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Telehealth interventions for reducing waiting lists and waiting times for specialist outpatient services: A scoping review
Abstract
We undertook a scoping review of the published literature to identify and summarise key findings on the telehealth interventions that influence waiting times or waiting lists for specialist outpatient services. Searches were conducted to identify relevant articles. Articles were included if the telehealth intervention restructured or made the referral process more efficient. We excluded studies that simply increased capacity. Two categories of interventions were identified – electronic consultations and image-based triage. Electronic consultations are asynchronous, text-based provider-to-provider consultations. Electronic consultations have been reported to obviate the need for face-to-face appointments between the patient and the specialist in between 34–92% of cases. However, it is often reported that electronic consultations are appropriate in less than 10% of referrals for outpatient care. Image-based triage has been used successfully to reduce unnecessary or inappropriate referrals and was used most often in dermatology, ophthalmology and otolaryngology (ENT). Reported reduction rates for face-to-face appointments by specialty were: dermatology 38–88%, ophthalmology 16–48% and ENT 89%. Image–based triage can be twice as effective as non-image based triage in reducing unnecessary appointments. Telehealth interventions can effectively be used to reduce waiting lists and improve the coordination of specialist services, and should be considered in conjunction with clinical requirements.
... 2,3 Frequent follow-ups to adjust injection dosage and locations are preferred, but cause increased patient traveling burdens. [3][4][5] Since the COVID-19 pandemic, the implementation of telemedicine has expanded globally for social distancing and convenience. [4][5][6][7][8] While the accuracy of telemedicine physical examinations has been validated for many disorders, there has been no evidence on the e cacy of using telemedicine for detecting and monitoring facial dystonia. ...
... [3][4][5] Since the COVID-19 pandemic, the implementation of telemedicine has expanded globally for social distancing and convenience. [4][5][6][7][8] While the accuracy of telemedicine physical examinations has been validated for many disorders, there has been no evidence on the e cacy of using telemedicine for detecting and monitoring facial dystonia. 3,[9][10][11][12][13][14][15][16] This study aimed to investigate the reliability and usability of telemedicine evaluations for facial dystonia compared to in-person evaluation by neuro-ophthalmologists. ...
... Telehealth saves me time travelling to a hospital or specialist clinic. 5 I think the visits provided over the telehealth system are the same as in-person visits. 4 7 6.45 0.81 ...
This study aimed to investigate telemedicine reliability and usability for facial dystonia. Eighty-two telemedicine recordings from 43 adults with blepharospasm (12,27.9%) and hemifacial spasm (31,72.1%) were obtained (mean age 64.5+9.3 years, 32 female (64.4%)). Two recorded in-hospital telemedicine visits were arranged on the same day as in-person visits at baseline and 4-6 weeks. The third non-recorded home-based telemedicine visit was held 2 days prior to the third in-person visit at 12-14 weeks. After 8 weeks, the neuro-ophthalmologists who performed the in-person visits also evaluated the telemedicine videos records. Spasm gradings by Jankovic Rating Scale (low, grades 0-2; high, grades 3-4), signs and symptoms indicating botulinum toxin complications were collected. Intra-rater agreements in assessing spasm gradings were moderate (severity: kappa=0.42, 95%CI 0.21 to 0.62, frequency: kappa=0.41, 95%CI 0.21 to 0.61) with substantial agreement in detecting lagophthalmos (kappa=0.61, 95%CI 0.36 to 0.86). Adding symptoms to signs increased sensitivity and negative predictive value in detecting lagophthalmos (66.7% to 100% and 94.3% to 100%) and drooping lips (37.5% to 75% and 93.6% to 96.4%), respectively. High mean usability score of 6.5(SD0.8) out of 7 was determined by “Thai version Telehealth Usability Questionnaire.” Therefore, telemedicine could be an alternative platform to evaluate facial dystonia.
... 2,3 Frequent follow-ups to adjust injection dosage and locations are preferred but necessitate increased patient traveling burdens. [3][4][5] Since the COVID-19 pandemic, the implementation of telemedicine has expanded globally for social distancing and convenience. [4][5][6][7][8] While the accuracy of telemedicine physical examinations has been validated for many disorders, there has been no evidence on the efficacy of using telemedicine for detecting and monitoring facial dystonia. ...
... [3][4][5] Since the COVID-19 pandemic, the implementation of telemedicine has expanded globally for social distancing and convenience. [4][5][6][7][8] While the accuracy of telemedicine physical examinations has been validated for many disorders, there has been no evidence on the efficacy of using telemedicine for detecting and monitoring facial dystonia. 3,[9][10][11][12][13][14][15][16] This study aimed to investigate the reliability and usability of telemedicine evaluations for facial dystonia compared to in-person evaluation by neuro-ophthalmologists. ...
This study investigated telemedicine reliability and usability in evaluating facial dystonia grading and treatment complications. Eighty-two telemedicine recordings from 43 adults with blepharospasm (12, 28%) and hemifacial spasm (31, 72%) were obtained (mean age 64.5 ± 9.3 years, 32 females [64%]). Two recorded in-hospital telemedicine visits were arranged with in-person visits at baseline and 4–6 weeks. After 8 weeks, neuro-ophthalmologists who performed the in-person visits re-evaluated the telemedicine video records. Intra-rater agreements in assessing spasm gradings were moderate (severity: kappa = 0.42, 95% confidence interval [CI] 0.21–0.62; frequency: kappa = 0.41, 95% CI 0.21–0.61) with substantial agreement in detecting lagophthalmos (kappa = 0.61, 95% CI 0.36–0.86). Adding symptoms to signs increased sensitivity and negative predictive value (NPV) in detecting lagophthalmos (67%–100% and 94%–100%) and drooping lips (38%–75% and 94%–96%), respectively. Thai version Telehealth Usability Questionnaire showed high mean usability score of 6.5 (SD 0.8) out of 7. Telemedicine could further be developed as an alternative platform to evaluate facial dystonia.
... In fact, the waiting time data from 2023 revealed that, although direct evidence on waitlist reduction is lacking, a comparison with other geographically related tertiary hospitals without the use of telemedicine, indicated promising outcomes (18). Moreover, while the NHS in the UK aims to decrease inperson visits over the next five years, previous studies indicate that 34%-92% of specialist referrals did not require face-to-face appointments, and 27% of these referrals may not occur without this form of consultation (19,20). ...
... Interestingly, the allergist's expertise is a key factor; those with less experience or a heavier daily workload tend to schedule more in-person appointments. A noticeable gap in current literature is the absence of comprehensive studies that systematically compare outcomes, including time differences, between telehealth and traditional inperson healthcare (5,20). While telemedicine may not necessarily save specialist time, it does mitigate the necessity for patients to travel. ...
In Spain, specialist outpatient care traditionally relied on in-person consultations at public hospitals, leading to long wait times and limited clinical analysis in appointment assignments. However, the emergence of Information and Communication Technologies (ICTs) has transformed patient care, creating a seamless healthcare ecosystem. At the Allergy Department, we aimed to share our experience in transitioning form a traditional linear model of patient flow across different healthcare levels to the implementation of a digital ecosystem. By telemedicine, we can prioritize individuals based on clinical relevance, promptly and efficiently addressing potentially life-threatening conditions such as severe uncontrolled asthma or hymenoptera venom anaphylaxis. Furthermore, our adoption of telephone consultations has markedly reduced the need for in-person hospital visits, while issues with unstable patients are swiftly addressed via WhatsApp. This innovative approach not only enhances efficiency but also facilitates the dissemination of personalized medical information through various channels, contributing to public awareness and education, particularly regarding allergies. Concerns related to confidentiality, data privacy, and the necessity for informed consent must thoroughly be addressed. Also, to ensure the success of ICT integration, it is imperative to focus on the quality of educational information, its efficient dissemination, and anticipate potential unforeseen consequences. Sharing experiences across diverse health frameworks and medical specialties becomes crucial in refining these processes, drawing insights from the collective experiences of others. This collaborative effort aims to contribute to the ongoing development of a more effective and sustainable healthcare system.
... Studies about email consultations and time in health care settings have primarily been concerned with the evaluation of digital tools, time pressure and effectiveness (Cowie et al., 2018), workloads (Drennan, 2018;Farr et al., 2018), waiting time (Caffery et al., 2016), improved access (Assing Fagerlund et al., 2019;Keely et al., 2013;Nijland et al., 2009) and coherence (Parikh et al., 2017). For instance, the potential of email consultations to offer a more timely and convenient method of accessing outpatient services has been recognized and discussed, as an additional method of accessing GP services with the potential to improve patients' self-management. ...
... However, some studies have shown that using email consultations has increased rather than decreased practice workloads, although some patients use email consultations to try to save their own and/or their GPs' time (Farr et al., 2018;Lichtner et al., 2013). Other studies have shown that email consultations from provider to provider can be used effectively to reduce waiting lists and waiting times for specialist outpatient services (Caffery et al., 2016). ...
In this study, we discuss how email consultations in general practice operate as a temporal technology, transforming working conditions and power relations between general practitioners (GPs) and patients. We draw on empirical material from Denmark in the form of a set of 68 semi-structured interviews with patients aged 65 + and two focus group discussions with 17 GPs. Our theoretical point of departure stems primarily from media theorist Sarah Sharma's (2014) concept of power-chronography, which describes how power is embedded in temporal relations and everyday life and secondarily from sociologist, Judy Wajcman's (2015) concept of multiple temporal landscapes. Patients and GPs calibrate their own time and attune their mutual time according to their expectations and ideas about the other party's time. The patient and the GP can both be viewed as 'time workers' and the email consultation as a digital technology fostering the recalibration of one person's time to that of another, requiring significant labour. The email consultation rearranges the GP-patient boundaries and thereby the power relations. Health institutions ought to consider whose time and labour is being 'saved' with digital systems.
... 16 Dental professionals can reduce patient interaction before acting by using teledentistry. 17 The dentist who is concerned about patient who have COVID-19, can find employing remote evaluation helpful. Subdivisions of teledentistry with significant roles in dental practice include teleconsultation, tele-diagnosis, teletriage, and telemonitoring. ...
... 31,32 Teledentistry is an effective method for screening the patient's health condition previous to an in person dental consultation. 16,17 Using teledentistry for consultations before patients reach dental facilities in a pandemic situation should be incorporated for both, dentists and patients' safety. ...
Background: The COVID-19 pandemic has grown to be a serious issue on a global scale. Dental care is one of the industries affected by COVID-19. The surveillance utilizing lifetime data, however, is still not clear. The purpose of this study was to use Google Trends (GT) analysis to examine symptom trends and challenges during the COVID-19 outbreak in Indonesia.
Methods: Covid-19 cases retrieve from Our World in Data. The cases were collected between 1 April 2021-30 September 2021. The GT was used to discover Indonesian relative search volume (RSVs) covering the timeframe of the first outbreak covid-19 pandemic in Indonesia on 1 March 2020 until 13 February 2022. The duration of the search was chosen to reflect the relative popularity of the keywords "symptoms and dentistry practice challenge-related terms" and "coronavirus". Results: We observed that there was a significant and positive correlation between the COVID-19 daily case using GT RSV data and the COVID-19 case from Our World in Data. The COVID-19 daily case had a strong correlation with search terms related to symptoms (such as fever, sore throat, flu, toothache, and cough), drugs (such as ibuprofen, paracetamol, demacolin, bodrex, and antibiotic), and health management (such as self-isolation and telemedicine).
Conclusion: Using GT may be helpful to observe the current symptoms trends as well as its challenge tendencies as a surveillance tool for a continuing pandemic like COVID-19. GT should be considered and used as it has the potential to be a powerful digital epidemiology tool that can provide more insight into disease dynamics.
... 16 Dental professionals can reduce patient interaction before acting by using teledentistry. 17 The dentist who is concerned about patient who have COVID-19, can find employing remote evaluation helpful. Subdivisions of teledentistry with significant roles in dental practice include teleconsultation, tele-diagnosis, teletriage, and telemonitoring. ...
... 31,32 Teledentistry is an effective method for screening the patient's health condition previous to an in person dental consultation. 16,17 Using teledentistry for consultations before patients reach dental facilities in a pandemic situation should be incorporated for both, dentists and patients' safety. ...
Background: The COVID-19 pandemic has grown to be a serious issue on a global scale. Dental care is one of the industries affected by COVID-19. The surveillance utilizing lifetime data, however, is still not clear. The purpose of this study was to use Google Trends (GT) analysis to examine symptom trends and challenges during the COVID-19 outbreak in Indonesia.
Methods: Covid-19 cases retrieve from Our World in Data. The cases were collected between 1 April 2021-30 September 2021. The GT was used to discover Indonesian relative search volume (RSVs) covering the timeframe of the first outbreak covid-19 pandemic in Indonesia on 1 March 2020 until 13 February 2022. The duration of the search was chosen to reflect the relative popularity of the keywords "symptoms and dentistry practice challenge-related terms" and "coronavirus". Results: We observed that there was a significant and positive correlation between the COVID-19 daily case using GT RSV data and the COVID-19 case from Our World in Data. The COVID-19 daily case had a strong correlation with search terms related to symptoms (such as fever, sore throat, flu, toothache, and cough), drugs (such as ibuprofen, paracetamol, demacolin, bodrex, and antibiotic), and health management (such as self-isolation and telemedicine).
Conclusion: Using GT may be helpful to observe the current symptoms trends as well as its challenge tendencies as a surveillance tool for a continuing pandemic like COVID-19. GT should be considered and used as it has the potential to be a powerful digital epidemiology tool that can provide more insight into disease dynamics.
... Apart from providing eye care, teleophthalmology has been proven helpful for disease screening by non-ophthalmologists. Most importantly, its significance in resource-limited regions of developing countries has been reported by studies and in rural and underserved populations worldwide [11][12][13][14][15]. However, there are various factors influencing the acceptance of teleophthalmology at a larger scale in various countries of the world [6,[15][16][17]. ...
... • Efficiency and suitability: Teleophthalmology is efficient and well suited for eye diseases where digital imaging systems are beneficial for diagnosis and intervention[8][9][10]. • Short examination time: It allows for quicker examinations, enabling non-ophthalmologists to screen eye diseases effectively[9][10][11]15].•Cost-effectiveness and accessibility: Teleophthalmology is cost-effective, accessible, reliable, and time-efficient, especially in rural areas where expert ophthalmologists may not be readily available[9,14,[107][108][109][110]. • Reduced transportation costs: It helps reduce transportation costs for rural residents who would otherwise need to travel long distances to visit an eye specialist. ...
Technological advancement has brought commendable changes in medicine, advancing diagnosis, treatment, and interventions. Telemedicine has been adopted by various subspecialties including ophthalmology. Over the years, teleophthalmology has been implemented in various countries, and continuous progress is being made in this area. In underserved populations, due to socioeconomic factors, there is little or no access to healthcare facilities, and people are at higher risk of eye diseases and vision impairment. Transportation is the major hurdle for these people in obtaining access to eye care in the main hospitals. There is a dire need for accessible eye care for such populations, and teleophthalmology is the ray of hope for providing eye care facilities to underserved people. Numerous studies have reported the advantages of teleophthalmology for rural populations such as being cost-effective, timesaving, reliable, efficient, and satisfactory for patients. Although it is being practiced in urban populations, for rural populations, its benefits amplify. However, there are certain obstacles as well, such as the cost of equipment, lack of steady electricity and internet supply in rural areas, and the attitude of people in certain regions toward acceptance of teleophthalmology. In this review, we have discussed in detail eye health in rural populations, teleophthalmology, and its effectiveness in rural populations of different countries.
... [13][14][15]17,18 Others have shown the effectiveness of telehealth in improving access for patients living in remote and rural areas to ear-health services. [19][20][21][22][23] Telehealth has been also shown to be an effective intervention for reducing waiting times to access different outpatient specialist services including ENT. 24 Telehealth has recently gained global recognition since healthcare provision became more restricted amid the outbreak of COVID-19, with outpatient consultations being one of the main settings where telehealth was most commonly implemented. 25 Whilst employing telehealth to expedite access to ENT specialists for patients living in rural and remote was the focus of previous studies, telehealth may also help improve access to ENT specialists in metropolitan areas where current service provision is also limited. ...
... These timeframes are usually difficult to adhere to in public hospitals in Australia, as the number of referrals often exceeds the specialists' capacity. 12,14,15,17,24 The median waiting time for receiving a diagnosis and care plan by the MDT in the Ear Portal service was 28 days, which is within the clinically recommended timeframes. Only one child (1.2%) in the Ear Portal group had to wait longer than these timeframes, compared to 80% of children in the Standard Healthcare group. ...
Introduction:
Shortage of ear, nose, and throat specialists in public hospitals can result in delays in the detection and management of otitis media. This study introduced a new hospital-based telehealth service, named the Ear Portal, and investigated its role in improving access to specialist care.
Methods:
The study included 87 children (aged 6 months to 6 years) referred to a tertiary children's hospital due to otitis media-related concerns. A specialist multidisciplinary team met fortnightly to review pre-recorded data and provide care plans.
Results:
The service resulted in a median waiting time of 28 days to receive a diagnosis and care plan by the multidisciplinary team, compared to a mean waiting time of 450 days for a reference group receiving standard healthcare services. Most children (90.3%) received bilateral ear diagnosis. Normal findings were found in 43.9%. However, the majority required further ear, nose, and throat with or without audiology face-to-face follow-up due to a diagnosis of middle-ear disease, unknown hearing status, or concerns not related to ears. The mean time required for clinical assessments completion by research assistants and multidisciplinary team review was 37.6 and 5.1 min per participant, respectively.
Discussion:
Children in the Ear Portal service received a diagnosis and care plan in a median of 28 days, which is within the clinically recommended timeframes. With sufficient clinical information, this service can provide faster access to specialist care than the standard healthcare pathway. The service can reduce the time required by the specialist to provide a diagnosis and care plan which may help increase the specialists' capacity.
... One study found that hospitalized patients with heart failure who received an outpatient follow-up either via telemedicine or in-person had a lower 30-day readmission rate than those who received no follow-up [12]. Telehealth has reduced wait times for appointments and may increase clinician visit frequency, which may help improve medication adherence [13]. However, to our knowledge, no study has examined the potential impact of the type of visits on medicine adherence among patients with heart failure using electronic medical records. ...
Background
Despite the exponential growth in telemedicine visits in clinical practice due to the COVID-19 pandemic, it remains unknown if telemedicine visits achieved similar adherence to prescribed medications as in-person office visits for patients with heart failure.
Objective
Our study examined the association between telemedicine visits (vs in-person visits) and medication adherence in patients with heart failure.
Methods
This was a retrospective cross-sectional study of adult patients with a diagnosis of heart failure or an ejection fraction of ≤40% using data between April 1 and October 1, 2020. This period was used because New York University approved telemedicine visits for both established and new patients by April 1, 2020. The time zero window was between April 1 and October 1, 2020, then each identified patient was monitored for up to 180 days. Medication adherence was measured by the mean proportion of days covered (PDC) within 180 days, and categorized as adherent if the PDC was ≥0.8. Patients were included in the telemedicine exposure group or in-person group if all encounters were video visits or in-person office visits, respectively. Poisson regression and logistic regression models were used for the analyses.
Results
A total of 9521 individuals were included in this analysis (telemedicine visits only: n=830 in-person office visits only: n=8691). Overall, the mean age was 76.7 (SD 12.4) years. Most of the patients were White (n=6996, 73.5%), followed by Black (n=1060, 11.1%) and Asian (n=290, 3%). Over half of the patients were male (n=5383, 56.5%) and over half were married or living with partners (n=4914, 51.6%). Most patients’ health insurance was covered by Medicare (n=7163, 75.2%), followed by commercial insurance (n=1687, 17.7%) and Medicaid (n=639, 6.7%). Overall, the average PDC was 0.81 (SD 0.286) and 71.3% (6793/9521) of patients had a PDC≥0.8. There was no significant difference in mean PDC between the telemedicine and in-person office groups (mean 0.794, SD 0.294 vs mean 0.812, SD 0.285) with a rate ratio of 0.99 (95% CI 0.96-1.02; P =.09). Similarly, there was no significant difference in adherence rates between the telemedicine and in-person office groups (573/830, 69% vs 6220/8691, 71.6%), with an odds ratio of 0.94 (95% CI 0.81-1.11; P =.12). The conclusion remained the same after adjusting for covariates (eg, age, sex, race, marriage, language, and insurance).
Conclusions
We found similar rates of medication adherence among patients with heart failure who were being seen via telemedicine or in-person visits. Our findings are important for clinical practice because we provide real-world evidence that telemedicine can be an approach for outpatient visits for patients with heart failure. As telemedicine is more convenient and avoids transportation issues, it may be an alternative way to maintain the same medication adherence as in-person visits for patients with heart failure.
... digital health applications has provided opportunities to address barriers to health services [13][14][15][16]. These services can reduce long waiting times, improve access for those with mobility challenges, lower the cost of care, and reduce the need for travel in rural and remote areas [17][18][19][20][21][22]. However, digital literacy is essential to access and benefit from virtual healthcare services [23,24]. ...
Rationale
Emerging digital technologies are accelerating the transition of healthcare services from traditional in‐person settings to virtual platforms. As a result, digital literacy is becoming essential for individuals to effectively engage with these services. However, inadequate digital literacy poses a significant barrier to both accessing and utilising virtual healthcare, potentially widening existing health disparities.
Aims and Objectives
This protocol outlines the approach for systematically reviewing and synthesising the existing literature on the influence of digital literacy on accessing and utilising virtual healthcare services.
Methods
A comprehensive literature search will be conducted across five databases: Web of Science, Medline, Scopus, CINAHL and IEEE Xplore, covering publications from 2014 to 2024. The review will include all age cohorts and demographics, focusing on studies that examine digital literacy and measures of access to and utilisation of virtual healthcare services. Two independent reviewers will screen studies using pre‐determined search strategies for inclusion.
Conclusion
Findings from this study will provide valuable insights into the challenges and facilitators of digital literacy in engaging with virtual healthcare services. This review will also offer evidence‐based recommendations to optimise digital health interventions and promote inclusive, equitable healthcare delivery.
... Caffery et al., Hickey et al., and Almathami et al. also discovered that the implementation of telehealth services was reported to be beneficial for patients because it reduced travel time and expenses, which were found to be the major hindrances to in-person consultations for the participants of this study regardless of the location of their physician/wheelchair assessor. [13][14][15] Despite the previous research done on the benefits of telehealth consultations for patients, researchers have also identified potential barriers to experiencing the benefits that may come with telehealth services. In other countries, it has been discovered that the major issue for patients engaging in telehealth consultations revolves around internet connectivity issues, resistance to technology, and difficulty expressing self and symptoms over a virtual platform. ...
Background. The Philippine General Hospital (PGH) is a tertiary government hospital that serves as the national referral center for Filipinos from across the country. In partnership with Latter-Day Saint Charities (LDSC), PGH has been serving patients in need of mobility devices, such as wheelchairs, through in-person services from screening to assessment, measurement, assembly, fitting, and mobility training. Given the patients’ barriers to in-person follow-up consultations, regular healthcare provision has been challenging. The use of telerehabilitation, a form of telemedicine, has emerged as a practical and innovative solution, but it needs further evaluation. Objectives. The study aimed to determine the wheelchair recipients’ perceived barriers to in-person and virtual follow-up consultations. Methods. This cross-sectional study involved a purposive sample of 413 patients who received a wheelchair from the LDSC through PGH. An original survey was prepared to determine patients’ perceived barriers to actual in-person and potential virtual follow-up consultations Consent was obtained prior to data collection. After the pretest and pilot testing were conducted, the final version of the survey was administered either electronically or through individual phone interviews. Descriptive statistics was used to analyze and present the data. Results. A total of 113 wheelchair recipients participated, with an average of 42.9 years of age. The majority resided outside Metro Manila (53.1%), and 86.7% were within the income bracket of less than PhP 9,520 per month. The majority received a standard type of wheelchair (85.8%). The top 3 reasons hindering compliance to in-person consultation follow-ups were accessibility issues (82.3%), costs of travel (79.6%), and distance to hospital/wheelchair assessor (71.7%). With respect to potential virtual follow-ups, 72% expressed willingness to experience telemedicine/ telerehabilitation in the future, despite having neither prior awareness (50.4%) nor experience (74.3%) of it. The majority had access to mobile phones (98.2%), and 67% had stable internet access. Conclusion. The main barriers to in-person follow-ups were related to accessibility, costs, and travel. Telehealth or telerehabilitation in particular, despite patients’ interest and willingness to try it, still has yet to be optimized in our country. Internet connectivity can still be improved, as well as our stakeholders’ level of telehealth awareness. Future efforts to improve and sustain the uptake of telehealth solutions are recommended, as well as studies comparing the cost-effectiveness of in-person versus virtual consultations especially among persons with lived experiences of disability.
... 20 Furthermore, the use of tele-triage to evaluate if specialist care is needed has been shown to cut costs by reducing the number of hospital visits 21 and unnecessary specialist outpatient appointments. 22 Effective tele-triage requires well-designed training in evidence-based protocols. 23 A tele-provider performing triage without a standard operating protocol (SOP) or not being trained in using one can lead to significant practice variation and limit service effectiveness. ...
India's free-to-use National Telemedicine Service, eSanjeevani, has provided over 276 million consultations and shown promise to reduce systemic inequalities in access to care. However, recent reports of dropping footfall have raised questions about the potential of eSanjeevani to bridge service provision gaps in India. We reveal important problems linked to the design and practice of triage and tele-referral nationally within eSanjeevani, corroborated by the experience of one of the co-authors' practice of Obstetrics and Gynaecology on the platform since 2022. Some of these factors include sub-optimal integration of general practitioners within the tele-referral pathway; inadequate training of health-workers leading to inappropriate and ineffective consultations; outdated or absent technological support; the absence of mechanisms for re-referrals; and lack of feedback loops. We propose measures to re-imagine eSanjeevani to become a more effective tool towards improving public health outcomes and achieving universal health coverage in India.
... This is particularly beneficial for patients living in rural and remote areas, who might find it burdensome to travel long distances to receive treatment (Butzner & Cuffee, 2021). Studies have also shown that virtual care can reduce the wait times for outpatient services (Caffery et al., 2016;Mahmoud et al., 2021;Uscher-Pines et al., 2020;Valentine et al., 2021). Additionally, the option to seek care from home can mitigate the stigma associated with accessing mental health treatments (Kim et al., 2022;Kim & Tesmer, 2021;Philip et al., 2022). ...
Mental health and substance use disorders affect the lives of many people worldwide. Prevention and treatment of these conditions is important for optimal health and wellbeing, yet service access barriers are common. Virtual models of care may help to reduce barriers to receiving care. However, to facilitate uptake and use of virtual services, they need to appeal to patients and clinicians. This systematic review aimed to synthesise preference elicitation studies to determine what features of virtual mental health and substance use care are preferred by service users and service providers. Following the PRISMA guidelines for systematic reviews, we searched PubMed, PsycINFO, EconLit, MEDLINE, CINAHL, Academic Search Ultimate, and ProQuest Central for all available studies from database inception until May 2023. The Mixed Methods Appraisal Tool was used to assess the methodological quality of included studies. Nineteen studies met the eligibility criteria. However, none examined preferences for elements of different models of virtual care. Across the included studies, we identified 41 unique features that mapped to four themes of mental health and substance use care (‘service’, ‘treatment’, ‘clinician’ and ‘additional supports’). Participant preferences were for individual, in-person, effective, flexible, and low-cost treatment. These preferences varied based on demographic factors, such as culture, gender, and participant type (e.g., patients, clinicians, general population). A user-centred approach should be adopted when designing and implementing mental health and substance use services. While preferences for features of mental health and substance use services more broadly are known, preferences for different models of virtual care remain unexplored. Future research should examine what features of virtual services would lead to optimal uptake and use across different users and stakeholders.
... Specifically, teleconsultations have consistently shown to reduce unnecessary in-person specialist appointments.For instance, Eldon Taylor and al. [4] evaluated a telepsychiatric consultation model, reporting statistically significant reductions in admissions and average length of stay post-implementation. Dermatology consultations reported reductions ranging from 38 to 88%, ophthalmology from 16 to 48%, and ENT (Otolaryngology) up to 89% [5]. ...
Introduction
Telemedicine encompasses all medical practices that allow patients to be remotely cared for through new information and communication technologies. This study aims to assess the remote management of patients consulting emergency services and not requiring in-hospital care during both pre-pandemic and pandemic periods of COVID-19.
Methods
This was a prospective, randomized, controlled study. The telemedicine group received follow-up at home after emergency room discharge according to a predefined protocol, with telephone calls on days 2, 7, 15, and 30. The control group received standard care without regular telephone follow-up (only a call on day 30). The study was conducted with patients consulting the emergency department of FarhatHached Hospital in Sousse. Patient inclusion occurred between November 1, 2019, and April 30, 2020. The primary outcome measures were the re-consultation rate and treatment adherence. The secondary outcome measure was patient satisfaction.SPSS version 23.0 for Windows was used for data analysis. Descriptive statistics calculated frequencies, percentages, means, standard deviations, medians, and range. Analytical study involved Student’s t-test and Pearson chi-square test for mean and frequency comparisons, respectively. Significance threshold (p) for all tests was set at 0.05.
Results
A total of 400 patients were included. The average age of patients was 40 years. Both groups were comparable in terms of demographics and clinical characteristics. Diagnoses included mainly benign infectious diseases, trauma, mild decompensations of chronic conditions (asthma, COPD, heart failure), and suspected COVID cases. Patients in the telemedicine group tended to reconsult less in the month following their initial emergency room visit (14% versus 26.5%) (p = 0.004). There was a significant difference in treatment adherence between the telemedicine group and the control group (97.5% versus 92%; p = 0.014). The satisfaction with telemedicine was higher than satisfaction with regard to an in-person consultation at the emergency department (90% versus 37.5%).
Conclusion
It is necessary to implement telemedicine in Tunisia, especially in emergency services. It ensures better remote patient care by reducing re-consultation rates, increasing treatment adherence, and improving patient satisfaction.
... Telemedicine might be effective for triage but not for all nail patients nor for procedures, with up to 6-10 weeks shorter wait time in other specialties and a 38-88% reduction in need for a subsequent in-person appointment in dermatology [5]. We corroborate these studies, with an almost 7-week shorter wait time for a new patient telemedicine vs in-person visit. ...
... Research efforts focused on developing effective non-pharmacological interventions such as technology-based solutions to address the long waiting for specialist appointments hold promise for providing accessible and evidence-based options for families [81]. Specifically designed sleep apps for children provide educational resources and behavioural advice such as relaxation exercises, guided meditations, and bedtime stories, with gamification elements enhancing the patients' engagement [82][83][84]. ...
Long outpatient waiting times pose a significant global challenge in healthcare, impacting children and families with implications for health outcomes. This paper presents the eHealth system called eADVICE (electronic Advice and Diagnosis Via the Internet following Computerised Evaluation) that is designed to address waiting list challenges for paediatricians. Initially designed for children’s incontinence, the system’s success in terms of health goals and user experience led to its adaptation for paediatric sleep problems. This paper focuses on user experiences and the development of a working alliance with the virtual doctor, alongside health outcomes based on a randomised controlled trial (N = 239) for incontinence. When reengineering eADVICE to sleep disorders, the promising results regarding the reciprocal relationship between user experience and building a working alliance encouraged a focus on the further development of the embodied conversational agent (ECA) component. This involved tailoring the ECA discussion to patient cognition (i.e., beliefs and goals) to further improve engagement and outcomes. The proposed eADVICE framework facilitates adaptation across paediatric conditions, offering a scalable model to enhance access and self-efficacy during care delays.
... has forced nations to consider the use of digital health, such as telehealth and e-health, which can contribute to the management of communicable diseases during the pandemic and possibly slow the infection rate of COVID-19 through supporting social distancing [31]. Digital health technologies provide and improve patients' health, and reduces expenses and as well as the need for care facilities [32]. Telemedicine and mobile care tele-mentoring, tele critical care were significantly useful to offer care facilities during COVID-19 [33]. ...
COVID-19 is a global pandemic, with the highest rates in the US [1]. Many countries have enforced lockdown and social distancing as a process to control the epidemic [2]. Despite such stringent global efforts, the numbers of cases are again continuing to rise [3], and all aspects of society are being impacted [4]. The cases of COVID-19 in South Asian are comparatively less than developed countries, even though poor health care facilities are available [5]. Internationally, health authorities and governments are warning older people (those over 65 years old) of the high risk of negative outcomes associated with COVID-19 [6]. Older people and those with dementia are at high-risk of COVID-19 due to their age and multiple comorbidities. An important element to consider is that people with dementia may have limited access to information on COVID-19 and experience difficulties in applying safety strategies (social isolation, self-quarantine measures, wearing masks, and personal hygiene). Therefore, people with dementia may be more dependent on family members and social caregivers to support them [7] to live within government guidelines. This is further impounded by the provision of information through social media and the implementation of digital health technologies. Older people with dementia living in residential settings have not been able to engage with their family members due to the banning of visitors and with the cessation of group activities [8], older people, and those with dementia, are becoming further isolated [9]. The consideration of the impact of COVID-19 on older people and those with dementia is essential due to the aging global population [10]. The global population of those over 65 years of age was estimated to be over 562 million in 2012, and the population of older adults rose by 55 million in 2015, which is projected to be double by 2050 [11]. Cognitive impairment is common in the older population, although is not a natural part of ageing [12]. The cognitive function of an individual may decrease with age, but mild cognitive impairment and dementia impacts on the person's ability to independently complete their own activities of daily living, as well as impacting on their memory , language, and orientation. Recent studies showed that the use of computer helped in cognitive stimulation and improved cognitive function with mild cognitive impairment of elderly people [45]. The combined intervention of digital inclusion and physical exercise helped to prevent cognitive and
... One specific example lies in the potential application of telemedicine interventions to address the challenge of long waiting lists and specialist consultations. Research demonstrates that strategically implemented telemedicine projects can effectively mitigate this issue while upholding service excellence [44]. ...
Objectives
To analyze Organization for Economic Cooperation and Development (OECD) indicators for the Health Systems of Costa Rica, Spain, and Italy, focusing on year-to-year changes.
Study design and methods
Examining each country’s healthcare systems utilizes a value-for-money approach, aiming to outline their healthcare expenditures relative to the OECD average, while also assessing the value obtained from these investments. This involves contrasting reported indicator values for each country and the OECD average during a year close to the last decade’s outset (year 1) with data around 2020 (year 2).
Results
Results obtained are based on different indicators and the countries being examined. Costa Rica stood out with lowest healthcare investment, while Chile had the less population coverage for a set core of services. Italy and Spain achieved 100% healthcare coverage. All four regions reported decreased tobacco consumption in terms of non-medical determinants of health. Costa Rica showcased the highest vaccination coverage and experienced the most significant increase in this aspect within healthcare utilization. In the context of resource accessibility, waiting times from specialist assessment to treatment increased the most for hip replacement procedures in Chile, Costa Rica, Italy, and Spain. The Pharmaceutical Consumption analysis highlighted agents acting on the Renin-Angiotensin system as the most widely consumed category.
Conclusion
This analysis helps reveal the workings of diverse health systems, allowing us to pinpoint areas for potential improvement within each region. By examining the achievements and obstacles faced by other nations, policymakers and healthcare stakeholders acquire a valuable foundation on which to enact reforms.
... (13) By providing a range of functions that address different facets of diabetes management, these technologies have upended the status quo. (Caffery et al., 2016)13 This real-time information enables patients to make wise decisions and lifestyle changes that improve glycemic control. The simplicity of tracking has made diabetic self-management more approachable and individualised than it was previously. ...
1) Cardiovascular disease is the leading cause of mortality as well as morbidity globally, and diabetes is a standalone risk factor for it. (Zhang et al., 2019)1 The treatment of diabetes and the provision of care have been transformed by the development of new mobile health (mHealth) technology. While recent studies have looked at mHealth devices as supplemental elements within behavioural interventions aimed at managing and preventing diabetes, a thorough understanding of the effectiveness of mHealth technology as (2) autonomous intervention tools in reducing diabetes risk remains elusive. (Wilson-Anumudu et al., 2021)2 Considering how far mobile health technology has come and become more specifically geared towards managing and preventing diabetes, these modalities will become more and more important in reducing cardiometabolic risk among Americans.
... Others report that patients are open to telehealth consultations, but retain a preference for face-to-face services (Eikelboom et al. 2014;Eikelboom and Atlas 2005;Tao et al. 2020). There was a strong recognition amongst audiologists that telehealth services can lead to better efficiency: less travel for clients or clinicians, more timely attention, and better overall access, as evidenced in the audiology (Saunders and Roughley 2020;Reginato and Ferrari 2014) and broader literature (Kokesh, Ferguson, and Patricoski et al. 2011;Caffery, Farjian, and Smith 2016;Taylor et al. 2018). ...
Purpose
The aim of this study was to investigate the perspectives of Australia-based hearing health care consumers regarding the (a) provision and utilization of teleaudiology services, (b) experiences with teleaudiology, and (c) barriers and enablers to future teleaudiology use.
Method
A national prospective self-report online survey was completed between April and October 2020, amid COVID-19. Data were analyzed using descriptive statistics (closed-answer items) and content analysis (open-text responses). A total of 381 participants ( M age = 72.07 years ± 10.08, 142 females) were recruited from different states and territories of Australia.
Results
Despite positive outcomes reported by those who undertook teleaudiology appointments during COVID-19, results indicate low-consumer teleaudiology uptake. It can be inferred that consumers were not aware of teleaudiology as an appointment option, clinicians/clinic staff had not informed and/or supported teleaudiology as an option, and biases existed that prevented teleaudiology being more widely adopted. It is unclear whether consumers who were eligible for government subsidies understood that teleaudiology appointments were reimbursed through government funding. Barriers to future teleaudiology uptake were largely related to concerns regarding confidentiality and privacy.
Conclusion
Low consumer uptake of teleaudiology appointments appears to be driven by consumer preference for in-person services, which appears to be driven by lack of knowledge regarding the availability and effectiveness of teleaudiology.
Supplemental Material
https://doi.org/10.23641/asha.25619808
... For example, a study conducted by Choi and Kim (2014) found that virtual technologies can help patients with high blood pressure manage their diet and lifestyle more effectively than face-to-face appointments. In addition, studies confirmed that telehealth interventions, which can be one of OHCSV's functions, can effectively reduce patient waiting time (Caffery et al., 2016;Xiong & Zuo, 2022). In this research, the term "online healthcare consultation services" (OHCSV) refers to an internetbased application or website that supports communication between patients and medical staff remotely (Liu et al., 2022). ...
... Interventions targeting these challenges, such as initiatives to increase specialty clinic capacity, ease of scheduling new appointments, and telehealth services, should be considered. 22,23 Additionally, interventions to improve language accessibility are integral for all practice locations and medical specialties. ...
The Press Ganey (PG) Outpatient Medical Practice Survey measures patients’ experiences of healthcare access in the U.S. We aimed to identify differences in experiences of access to care by patient race, ethnicity, and other sociodemographic characteristics, an important first step in informing health policy and ensuring equitable healthcare delivery. We performed a cross-sectional analysis of PG surveys for adult outpatient visits within the University of Pennsylvania Health System from 2014–2017, including 119,373 unique patients. Compared with White patients, Black (odds ratio [OR] 0.84; 95% confidence interval [CI] 0.80–0.87), Asian (OR 0.62; 95% CI 0.58–0.66), and other/unknown race patients (OR 0.83; 95% CI 0.72–0.94) were each less likely to report the maximum score for timely access to care. Patients of all minoritized groups, as well as those whose primary language was not English, reported lower scores in secondary access measures related to communication and respect, compared to White and primarily English-speaking patients, respectively. Efforts to improve the experience of access to care among racial and ethnic minoritized patients are imperative to achieve equity in healthcare delivery.
... Another beneficial aspect for the patient is time savings. Telemedical visits allow for the shortening of both the visit itself and travel to the facility [55,[57][58][59][60]. Concurrently, it enables doctors to increase the number of patient visits within a specific time frame. ...
Teledermatology is a dynamically developing field of medicine with the potential to significantly impact the future functioning of the healthcare system, including the prevention, diagnostics, and treatment of sexually transmitted infections (STIs). While its implementation has resolved numerous issues associated with the traditional patient management model for STIs, the risk associated with handling sensitive patient data in a virtual space must not be overlooked. This article presents a literature review regarding the application of teledermatology in the diagnostics and treatment of STIs, with a particular focus on addressing relevant problems, potential obstacles, and examining the impact of the COVID-19 global epidemic on the development of this field.
... Thus, the integration of telemedicine technologies into healthcare systems presents significant opportunities to transform healthcare delivery, improve business strategies, and promote sustainability (World Health Organization WHO 2020). However, several challenges hinder the widespread adoption and effective implementation of telemedicine in practice (Caffery et al. 2019). It is crucial to address these issues to fully leverage the potential of telemedicine in achieving efficient, accessible, and sustainable healthcare outcomes ). ...
In today's world, businesses are increasingly recognizing the importance of sustainability and technology as essential components of their operations. This book offers a comprehensive guide to help you navigate the complexities of the interconnected areas of business, sustainability and technology. The book further shows how sustainability and technology are transforming the business landscape and how they can harness their power to drive innovation, create value and achieve long-term success. Drawing on the latest research and real-world case studies, the book provides practical insights and strategies that readers can use to navigate this rapidly changing landscape. The book further offers a comprehensive roadmap to navigate the intersection of business, sustainability and technology, including developing sustainable business models and cutting-edge technologies such as artificial intelligence and blockchain. This book is an essential resource for business leaders, entrepreneurs, investors and students.
... Telemeds have been reported to reduce waiting times for specialist services by eliminating the need for a F2F appointment. 12 Effectiveness of reduction in F2F appointments for Gynaecological services was 34% and as high as 92% for vascular services. 10,13 Financial savings ...
Abstract
The SARS-CoV-2 pandemic triggered an increased need in a method of delivering
healthcare that simultaneously do not put patients at an increased risk of transmission. A remote consultation service (Telemed) for patients referred for dentoalveolar procedures was trialled.
Objective: To investigate the outcome of the Telemeds and if treatment booked as a result of the Telemeds was successful, and could be made common practice.
Materials and Methods: Data was collected from Telemeds between 04 August 2020 and 30 November 2020. Data collected included whether treatment was booked as a result of the Telemed, if the treatment was successfully completed at the resulting appointment (one-stop treatment), if an additional face-to-face
(F2F) consultation was required and any related reasons as to why this was the case.
Results: After 499 Telemeds, 46.3% (N = 231) of patients required a F2F appointment being booked, 43.0% (N = 215) resulted in treatment being booked, 6.6% (N = 33) were discharged and 4% (N = 20) of patients did not answer when contact was attempted. Of the 215 patients who had a Telemed that led to booking of treatment, 110 had attended their follow up appointment and 95.4% (N = 105) successfully had their treatment carried out in one visit.
Conclusion: Remote consultations are a feasible, successful and useful tool in assessing and booking dentoalveolar cases suitable for one-stop treatment under local anaesthesia, as long as there is a specific and organized triage process, regardless of the number of teeth to be extracted or the patient's medical history. Patients requiring general anaesthesia, sedation or further radiographic imaging did not benefit from Telemeds as they needed to attend F2F anyway for pre-operative
assessment or to have their further imaging taken in the department.
... Individuals residing in urban areas may also experience delayed access to specialist outpatient clinics and elective surgery due to a multitude of reasons, including unnecessary referrals and the increasing demand on Australia's public hospital outpatient clinics, which is further worsened by the recent outbreak of COVID-19. [15][16][17][18] Patients in urban regions often exceed the clinically recommended timeframes to receive their initial outpatient consultation, which may lead to deterioration in patient health and quality of life and add a significant economic burden to patients and the healthcare system. 16,19 Several initiatives have been undertaken to improve access to ear, nose, and throat (ENT) outpatient speciality care. ...
Aim
The purpose of this study is to explore the effectiveness of a hospital-based asynchronous ear, nose, and throat (ENT) telehealth service (the Ear Portal) in reducing cost and improving access for children with otitis media.
Methods
Participants were recruited to the Ear Portal from a tertiary hospital ENT waiting list. Ear and hearing assessments were conducted during appointments by the Ear Portal research assistant, and data was stored for an asynchronous review by the Ear Portal multidisciplinary team. A cost-minimisation analysis was conducted for the Ear Portal and the standard care pathways. Waiting times to provide care for both pathways were calculated for children with semi-urgent (i.e. Category 2) and non-urgent (i.e. Category 3) referrals.
Results
The running cost for the Ear Portal was 37.34 for follow-up appointments. Conversely, the running cost for the standard care pathway was 86.10 for follow-up appointments. A total of 223 appointments were required to offset the initial Ear Portal investment of $19,384.00. The median waiting time for the Ear Portal from initial contact to care plan delivery was <30 days, whereas the median waiting times for children in the standard care pathway were 291 days (interquartile range (IQR) = 117) for Category 2 and 371 days (IQR = 311) for Category 3 referrals.
Conclusion
Under the current circumstances, the Ear Portal service can reduce costs for the health care system by reducing marginal costs per patient in addition to providing ENT specialist care within the clinically recommended timeframes.
... Studies examining the feasibility of ENT telehealth services have demonstrated promising results, highlighting their potential to reduce waiting times and providing timely access to care for children with OM. 14,23,24 Hence, the implementation of telehealth review as part of the advanced triage of patients in ENT departments with long waiting lists may serve as a feasible approach that may enable regular, prompt, and comprehensive monitoring of recurrent and persistent OM. This would help facilitate early identification and intervention of children at risk of behavioral problems who are currently waiting for assessment. ...
Aim: Children with otitis media (OM) experience long waiting times to access Australia's public hospitals due to limited capacity. The aim of this article is to utilize an Ear, Nose, and Throat (ENT) telehealth service (the Ear Portal) to examine whether delayed access to specialist care is associated with poorer behavioral outcomes for children with OM.
Methods: Participants in the study included 45 children who were referred to ENT specialists due to recurrent and persistent OM. Children were triaged as semiurgent with a target time-to-assessment of 90 days or nonurgent with a target time-to-assessment of 365 days. The behavioral outcomes of children were assessed using the parent report Strengths and Difficulties Questionnaire (SDQ). Descriptive statistics and adjusted multiple linear regression models were used to compare children who received access to the service within the time-to-assessment target of their triage category (“on-boundary”; n = 17) and outside the time-to-assessment target (“off-boundary”; n = 28). Spearman correlation analysis was used to explore the relationship between the internalizing, externalizing, and total SDQ scores as a function of waiting times in days.
Results: Borderline or abnormal SDQ scores ranged from 24.4% to 42.2% across the study participants. The regression analysis showed a statistically significant association between the off-boundary group and higher scores (i.e., poorer) on the peer, emotional, conduct, internalizing, and total problems subscales. Further, lengthy waiting times were significantly correlated with higher internalizing problems. These findings indicate that longer waiting times may lead to poorer behavioral outcomes for children with OM.
Clinical Trial Registration: (ACTRN1269000039189p).
Conclusion: Children with recurrent and persistent OM referred to ENT outpatient care were found to have significantly more behavioral difficulties if their waiting times exceeded the recommended timeframes for their triaged referrals. Additionally, they experienced more internalizing problems that correlated with longer waiting times. This highlights the calls for alterations in current clinical practice given the lengthy waiting times in Australia's public hospitals.
... Telehealth refers to the use of information and communication technologies (ICTs), such as video-based consultations and remote monitoring devices, to deliver healthcare services and facilitate communication between various stakeholders including healthcare providers and patients [5,6]. It offers distinctive advantages for older adults, including promoting self-sufficiency, reducing the risk of falls, improving the management of chronic illnesses such as dementia and depression, enhancing medication compliance, and addressing social isolation to improve the overall quality of life, especially for individuals with limited mobility or residing in rural areas [7,8]. ...
... In addition, there is evidence on the benefits of telehealth, such as reducing the time of care, cost / time of travel of the patient to the health service and quality of service provided. Thus, it has become a tool that enables more agile access to expert professionals 39,40 . ...
Introducción: Among the systems most affected by COVID-19, the renal system stands out, which leads to challenges in the management of nursing care for these patients. Objective: To describe the scientific evidence on nursing care management in patients diagnosed with COVID-19 undergoing Renal Replacement Therapy. Methodology: Articles were searched in PubMed, SCOPUS, Web of Science, LILACS, BDENF, EMBASE, IBECS, CINAHL, COCHRANE LIBRARY, and Scielo databases, using the following cross-references: “renal therapy” AND “nursing care” AND “covid-19”. To systematize the searches, the Boolean operator “AND” was used. Initially, 167 primary references were identified in the selected databases/virtual library, and as a final sample, 14 articles were included. Results: It was found that among the contributions to nursing care management in hemodialysis patient care in the context of the COVID-19 pandemic, the use of health technologies (examples: use of telehealth and the development of new protocols), development of new methods in nursing care management and continuing education are described in the literature. These tools were essential for the continuity of nursing care. Conclusion: Among the tools used for nursing care management in the context of the pandemic of COVID-19 in hemodialysis patients, health technologies and continuing education in health are included, enabling qualified care management.
... The COVID-19 pandemic introduced extreme burden to health systems globally 1 , highlighting the need for all countries to strengthen the health information technology infrastructure. Telehealth 2 , which employs telecommunications and virtual technologies to deliver care outside of traditional clinical settings, has been proven to be effective in improving healthcare delivery, including patients triage 3 , consultation 4 , treatment 5 , clinical care 6 , and education of healthcare workers and patients 7 . ...
The rapid advancement of telehealth technologies has the potential to revolutionize healthcare delivery, especially in developing countries and resource-limited settings. Telehealth played a vital role during the COVID-19 pandemic, supporting numerous healthcare services. We conducted a systematic review to gain insights into the characteristics, barriers, and successful experiences in implementing telehealth during the COVID-19 pandemic in China, a representative of the developing countries. We also provide insights for other developing countries that face similar challenges to developing and using telehealth during or after the pandemic. This systematic review was conducted through searching five prominent databases including PubMed/MEDLINE, Embase, Scopus, Cochrane Library, and Web of Science. We included studies clearly defining any use of telehealth services in all aspects of health care during the COVID-19 pandemic in China. We mapped the barriers, successful experiences, and recommendations based on the Consolidated Framework for Implementation Research (CFIR). A total of 32 studies met the inclusion criteria. Successfully implementing and adopting telehealth in China during the pandemic necessitates strategic planning across aspects at society level (increasing public awareness and devising appropriate insurance policies), organizational level (training health care professionals, improving workflows, and decentralizing tasks), and technological level (strategic technological infrastructure development and designing inclusive telehealth systems). WeChat, a widely used social networking platform, was the most common platform used for telehealth services. China’s practices in addressing the barriers may provide implications and evidence for other developing countries or low-and middle- income countries (LMICs) to implement and adopt telehealth systems.
... In addition, telehealth can assist (or manage the burden) with remote screening and the facilities of care during such pandemic situation. 23 People with asymptomatic and risky population (pregnancy, child and elderly,) will be most significantly benefit without the risk of exposure in a congested hospital or out patients' clinician waiting rooms where the containment and mitigation possibilities are more. WHO says telemedicine strategy in the delivery of health care services is playing a crucial factor where the distance is barriers. ...
COVID-19 has created huge challenges for health systems worldwide for health career sources and health care providers in health institutions. An immense range of digital health technologies can be considerable health strategies in recent years. We searched electronically published relevant articles in English language using these “COVID-19”, “coronavirus”, “technologies”, “severe acute respiratory syndrome”, “dementia”, “digital-health”, and “older adult care”. It helps to collect the digital information, collect data, transfer, store, frontline protection, to reduce the risk of rapid contamination, analysis and proper monitor information system, holistic control, manage, care and prevention, decrease the patients overload to the health care professionals’ in the institutions, prevent from contamination for health care providers, general peoples and patients. Still, lacking in many countries as alternative ways to adapt for digital health technologies in health care practices. Thus, it is necessary to adapt digital health technologies although there are few studies on the use of digital health technologies focusing on COVID-19. It is not only for COVID-19 issues but also should be implement to make our daily life easiest than before to fight with communicable disease.
... In the post-pandemic era, hospitals are increasingly utilising hybrid systems where patients are triaged virtually or over the telephone. Published literature suggests these can help reduce DNAs and clinic wait times [20]. Future studies should assess whether face-to-face DNAs amongst first seizure patients should be called and how this will impact on other referrals. ...
Background:
Current guidelines set clinical standards for the management of suspected first seizures and epilepsy. We aimed to assess if these standards are being met across first seizure clinics nationally, to describe variations in care and identify opportunities for service delivery improvement.
Methods:
Multicentre audit assessing the care of adults (≥16 years) referred to first seizure clinics from 31st December 2019 going backwards (30 consecutive patients per centre). Patients with pre-existing diagnosis of epilepsy were excluded. Anonymised referral, clinic, and follow-up data are reported with descriptive statistics.
Results:
Data provided for 727 patients from 25 hospitals in the UK and Ireland (median age 41 years [IQR 26-59], 52% males). Median time to review was 48 days (IQR 26-86), with 13.8% (IQR 3.3%-24.0%) of patients assessed within 2 weeks. Seizure recurrence was seen in 12.7% (IQR 6.6%-17.4%) of patients awaiting first appointment. Documentation for witness accounts and driving advice was evident in 85.0% (IQR 74.0%-100%) and 79.7% (IQR 71.2%-96.4%) of first seizure/epilepsy patients, respectively. At first appointment, discussion of sudden unexpected death in epilepsy was documented in 30.1% (IQR 0%-42.5%) of patients diagnosed with epilepsy. In epilepsy patients, median time to MRI neuroimaging was 37 days [IQR 22-56] and EEG was 30 days [IQR 19-47]. 30.4% ([IQR 0%-59.5%]) of epilepsy patients were referred to epilepsy nurse specialists.
Conclusions:
There is variability nationally in the documented care of patients referred to first seizure clinics. Many patients are facing delays to assessment with epilepsy specialists with likely subsequent impact on further management.
... Telemedicine is in fact similar to the in-person doctor-patient contact in several ways and can positively influence the patients' sense of security, health consciousness and adherence (8,9). It also has the potential to promote time efficiency and increases cost effectiveness (10). ...
The past two decades have witnessed telemedicine becoming a crucial part of health care as a method to facilitate doctor-patient interaction. Due to technological developments and the incremental acquisition of experience in its use, telemedicine’s advantages and cost-effectiveness has led to it being recognised as specifically relevant to diabetology. However, the pandemic created new challenges for healthcare systems and the rate of development of digital services started to grow exponentially. It was soon discovered that COVID-19-infected patients with diabetes had an increased risk of both mortality and debilitating sequelae. In addition, it was observed that this higher risk could be attenuated primarily by maintaining optimal control of the patient’s glucose metabolism. As opportunities for actual physical doctor-patient visits became restricted, telemedicine provided the most convenient opportunity to communicate with patients and maintain delivery of care. The wide range of experiences of health care provision during the pandemic has led to the development of several excellent strategies regarding the applicability of telemedicine across the whole spectrum of diabetes care. The continuation of these strategies is likely to benefit clinical practice even after the pandemic crisis is over.
... the service should provide call backs, which is an idea that has since enhanced delivery. can reduce wait times (Caffery et al., 2016). While these studies did not analyze a phone-based 367 service nor were conducted in the context of rehabilitation, they suggest that if the 368 telerehabilitation service from the current study was employed as a method to provide 369 referrals and subsequently reduce wait times, it may have positive effects on the efficiencies of 370 other services. ...
Scope
Early in the COVID-19 pandemic, community rehabilitation stakeholders from a provincial health system designed a novel telerehabilitation service. The service provided wayfinding and self-management advice to individuals with musculoskeletal concerns, neurological conditions, or post-COVID-19 recovery needs. This study evaluated the efficiency of the service in improving access to care.
Methodology
We used multiple methods including secondary data analyses of call metrics, narrative analyses of clinical notes using artificial intelligence (AI) and machine learning (ML), and qualitative interviews.
Conclusions
Interviews revealed that the telerehabilitation service had the potential to positively impact access to rehabilitation during the COVID-19 pandemic, for individuals living rurally, and for individuals on wait lists. Call metric analyses revealed that efficiency may be enhanced if call handling time was reduced. AI/ML analyses found that pain was the most frequently-mentioned keyword in clinical notes, suggesting an area for additional telerehabilitation resources to ensure efficiency.
... For patients living with obesity, the pandemic has resulted in increased waiting times [23] and cancellation of bariatric surgery [14]. Digital healthcare is being championed as a way of improving healthcare delivery [34] and affords many opportunities and benefits to weight management patients, including increasing capacity, geographical reach and convenience, and decreasing waiting [7]. Guidance on the provision of digital healthcare prioritises patient usability and acceptability [25,26], therefore the impact of digital consultations on the unique experiences of patients living with obesity warrants examination. ...
Receiving digital healthcare consultations for weight management, in place of in-person appointments, has proliferated in recent years, accelerated by the COVID-19 pandemic. The objective of the present study was to investigate patients' experiences of digital weight management services (DWMS) provided by the National Health Service (NHS). Particular emphasis was placed on examining the perceived benefits and limitations of DWMS so as to identify potential means of improving provision. Sixteen patients (eight male; eight female) accessing digital consultations at one of two West Midlands (UK) NHS trusts, participated in semi-structured interviews. Interviews were transcribed verbatim and analysed via thematic analysis. We identified three overarching themes and associated sub-themes that reflect the perceived benefits and limitations of service provision as identified by patients. These were technology acceptability (sub-themes 'challenges', 'requirements/facilitators', and 'beneficial features'); treatment acceptability (sub-themes 'treatment features', 'patient attributes', and 'practitioner skills'); and treatment efficacy (sub-themes 'treatment features', 'patient attributes', and 'practitioner skills'). Themes identified in this study have informed recommendations intended to enhance acceptability of DWMS technology and treatment, potentially encouraging engagement and increasing treatment efficacy. Limitations of the present study and recommendations for further research are also presented.
Background
No-show visits have serious consequences for patients, providers, and healthcare systems as they lead to delays in care, increased costs, and reduced access to services. Telemedicine has emerged as a promising alternative to in-person visits by reducing travel barriers, but risks exacerbating the digital divide. The aim of this study was to assess the impact of telemedicine (video and phone) at a tertiary care academic center on no-show visits compared to in-person visits.
Methods
A retrospective cohort analysis of all weekday clinic visits among in-state adult patients at a single tertiary care center in the southeast from January 2020 to April 2023 was performed. Rates of no-show visits for patients who were seen via phone and video were compared with those who were seen in-person. Demographic and clinical characteristics of these groups were also compared, including age, sex, race/ethnicity, socioeconomic status, and visit type. The primary outcome was the rate of no-show visits for each visit type.
Results
Our analysis included 3,105,382 scheduled appointments, of which 81.2% were in-person, 13.4% via video, and 5.4% via phone calls. Compared to in-person visits, phone calls and video visits reduced the odds of no-show visits by 50% (aOR 0.5, CI 0.49–0.51) and 15% (aOR 0.85, CI 0.84–0.86), respectively. Older patients, Black patients, patients furthest from clinic, and patients from counties with the greatest degree of vulnerability and disparities in digital access were more likely to use phone visits. No-shows were more common among non-white, male, and younger patients from counties with lower socioeconomic status.
Conclusion
Telemedicine effectively reduced no-show visits. However, limiting telemedicine to video-based visits only exacerbated disparities in access. Phone calls allow historically underserved patients from lower socioeconomic backgrounds to access healthcare and should be included within the definition of telemedicine.
We aimed to (1) identify existing triage approaches for referral of patients with suspected inflammatory arthritis (IA) from primary care physicians (PCP) to rheumatologists, (2) describe their characteristics and methodologies for clinical use, and (3) report their level of validation for use in a publicly funded healthcare system. The comprehensive search strategy of multiple databases up to October 2023 identified relevant literature and focussed on approaches applied at the PCP–Rheumatologist referral stage. Primary, quantitative studies, reported in English were included. Triage approaches were grouped into patient conditions as defined by the authors of the reports, including IA, its subtypes and combinations. 13952 records were identified, 425 full text reviewed and 55 reports of 53 unique studies were included. Heterogeneity in disease nomenclature and study sample pretest probability was found. The number of published studies rapidly increased after 2012. Studies were mostly from Europe and North America, in IA and Axial Spondyloarthritis (AxSpa). We found tools ranging the continuum of development with those best performing, indicated by the area under the receiver operating curve (AUC) >0.8), requiring only patient-reported questions. There were AUCs for some tools reported from multiple studies, these were in the outstanding to excellent range for the Early IA Questionnaire (EIAQ) (0.88 to 0.92), acceptable for the Case Finding AxSpa (CaFaSpa) (0.70 to 0.75), and poor to outstanding for the Psoriasis Epidemiology Screening Tool (PEST) (0.61 to 0.91). Given the clinical urgency to improve rheumatology referrals and considering the good
The integration of telemedicine technologies into healthcare systems presents significant opportunities to transform healthcare delivery, improve business strategies, and promote sustainability. However, several challenges are hindering the prevalence and effective implementation of telemedicine in practice. This comprehensive literature review aims to address these issues with a view to exploring the role of telemedicine in revolutionizing healthcare delivery through technological advancements, with a specific focus on its implications for business strategies and sustainability. The findings of this review indicate that telemedicine is a prevailing technology that can cut costs, enhance quality, and increase patient satisfaction. Furthermore, telemedicine streamlines workflows reduces waiting times, and improves the quality of care. The implications of this study are significant for healthcare organizations and policymakers. The findings highlight the potential of telemedicine to improve healthcare outcomes and provide accessible and cost-effective care. The study underscores the need for healthcare organizations to embrace digital transformation and develop strategies to leverage the benefits of telemedicine effectively. Policymakers should consider the ethical and legal implications of telemedicine so as to establish a robust policy framework that ensures its safety and equitable adoption. Overall, this study contributes to the understanding of the telemedicine industry by synthesizing existing literature. It provides valuable insights into the technological innovations in telemedicine, their impact on patient care, accessibility, and cost-effectiveness, as well as the transformation of organizations’ strategies in the telemedicine industry.
Introduction:
Burns are global public health devastating and life-threatening injuries. Telehealth can be an appropriate answer for the effective utilization of health care resources, prevention referrals and reduce socio-economic burden of burns injuries. Thus, this study aimed to systematically evaluate the applications, opportunities, and challenges of using telehealth in burn injuries management.
Methods:
A structured search was conducted according to PRISMA statement guidelines in the Web of Science, PubMed, Scopus, and Science Direct as well as the Google Scholar for studies published until June 28, 2022. Of the total 2301 yielded studies, 36 articles were included in the final review. Quality appraisal was done according to the Mixed Methods Appraisal Tool (MMAT) version 2018. Thematic analysis was applied for data analysis.
Results:
Patient triage, transfer, and referral (38.9%) follow-up (22%), care (22%), consultation (9%), education (3%), and rehabilitation (3%) were the most prevalent application of telehealth, respectively. Our findings identified 72 unique concepts, eight initial themes, and two clinical and administrative final themes for opportunities of using telehealth in burn injury management. Furthermore, we identified 27 unique concepts, three initial themes, and two clinical and administrative final themes for remaining challenges.
Conclusions:
Despite providing pivotal opportunities such as improving burn injury diagnosis and quality of care, increasing patient and provider satisfaction, and cost containment using telehealth in burn injuries management, the concept faces challenges such as the impossibility of the physical examination of patients and technological difficulties. Our findings provide valuable information for policymakers and decision-makers infield of burn injuries and effective planning for using telehealth technology.
Introduction:
The COVID-19 pandemic has caused an unexpected boost to telemedicine. We analyse the impact of the pandemic on telemedicine applied in Spanish headache consultations, review the literature, and issue recommendations for the implementation of telemedicine in consultations.
Method:
The study comprised 3 phases: 1) review of the MEDLINE database since 1958 (first reported experience with telemedicine); 2) Google Forms survey sent to all members of the Spanish Society of Neurology's Headache Study Group (GECSEN); and 3) online consensus of GECSEN experts to issue recommendations for the implementation of telemedicine in Spain.
Results:
COVID-19 has increased waiting times for face-to-face consultations, increasing the use of all telemedicine modalities: landline telephone (from 75% before April 2020 to 97% after), mobile telephone (from 9% to 27%), e-mail (from 30% to 36%), and video consultation (from 3% to 21%). Neurologists are aware of the need to expand the availability of video consultations, which are clearly growing, and other e-health and m-health tools.
Conclusions:
The GECSEN recommends and encourages all neurologists who assist patients with headaches to implement telemedicine resources, with the optimal objective of offering video consultation to patients under 60-65 years of age and telephone calls to older patients, although each case must be considered on an individual basis. Prior approval and advice must be sought from legal and IT services and the centre's management. Most patients with stable headache and/or neuralgia are eligible for telemedicine follow-up, after a first consultation that must always be held in person.
Juvenile ossifying fibroma (JOF) is a rare benign neoplastic fibro-osseous tumor commonly found in the maxilla and mandible of children usually between the ages of five and 15. Patients often present with aggressive, painless growth which is well demarcated from surrounding bone resulting in severe facial asymmetry. JOFs have high recurrence rates if not completely resected and should therefore be treated by a multidisciplinary team of physicians including a neurosurgeon to assess cranial nerve function. This case describes a child who presented to the ED after being referred by his primary care provider for facial swelling. The patient was diagnosed with JOF and had a delay in care due to a lack of access to multidisciplinary specialties to provide care due to payer difficulties which placed the patient at high risk of complications.
The authors hypothesize that standardized telehealth (TH) scheduling processes will improve TH utilization without increasing adverse events. Fifty visits preimplementation and 67 visits postimplementation were audited from June 2021 to January 2022. Both leadership and frontline stakeholders were engaged to identify current workflows and potential interventions targeting outpatient elective procedures. Process mapping outlined current TH scheduling workflows. Outcomes related to TH completion, cost, and TH scheduling were collected after implementation. Preimplementation TH scheduling rate was 32%. The intervention required TH postoperative appointments to be scheduled in clinic at the time of surgery scheduling with TH being the default postsurgical appointment for a standardized list of eligible procedures. Following implementation, 95% of patients undergoing eligible procedures had TH follow-up. This provided improved access to surgical follow-up care, by reducing travel needs to the Veterans Affairs facility. Secondarily, this intervention increased clinic appointment availability and resulted in possible increased revenue for billable visits. Standardizing TH scheduling based on the procedure improves the utilization of TH resulting in improved clinic efficiency and increased revenue, without increasing adverse events.
Objectives:
To conduct a scoping systematic review of the literature on the use of telemedicine to evaluate, diagnose, and manage patients with dizziness.
Data sources:
Web of Science, SCOPUS, and MEDLINE PubMed databases.
Study selection:
The inclusion criteria included the following: pertaining to telemedicine and the evaluation, diagnosis, treatment, or management of dizziness. Exclusion criteria included the following: single-case studies, meta-analyses, and literature and systematic reviews.
Data extraction:
Outcomes recorded for each article included the following: study type, patient population, telemedicine format, dizziness characteristics, level of evidence, and quality assessment.
Data synthesis:
The search returned 15,408 articles, and a team of four screened the articles for inclusion criteria status. A total of 9 articles met the inclusion criteria and were included for review. Of the nine articles, four were randomized clinical trials, three were prospective cohort studies, and two were qualitative studies. The telemedicine format was synchronous in three studies and asynchronous in six studies. Two of the studies involved acute dizziness only, four involved chronic dizziness only, one involved both acute and chronic dizziness, and two did not specify dizziness type. Six of the studies included the diagnosis of dizziness, two involved the evaluation of dizziness, and three involved treatment/management. Some of the reported benefits of telemedicine for dizziness patients included cost savings, convenience, high patient satisfaction, and improvement in dizziness symptoms. Limitations included access to telemedicine technology, Internet connectivity, and dizziness symptoms interfering with the telemedicine application.
Conclusions:
Few studies investigate the evaluation, diagnosis, or management of dizziness using telemedicine. The lack of protocols and standards of care for telemedicine evaluation of dizzy patients creates some challenges in care delivery; however, these reviewed studies provide examples of the breadth of care that has been provided remotely.
Background:
SATISPART-Stroke (SATIS-Stroke) is the most complete instrument for the assessment of activity and participation following a stroke. However, its use in a developing country has only been tested through in-person interviews.
Objective:
To determine the validity, reproducibility and viability of the SATIS-Stroke scale administered in two tele-assessment modalities: self-assessment of an electronic form versus videoconference.
Methods:
Methodological study with Brazilian chronic stroke survivors was conducted. Stage I comprised an in-person interview to apply the SATIS-Stroke and a self-assessment by completing an electronic form to respond to the SATIS-Stroke items. Step II occurred 6 to 8 months after Step I, during which SATIS-Stroke was administered again in-person and via videoconference. The order was randomized.
Results:
Ninety-five stroke survivors were recruited, but only 50 answered the electronic form (adherence: 52.6%). Mean scores were higher in the self-administration of electronic form compared to the in-person interview (mean difference = -0.36 ± 0.93; P = 0.009). Adequate reliability was found in the comparison of the in-person and self-assessment of electronic form (ICC2,1 = 0.66; 95%CI: 0.40-0.81). Fifty stroke survivors participated in Step II, during which adequate reliability was found in the comparison of the in-person administration and videoconference (ICC2,1 = 0.55; 95%CI: 0.21-0.74) and a moderate correlation was found between the assessment methods (r = 0.43; P = 0.02).
Discussion:
Adequate validity and reliability were found in the tele-assessment. Thus, this method is appropriate and viable for use in developing countries. Although reliable, the self-assessment did not have good adherence in the Brazilian population due to internet access problems, lack of familiarity with the digital form and lack of autonomy to answer the questions alone.
INTRODUÇÃO: A telerreabilitação é uma modalidade de atendimento realizado à distância que foi considerada um recurso fundamental durante a pandemia da COVID-19. Entretanto, era uma modalidade ainda não vivenciada por muitos profissionais e familiares. OBJETIVO: Descrever a percepção dos pais ou responsáveis por crianças em tratamento fisioterapêutico, sobre os desafios e as contribuições da experiência com a telerreabilitação realizada em serviço ambulatorial durante a pandemia de COVID-19. MATERIAIS E MÉTODOS: Estudo observacional transversal exploratório, realizado com pais ou responsáveis por crianças, com idade entre 0 a 12 anos, com qualquer condição de saúde neurológica ou musculoesquelética em acompanhamento fisioterapêutico por telerreabilitação, no período de junho a agosto de 2021. Um questionário elaborado pelas autoras com perguntas sobre a percepção dos responsáveis, desafios e contribuições da telerreabilitação foi encaminhado para os responsáveis por meio de um link do Google Forms, via e-mail ou aplicativo de mensagem no celular, e foi auto aplicado. Realizaram-se análises descritivas dos dados coletados por meio da frequência de respostas dos pais ou responsáveis nas questões específicas. As variáveis numéricas foram apresentadas como média ± desvio-padrão e as variáveis categóricas, como frequências absolutas e relativas. RESULTADOS: Dezoito responsáveis receberam e responderam o questionário completamente. A mãe foi a responsável mais citada, a maioria das crianças receberam atendimento duas vezes na semana e o diagnóstico mais prevalente foi paralisia cerebral. Setenta e três por cento dos responsáveis avaliaram a telerreabilitação como acima do nível esperado e com contribuição além de suas expectativas. CONCLUSÃO: De acordo com a percepção dos pais, sobre os desafios e as contribuições da experiência com a telerreabilitação realizada em serviço ambulatorial, os benefícios parecem superar os desafios.
Purpose:
Communication between specialists and primary care clinicians is suboptimal, and access to referrals is often limited, which can lead to lower quality, inefficiency, and errors. An electronic consultation (e-consultation) is an asynchronous, non-face-to-face consultation between a primary care clinician and a specialist using a secure electronic communication platform. The purpose of this study was to conduct a randomized controlled trial of e-consultations to test its efficacy and effectiveness in reducing wait times and improving access to specialty care.
Methods:
Primary care clinicians were randomized into a control (9 traditional) or an intervention (17 e-consultation) arm for referrals to cardiologists. Primary care clinicians were recruited from 12 practice sites in a community health center in Connecticut with mainly medically underserved patients. Two end points were analyzed with a Cox proportional hazards model where the hazard of either a visit or an e-consultation was linked to study arm, sex, race, and age.
Results:
Thirty-six primary care clinicians participated in the study, referring 590 patients. In total, 69% of e-consultations were resolved without a visit to a cardiologist. After adjusting for covariates, median days to a review for an electronic consultation vs a visit for control patients were 5 and 24, respectively. A review of 6-month follow-up data found fewer cardiac-related emergency department visits for the intervention group.
Conclusion:
E-consultation referrals improved access to and timeliness of care for an underserved population, reduced overall specialty utilization, and streamlined specialty referrals without any increase in adverse cardiovascular outcomes. e-consultations are a potential solution for improving access to specialty care.
Background
Access to specialty care remains a challenge for primary care providers and patients. Implementation of electronic referral and/or consultation (eCR) systems provides an opportunity for innovations in the delivery of specialty care. We conducted key informant interviews to identify drivers, facilitators, barriers and evaluation metrics of diverse eCR systems to inform widespread implementation of this model of specialty care delivery.
Methods
Interviews were conducted with leaders of 16 diverse health care delivery organizations between January 2013 and April 2014. A limited snowball sampling approach was used for recruitment. Content analysis was used to examine key informant interview transcripts.
Results
Electronic referral systems, which provide referral management and triage by specialists, were developed to enhance tracking and operational efficiency. Electronic consultation systems, which encourage bi-directional communication between primary care and specialist providers facilitating longitudinal virtual co-management, were developed to improve access to specialty expertise. Integrated eCR systems leverage both functionalities to enhance the delivery of coordinated, specialty care at the population level. Elements of successful eCR system implementation included executive and clinician leadership, established funding models for specialist clinician reimbursement, and a commitment to optimizing clinician workflows.
Conclusions
eCR systems have great potential to streamline access to and enhance the coordination of specialty care delivery. While different eCR models help solve different organizational challenges, all require institutional investments for successful implementation, such as funding for program management, leadership and clinician incentives.
Electronic supplementary material
The online version of this article (doi:10.1186/s12913-015-1233-1) contains supplementary material, which is available to authorized users.
Introduction:
This article presents the scientific evidence for the merit of telemedicine interventions in the diagnosis and management of skin disorders (teledermatology) in the published literature. The impetus for this work derives from the high prevalence of skin disorders, the high cost, the limited availability of dermatologists in certain areas, and the promise of teledermatology to address unmet needs in this area.
Materials and methods:
The findings are based on a targeted review of scientific studies published from January 2005 through April 2015. The initial search yielded some 5,020 articles in Google Scholar and 428 in PubMed. A review of the abstracts yielded 71 publications that met the inclusion criteria for this analysis. Evidence is organized according to the following: feasibility and acceptance; intermediate outcomes (use of service, compliance, and diagnostic and treatment concordance and accuracy); outcomes (health improvement and problem resolution); and cost savings. A special section is devoted to studies conducted at the Veterans Health Administration.
Results:
Definitions of teledermatology varied across a wide spectrum of skin disorders, technologies, diagnostic tools, provider types, settings, and patient populations. Outcome measures included diagnostic concordance, treatment plans, and health.
Conclusions:
Despite these complexities, sufficient evidence was observed consistently supporting the effectiveness of teledermatology in improving accessibility to specialty care, diagnostic and treatment concordance, and skin care provided by primary care physicians, while also reducing cost. One study reported suboptimal clinical results from teledermatology for patients with pigmented skin lesions. On the other hand, confocal microscopy and advanced dermoscopy improved diagnostic accuracy, especially when rendered by experienced teledermatologists.
Management of chronic disease often requires multidisciplinary clinical efforts and specialist care. With the emergence of Accountable Care Organizations (ACOs), health care systems are incentivized to evaluate methods of information exchange between generalists and specialists in order to provide value while preserving quality. Our objective was to evaluate patient and referring provider satisfaction and outcomes of asynchronous electronic consultations in vascular care in a large tertiary academic medical center. Referring providers were offered a vascular 'e-consult' option through an electronic referral management system. We conducted chart review to understand the downstream effects and surveyed patients and referring providers to assess satisfaction. From 24 March 2014 to 1 March 2015, 54 e-consults were completed. Additional testing and recommendations were made in 49/54 (90.7%) e-consults, including lower-extremity venous duplex ultrasonography with reflux testing, duplex ultrasonography of the carotid artery, computed tomography, magnetic resonance imaging, non-invasive physiology arterial studies, laboratory tests, medications, compression stockings, and sequential lymphedema compression therapy. Referring providers were compliant with recommendations in 40/49 (81.6%) of e-consults. A total of 17/54 (31.5%) patients were surveyed with a median patient satisfaction score of 13.7/15 (91.3%) (SD ± 6.4). The program was associated with high referring provider satisfaction, with 87.0% finding the e-consult very helpful and 80.0% stating it averted the need for a traditional visit. Our experience suggests that e-consults are an effective way to provide vascular care in some patients and are associated with high patient and provider satisfaction. E-consults may therefore be an efficient method of care delivery for vascular patients within an ACO.
Background: We define electronic consultations (‘‘e-consults’’) as asynchronous, consultative, provider-to-provider communications within a shared electronic health record (EHR) or web-based platform. E-consults are intended to improve access to specialty expertise for patients and providers without the need for a face-to-face visit. Our goal was to systematically review and summarize the literature describing the use and effects of e-consults.
Methods: We searched PubMed, EMBASE, the Cochrane Library, and CINAHL for studies related to e-consults published between 1990 through December 2014. Three reviewers identified empirical studies and system descriptions, including articles on systems that used a shared EHR or web-based platform, connected providers in the same health system, were used for two-way provider communication, and were text-based.
Results: Our final review included 27 articles. Twenty-two were research studies and five were system descriptions. Eighteen originated from one of three sites with well-developed e-consult programs. Most studies reported on workflow impact, timeliness of specialty input, and/or provider perceptions of e-consults. E-consultations are used in a variety of ways within and across medical centers. They provide timely access to specialty care and are well-received by primary care providers.
Discussion: E-consults are feasible in a variety of settings, flexible in their application, and facilitate timely specialty advice. More extensive and rigorous studies are needed to inform the e-consult process and describe its effect on access to specialty visits, cost and clinical outcomes.
Electronic consultation can improve access to specialist care. However, specialists have been identified as less likely to adopt electronic solutions in clinical settings. We conducted an online survey to explore the perspectives of specialists who use the Champlain BASE eConsult service in Eastern Ontario, Canada. Specialists were asked their opinions on experience with the service, their current consult/referral practices, recommendations for change and expansion of the service, and compensation models. We tabulated descriptive statistics from the multiple choice and Likert scale responses and performed a content analysis with an emergent code strategy for open-text responses. Specialists (n=34, 77% response rate) agreed that the Champlain BASE eConsult service is a feasible way to improve access to specialist care (94%), improves communication between specialists and primary care providers (PCPs) (94%), has educational value for PCPs (91%), and is user friendly (82%). A majority of specialists (88%) felt the service should be expanded provincially and 67% felt it should allow specialist-to-specialist consultation. 88% of specialists agreed that the current compensation process is best. This study provides an in-depth look at the perspective of the specialist physicians who use the Champlain BASE eConsult service. Specialists stated specific recommendations for change that will allow us to ensure the service remains sustainable.
In this open, controlled, multicentre and prospective observational study, smartphone teledermoscopy referrals were sent from 20 primary healthcare centres to 2 dermatology departments for triage of skin lesions of concern using a smartphone application and a compatible digital dermoscope. The outcome for 816 patients referred via smartphone teledermoscopy was compared with 746 patients referred via the traditional paper-based system. When surgical treatment was required, the waiting time was significantly shorter using teledermoscopy for patients with melanoma, melanoma in situ, squamous cell carcinoma, squamous cell carcinoma in situ and basal cell carcinoma. Triage decisions were also more reliable with teledermoscopy and over 40% of the teledermoscopy patients could potentially have avoided face-to-face visits. Only 4 teledermoscopy referrals (0.4%) had to be excluded due to poor image quality. Smartphone teledermoscopy referrals allow for faster and more efficient management of patients with skin cancer as compared to traditional paper referrals.
Abstract There is dissatisfaction among primary care physicians, specialists, and patients with respect to the consultation process. Excessive wait times for receiving specialist services and inefficient communication between practitioners result in decreased access to care and jeopardize patient safety. We created and implemented an electronic consultation (e-consultation) system in Eastern Ontario to address these problems and improve the consultation process. The e-consultation system has passed through the proof-of-concept and pilot study stages and has effectively reduced unnecessary referrals while receiving resoundingly positive feedback from physician-users. Using our experience, we have outlined the 10 steps to developing an e-consultation service. We detail the technical, administrative, and strategic considerations with respect to (1) identifying your partners, (2) choosing your platform, (3) starting as a pilot project, (4) designing your product, (5) ensuring patient privacy, (6) thinking through the process, (7) fostering relationships with your participants, (8) being prepared to provide physician payment, (9) providing feedback, and (10) planning the transition from pilot to permanency. In following these 10 steps, we believe that the e-consultation system and its associated improvements on the consultation process can be effectively implemented in other healthcare settings.
Background:
Access to specialist advice remains a barrier for primary care providers (PCPs) and their patients. Virtual consultations have been used to expedite access. There are few studies demonstrating the utilization and impact of such services. We established a regional e-consultation service that was used across a wide range of specialty services and PCPs.
Materials and methods:
We prospectively collected all e-consultations submitted from April 1, 2011 to June 30, 2012. Utilization data collected included number of e-consultations submitted, specialist response, and time required for the specialist to complete the e-consultation. Perceived benefit to the PCPs and their patients and the impact on care delivery were determined from a close-out survey.
Results:
Fifty-nine PCPs submitted 406 e-consultations to 16 specialty services. The specialist provided an answer without requesting further information in 89% of cases, with >90% of cases taking <15 min for the specialist to complete. Seventy-five percent of cases were answered in <3 days. The service was perceived as highly beneficial to providers and patients in>90% of cases. In 43% of submitted cases a traditional referral was originally contemplated but was now avoided.
Conclusions:
We successfully implemented an e-consultation service across diverse PCPs and specialty services that was highly valued. Almost half of referrals submitted would have required a face-to-face consultation if the service had not been available. Thus e-consultation has tremendous potential for improving access to specialist advice in a much more timely manner than the traditional referral-consultation process.
Limited access to specialist care remains a major barrier to health care in Canada, affecting patients and primary care providers alike, in terms of both long wait times and inequitable availability. We developed an electronic consultation system, based on a secure web-based tool, as an alternative to face-to-face consultations, and ran a pilot study to evaluate its effectiveness and acceptability to practitioners.
In a pilot program conducted over 15 months starting in January 2010, the e-consultation system was tested with primary care providers and specialists in a large health region in Eastern Ontario, Canada. We collected utilization data from the electronic system itself (including quantitative data from satisfaction surveys) and qualitative information from focus groups and interviews with providers.
Of 18 primary care providers in the pilot program, 13 participated in focus groups and 9 were interviewed; in addition, 10 of the 11 specialists in the program were interviewed. Results of our evaluation showed good uptake, high levels of satisfaction, improvement in the integration of referrals and consultations, and avoidance of unnecessary specialist visits. A total of 77 e-consultation requests were processed from 1 Jan. 2010 to 1 Apr. 2011. Less than 10% of the referrals required face-to-face follow-up. The most frequently noted benefits for patients (as perceived by providers) included improved access to specialist care and reduced wait times. Primary care providers valued the ability to assist with patient assessment and management by having access to a rapid response to clinical questions, clarifying the need for diagnostic tests or treatments, and confirming the need for a formal consultation. Specialists enjoyed the improved interaction with primary care providers, as well as having some control in the decision on which patients should be referred.
This low-cost referral system has potential for broader implementation, once payment models for physicians are adapted to cover e-consultation.
Purpose:
A Web-based consultation system (telenephrology) enables family physicians to consult a nephrologist about a patient with chronic kidney disease. Relevant data are exported from the patient's electronic file to a protected digital environment from which advice can be formulated by the nephrologist. The primary purpose of this study was to assess the potential of telenephrology to reduce in-person referrals.
Methods:
In an observational, prospective study, we analyzed telenephrology consultations by 28 family practices and 5 nephrology departments in the Netherlands between May 2009 and August 2011. The primary outcome was the potential reduction of in-person referrals, measured as the difference between the number of intended referrals as stated by the family physician and the number of referrals requested by the nephrologist. The secondary outcome was the usability of the system, expressed as time invested, the implementation in daily work hours, and the response time. Furthermore, we evaluated the questions asked.
Results:
One hundred twenty-two new consultations were included in the study. In the absence of telenephrology, 43 patients (35.3%) would have been referred by their family physicians, whereas the nephrologist considered referral necessary in only 17 patients (13.9%) (P <.001). The family physician would have treated 79 patients in primary care. The nephrologist deemed referral necessary for 10 of these patients. Time investment per consultation amounted to less than 10 minutes. Consultations were mainly performed during office hours. Response time was 1.6 days (95% CI, 1.2-1.9 days). Most questions concerned estimated glomerular filtration rate, proteinuria, and blood pressure.
Conclusion:
A Web-based consultation system might reduce the number of referrals and is usable. Telenephrology may contribute to an effective use of health facilities by allowing patients to be treated in primary care with remote support by a nephrologist.
Purpose:
Demands on publicly funded ophthalmic services worldwide continue to increase with new treatments, waiting time targets, working time limits, and restricted budgets. These highlight the necessity to develop innovative ways of utilising existing capacity more effectively.
Method:
A new regional, fully electronic ophthalmic-referral service with digital imaging was trialled using existing information-technology (IT) infrastructure. Following successful pilot study, the service was rolled out regionally. Service delivery data was prospectively collated for all the attendances in the year prior to (2006) and the year following (2008) introduction.
Results:
Comparing 2006 against 2008, median waiting times reduced (14 vs 4 weeks), and fewer new patients were observed (8714 vs 7462 P<0.0001), with 1359 referrals receiving electronic diagnosis (e-diagnosis). New patient did not arrive (635 vs 503 P<0.0001) and emergencies also reduced (2671 v 1984 P<0.0001).
Discussion:
Novel use of existing IT infrastructure improves communication between primary and secondary care. This promotes more effective use of limited outpatient capacity by retaining patients with non-progressive, asymptomatic pathology in the community, whilst fast-tracking patients with sight-threatening disease. Resultant significant, sustained improvements in regional service delivery point to a simple model that could easily be adopted by other providers of universal healthcare globally.
Health reforms in high-income countries increasingly aim to redesign primary care to improve the health of the population and the quality of health care services, and to address rising costs. Primary care improvements aim to provide patients with better access to care and develop more-integrated care systems through better communication and teamwork across sites of care, supported by health information technology and feedback to physicians on their performance. Our international survey of primary care doctors in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Switzerland, the United Kingdom, and the United States found progress in the use of health information technology in health care practices, particularly in the United States. Yet a high percentage of primary care physicians in all ten countries reported that they did not routinely receive timely information from specialists or hospitals. Countries also varied notably in the extent to which physicians received information on their own performance. In terms of access, US doctors were the most likely to report that they spent substantial time grappling with insurance restrictions and that their patients often went without care because of costs. Signaling the need for reforms, the vast majority of US doctors surveyed said that the health care system needs fundamental change.
Background
Patients have typically received health care through face-to-face encounters. However, expansion of electronic communication and electronic health records (EHRs) provide alternative means for patient and physicians to interact. Electronic consultations may complement regular healthcare by providing “better, faster, cheaper” processes for diagnosing, treating, and monitoring health conditions. Virtual consultation between physicians may provide a method of streamlining care, potentially saving patients the time and expense of added visits. The purpose of this study was to compare physician usage and patient satisfaction with virtual consultations (VCs) with traditional consultations (TCs) facilitated within an EHR.
Methods
We conducted an observational case–control survey study within Kaiser Permanente, Colorado. A sample of patients who had VCs requested by physicians (N = 270) were matched with patients who had TCs requested by physicians (N = 270), by patient age, gender, reason for the consult, and specialty department. These patients (VC and TC), were invited to participate in a satisfaction survey. In addition, 205 primary care physicians who submitted a VC or TC were surveyed.
Results
During the study period, 58,146 VC or TC were requested (TC = 96.3%). Patients who completed a satisfaction survey (267 out of 540 patients, 49.4% response rate) indicated they were satisfied with their care, irrespective of the kind of consult (mean 10-point Likert score of 8.5). 88 of 205 primary care physicians surveyed (42.9%) returned at least one survey; VC and TC survey response rates and consulted departments were comparable (p = 0.13). More TCs than VCs requested transfer of patient care (p = 0.03), assistance with diagnosis (p = 0.04) or initiating treatment (p =0.04). Within 3 weeks of the consultation request, 72.1% of respondents reported receiving information from VCs, compared with 33.9% of the TCs (p < 0.001). Utility of information provided by consultants and satisfaction with consultations did not differ between VCs and TCs.
Conclusions
Referring physicians received information from consultants more quickly from VCs compared with TCs, but the value and application of information from both types of consultations were similar. VCs may decrease the need for face-to-face specialty encounters without a decrease in the patient’s perception of care.
A virtual lesion clinic (VLC) using store-and-forward teledermoscopy was introduced to reduce waiting times and improve access for skin lesion assessment by dermatologists. We aimed to review the efficiency and patient acceptance of a new community-based teledermoscopy service by comparing it to hospital-based face-to-face (FTF) skin lesion clinics.
A prospective study compared patient flow through a community-based VLC and a tertiary hospital FTF dermatology clinic. Surveys were sent to patients and their referring doctors after attendance. Waiting times, diagnosis, outcomes, financial costs, patient acceptability and convenience were compared.
A total of 300 patients were assessed; 200 were seen in the VLC and 100 in the conventional FTF clinic. Of the 200 patients seen in the VLC, 88% did not require a subsequent FTF clinic assessment to establish the diagnosis. Mean waiting times for first assessment were reduced by two thirds (from 114 days to 39 days) in those seen by the VLC compared to FTF. Financial analysis demonstrated cost savings of 14%. Surveyed patients were highly satisfied and confident in the VLC service.
A community-based teledermoscopy service may allow improved management of outpatient referrals while providing a better, quicker and more convenient service. It may also provide cost savings, as teledermoscopy assessment can be cheaper than traditional assessment.
To describe a quality improvement for referral of National Health Service patients with macular disorders from a community optometry setting in an urban area.
Service evaluation of teleophthalmology consultation based on spectral domain optical coherence tomography images acquired by the community optometrist and transmitted to hospital eye services.
Fifty patients with suspected macular conditions were managed via telemedicine consultation over 1 year. Responses were provided by hospital eye service-based ophthalmologists to the community optometrist or patient within the next day in 48 cases (96%) and in 34 (68%) patients on the same day. In the consensus opinion of the optometrist and ophthalmologist, 33 (66%) patients required further "face-to-face" medical examination and were triaged on clinical urgency. Seventeen cases (34%) were managed in the community and are a potential cost improvement. Specialty trainees were supervised in telemedicine consultations.
Innovation and quality improvement were demonstrated in both optometry to ophthalmology referrals and in primary optometric care by use of telemedicine with spectral domain optical coherence tomography images. E-referral of spectral domain optical coherence tomography images assists triage of macular patients and swifter care of urgent cases. Teleophthalmology is also, in the authors' opinion, a tool to improve interdisciplinary professional working with community optometrists. Implications for progress are discussed.
Our Problem
The length of wait lists to access specialist clinics in the public system is problematic for Queensland Health, general practitioners and patients. To address this issue at The Townsville Hospital, the GP Liaison Officer, GPs and hospital staff including specialists, collaborated to develop a process to review patients waiting longer than two years. GPs frequently send referrals to public hospital specialist clinics. Once received, referrals are triaged to Category A, B or C depending on clinical criteria resulting in appointment timeframes of 30, 90 or 365 days for each category, respectively. However, hospitals often fail to meet these targets, creating a long wait list. These wait listed patients are only likely to be seen if their condition deteriorates and an updated referral upgrades them to Category A.
Process to Address the Problem
A letter sent to long wait patients offered two options 1) take no action if the appointment was no longer required or 2) visit their GP to update their referral on a clinic specific template if they felt the referral was still required. Local GPs were advised of the trial and provided education on the new template and minimum data required for specialist referrals.
What Happened
In 2008, 872 letters were sent to long wait orthopaedic patients and 101 responded. All respondents were seen at specially arranged clinics. Of these, 16 patients required procedures and the others were discharged. In 2009 the process was conducted in the specialties of orthopaedics, ENT, neurosurgery, urology, and general surgery. Via this new process 6885 patients have been contacted, 633 patients have been seen by public hospital specialists at specially arranged clinics and 197 have required a procedure.
Learnings
Since the start of this process in 2008, the wait time to access a specialist appointment has reduced from eight to two years. The process described here is achievable across a range of specialties, deliverable within the routine of the referral centre and identifies the small number of people on the long wait list in need of a procedure.
Scoping studies are an increasingly popular approach to reviewing health research evidence. In 2005, Arksey and O'Malley published the first methodological framework for conducting scoping studies. While this framework provides an excellent foundation for scoping study methodology, further clarifying and enhancing this framework will help support the consistency with which authors undertake and report scoping studies and may encourage researchers and clinicians to engage in this process.
We build upon our experiences conducting three scoping studies using the Arksey and O'Malley methodology to propose recommendations that clarify and enhance each stage of the framework. Recommendations include: clarifying and linking the purpose and research question (stage one); balancing feasibility with breadth and comprehensiveness of the scoping process (stage two); using an iterative team approach to selecting studies (stage three) and extracting data (stage four); incorporating a numerical summary and qualitative thematic analysis, reporting results, and considering the implications of study findings to policy, practice, or research (stage five); and incorporating consultation with stakeholders as a required knowledge translation component of scoping study methodology (stage six). Lastly, we propose additional considerations for scoping study methodology in order to support the advancement, application and relevance of scoping studies in health research.
Specific recommendations to clarify and enhance this methodology are outlined for each stage of the Arksey and O'Malley framework. Continued debate and development about scoping study methodology will help to maximize the usefulness and rigor of scoping study findings within healthcare research and practice.
Audiology in rural Alaska has changed dramatically in the past 6 years by integrating store and forward telemedicine into routine practice. The Audiology Department at the Norton Sound Health Corporation in rural Nome Alaska has used store-and-forward telemedicine since 2002. Between 2002 and 2007, over 3,000 direct audiology consultations with the Ear, Nose, and Throat (ENT) Department at the Alaska Native Medical Center in Anchorage were completed. This study is a 16-year retrospective analysis of ENT specialty clinic wait times on all new patient referrals made by the Norton Sound Health Corporation providers before (1992-2001) and after the initiation of telemedicine (2002-2007). Prior to use of telemedicine by audiology and ENT, 47% of new patient referrals would wait 5 months or longer to obtain an in-person ENT appointment; this dropped to 8% of all patients in the first 3 years with telemedicine and then less than 3% of all patients in next 3 years using telemedicine. The average wait time during the first 3 years using telemedicine was 2.9 months, a 31% drop compared with the average wait time of 4.2 months for the preceding years without telemedicine. The wait time then dropped to an average of 2.1 months during the next 3 years of telemedicine, a further drop of 28% compared with the first 3 years of telemedicine usage.
Chronic kidney disease is increasingly recognised in the UK, leading to a greater demand for specialist services. Traditional means of meeting this demand rely on GP referral of patients to see a nephrologist. Hospital assessment may be inconvenient for patients and inefficient for health services.
17 general practices and a secondary care nephrology service in Bradford, UK.
A before and after evaluation comparing nephrology referrals from implementation and non-implementation practices following the introduction of electronic consultations (e-consultations) for chronic kidney disease.
The number, appropriateness and quality of new referrals (paper and electronic) from primary care, the timeliness of responses and the satisfaction of patients and health professionals with the new service. Strategies for change Electronic sharing of primary care electronic health records with the nephrology service was introduced to implementation practices. Participating GPs attended education workshops and received paper and e-guidance about the new service.
There was a significant reduction in paper referrals from implementation practices. E-consultation provided nephrologists with access to more clinical information. GPs reported that the service was convenient, provided timely and helpful advice, and avoided outpatient referrals. Specialist recommendations were well followed, and GPs felt more confident about managing chronic kidney disease in the community.
E-consultation promotes effective management of patients with mild-to-moderate chronic kidney disease in primary care, allowing specialist resources to be directed towards supporting patients with more complex needs. There is a potential role for e-consultation in other chronic disease specialties.
Teledermatology is a rapidly growing field with studies showing high diagnostic accuracy when compared with face-to-face diagnosis. Teledermoscopy involves the use of epiluminescence microscopy to increase diagnostic accuracy. The utility of teledermoscopy as a triage tool has not been established.
To assess teledermoscopy as a triage tool for a hospital skin lesion clinic.
Patients referred to a dermatology skin lesion clinic were recruited. Digital and dermoscopic photographs were taken of skin lesions of concern and the patients were then seen independently face-to-face by two out of three dermatologists. The digital images were evaluated 4 weeks later, as a teledermoscopy consultation, by two of these dermatologists. The diagnosis and management from both types of consultation were compared.
Two hundred patients with a total of 491 lesions were seen. There was excellent agreement between teledermoscopy and face-to-face diagnosis with only 12.3% of lesions having disparate diagnoses of clinical significance. Twelve of 491 (2.4%) lesions appeared to have been under-reported by teledermoscopy when compared with face-to-face diagnosis. However, when histopathology became available, only one malignant lesion had been missed (a basal cell carcinoma diagnosed as solar keratosis) by teledermoscopy. Teledermoscopy approximated 100% sensitivity and 90% specificity for detecting melanoma and nonmelanoma skin cancers. Importantly, 74% of all lesions were determined to be manageable by the general practitioner without needing to be seen face-to-face by a dermatologist.
This use of teledermoscopy as a triage tool offers the potential to shorten waiting lists and thus improve healthcare access and delivery.
This project increased access to otolaryngology services by having an audiologist travel to remote Alaska and communicate with an otolaryngologist using store-and-forward electronic consultation. The audiologist was instructed to effectively image appropriate parts of the otolaryngology exam and create telemedicine cases that included clinical histories, images, audiograms, tympanograms, otoacoustic emission testing and/or other documents. The otolaryngology consultants reviewed new referrals as well as follow up cases and made treatment and triage recommendations. Over a 57 month period, 54 trips were made to 14 villages providing 197 clinic service days. The 1,458 patient encounters resulted in referral for surgery or special diagnostic testing 26%, referral for monitoring 23%, starting of medications 19%, referral to regional ENT clinic 15%, and referral to another specialty 5%. Approximately 27% patients did not need to see the otolaryngologist and were triaged out of the specialty clinic. The total cost to run this project was 496,420. These services were provided at a significantly lower cost and with fewer burdens to the patients when compared to the standard referral system. An audiologist that travels to remote locations and uses store-and-forward telemedicine can rapidly deliver otolaryngology services. This model is a proven mechanism of efficient healthcare delivery that may be expanded to other specialties.
To test the hypotheses that, compared with conventional outpatient consultations, joint teleconsultation (virtual outreach) would incur no increased costs to the NHS, reduce costs to patients, and reduce absences from work by patients and their carers.
Cost consequences study alongside randomised controlled trial.
Two hospitals in London and Shrewsbury and 29 general practices in inner London and Wales.
3170 patients identified; 2094 eligible for inclusion and willing to participate. 1051 randomised to virtual outreach and 1043 to standard outpatient appointments.
NHS costs, patient costs, health status (SF-12), time spent attending index consultation, patient satisfaction.
Overall six months costs were greater for the virtual outreach consultations ( pound 724 per patient) than for conventional outpatient appointments ( pound 625): difference in means pound 99 ($162; 138) (95% confidence interval pound 10 to pound 187, P=0.03). If the analysis is restricted to resource items deemed "attributable" to the index consultation, six month costs were still greater for virtual outreach: difference in means pound 108 ( pound 73 to pound 142, P < 0.0001). In both analyses the index consultation accounted for the excess cost. Savings to patients in terms of costs and time occurred in both centres: difference in mean total patient cost pound 8 ( pound 5 to pound 10, P < 0.0001). Loss of productive time was less in the virtual outreach group: difference in mean cost pound 11 ( pound 10 to pound 12, P < 0.0001).
The main hypothesis that virtual outreach would be cost neutral is rejected, but the hypotheses that costs to patients and losses in productivity would be lower are supported.
To determine whether an email triage system between general practitioners and a neurologist for new outpatient referrals is feasible, acceptable, efficient, safe, and effective.
This was a prospective single cohort study on the interface between primary care practitioners and the neurology clinic of a district general hospital. Seventy six consecutive patients with neurological symptoms from nine GPs, for whom a specialist opinion was deemed necessary, were entered in the study. The number of participants managed without clinic attendance and the reduction in neurologist's time compared with conventional consultation was measured, as was death, other specialist referral, and change in diagnosis in the 6 months after episode completion. The acceptability for GPs was ascertained by questionnaire.
Forty three per cent of participants required a clinic appointment, 45% were managed by email advice alone, and 12% by email plus investigations. GP satisfaction was high. Forty four per cent of the neurologist's time was saved compared with conventional consultation. No deaths or significant changes in diagnosis were recorded during the 6 month follow up period.
Email triage is feasible, acceptable to GPs, and safe. It has the potential for making the practice of neurologists more efficient, and this needs to be tested in a larger randomised study.
To evaluate a store-and-forward teledermatology system aimed at the routine triage of patients with skin cancer.
A multicenter, longitudinal, 4-phase, descriptive and evaluation study of a referred sample of patients attended through teleconsultation between March 2004 and July 2005 (n = 2009). Clinical and dermoscopical examination and histopathological study were considered the gold standard.
A skin cancer unit of a public university hospital and 12 primary care centers in southern Spain.
The study population comprised patients with circumscribed lesions fulfilling at least 1 of the following criteria: changes in ABCD criteria (asymmetry, border irregularity, color variegation, and diameter >6 mm), recent history, multiple melanocytic lesions, symptoms, and/or patient's application for surgical treatment and concern about moles.
Diagnosis, diagnostic category (malignant lesions, high-risk lesions, benign lesions, special lesions, and other lesions), diagnostic confidence level on a 3-point scale, and management decision (referral vs nonreferral) were listed after the evaluation of each teleconsultation. A face-to-face evaluation and biopsy of selected patients were performed.
The filtering percentage, as the percentage of patients not referred to the face-to-face clinic, as well as waiting intervals and pick-up or skin cancer detection rates were evaluated as effectiveness indicators. Reliability measures (kappa agreement), accuracy, and diagnostic performance indicators (validity) were also evaluated.
The filtering percentage was 51.20% (95% confidence interval [CI], 49.00%-53.40%). The waiting interval to attend the clinic was 12.31 days (95% CI, 8.22-16.40 days) through teledermatology and 88.62 days (95% CI, 38.42-138.82 days; P<.001) for the letter referral system. Pick-up rates were 2.02% (95% CI, 1.10%-2.94%) for malignant melanoma and 27.94% (95% CI, 24.98%-30.90%) or 1:3.71 for patients with any malignant or premalignant lesion. Intraobserver agreement was kappa = 0.91 (95% CI, 0.89-0.93) for the management decision and kappa = 0.95 (95% CI, 0.94-0.96) for the diagnosis. Interobserver concordance was kappa = 0.83 (95% CI, 0.78-0.88) for the management decision and kappa = 0.85 (95% CI, 0.79-0.91) for the diagnosis. Accuracy was kappa = 0.81 (95% CI, 0.78-0.84). Sensitivity was 0.99 (95% CI, 0.98-1.00); specificity, 0.62 (95% CI, 0.56-0.69); pretest likelihood, 0.42 (95% CI, 0.37-0.47); positive posttest likelihood, 0.65 (95% CI, 0.61-0.69); and negative posttest likelihood, 0.01 (95% CI, 0.00-0.05).
Store-and-forward teledermatology has demonstrated in this series to be an effective, accurate, reliable, and valid approach for the routine management of patient referrals in skin cancer and pigmented lesion clinics.