teleconsultation have to be developed and adopted on a large scale. Successful teleconsultation services should be further transformed into a system of reliable and certified products and applications. Baseline, generic guidelines help ensure quality management across a broad range of different telemedicine services In order to reduce and avoid human, technical and logistic errors and pitfalls, checklists have to be integrated into the practice of telemedicine. An appropriate illumination is important to obtain usable and diagnosable images. Filters can be useful to prepare the image or to emphasize relevant image areas. Because of potential loss of information, lossless image compression should be preferred rather than lossy compression.
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Cardiology is a very promising field in telemedicine. The transmission of electrocardiograms (ECG) from remote health services or ambulances to a central for analysis is already routine in the approach to acute coronary syndromes (ACS). This approach allows the obtention of expert guidance and referral to appropriate health units, with the potential of saving lives. This impact may be seen in acute myocardial infarction (MI), in which telemedicine has reduced intra-hospital mortality rates from 12.3% to 7.1%
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Communication theory based analysis sheds new light on the use of health telematics. This analysis of structures in electronic medical communication shows communicative structures with special features. Current and evolving telemedical applications are analyzed. The methodology of communicational theory (focusing on linguistic pragmatics) is used to compare it with its conventional counterpart. The semiotic model, the roles of partners, tiie respective message and their relation are discussed. Channels, sender, addressee, and other structural roles are analyzed for different types of electronic medical communication. The commimicative processes are shown as mutual, rational action towards a common goal. The types of communication/texts are analyzed in general. Furthermore the basic communicative structures of medical education via intemet are presented with their special features. The analysis shows that electronic medical communication has special features compared to everyday communication: A third participant role often is involved: the patient. Messages often are addressed to an unspecified partner or to an unspecified partner within a group. Addressing in this case is (at least partially) role-based. Communication and message often directiy (rather than indirectly) influence actions of the participants. Communication often is heavily regulated including legal implications like liability, and more. The conclusion from the analysis is that the development of telemedical applications so far did not sufficiently take communicative structures into consideration. Based on these results recommendations for future developments of telemedical applications/services are given.
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The practice of acute care surgery varies in the international community and depends on many factors, for example, economics, politics, education, hygiene, diet, climate, religion, and social custom. This book is written by authors from those communities where acute care surgery is carried out in well-established forms. In some developing countries, however, acute care surgery cannot be practiced properly because medical resources are not sufficiently supplied, and education for surgeons and medical personnel is not appropriately organized.1 Acute care surgery is the most common form of surgical practice in developing countries, and one of the purposes of this new textbook is to help bridge the gap between the practice of surgery in developed and in developing countries.
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Unlabelled: To establish a guideline for the use of teleconsultation, which is one of the most important applications in telemedicine beeing perfomed very frequently in daily medical practice in almost any field of medicine. Evidence: The recommendations are based on expert knowledge, because of the lack of evidence based data in the telemedical scientific literature. In addition, scientific articles of the highest level of evidence available published between 1970 and 1999 were reviewed. DEVELOPEMENT AND CONSENUS PROCESS: A guideline draft was prepared using the attributes of clinical practice guidelines developed by the Institute of Medicine (IOM) of the National Academy of Sciences. This draft was reviewed by telemedicine experts and the content of the guideline was approved by 100% group consensus in 5 meetings held between 1997 and 2000 by a panel of members of the Subproject 4 Group of the Global Health Care Application Project of the G8 countries. Conclusions: The guideline gives recommendations on all aspects of teleconsultation in any field of medicine and will be updated regularly implementing new evidence.
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Establishing sustainable telemedicine has become a goal of many developing countries around the world. Yet, despite initiatives from a select few individuals and on occasion from various governments, often these initiatives never mature to become sustainable programs. The introduction of telemedicine and e-learning in Kosova has been a pivotal step in advancing the quality and availability of medical services in a region whose infrastructure and resources have been decimated by wars, neglect, lack of funding, and poor management. The concept and establishment of the International Virtual e-Hospital (IVeH) has significantly impacted telemedicine and e-health services in the Balkans. The success of the IVeH in Kosova has led to the development of similar programs in other Balkan countries and other developing countries in the hope of modernizing and improving their healthcare infrastructure. A comprehensive, four-pronged strategy, "Initiate-Build-Operate-Transfer" (IBOT), may be a useful approach in establishing telemedicine and e-health educational services in developing countries. The development strategy, IBOT, used by the IVeH to establish and develop telemedicine programs, was discussed. IBOT includes assessment of healthcare needs of each country, the development of a curriculum and education program, the establishment of a nationwide telemedicine network, and the integration of the telemedicine program into the healthcare infrastructure. The endpoint is the transfer of a sustainable telehealth program to the nation involved. By applying IBOT, a sustainable telemedicine program of Kosova has been established as an effective prototype for telemedicine in the Balkans. Once fully matured, the program will be transitioned to the national Ministry of Health, which ensures the sustainability and ownership of the program. Similar programs are being established in Albania, Macedonia, and other countries around the world. The IBOT model has been effective in creating sustainable telemedicine and e-health integrated programs in the Balkans and may be a good model for establishing such programs in developing countries.
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This study assessed current perspectives and expectations for telemedicine by nursing home caregivers and families of nursing home patients in Taipei, Taiwan. A total of 116 interviews were conducted with family members (n=37) and caregivers (n=79) using an original, four-part questionnaire devised to assess the expectations and concerns related to prospective telemedicine opportunities, including consumer attitude, knowledge of and interest in medicine, concerns and worries about telemedicine, and anticipated benefits of telemedicine. Statistical significance between the two groups was observed in sex, age, and educational level (all p<0.001). Most respondents had heard about telemedicine before participation and showed some interest in telemedicine implementation. More than 70.0% of subjects in both groups had perceptions of telemonitoring of patients, notifications of health abnormalities, teleconferencing between physicians and family members, obtaining test/exam results and face-to-face consultation through telenetworks. Both groups hoped for information and education through telemedicine. More caregivers were concerned about increased costs (p=0.020), poor hardware quality (p<0.001), poor security, confidentiality, and reliability (p=0.036), inconvenience to patients (p=0.006), associated moral and ethical issues (p=0.006), and uncertainty about responsibility (p=0.022). The two groups did not differ in expectations concerning benefits of telemedicine. More than 60% of family members or caregivers expected improved efficiency and quality of hospital and nursing home health care, greater rapport between nursing homes and either staff or patients, reduced overall medical costs of caregiving, and reduced staff/caregiver working hours. The acceptable cost was anything up to $15.30 USD per month. Nursing home caregivers and families of nursing home patients are highly interested in telemedicine; however, they are only willing to pay a slightly higher cost of nursing care for this service. The challenge for the future in this industry is to balance peoples' demands and telemedicine's associated costs. Results of this study suggest that caregivers and families of nursing home residents favour telemedicine implementation to provide enhanced care coordination in nursing homes when economic circumstances are favourable.
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Videoconferencing between patients and their physicians can increase patients' access to healthcare. Unscheduled videoconferencing can benefit patients with acute medical problems but has not been studied extensively. We conducted a clinical trial of unscheduled, nighttime videoconferencing in a nursing home, where on-call physicians usually provide care by telephone from remote locations. Although most calls for medical problems did not lead to videoconferencing, physicians and nursing-home residents were satisfied with videoconferencing when it did occur, and physicians reported that making medical decisions was easier with videoconferencing. Videoconferencing was most often conducted to assess residents with changes in mental status, abnormal laboratory values, or falls. Physicians often lacked immediate access to videoconferencing equipment when medical problems with residents occurred. This application could benefit from improved access and portability of equipment.
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A Canadian project (the National Initiative for Telehealth Guidelines) was established to develop telehealth guidelines that would be used by health professionals, by telehealth providers as benchmarks for standards of service and by accrediting agencies for accreditation criteria. An environmental scan was conducted, which focused on organizational, human resource, clinical and technological issues. A literature review, a stakeholder survey (245 mail-outs, 84 complete responses) and 48 key informant interviews were conducted. A framework of guidelines was developed and published as a preliminary step towards pan-Canadian policies. Interim recommendations were that organizations and jurisdictions might consider formal agreements to specify: (1) organizational interoperability; (2) technical interoperability; (3) personnel requirements; (4) quality and continuity-of-care responsibilities; (5) telehealth services; (6) remuneration; and (7) quality assurance processes. An additional recommendation was that flexible mechanisms were needed to ensure that accreditation criteria will be realistic and achievable in the context of rapid changes in technology, service integration and delivery, as well as in the context of operating telehealth services in remote or underserved areas.
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The medical system of Kosova was largely destroyed in 1999 by the departing Serbian forces, leaving behind Albanian physicians systematically excluded from advanced medical services for a decade and medical facilities severely damaged in the course of departure in a region with an infrastructure fragmented over the years. The medical system of Kosova can be analyzed for the effectiveness of the many efforts following the disruption of medical care in the 1990s. In this paper, the application of telemedicine and information is recounted. The medical system of Kosova was offered the concept of the International Virtual E-Hospital and this model was used to support, supplement, and guide a massive program development that involved essentially every physician and medical personnel in the region. Currently, the Telemedicine Center of Kosova (TCK) is providing information resources for medical education programs within the Kosova's medical system as well as regional and international consultations and collaboration. Furthermore, it is developing the human resources that will lead and implement telemedicine programs in this region and making serious strides in the redevelopment of medical systems using information technology.
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As part of a randomized controlled trial of the costs and benefits of realtime teledermatology in comparison with conventional face-to-face appointments, patients were asked to complete a questionnaire at the end of their consultation. One hundred and nine patients took part in an initial teledermatology consultation and 94 in a face-to-face consultation. The proportion of patients followed up by the dermatologist was almost the same after teledermatology (24%) as after a hospital appointment (26%) and for similar reasons. Two hundred and three questionnaires were completed after the first visit and a further 20 after subsequent visits. Patients seen by teledermatology at their own health centre travelled an average of 12 km, whereas those who attended a conventional clinic travelled an average of 271 km. The telemedicine group spent an average of 51 min attending the appointment compared with 4.3 h for those seen at the hospital. The results of the present study, as in a similar study conducted in Northern Ireland, show that the economic benefits of teledermatology favour the patient rather than the health-care system.
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To review research into patient satisfaction with teleconsultation, specifically clinical consultations between healthcare providers and patients involving real time interactive video. Systematic review of telemedicine satisfaction studies. Electronic databases searched include Medline, Embase, Science Citation Index, Social Sciences Citation Index, Arts and Humanities Citation Index, and the TIE (Telemedicine Information Exchange) database. Subjects: Studies conducted worldwide and published between 1966 and 1998. Quality of evidence about patient satisfaction. 32 studies were identified. Study methods used were simple survey instruments (26 studies), exact methods not specified (5), and qualitative methods (1). Study designs were randomised controlled trial (1 trial); random patient selection (2); case-control (1); and selection criteria not specified or participants represented consecutive referrals, convenience samples, or volunteers (28). Sample sizes were </=20 (10 trials), </=100 (14), >100 (7), and not specified (1). All studies reported good levels of patient satisfaction. Qualitative analysis revealed methodological problems with all the published work. Even so, important issues were highlighted that merit further investigation. There is a paucity of data examining patients' perceptions or the effects of this mode of healthcare delivery on the interaction between providers and clients. Methodological deficiencies (low sample sizes, context, and study designs) of the published research limit the generalisability of the findings. The studies suggest that teleconsultation is acceptable to patients in a variety of circumstances, but issues relating to patient satisfaction require further exploration from the perspective of both clients and providers.
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The growing complexity of the performance processes in medicine makes it mandatory that the flow of information is faster and more consistent, especially when the sites of health care are far away from each other. The Regensburg model, a realization of lean telemedicine from a low-cost domain, using PC-based standard videoconferencing systems shows the use of modern telecommunications, especially in trauma surgery. In 203 prospectively evaluated teleconsultations between 15 participants a total of 697 images were transmitted via videoconferencing. In 95% of the trauma cases the transmitted material was judged as at least sufficient. In project-attending evaluations the efficacy of these systems and their use were clearly demonstrated. Savings in transportation costs of up to 4,400 DM per case were achieved. Through quicker flow of information quality improvements for all participants resulted; to some extent considerable costs for health care were avoided or reduced. Based on these thoughts, a new platform of communication will be established in Regensburg as a closed medical intranet for the region of eastern Bavaria.
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Telekonsultation ist die Beratung zwischen zwei oder mehreren Ärzten über das diagnostisch-therapeutische Vorgehen in der Behandlung eines konkreten Krankheitsfalles mittels der modernen Telematik. Infolge zunehmend komplexer Behandlungsstrategien und auch rechtlicher Vorgaben wird in Zukunft der Bedarf an Telekonsultationsmöglichkeiten erheblich zunehmen. Die praktische Anwendung wird durch Verbesserungen in der Telematik (zunächst ISDN-Verbindungen, später Nutzung einer nationalen Gesundheitsplattform) zunehmend erleichtert werden. Die rechtlichen Rahmenbedingungen für die Telekonsultation im klinischen Alltag sind weitestgehend definiert, unklar ist derzeit noch eine adäquate Honorierung dieser eigenständigen ärztlichen Leistung. Teleconsultation is a consultation between two or more physicians about the diagnostic work-up and therapeutic strategy in the treatment of an individual case by means of modern telematics. Due to more complex therapeutic strategies and legally defined formal requirements, the need for teleconsultation will increase significantly in the future. Rapid technical improvements in telematics will progressively facilitate the practical performance of teleconsultation (based upon an ISDN network in the beginning, later on by the use of a national health network). The medicolegal aspects of teleconsultation have already been defined sufficiently for use in surgery. However, the question of adequate financial compensation for this type of medical service is still unclear.
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The growing complexity of the performance processes in medicine makes it mandatory that the flow of information is faster and more consistent, especially when the sites of health care are far away from each other. The Regensburg model, a realization of lean telemedicine from a low-cost domain, using PC-based standard videoconferencing systems shows the use of modern telecommunications, especially in trauma surgery. In 203 prospectively evaluated teleconsultations between 15 participants a total of 697 images were transmitted via videoconferencing. In 95 % of the trauma cases the transmitted material was judged as at least sufficient. In project-attending evaluations the efficacy of these systems and their use were clearly demonstrated. Savings in transportation costs of up to 4,400 DM per case were achieved. Through quicker flow of information quality improvements for all participants resulted; to some extent considerable costs for health care were avoided or reduced. Based on these thoughts, a new platform of communication will be established in Regensburg as a closed medical intranet for the region of eastern Bavaria.
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It is hoped that the implementation of teleradiology will improve the quality and economic effectiveness of health care in the future. The German federal government has submitted a bill for a legal statute, thereby creating the necessary framework to guarantee the essential “document security”. The responsibility of those involved with orderly data transmission as well as the limited responsibility for physicians' findings are both governed by general liability. General principles apply also with regard to professional discretion. Authorized utilization of external networks depends upon the quality of data security. Networks with unlimited public access may not be used without explicit consent from those concerned.
Article
Telemedicine coupled with digital photography could potentially improve the quality of outpatient wound care and decrease medical cost by allowing home care nurses to electronically transmit images of patients' wounds to treating surgeons. To determine the feasibility of this technology, we compared bedside wound examination by onsite surgeons with viewing digital images of wounds by remote surgeons. Over 6 weeks, 38 wounds in 24 inpatients were photographed with a Kodak DC50 digital camera (resolution 756 x 504 pixels/in2). Agreements regarding wound description (edema, erythema, cellulitis, necrosis, gangrene, ischemia, and granulation) and wound management (presence of healing problems, need for emergent evaluation, need for antibiotics, and need for hospitalization) were calculated among onsite surgeons and between onsite and remote surgeons. Sensitivity and specificity of remote wound diagnosis compared with bedside examination were calculated. Potential correlates of agreement, level of surgical training, certainty of diagnosis, and wound type were evaluated by multivariate analysis. Agreement between onsite and remote surgeons (66% to 95% for wound description and 64% to 95% for wound management) matched agreement among onsite surgeons (64% to 85% for wound description and 63% to 91% for wound management). Moreover, when onsite agreement was low (i.e., 64% for erythema) agreement between onsite and remote surgeons was similarly low (i.e., 66% for erythema). Sensitivity of remote diagnosis ranged from 78% (gangrene) to 98% (presence of wound healing problem), whereas specificity ranged from 27% (erythema) to 100% (ischemia). Agreement was influenced by wound type (p < 0.01) but not by certainty of diagnosis (p > 0.01) or level of surgical training (p > 0.01). Wound evaluation on the basis of viewing digital images is comparable with standard wound examination and renders similar diagnoses and treatment in the majority of cases. Digital imaging for remote wound management is feasible and holds significant promise for improving outpatient vascular wound care.
Article
Teleconsultation is a consultation between two or more physicians about the diagnostic work-up and therapeutic strategy in the treatment of an individual case by means of modern telematics. Due to more complex therapeutic strategies and legally defined formal requirements, the need for teleconsultation will increase significantly in the future. Rapid technical improvements in telematics will progressively facilitate the practical performance of teleconsultation (based upon an ISDN network in the beginning, later on by the use of a national health network). The medicolegal aspects of teleconsultation have already been defined sufficiently for use in surgery. However, the question of adequate financial compensation for this type of medical service is still unclear.
Article
The growing complexity of the performance processes in medicine makes it mandatory that the flow of information is faster and more consistent, especially when the sites of health care are far away from each other. The Regensburg model, a realization of lean telemedicine from a low-cost domain, using PC-based standard videoconferencing systems shows the use of modern telecommunications, especially in trauma surgery. In 203 prospectively evaluated teleconsultations between 15 participants a total of 697 images were transmitted via videoconferencing. In 95% of the trauma cases the transmitted material was judged as at least sufficient. In project-attending evaluations the efficacy of these systems and their use were clearly demonstrated. Savings in transportation costs of up to 4,400 DM per case were achieved. Through quicker flow of information quality improvements for all participants resulted; to some extent considerable costs for health care were avoided or reduced. Based on these thoughts, a new platform of communication will be established in Regensburg as a closed medical intranet for the region of eastern Bavaria.
Article
Level of acuity and number of referrals for home health care have been escalating exponentially. As referrals continue to increase, health care organizations are encouraged to find more effective methods for providing high-quality patient care with cost savings. To evaluate the use of remote video technology in the home health care setting as well as the quality, use, patient satisfaction, and cost savings from this technology. Quasi-experimental study conducted from May 1996 to October 1997. Home health department in the Sacramento, Calif, facility of a large health maintenance organization. Newly referred patients diagnosed as having congestive heart failure, chronic obstructive pulmonary disease, cerebral vascular accident, cancer, diabetes, anxiety, or need for wound care were eligible for random assignment to intervention (n = 102) or control (n = 110) groups. The control and intervention groups received routine home health care (home visits and telephone contact). The intervention group also had access to a remote video system that allowed nurses and patients to interact in real time. The video system included peripheral equipment for assessing cardiopulmonary status. Three quality indicators (medication compliance, knowledge of disease, and ability for self-care); extent of use of services; degree of patient satisfaction as reported on a 3-part scale; and direct and indirect costs of using the remote video technology. No differences in the quality indicators, patient satisfaction, or use were seen. Although the average direct cost for home health services was $1830 in the intervention group and $1167 in the control group, the total mean costs of care, excluding home health care costs, were $1948 in the intervention group and $2674 in the control group. Remote video technology in the home health care setting was shown to be effective, well received by patients, capable of maintaining quality of care, and to have the potential for cost savings. Patients seemed pleased with the equipment and the ability to access a home health care provider 24 hours a day. Remote technology has the potential to effect cost savings when used to substitute some in-person visits and can also improve access to home health care staff for patients and caregivers. This technology can thus be an asset for patients and providers.
The main objective of G-7/8 Global Healthcare Applications sub-project 4 is to enable an international concerted action on collaboration in telemedicine. To promote and facilitate the implementation of telemedicine or health telematics networks around the world, it was felt necessary to solve certain key issues. Five thematic solution-seeking FORUMS are each addressing a specific item. The first FORUM held in Montréal, Canada on May 28-30 1998 focussed on Interoperability of telemedicine and telehealth systems. Other FORUMS address other themes such as: Impacts of Telemedicine on health care management (Regensburg, Germany, November 21-23 1998); Evaluation and Cost Effectiveness of Telemedicine (Melbourne, Australia, February 19-20 1999); Clinical and technical quality and standards (Washington, USA, April 29-30 1999); Medico-legal aspects of national and international applications (Oxford, UK, fall 1999). The main objective of these FORUMS is to arrive at best practices through consultation amongst experts who seek together the best solutions to facilitate global international telemedicine networks. Towards this goal, G-8 sub-project-4 will also conduct the IMPACT (International Multipoint Project of Advanced Communication in Telemedicine) feasibility study which will aim at conducting multipoint exchanges between telemedicine units in the academic centers of the participating G-8 and other countries. More detailed information on this project and summaries of the initial FORUMS are found on our Web site at www.g7sp4.org.
Article
Echocardiography is an important tool in the diagnosis and management of critically ill neonates. The authors hypothesized that live telemedicine guidance and interpretation of neonatal echocardiograms from underserved areas would improve management, prevent unnecessary transports, enhance sonographer proficiency, and result in monetary savings. Using personal computers capable of real-time transmission of echocardiograms over three integrated services digital network (ISDN) telephone lines, pediatric cardiologists interpreted echocardiograms, suggested views to sonographers, and made recommendations to neonatologists 200 miles away. Analyses of accuracy, management, echocardiogram quality, time, and costs were carried out prospectively. Sixty studies were transmitted over 7 months. Indications for echocardiography were suspected congenital heart disease (n = 29), suspected patent ductus arteriosus (PDA) (n = 27), and hemodynamic instability (n = 4). Diagnoses were critical congenital heart disease (n = 4), noncritical heart disease (n = 8), PDA (n = 21), ventricular dysfunction (n = 5), persistent pulmonary hypertension (n = 3), and normal (n = 19). Videotape review confirmed all telemedicine interpretations. The echocardiogram led to immediate change in management in 25 cases (42%), and echocardiogram quality was improved in 53 studies (88%). Time from request to completion of echocardiography was 43+/-30 min. Monetary savings from five avoided transports exceeded all expenses. Live transmission of neonatal echocardiograms over three ISDN lines is diagnostic, improves patient care and echocardiography quality, and is cost effective.
Article
To study the accuracy, patient satisfaction, and cost of telecardiographic evaluations of pediatric patients. Patients referred to a rural pediatric cardiology outreach clinic were examined in person by a pediatric cardiologist. A second pediatric cardiologist who had no knowledge of the findings of face-to-face examination reevaluated the same patients utilizing a 768-Kbps telemedicine system. Any additional testing was performed by personnel who had no knowledge of the face-to-face evaluation. The main outcome measures included the final cardiac diagnosis, frequency of additional tests such as electrocardiography, (ECG) echocardiography (ECHO), and patient satisfaction. The diagnosis was agreed upon in 19 of the 21 patients studied. Two patients with small ventricular septal defects were missed during the telemedicine evaluation. The utilization rates of additional studies for both the face-to-face cardiologist and the telemedicine cardiologist were not significantly different. Patient satisfaction with the telemedicine encounter was good. Telemedicine appears to be effective and useful for the cardiac evaluation of pediatric patients. In spite of high data-transfer rates, differences between telemedicine and face-to-face patient encounters were observed.
Article
Congenital fetal abnormalities are major causes of perinatal mortality and morbidity. The performance of ultrasound in the diagnosis and assessment of fetal anomalies varies enormously between tertiary referral centers and general units. Telemedicine offers a chance for tertiary realtime ultrasound consultations using standard telephone lines for remote sites. Preliminary investigations by our group have shown that real-time transmission of fetal ultrasound images over long distances via telephone (integrated systems digital network [ISDN]) lines is technically feasible. A live link of up to 2 Mb/s was established between Mater Mothers Hospital in Brisbane and Kirwan Hospital for Women in Townsville, which are 1,500 km apart. The objective of the current study was to evaluate the clinical value of a tertiary teleultrasound consultation service. Patients requiring tertiary ultrasound consultations were recruited from North Queensland. Clinicians from the referral site established an initial diagnosis and management plan. Using standard ISDN lines, the real-time ultrasound images were transmitted to the maternal fetal medicine subspecialists in Brisbane. The ultrasound examination was completed under the direction of the subspecialist. The subspecialist explained the findings to the patient at the end of the session, and discussed the diagnosis and management plans with the clinicians involved. Any diagnosis and management variations were classified into minor and major upon agreement by the two teams of clinicians involved. The clinicians and patients in Townsville rated the value of the consultation, and the subspecialists rated the confidence of their diagnoses on five-point scales. Pregnancy outcomes were obtained and the data analyzed. Over a 3-month period, 24 teleultrasound consultations were carried out. The indications for referral were: assessment of growth restriction/fetal wellbeing in the third trimester (6); detailed assessment for high-risk patients (5); evaluation of markers for anomalies (5); isolated fetal anomalies (1); and complex fetal problems such as twin/twin transfusion, multiple anomalies, etc. (7). Overall, the consultations resulted in some modifications to the clinical diagnosis in 45.8% of the cases, and modifications to the management plan in 33.3% of the cases (about half of which were minor variations). The clinicians rated the teleconsultations highly (mean rating 4.7, SD 0.44). The patients also rated the consultations highly, and were comfortable that their privacy and confidentiality were maintained during the consultation. The subspecialists were confident in making their diagnoses by telemedicine (mean score for confidence 4.2, SD 0.43). All the pregnancies have now been completed, with all antenatal diagnoses confirmed to be correct postnatally. Tertiary real-time ultrasound consultation by telemedicine is not only technically feasible, it is welcomed by the clinicians and patients involved. It also contributes to diagnostic and management differences. Larger scale clinical trials are needed to evaluate the true benefits and costs involved. The social benefits in bridging the healthcare gap between the country and the city, and in enabling patients in remote areas to stay close to their family under times of stress is well recognized by all involved.
Few laparoscopic surgical experts exist relative to the number of surgeons needing training in laparoscopic surgical techniques. This study tested application of telemedicine technology in the mentoring of surgeons during laparoscopic cholecystectomy. Our Surgical Telementoring Suite provided real-time audio and video telecommunication to the operating room. Data points for telementored laparoscopic cholecystectomy (TLC, n = 6) were compared to age and sex-matched controls having standard laparoscopic cholecystectomy (SLC, n = 6) with mentors physically present in the operating room. TLC data were also compared between cases performed with a staff surgeon and resident as mentorees (SRM, n = 3), versus two residents as mentorees (RRM, n = 3). Data were analyzed with chi-square testing. The level of statistical significance was set at p < 0.05. No major operative complications occurred in either group (p > 0.05). Total operative times were similar (92.2 +/- 18.4 minutes SLC vs. 94.7 +/- 25.3 minutes TLC, p > 0.05). Additional data compared between SRM and RRM groups included time to establishment of a pneumoperitoneum of 12-15 mm Hg (7.0 +/- 6.1 minutes SRM vs. 6.7 +/- 2.9 minutes RRM), time to placement of all four trocars (13.0 +/- 3.6 minutes SRM vs. 10.3 +/- 3.1 minutes RRM, time to isolation and proximal clipping of the cystic duct (38.0 +/- 12.1 minutes SRM vs. 55.7 +/- 29.0 minutes RRM), and time to removal of the gallbladder (77.3 +/- 25.4 minutes vs. 77.7 +/- 27.5 minutes RRM). For all data points, p > 0.05. We conclude that telementoring is a safe, effective method for teaching the techniques of LC. This is true for operating teams composed of surgical residents, with or without staff surgeons present.
Article
We carried out a prospective study of realtime videoconferencing in surgical consultations. Videoconferencing equipment at the Satakunta Central Hospital, Pori, was connected by ISDN at 384 kbit/s to two health centres in the cities of Kankaanpää and Huittinen (55 and 60 km from Pori, respectively). A document camera was used to transmit images of radiographs and paper documents. Fifty patients who needed a surgical consultation were examined by a doctor in the health centres, and the surgeon interviewed and observed the physical examination by videoconference. The consultation time ranged from 12 to 23 min (mean 15 min). Technically the equipment functioned reliably and the quality of the video-picture was good. According to the consulting surgeon, the decision made in the videoconference was reliable in 48 cases (96%). According to the doctors in the health centres, the consultation was useful in 49 cases (98%) and was considered satisfactory in one. The doctors thought that the teleconsultation was as reliable as an outpatient appointment in 49 cases (98%). The educational benefit of the consultation was excellent or good in 38 cases (76%). The overall satisfaction of patients was very good or good in 45 cases (96%). All patients, except one, avoided travelling to a face-to-face appointment because they received a definite treatment decision during the teleconsultation.
Article
Realtime teledermatology has been a routine service provided by the University Hospital of Tromsø to a primary-care centre in Kirkenes since 1989. The cost of the teledermatology service was compared with the costs of three alternative methods of treatment for the patients. The first was a combination of a visiting service and patient travel to hospital. The second was patient travel to the nearest secondary-care centre. The third was a locally employed dermatologist. At the actual 1998 workload of 375 patients, the total cost of teledermatology was NKr470,780, while the three alternatives cost NKr880,530, NKr1,635,075 and NKr958,660, respectively. Analysis of the unit costs showed that the realtime teledermatology service, including local phototherapy, was less costly than the three alternatives for annual workloads above 195 patients per year. A sensitivity analysis showed that the results were robust to changes in the assumptions about the cost structure.
Due to the time delay, intraoperative consultations result in an extension of operation times, leading to prolonged anesthesia and idle time during surgery. Using a remote controlled microscope for telepathology, transfer times between hospital and pathologist can be eliminated and pathological expertise obtained independently of the geographic location of the hospital. In cooperation with a community hospital located 100 km apart from the Institute of Pathology of the Justus Liebig University Giessen, telepathological intraoperative consultations have been performed since 1999. After preparation and staining of the cryosection in the hospital, the slide was examined in our institute using a remote-controlled microscope (Leica DMRXA) and a special telepathological software (Leica TPS1). Data were transferred via two ISDN connections in parallel. The telepathology system contains an additional macroscopic examination equipment. Up to now more than 40 telepathological consultations have been done. Time required for the microscopic diagnosis ranged between 4 and 25 minutes. The amount of time saved, compared to the transfer to the next available pathologist, was approximately 45 minutes. In our experience, telepathological diagnoses were fully in accordance with conventional diagnoses routinely performed afterwards. The application of telepathology can lead to a significant shortening of surgery time if a pathologist is locally not available. In the study presented, no diagnostic errors occurred. The additional application of a macroscopic equipment allows inspection and interactive guidance for sampling, thus preventing sampling errors.
Article
The aim of this study is to evaluate the cost savings of 3 years of telecardiology used in a prison. This study compares the cost per visit of providing cardiology services by telemedicine (telecardiology) to patients at Powhatan Correctional Center of the Virginia Department of Corrections (PCC) and the cost of providing traditional cardiology services at the cardiology clinic of the Medical College of Virginia Campus of Virginia Commonwealth University (MCV Campus). During 1996 to 1998, telecardiology visits increased from 24 per year to 86. In this study, lower use of telecardiology services in 1996 resulted in higher cost per visit of $189. This was $45 more than the cost of traditional cardiology in the cardiology clinic at the MCV Campus. In 1997 and 1998, however, higher utilization of telecardiology services decreased the cost per visit to $135 and $132, respectively. This resulted in a cost saving with telecardiology of $15 per visit in 1997 and $46 per visit in 1998. Because the vast proportion of telemedicine operating costs are fixed, increased utilization causes reduced cost per visit and results in a cost saving compared with providing these services via a non-telemedicine program.
Article
Rapid expansion of communication technology has permitted the clinician to perform a consultation with a patient located at a different site. Assuming adequate diagnostic accuracy, it could theoretically be possible to use telemedical techniques as a triage tool. Images of pigmented lesions sent by the primary care physician could be viewed by the consultant dermatologist, and those with banal lesions spared from attending clinic. Previous studies assessing diagnostic accuracy of images of lesions have used 'face-to-face' diagnoses as the 'gold standard'. We set out to compare diagnostic accuracy of image examination compared with that of clinical examination, using histological examination as the diagnostic benchmark. We found that pigmented lesions may be diagnosed as accurately by stored video image evaluation as by conventional clinical examination. None of the malignant skin tumours was misdiagnosed as benign in either group. Whilst these results are encouraging in terms of the clinical safety of store-and-forward imaging, the inability to examine the whole patient or to palpate the lesions may limit the acceptability of the technique severely. Further evaluation of the cost : benefit ratio of such a system to the health care provider must be undertaken before considering this technique as a potential adjunct to managing outpatient referrals.
Article
Over three and a half years there were 200 teleconsultations between emergency nurse practitioners at a minor accident and treatment service and the orthopaedic service of a main hospital. The main problems were fractures (93% of cases). The reasons for consultation fell almost equally into four groups: request for direct ward admission; discussion and decision about treatment; decision about the disposition of a case; and diagnosis. The technical quality of the majority of teleconsultations was considered satisfactory. Following the teleconsultation, 39% of patients were admitted to hospital, 6% were transferred to the accident and emergency department for a face-to-face consultation, and 56% were discharged and referred to a review clinic. Of the 200 cases, 193 needed teleradiology and the nurse practitioners and the orthopaedic registrars diagnosed all these cases correctly, as judged by the subsequent radiologist's report. Teleconsultations save time and prevent the unnecessary transfer of patients to main hospitals.
Article
Outpatient followup of rural trauma patients is problematic for physicians and patients. Our hypothesis was that telemedicine-based followup of trauma patients discharged to remote areas is feasible and is associated with high patient and physician satisfaction. We chose 11 counties in Kentucky surrounding a remote telemedicine site as our region of interest. Any adult trauma patient who was discharged from our Level I trauma center to this geographic region was eligible to have routine followup appointment(s) at the TeleTrauma Clinic. Patients were examined and interviewed with the assistance of a nurse, an electronic stethoscope, and a close-up imaging instrument. Radiographs performed at the telemedicine site were viewed. Patients and physicians completed a survey after the appointment. To date, we have conducted 22 telemedicine-based followup assessments of trauma patients. The average age and Injury Severity Score were 42 years and 18, respectively. Plain radiographs were reviewed in 13 cases. Our patient surveys indicated a high degree of satisfaction with the teleappointment. In 15 of 22 patients, no further clinical followup was arranged. The differences in travel distances and times for an appointment at the TeleTrauma Clinic versus an appointment at our Level I trauma center were significant. The average and median duration of the appointments was 14 minutes. All telemedicine encounters were done by two physicians, who recorded a high level of satisfaction. Our early experience with the outpatient followup of remote trauma victims by telemedicine is encouraging. Patient surveys indicate a high degree of satisfaction. As a result of our favorable experience, telemedicine-based followup may be expanded to other regions of Kentucky.
Article
During time-critical brain surgery, the detection of developing cerebral ischemia is particularly important because early therapeutic intervention may reduce the mortality of the patient. The purpose of this system is to provide an efficient means of remote teleconsultation for the early detection of ischemia, particularly when subspecialists are unavailable. The hardware and software design architecture for the multimedia brain function teleconsultation system including the dedicated brain function monitoring system is described. In order to comprehensively support remote teleconsultation, multi-media resources needed for ischemia interpretation were included: EEG signals, CSA, CD-CSA, radiological images, surgical microscope video images and video conferencing. PC-based system integration with standard interfaces and the operability over the Ethernet meet the cost-effectiveness while the modular software was customized with a diverse range of data manipulations and control functions necessary for shared workspace and standard interfaces.
Article
A randomized controlled trial was carried out to measure the cost-effectiveness of realtime teledermatology compared with conventional outpatient dermatology care for patients from urban and rural areas. One urban and one rural health centre were linked to a regional hospital in Northern Ireland by ISDN at 128 kbit/s. Over two years, 274 patients required a hospital outpatient dermatology referral--126 patients (46%) were randomized to a telemedicine consultation and 148 (54%) to a conventional hospital outpatient consultation. Of those seen by telemedicine, 61% were registered with an urban practice, compared with 71% of those seen conventionally. The clinical outcomes of the two types of consultation were similar--almost half the patients were managed after a single consultation with the dermatologist. The observed marginal cost per patient of the initial realtime teledermatology consultation was 52.85 Pounds for those in urban areas and 59.93 Pounds per patient for those from rural areas. The observed marginal cost of the initial conventional consultation was 47.13 Pounds for urban patients and 48.77 Pounds for rural patients. The total observed costs of teledermatology were higher than the costs of conventional care in both urban and rural areas, mainly because of the fixed equipment costs. Sensitivity analysis using a real-world scenario showed that in urban areas the average costs of the telemedicine and conventional consultations were about equal, while in rural areas the average cost of the telemedicine consultation was less than that of the conventional consultation.
Article
An assessment was undertaken of a routine telepsychiatry service in rural areas of a Canadian province as a follow-up to a pilot telepsychiatry project. Over two years, there were 546 consultations at the five participating general hospitals, although the level of use varied considerably between them. Health professionals expressed high satisfaction with the service. While there were equipment problems in 17% of all consultations in the second year, they did not seem to affect acceptance of the technique. A cost analysis comparing consultations provided by a visiting psychiatrist and telepsychiatry found a break-even point of 348 consultations a year. However, when use of the videoconferencing network for administrative meetings was considered, the break-even point was 224 consultations a year, substantially below the actual utilization of telepsychiatry. Telepsychiatry appeared to result in increased access to community mental health services, suggesting future increased demand for these. From the perspective of health authorities and health professionals, telepsychiatry proved to be a useful and sustainable addition to existing mental health services.
Article
Teleconsultations were performed between a health centre in a small Finnish town and a university hospital 55 km away. Telemedicine consultations were carried out with a total of 42 patients suffering from various eye and skin disorders. We evaluated the costs of the teleconsultations in the health centre and the conventional alternative of the patient travelling to the hospital. The cost of conventional consultations, which was not affected by the patient workload, was EU126 per patient for ophthalmology and EU143 per patient for dermatology. The cost of the teleconsultations per patient decreased as the number of patients increased. There were cost savings in relation to teleconsultations when the annual numbers of patients were more than 110 in ophthalmology and 92 in dermatology. Benefits and savings achieved through teleconsultations mainly consisted of reduced transportation costs and reduced paperwork both at the health centre and at the university hospital, as well as time savings for the patient. Another important benefit was improved medical education. The present study shows that teleconsultations can be performed in a cost-effective way in a relatively small health centre.
Telematik im Gesundheitswesen
  • C Goetz
  • Die
  • Herausforderung
Goetz C. Die Herausforderung " Telematik im Gesundheitswesen ". Bayer Ärzt 1999;10:23.
Datenschutz in der Arztpraxis
  • H Keller
  • Ärztliche
  • Schweigepflicht
Keller H. Ärztliche Schweigepflicht, Datenschutz in der Arztpraxis, Sicherheit der Praxis-EDV. Brochüre der Kassenärztlichen Vereinigung Bayerns, 2nd ed.
Wer haftet? Telemedizin—Haftun-gsrechtliche Risiken ohne Versicherungsschutz
  • K Schöne
Schöne K. Wer haftet? Telemedizin—Haftun-gsrechtliche Risiken ohne Versicherungsschutz. Man-agement Krankenh 1999;9:15–16.
Arztstrafrecht in der Praxis
  • K Ulsenheimer
Ulsenheimer K. Arztstrafrecht in der Praxis, 2nd ed. Heidelberg: Müller Verlag, 1998.