No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Disruptive Innovation: The Future of Healthcare?
Abstract
The traditional face-to-face doctor-patient relationship is the core of conventional medical practice. One key aspect of this changing relationship is the increasing dependency on asynchronous data collection in clinical consultations. Such electronic communications and data streams may be numeric, text-based, audio, digitized still pictures, video and radiologic, as well as emanating from multiple medical devices. While asynchronous medicine may be established in specialties like radiology and dermatology, there is little research regarding the use of asynchronous medicine in areas of medicine that traditionally rely on the physical doctor-patient interaction such as primary care, internal medicine, geriatrics, and psychiatry. The practice of psychiatry stands out as a discipline that is highly dependent on the quality of the physical meeting between the doctor and the patient, yet even in this specialty it is possible to utilize asynchronous medicine for some types of psychiatric consultations. Asynchronous medicine has the potential to be significantly disruptive to our current healthcare processes, as well as more clinically and economically efficient.
... The role of advanced network technologies and their relation with healthcare innovation have been widely discussed. [1][2][3][4][5][6][7][8][9][10] There has been an increasing interest in understanding how infrastructure changes will impact on future telehealth applications. ...
... 9,14,15 However, studies have shown that cutting-edge telehealth technologies and pilot applications developed a decade ago are becoming common today, 1 some technologies that will be adopted by telehealth over the next couple of decades could have already been developed in other contexts, 6 and experimental clinical implementations with advanced technologies and infrastructure can provide helpful empirical evidence. 1,8,16 Based on these understandings, we adopted a mixed method for assessing future trends. Details of these approaches are outlined below. ...
... Asynchronous (store-and-forward) information sharing can play a role in this to support access to symptom data. 8,32 Future clinical interactions will occur ''anytime, anywhere.'' 8 This will be enabled by new communication patterns based on advanced telecommunication infrastructure and mobile communication. ...
Background:
As telehealth takes advantage of improved networks, there is a growing need to understand the infrastructure needs of future telehealth developments. This work aims to predict such needs based on current trends and research.
Materials and methods:
We conducted a literature review of telehealth with a focus on advanced network infrastructure. We drew inferences from our previous demonstrator projects in advanced telehealth, but the most important findings emerged from interviews with a panel of thought leaders.
Results:
Our results show that there will be simultaneous and coupled evolution of telehealth through the space spanned by three axes: care models, clinical applications, and technology. We also consider a two-dimensional model of reach and complexity to describe future applications. Universal access to advanced networks will drive fundamental changes in healthcare deliver. The biggest change will be seen in home and mobile health care delivery, forming part of a trend toward patient-centric models. Other aspects of decentralization in healthcare systems will include networks of caregivers. Besides this reach trend, the complexity trend will include integrating multiple-channel applications and seamlessly moving large datasets in real time among hospitals, other medical facilities, and homes. There is a need to provide infrastructure that does not have an upper limit on quality of service and allows telehealth to address mobility, usability, interoperability, intelligence, and adaptability in a systematic way.
... In the era of digital transformation, this initiative is particularly significant, as it aligns with the MoH's vision of implementing a regulatory sandbox for disruptive healthtech. The rapid emergence of disruptive innovations poses a profound challenge to our health care system as it empowers a broader population with limited expertise and resources to access convenient and cost-effective health care services that may harbor unknown risks [20]. By implementing a regulatory sandbox, we created a safe testing environment that allows innovators to explore and refine their technologies, whereas regulators gain invaluable insights into effectively governing these transformative advancements, as mandated by the MoH's strategic plan [21]. ...
... However, the adoption of a regulatory sandbox encounters unique challenges in the health sector of a country that adheres to positive laws despite successful implementation in the financial sector. To ensure the successful integration of disruptive digital technologies in malaria programs, it is crucial to establish a secure space where private sector entities, including healthtech start-ups and incubators, can test their innovations under regulatory supervision [20]. ...
Background
Regulatory sandboxes offer an alternative solution to address regulatory challenges in adopting disruptive technologies. Although regulatory sandboxes have been widely implemented in the financial sector across more than 50 countries, their application to the health sector remains limited.
Objective
This study aims to explore stakeholders’ perspectives on introducing a regulatory sandbox into the Indonesian health system using e-malaria as a use case.
Methods
Using a participatory action research approach, this study conducted qualitative research, including desk reviews, focus group discussions, and in-depth interviews with stakeholders. This study sought to understand stakeholders’ concerns and interests regarding the regulatory sandbox and to collaboratively develop a regulatory sandbox model to support the malaria program.
Results
The study revealed that most stakeholders had limited awareness of the regulatory sandbox concept. Concerns have been raised regarding the time required to establish regulations, knowledge gaps among stakeholders, data protection issues, and limited digital infrastructure in malaria endemic areas. Existing regulations have been found to be inadequate to accommodate disruptive healthtech for malaria. Nevertheless, through a collaborative process, stakeholders successfully developed a regulatory sandbox model specifically for e-malaria, with the crucial support of the Ministry of Health.
Conclusions
The regulatory sandbox holds the potential for adoption in the Indonesian health system to address the limited legal framework and to facilitate the rapid and safe adoption of disruptive healthtech in support of the malaria elimination program. Through stakeholder involvement, guidelines for implementing the regulatory sandbox were developed and innovators were successfully invited to participate in the first-ever trial of a health regulatory sandbox for e-malaria in Indonesia. Future studies should provide further insights into the challenges encountered during the e-malaria regulatory sandbox pilot study, offering a detailed account of the implementation process.
... AI can reduce healthcare costs by reducing staff burnout, reducing patient wait times, and tackling disease complexity (Bellucci,2002). These entail innovations in the form of using AI assistants to grade and sort patient images and text data, being able to address or at least route patient concerns through natural language processing modalities, to examine literature, patient data, and health care provider inputs to either decipher patient pathologies or solution(s) to patient pathologies and reduce harms and lawsuits that would result, among other innovations (Wynants et al., 2020;Shaheen,2021). Reflecting on benefits of these disruptive innovations and the move towards adoption, it is essential to consider the security implications of these proposed innovations, post-adoption, especially with the impact of COVID-19 on the industry. ...
... By leveraging disruptive innovation, incorporating evidence into care delivery and decision-making, involving patients and families in healthcare decisions, and improving care coordination across organizations, we will accelerate progress toward improving our nation's health. Yellowlees et al. (2011) state that asynchronous medicine would thrive within a facilitated network model, which would change the jobs of most of the people involved in caring for a patient. The facilitated network model would consist of an electronic system through which healthcare professionals and patients share information, like transmitting healthcare records. ...
Exploits of technology have been an issue in healthcare for many years. Many hospital systems have a problemwith “disruptive innovation” when introducing new technology. Disruptive innovation is “an innovation thatcreates a new market by applying a different set of values, which ultimately overtakes an existing market”(Sensmeier, 2012). Modern healthcare systems are historically slow to accept new technological advancements .This may be because patient-based, provider-based, or industry-wide decisions are tough to implement, giving wayto dire consequences. One potential consequence is that healthcare providers may not be able to provide the bestpossible care to patients. For example, if a healthcare provider does not adopt new technologies or approaches tomedical treatment, they may not be able to offer the same level of care as a provider who has embraced thoseinnovations. This leads to lower quality of care and poorer patient outcomes.Another consequence is that healthcare providers who do not adapt to disruptive innovations may lose marketshare to competitors who are more forward-thinking and willing to embrace new technologies and approaches.This can harm the provider's financial performance and sustainability.Not adapting to disruptive innovations inhealthcare can result in missed opportunities to improve the efficiency and effectiveness of medical treatment. If ahealthcare provider does not adopt electronic medical records, they may miss out on the benefits of faster andmore accurate information sharing, improving patient care.Once the decision to implement technology in a specific healthcare industry is made, concerns about patientsafety, an aversion to change, and hospital-wide compliance with regulations begin to arise (WynHouse, nd.). Thehealthcare technology industry also boomed with the COVID-19 outbreak. The COVID-19 outbreak has led tosignificant advancements and innovations in medical technology. In order to diagnose, treat, and prevent thespread of the virus, healthcare providers and researchers have had to develop and deploy new technologies andapproaches. The COVID-19 outbreak has highlighted the importance of the medical industry and the essential roleit plays in society. This has led to increased funding, support for medical research and development, as well as agreater appreciation for the work of healthcare providers. This has created opportunities for growth andinnovation in the medical industry. It also placed enormous strain on global health systems, disrupting healthcareby increasing the risk of fraud and deception; the risk of hospital operations and assets being compromised,disrupted, or altered; and the increased use of telehealth resulting in a breakdown between providers andconsumers (Kuehn,2021). This article will cover the effects/impact of disruptive innovations/technologiesintroduced into healthcare industries over the short term through a light review of disruptions and responses,followed by commentary and policy recommendations.
... Telemedicine can not only make health care cheaper by decentralizing care, but also more convenient by bringing care closer to the patient. Thus, telemedicine presents a hybrid between low-end and new-market disruption: on the one hand, it may be attractive to less demanding patients in developed health care systems, while on the other hand, it may compete against non-consumption in developing health care systems where patients did not previously have access to health care providers (Christensen, 1997;Christensen et al., 2009;Christensen and Raynor, 2003;Shah et al., 2013;Steinhauser et al., 2015;Yellowlees et al., 2011). Even though telemedicine will not entirely replace traditional treatment, it substantially increases the public impact of the underlying technology and service (Rotheram-Borus et al., 2012). ...
... Moreover, physicians consider autonomy and power to be a cornerstone of their profession (e.g., Blumenthal, 1994). The usage of HIT innovations like telemedicine significantly alters the physician-patient relationship, lowers physicians' autonomy and control, and requires fundamental changes to care delivery as well as thought processes (Anderson, 1997;Boonstra and Broekhuis, 2010;Christensen et al., 2009;Yellowlees et al., 2011). The findings of Bhattacherjee and Hikmet (2007) and Smith et al. (2014) indicate that the perception of HIT innovations as a threat may cause resistance. ...
Incumbents’ inertia in the face of disruptive innovations has been emphasised in prior literature. The relevance of inertia is particularly topical in the context of digital transformation. However, incumbents may be able to invest in disruptive digital innovations appropriately if they possess the motivation and ability to do so. In this paper, I use three streams of research in order to investigate contextual, organisational, and individual antecedents of incumbents’ motivation and ability to adopt and use potentially disruptive digital innovations in health care: institutional theory, the resource-based view, and technology acceptance literature. I employ factor analyses and logistic regressions to test the impact on the adoption and usage of telemedicine applications using a dataset of 9,196 European general practitioners. I examine B2B as well as B2C applications in order to determine the effect of the antecedents on different business models. My findings suggest that only isomorphic pressure, complementary assets, and perceived output quality significantly influence both adoption and usage as well as B2B and B2C business models in the same way. Formal institutions and individual factors yield ambiguous results. These findings provide important implications for the understanding of incumbents’ response to potentially disruptive digital innovations in regulated contexts.
... Egyes szerzôk szerint a digitális forradalom eredményeként a beteg fizikális jelenlétén alapuló orvos-beteg kapcsolatok jelentôségük ellenére a jövôben valamelyest veszítenek súlyukból és mellettük egyre nagyobb szerepet kapnak az infokommunikációs technológiák is, mint a kontaktust megteremtô közvetítô közegek (26). Ebbôl adódóan az orvos-beteg "találkozás" -némi túlzással -tértôl, távolságtól és idôtôl függetlenül létrejöhet (27). A nemzetközi szakirodalom szerint azonban a telemedicinális lehetôségek sokkal inkább kiegészítô és nem helyettesítô funkciót töltenek be (28). ...
... A nemzetközi szakirodalom szerint azonban a telemedicinális lehetôségek sokkal inkább kiegészítô és nem helyettesítô funkciót töltenek be (28). Ráadásul az orvostudományon belül vannak olyan szakterületek (például alapellátás, belgyógyászat stb.), amelyek erôsen kötôdnek és igénylik a beteg fizikális jelenlétét (27). ...
INTRODUCTION: The doctor-patient relationship has always been an essential part of health care, however, in parallel with the integration infocommunication technologies in health care the doctor-patient communication is also transforming. Therefore, the aim of the study is to examine the effect of telemedicine on this relationship. METHODS: During the study, we applied qualitative research methods and a total number of 58 semi-structured interviews (45 men, 13 women) were conducted among physicians having experience in telemedicine. The majority of the interviewees were radiologist, general practitioners, and internists. The interview questions concerned that what characterises the doctor-patient relationship in telemedicine. RESULTS: The interviews pointed out that in teleradiology the doctor-patient relationship depersonalises and almost terminates. In this respect, the problem is often the incomplete clinical information about the patient. In turn, telemonitoring can bring a quality change in the doctor-patient communication and through remote contact the patients' satisfaction, the sense of security, and the doctor-patient relationship will be further enhanced. CONCLUSIONS: In accordance with the academic literature - based on the research results - there is no clear evidence that telemedicine would affect doctor-patient communication only positively or only negatively. In some areas of telemedicine, this relationship is reducing (e.g. teleradiology) while in other areas it could be further strengthened (e.g. telemonitoring).
... The World Health Organization [18] has estimated that 450 million people are affected by mental or behavioural disorders worldwide, and five of the ten leading causes of disability and premature death are associated with psychiatric conditions. The potentially fatal effects of depression and other mental conditions can be prevented or greatly attenuated with timely intervention, but this is difficult to implement, due to such factors as limitations in access to providers [19]. Most recently, the time-critical nature of some telemental health interventions has prompted innovation in this long-established field. ...
... For example, while the basic mental health consultation is an interview between clinician and patient, the ease of access provided by telemedicine can allow a single 50-minute consultation to be replaced by two or three shorter interviews [20]. Scheduling difficulties for both patient and clinician can be eased through the use of asynchronous consultations [19]. Standard interviews can be conducted through semi-specialist clinicians and reviewed by the specialist before evidence-based treatment is recommended. ...
Objectives
Healthcare is now routinely delivered by telecommunications-based services in all developed countries and an increasing number of developing countries. Telemedicine is used in many clinical specialities and across numerous healthcare settings, which range from mobile patient-centric applications to complex interactions amongst clinicians in tertiary referral hospital settings. This paper discusses some recent areas of significant development and progress in the field with the purpose of identifying strong trends in both research and practice activities.
Methods
To establish the breadth of new ideas and directions in the field, a review of literature was made by searching PubMed for recent publications including terms (telemedicine OR telehealth) AND (challenge OR direction OR innovation OR new OR novel OR trend), for all searchable categories. 3,433 publications were identified that have appeared since January 1, 2005 (2,172 of these since January 1, 2010), based on a search conducted on June 1, 2015.
Results
The current interest areas in these papers span both synchronous telemedicine, including intensive care, emergency medicine, and mental health, and asynchronous telemedicine, including wound and burns care, dermatology and ophthalmology.
Conclusions
It is concluded that two major drivers of contemporary tele medicine development are a high volume demand for a particular clinical service, and/or a high criticality of need for clinical exper tise to deliver the service. These areas offer promise for further study and enhancement of applicable telemedicine methods and have the potential for large-scale deployments internationally, which would contribute significantly to the advancement of healthcare.
... The psychiatrist then writes a consult note for the patient's primary care provider. This method is similar to store-andforward teledermatology and teleradiology [30,31], representing a disruptive innovation in mental healthcare that has demonstrated feasible outcomes plus clinical and economic efficiency [32]. Cost analyses show that, with sufficient patient volume, asynchronous telepsychiatry is more costeffective compared to both synchronous telepsychiatry and in-person psychiatric consultations [33]. ...
... As a result of the difficulty some Hispanic field workers had attending consultations, asynchronous telepsychiatry consultations have been tested in this population, with both Spanish-and English-speaking psychiatrists providing the asynchronous consultations [71]. This innovative approach has been shown to be feasible with broad diagnostic reliability demonstrated across languages following translation [32]. These asynchronous, or store-and-forward, encounters that are amenable to translation could potentially be used across many ethnic groups and languages and may well be a model for future telepsychiatry directions and innovations. ...
The use of video-based telepsychiatry is increasing in response to consumer demand for convenient, inexpensive, and readily accessible services; improved financial reimbursement; and a robust body of evidence-based literature. Telepsychiatry leads to high patient and provider satisfaction ratings, and outcomes equivalent to in-person care, while younger generations often prefer telepsychiatry over face-to-face encounters. The evidence base for telepsychiatry is especially strong with respect to the treatment of post-traumatic stress disorder (PTSD), depression, and ADHD, while its use in underserved ethnic groups is well described in the American Indian, Hispanic, and Asian populations. Despite this, telepsychiatry barriers still persist. These include personal bias-especially in leadership-and insufficient training; the challenging business environment and legislative processes; and inconsistent reimbursement, licensing, and prescription policies. Technology is now less of a barrier, and it is clear that telepsychiatry overall is flourishing and changing the way that providers are working and patients are being treated.
... however, the work practices of GPs have evolved; for example, fewer GPs today make house calls compared to earlier [3], and the 'coordination Reform' of 2012 involved expectations of increased municipal control and integration of general practitioners, as well as expectations to strengthen the GPs' vertical relationship with specialist health services [4]. additionally, there has been an increased interest and use of digital health technology [5][6][7]. During the time of this research, digital health technologies in GP offices primarily included secure digital messaging (sDM), teleconsultations, and electronic health records (ehRs). ...
Abstract
Objective
This study explores the experiences of General Practitioners (GPs) in Norway, examining the role of care in their practice and the impact of digital health technologies on their caregiving approach.
Design
A qualitative study employing semi-structured interviews. The data was analysed by systematic text condensation.
Setting
Conducted in various general practice settings within an urban region in southwestern Norway.
Subjects
Eleven GPs were interviewed, chosen to reflect a diverse mix of ages, genders, and professional experiences.
Results
The findings reveal that care occupied a central and multifaceted role in GPs daily practice, and that the care aspect of their practice was experienced as a source of personal fulfilment. Technologies such as Secure Digital Messaging (SDM) and Electronic Health Records could enhance the efficiency of care delivery and facilitate better management of patient interactions, however these technologies also present challenges in maintaining the depth of personal engagement that is central to the care ethics that characterise their caring role. The GPs emphasized the necessity of integrating digital tools in a way that supports the relational and ethical foundations of their caregiving role.
Conclusion
This study underscores the enduring importance of care in general practice, even as digital technologies become increasingly prevalent. GPs maintain their caregiving roles by navigating the complexities of digital tools, highlighting the need for a careful balance between leveraging digital advancements and preserving the core values of care. The findings suggest a need for ongoing evaluation of digital tools to align them with the ethical foundations of care in general practice.
... The first aspect of disruptive innovation is its technological (and engineering) dimension. Technological and product innovations like telemedicine (Bagot et al. 2015), cloud-based platforms (Brooks 2014), electronic health records systems (Garrety, McLoughlin, and Zelle 2014), precision laboratory medicine (Khatab and Yousef 2021), and asynchronous medicine (Yellowlees et al. 2011) have received the majority of attention in research on disruptive innovations in healthcare. Second, grassroots organizations that work to improve access to healthcare services include non-for-profit organizations (NGOs), non-profit organizations (NFPOs). ...
... Asynchronous medicine has the potential to be significantly disruptive to our current healthcare processes, as well as more clinically and economically efficient. [21] recently developed technologies for better handling of image information: photorealistic visualization of medical images with Cinematic Rendering, artificial agents for in-depth image understanding, support for minimally invasive procedures, and patient-specific computational models with enhanced predictive power. [22] THE PHYSICIAN ...
Ultimately, healthcare innovation leads to improved clinical care, with new technology improving healthcare efficiency, effectiveness, quality, and affordability. With ever-increasing demand on health systems worldwide, the ultimate goal of healthcare innovation is to improve the ability to meet public and personal healthcare needs through the optimization of health systems' performance. In this article, we will discuss hospital-based innovation within the next decade that yields scalable solutions within the fields of preventative, treatment, and infection control healthcare innovation. Governments face tough choices since medical innovations hold promises and perils. These innovations occur across multiple dimensions, including core sciences, drug development, care delivery, and organizational and business models. In particular, medical technology-related innovations are blossoming, with medical technology patents more numerous and growing faster than pharmaceutical patents over the last decade. Despite this enormous investment in innovation and the magnitude of the opportunity for innovators to both do good and do well, all too many efforts fail, losing billions of investor resources along the way. [1] Barriers to disruptive innovation are often the public themselves acting through fear, enacting stringent regulation, supported by established professionals afraid to lose income and hospitals their investment in expensive systems. [2]
... However, despite the significant improvement of healthcare quality over the years, inefficiency within the healthcare sector still exists, and detailed research has been undertaken on how to overcome the inefficiencies using innovation (Thakur et al., 2012), as evidenced by the recent COVID-19 pandemic. Thus, in the face of this ever-changing healthcare environment, both academicians and practitioners have started focusing their attention towards DI as a force to combat healthcare issues (Yellowlees et al., 2011). The term "Disruptive Innovation", coined by Clayton M. Christensen (1997), refers to an innovation process whose sudden arrival in the marketplace signifies the eventual displacement of the dominant technology in that sector. ...
Disruptive innovation (DI) refers to a mode of low cost high ancillary performance innovation that starts at the lower end of the market and gradually moves up to eventually displace its incumbent counterparts. The concept of DI has become more and more popular in the healthcare sector. The paper studies how healthcare research has embraced the concept of DI in various areas within the healthcare sector. Areas of healthcare, where DI has been adopted as a management strategy, were identified in the last two decades, through initially shortlisting 157 papers and the final reviewed set of 117 papers. Through a multi-method approach comprising of co-word analysis, identification of themes, mapping of research work across these themes and geography, the study found that, although from a management perspective there are 13 major themes, the majority of the focus is on four major themes–healthcare delivery and services, healthcare administration, technology and equipment, and nursing and palliative care. Furthermore, the majority of the geography-specific research was conducted in developed countries, especially the USA. It was also observed that organisational strategies for successfully implementing DI in the healthcare sector are still in the nascent stage and the focus is mostly in the area of healthcare delivery and administration from the management perspective. Future research studies could aim at looking at the role that DI plays in the healthcare sector of the developing countries, as well as using DI in other areas of healthcare, rather than a few concentrated areas.
... Although the price of sequencing the exome is more affordable, the issue of storing the information and analyzing it are at best problematic. Moreover, a practical challenge to implementation of precision medicine within the healthcare systems is the reluctance of physicians to disruptive innovation, i.e., to changes that interrupt daily clinical routine and practice (Yellowlees et al. 2011). ...
... Synchronous telepsychiatry involves a live two-way interactive video to a remote site between the psychiatrist and the patient (either alone, with the PCP, or more commonly with the CM). Yellowlees et al. noted that asynchronous telepsychiatry includes a process in which the PCP initiates a referral and a video-recorded structured interview is conducted and transmitted together with patient's medical records via a secure Web site for a psychiatrist to evaluate and then write up a diagnostic assessment and treatment plan (30). Asynchronous psychiatry has been shown to be useful in providing services to culturally diverse groups (31). ...
The objective of this article is to inform psychiatrists and other mental health professionals and primary care providers about the role of telepsychiatry in facilitating integrated care models, particularly in remote primary care practices. A narrative literature review was conducted to highlight the evidence and challenges of using telepsychiatry for integrated care. Telepsychiatry uses communication technologies to facilitate audiovisual interaction between patients and care teams to deliver services and expertise across distances and practice settings. It is particularly suited for integrated care settings, if business model innovations such as collaborative care models are implemented alongside to improve the access and delivery of care to patients. Telepsychiatry has been shown to be equivalent to face-to-face evaluations and, in certain instances, may lead to better outcomes in integrated care settings. Several challenges of adopting telepsychiatry in real practice are highlighted, including reimbursement and licensing across states, which continue to be an important barrier. It is critical to use an established framework to understand the potential users of telepsychiatry and develop and promote competency-based telepsychiatry training for novice, competent, and expert users. Psychiatrists who want to extend their expertise to distant sites, improve access to care, and partake in the new business models of collaborative care will need to consider these benefits and challenges.
... A randomized clinical trial evaluating the use of speech recognition and language interpretation is underway (see Fig. 2) [24,25]. Asynchronous telemedicine could potentially expand, in the future, to internal medicine, geriatrics, and primary care, all of which rely on physical doctor-patient interaction [26]. ...
Purpose of Review
Mental health clinicians should understand how technologies augment, enhance, and provide alternate means for the delivery of mental healthcare. These technologies can be used asynchronously, in which the patient and the clinician need not be communicating at the same time. This contrasts with synchronous technologies, in which patient and clinician must communicate at the same time.
Recent Findings
The review is based on research literature and the authors’ clinical and healthcare administration experiences. Asynchronous technologies can exist between a single clinician and a single patient, such as patient portal e-mail and messaging, in-app messaging, asynchronous telepsychiatry via store-and-forward video, and specialty patient-to-provider mobile apps. Asynchronous technologies have already been used in different countries with success, and can alleviate the psychiatric workforce shortage and improve barriers to access. Multiple studies referred to in this review demonstrate good retention and acceptability of asynchronous psychotherapy interventions by patients.
Summary
Asynchronous technologies can alleviate access barriers, such as geographical, scheduling, administrative, and financial issues. It is important for clinicians to understand the efficacy, assess the ethics, and manage privacy and legal concerns that may arise from using asynchronous technologies.
... Within health care, e-health overall has been defined as health practice supported by any kind of electronic processes and communication and it dates back to 1999 (Oh et al. 2005;Yellowlees et al. 2011;Lal and Adair 2014). Mobile health (mHealth), on the other hand, has been defined as health services delivered specifically by mobile devices (e.g., mobile phones, PDAs, tablets and other wireless devices) (WHO 2011;Anthes 2016). ...
In 2001, the WHO stated that: "The use of mobile and wireless technologies to support the achievement of health objectives (mHealth) has the potential to transform the face of health service delivery across the globe". Within mental health, interventions and monitoring systems for depression, anxiety, substance abuse, eating disorder, schizophrenia and bipolar disorder have been developed and used. The present paper presents the status and findings from studies using automatically generated objective smartphone data in the monitoring of bipolar disorder, and addresses considerations on the current literature and methodological as well as clinical aspects to consider in the future studies.
... Telehealth is recognised as an example of disruptive innovation which often affects the manner in which health professionals and the health system interact with patients. 5 There are often concerns that service fidelity may be affected, and that the patient experience may be inferior to conventional in person consultations. In government-subsidised fee-for-service settings, the funder may be interested in the costs associated with establishing and operating a telehealth service. ...
Planning a research strategy and formulating the right research questions at various stages of developing a telehealth intervention are essential for producing scientific evidence. The aim of research at each stage should correspond to the maturity of the intervention and will require a variety of study designs. Although there are several published evaluation frameworks for telemedicine or telehealth as a subset of broader eHealth domain, there is currently no simple model to guide research planning. In this paper we propose a five-stage model as a framework for planning a comprehensive telehealth research program for a new intervention or service system. The stages are: (1) Concept development, (2) Service design, (3) Pre-implementation, (4) Implementation, (5) Post-implementation, and at each stage a number of studies are considered. Robust evaluation is important for the widespread acceptance and implementation of telehealth. We hope this framework enables researchers, service administrators and clinicians to conceptualise, undertake and appraise telehealth research from the point of view of being able to assess how applicable and valid the research is for their particular circumstances.
... Radiologists using systems such as Illuminate were able to improve workflow, improve patient care, improve patient safety and cut costs [19][20][21][22][23][24][25]. This was primarily related to their improved ability in gathering information across hospital systems and providing instant access to relevant patient history and results of prior procedures to make better-informed decisions in less time. ...
Timely pathology results are critical for appropriate diagnosis and management of patients. Yet workflows in laboratories remain ad hoc and involve accessing multiple systems with no direct linkage between patient history and prior or pending pathology records for the case being analyzed. A major hindrance in timely reporting of pathology results is the need to incorporate/interface with multiple electronic health records (EHRs). We evaluated the Illuminate PatientView software (Illuminate) integration into pathologist's workflow. Illuminate is a search engine architecture that has a repository of textual information from many hospital systems. Our goal was to develop a comprehensive, user friendly patient summary display to integrate the current fractionated subspecialty specific systems. An analytical time study noting changes in turnaround time (TAT) before and after Illuminate implementation was recorded for reviewers, including pathologists, residents and fellows. Reviewers' TAT for 359 cases was recorded (200 cases before and 159 after implementation). The impact of implementing Illuminate on transcriptionists’ workflow was also studied. Average TAT to retrieve EHRs prior to Illuminate was 5:32 min (range 1:35-10:50). That time was significantly reduced to 35 seconds (range 10 sec-1:10 min) using Illuminate. Reviewers were very pleased with the ease in accessing information and in eliminating the draft paper documents of the pathology reports, eliminating up to 65 min/day (25-65 min) by transcriptionists matching requisition with paperwork. Utilizing Illuminate improved workflow, decreased TAT and minimized cost. Patient care can be improved through a comprehensive patient management system that facilitates communications between isolated information systems.
... The courses we do, and they last just one or two days, are taught by people called by the board of health, so, we are not used to asking". This collective discourse highlights how the CHWs concluded that basic computer knowledge mental conceptions of everything in the world 21,22 . In this regard, the motivational stimulus e quite relevant, and if the community is not motivated or retro-fed, there is a high risk of withdrawal from the course. ...
Purpose
to verify and to feature the conditions of the effective participation of community health workers (CHW) in virtual learning environment with topic “breast-feeding”;.
Methods
participated in the study 49 CHW from Rondônia, and after 45 days, in wich all the process was monitored, occurred a videoconference to take testimonials about the access and content. It was used the Collective Subject Discurse to identify difficulties/easiness/suggestions/ proposals of wich were extracted three categories: (a) Willing to obtain knowledge; (b) Conditions to the achieving of the study; and (c) Assesment of professional education and the content.
Results
8 CHW (15.69%) accessed the cybertutor in correct time; 100% folowed the introductory module complete; 62.50% the modulus 2 and 3; 37.50% the modulus 4 at 8. For the Category (a) 8 CHW reported were motivated in using cybertutor, since it is a way to reinforce and acquire new knowledge. As to Category (b) the main difficulties were described as lack of knowledge on technology, material and financial resources and time availabilities. In Category (c) it was reported having obtained new knowledge that could be passed immediately to population and the desire to have similar experiences.
Conclusion
the requeriments for the distance courses for CHW imply the viability of resources by local administrators, prior knowledge of basic computer, Internet access, computers availables in appropriate sites, well as others aspects such, to time available during working hours and/or extra time and challenging themes to make effect continuing distance education.
... Telemedicine is inevitable according to all economic trends and public opinion. The approach for concerned and conscientious physicians is to learn about the matter, to become leaders rather than followers, and to bring this tool into the daily practice of medicine rather than having a disruptive technology eroding our basic bond of patient care [27]. ...
Objectives
The global population of elderly people is increasing at a remarkable rate, which may be expected to continue for some time. Older patients require more care, and with the current model of care delivery, the costs may be expected to rise, although higher cost is unsustainable. For this reason, a new pattern of practice is needed. Telemedicine will be presented as a highly effective and necessary tool in geriatrics.
Methods
This review will present some of the background and evidence for telemedicine as a way to address the challenges of geriatrics through geriatric telemedicine. Some of the evidence for the value of telemedicine as a tool for physicians and healthcare systems is presented.
Results
Telemedicine offers many means to address the problems of geriatric care in creative ways. The use of electronic medicine, telecommunications, and information management has now found its way into the very fabric of health care. The use of telemedicine is a fait accompli in much of the world, and it continues to have an increasing role deeply imbedded in our electronic practices coupled with social media.
Conclusions
The evidence for successful incorporation of telemedicine into practice is abundant and continues to accrue. This is a great opportunity for medical practice to evolve to new levels of engagement with patients and new levels of attainment in terms of quality care.
... The courses we do, and they last just one or two days, are taught by people called by the board of health, so, we are not used to asking". This collective discourse highlights how the CHWs concluded that basic computer knowledge mental conceptions of everything in the world 21,22 . In this regard, the motivational stimulus e quite relevant, and if the community is not motivated or retro-fed, there is a high risk of withdrawal from the course. ...
... Recorded structured assessments could lead to the development of algorithms using movement and facial recognition software to more accurately quantify DIMDs. 12 ...
The purpose of this brief report is to make clinical and research recommendations to advance current knowledge and practices related to the assessment of antipsychotic drug-induced movement disorders (DIMDs) via live interactive videoconferencing.
The authors provide an overview of the frequent neurological side effects of antipsychotic drugs and review relevant telemedicine research. DIMD prevention is critical, but these disorders remain underdetected and under-reported. Although there are not yet formal recommendations for specific screening tools or screening frequency, baseline and annual assessments are generally agreed-upon minimums. As DIMD awareness increases and more specific guidelines are developed to steer assessments, telemental health may aid practitioners in efficiently and regularly monitoring onset and severity. Research shows that videoconferencing can be used for effective psychiatric treatments and assessment, with at least one study validating the use of videoconference assessment for a subset of movement disorders.
Clinical recommendations include developing practice-level protocols and procedures that include regular DIMD assessment (either in-person or via telemedicine) for the full spectrum of possible movement disorders for all patients taking antipsychotic medications. Research and evaluation recommendations include replicating and expanding upon the existing study using videoconferencing to assess movement disorder symptoms, using asynchronous telemental health assessments of DIMDs, and pilot-testing facial and movement recognition software to allow for clinical comparison of patients' movement patterns over time.
... The courses we do, and they last just one or two days, are taught by people called by the board of health, so, we are not used to asking". This collective discourse highlights how the CHWs concluded that basic computer knowledge mental conceptions of everything in the world 21,22 . In this regard, the motivational stimulus e quite relevant, and if the community is not motivated or retro-fed, there is a high risk of withdrawal from the course. ...
Conflict of interest: non-existent has been an alternative to improve the quality of life and well being of citizens 2 . DL is a technological system of bidirectional and /or multidirectional communication, which can be used in population groups, based on systematic and joint action of learning resources, or give support to an organization and tutorial guidance, providing an independent and/or cooperative 2 . Therefore, distance learning is an option for educational action, combining communication and computer technol-ogies. Its merit lies in the possibility of multiplying its effects in a mass and low cost 1 perspective, thus, studies on DL in Brazil 2 have shown a growing interest in the subject. In addition to well-defined systems and programs, DL depends on trained human resources, adequate teaching material and, fundamentally, appropriate means of taking the teaching from the production centers to the student 3 . INTRODUCTION Increasingly valued, distance education (DE) or distance learning (DL) corresponds to the midpoint of a continuous line in whose extremes is the teacher-student 1 presential relation, and, on the other hand, the open self-taught education, in which the pupil manages the content, time, sequence and pace of learning 1 , and this means of communication ABSTRACT Purpose: to verify and to feature the conditions of the effective participation of community health workers (CHW) in virtual learning environment with topic "breast-feeding". Methods: participated in the study 49 CHW from Rondônia, and after 45 days, in wich all the process was monitored, occurred a videoconference to take testimonials about the access and content. It was used the Collective Subject Discurse to identify difficulties/easiness/suggestions/ proposals of wich were extracted three categories: (a) Willing to obtain knowledge; (b) Conditions to the achieving of the study; and (c) Assesment of professional education and the content. Results: 8 CHW (15.69%) accessed the cybertutor in correct time; 100% folowed the introductory module complete; 62.50% the modulus 2 and 3; 37.50% the modulus 4 at 8. For the Category (a) 8 CHW reported were motivated in using cybertutor, since it is a way to reinforce and acquire new knowledge. As to Category (b) the main difficulties were described as lack of knowledge on technology, material and financial resources and time availabilities. In Category (c) it was reported having obtained new knowledge that could be passed immediately to population and the desire to have similar experiences. Conclusion: the requeriments for the distance courses for CHW imply the viability of resources by local administrators, prior knowledge of basic computer, Internet access, computers availables in appropriate sites, well as others aspects such, to time available during working hours and/or extra time and challenging themes to make effect continuing distance education.
... Asynchronous telemedicine has made it possible for a doctor in one location to get expert advice on a diagnosis and treatment plan from specialists around the world without the need for the doctor and the patient to be connected together in real time. 11,12 The inclusion of health information technology into the general medical field has allowed for the development and broad use of asynchronous medicine where patient information, such as pictures and written documents, is securely stored (e.g., in an electronic medical record) and later securely forwarded to a consulting specialist or party for review. This technology has been well received in many fields such as pathology, dermatology, and cardiology [13][14][15][16][17] and has recently been used in psychiatry 18-20 but has not been used with translation across languages in any discipline. ...
Objective:
To examine the feasibility and diagnostic reliability of asynchronous telepsychiatry (ATP) consultations in Spanish and ATP consultation with Spanish-to-English translation.
Subjects and methods:
Twenty-four interviews of Spanish-speaking patients were videorecorded by a bilingual clinician who also collected patient history data and gave the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) to each patient. The ATP data (video of the interview and patient history) were forwarded for psychiatric consultation and a diagnostic assessment by the investigators. The ATP data were then examined separately by two Spanish-speaking psychiatrists, before being translated into English and then re-examined by two English-speaking psychiatrists. Agreement between the expert diagnoses of the investigators and the diagnoses from the Spanish consultations, the Spanish-to-English translated consultations, and the SCID-I results was assessed using kappa statistics.
Results:
We found acceptable levels of agreement for major diagnostic groupings among the Spanish- and English-speaking psychiatrists. Kappa values for diagnostic agreement between the expert and the translated consultations, the original language consultations, and the SCID-I were at least 0.52 (percentage agreement, 79%) and higher.
Conclusions:
ATP consultations in Spanish, and those translated from Spanish to English, are feasible, and broad diagnostic reliability was achieved. The ATP process allows for rapid language translation. This approach could be useful across national boundaries and in numerous ethnic groups. Cross-language ATP may also offer significant benefits over the use of real-time interpreting services and has the potential to improve the quality of care by allowing for the addition of culturally relevant information.
Uncorrectable vision loss due to macular degeneration, diabetic retinopathy, etc., is a critical diagnosis resulting in individuals facing changes in their daily lives resulting in safety and independent travel challenges. Ophthalmologists and optometrists face limitations to refer patients for specialty low vision rehabilitation services several miles away from partially sighted individuals who live in rural areas. Low vision TeleEye rehabilitation services were developed in 2012 and enable a low vision specialty optometrist or ophthalmologist to provide basic low vision TeleEye rehabilitation services as early as possible to initial diagnosis. The telehealth evaluation can be followed with therapy and training with a low vision therapist. Increasing access of low vision rehabilitative specialty services utilizing telehealth prevents further delay in beginning low vision services due to travel restrictions, accommodates health and safety issues, and is important to prevent a potential decline in functional ability over time. Low vision TeleEye rehabilitation evaluations and low vision telehealth therapy and training sessions is a practical, time, and cost-saving alternative option to traditional in-person consultations with a low vision optometrist and therapist.KeywordsLow vision TeleEye rehabilitationLow vision ocular rehabilitationClinical video telehealthLow vision optometrist or ophthalmologistLow vision therapyTelerehabilitationVirtual medical roomLow vision telerehabilitationSynchronous TelemedicineTelepresence
Telebehavioral health (TBH) is the use of information and communication technologies (ICT), including but not limited to videoconferencing, to remotely deliver behavioral health services (BHS). While this is the most widely accepted definition, TBH has evolved with the advances in ICT and models of healthcare delivery, and the more “traditional” definition of two-way live videoconferencing has expanded to incorporate digital self-navigated modules, asynchronous care delivery, smartphone applications, and different consultative models. This has led to the use of some terms such as electronic health (e-health), mobile health (m-health), and digital health under the umbrella of TBH. As mentioned in Chap. 1, while recognizing the utility of different approaches to delivering virtual BHS, this book focuses primarily on the delivery of direct patient care via videoconferencing in a synchronous manner between two parties, the teleclinician and the patient.
The outbreak of COVID-19 has raised concerns about the availability of health care facilities globally. Disruptive innovations in health care may impact a new system that provides a continuum of treatment tailored to each patient’s specific requirements. In light of this evolution, this study aimed to visualize global research output on disruptive innovation in health care between 2001 to 2021 as indexed in the Scopus database. The dataset was extracted on January 10, 2022, and 204 records were identified for data analysis. Various bibliometric indicators were used to identify publication trends. VOSviewer visualization software was also used to analyze data. The findings revealed the increasing pattern of publication growth with slight fluctuation over time. M. Friebe was the most prolific author having contributed four publications. The Harvard Medical School was the most productive institution with eight publications and the United States was the most productive country with 84 publications on disruptive innovation in health care. Furthermore, human, health care, and disruptive innovation were the top keywords in this field. These findings are expected to be useful to academics and administrators all across the world. This study also gives readers insight into this domain and will allow them to begin their research by selecting a topic of their choice.
Low vision ocular rehabilitation is a thorough assessment of a patient’s functional vision and utilizes optical or nonoptical devices, with the goal that through therapy, one can help an individual improve their activities of daily living. However, as beneficial as low vision rehabilitation services are, there are several barriers preventing patients with low vision from receiving this important care. Patients with low vision who live in rural communities have limited access to low vision ocular rehabilitation services unless they are able to travel several miles to a specialty low vision clinic. The vision limitations of these patients often prevent them from driving themselves, which means that their family members must take time to accompany them. This makes the burden of travel even greater, thus possibly resulting in delayed evaluation and critically reduced access to low vision services. Telehealth modalities may be utilized both to mitigate travel difficulties and to reduce health disparities, especially for rural and medically underserved low vision patients.
To prevent a potential decline in functional ability over time, basic low vision ocular rehabilitation telehealth services (1) increase access of low vision rehabilitative specialty services and (2) prevent further delay of beginning low vision services due to travel restrictions, leading to reduced health and safety issues.
Low vision ocular rehabilitation telehealth is an accepted, practical, timesaving, and cost-saving alternative option to traditional in-person consultations with a low vision optometrist and therapist.
Background: In March 2020, the pandemic added a major barrier resulting in the cancelation of all low vision ocular rehabilitation services. To prevent delay of beginning low vision ocular rehabilitation services, all low vision care was switched to telerehabilitation to home. Methods: Case managers began to cancel all in-person services and offer Veterans Affairs (VA) video connect services to their home. Patients with video access scheduled a home VA video connect telerehabilitation evaluation and therapy assessment. Patients who did not have video access waited to schedule a future in-person low vision appointment (postpandemic). Results: Of the in-person canceled appointments, 54% who scheduled the new home telerehabilitation evaluation were delayed on average 25 calendar days. Patients who waited for in-person low vision care were delayed on average 98, 138, or 153 calendar days. Of the 56 new patients referred for low vision optometry services during this 4-month period (COVID-19), 91% scheduled home low vision ocular telerehabilitation evaluations without delay; 5% waited until in-person clinics were open; and 4% waited until rural VA's and community-based outpatient centers were open. Discussion: Veterans with low vision who live in rural communities have limited access to services unless they are able to travel several miles to a specialty low vision clinic. Low vision ocular rehabilitation telehealth services have been successfully provided at the VA Western New York Healthcare System (Buffalo, NY) low vision clinic. Conclusions: Home low vision ocular rehabilitation telehealth increases access as early as possible once diagnosed with ocular pathology resulting in low vision.
In the past three years, the Trump administration has taken unprecedented actions to slow the flow of refugees to the United States and undermine the foundations of the world’s largest refugee resettlement system. This article considers both the empirical substance of the White House’s anti-refugee policies, as well as their broader theoretical significance as a critical example of the Trump administration’s so-called “administrative deconstruction” agenda. Analyzing refugee policy as a theory-building case study, this article advances a novel argument reframing the administration’s actions through the lens of strategic disruption. Short of systemically deconstructing targeted programs, I contend that the Trump administration is engaged in an improvisational and deliberately antagonistic campaign to upend existing policies for the sake of disruption itself. Ultimately, Trump’s open disregard for established laws and conventions is a distinguishing feature of the administration’s approach, which limits its ability to implement lasting and legally binding change. In the case of refugee resettlement, this approach has produced a series of temporary and highly controversial policies, which have done measurable harm to refugees and humanitarian aid organizations. However, the legal and institutional foundations of the resettlement system remain firmly intact.
E-health is a rising star that marks the collaboration of medical science and information technology, a ray of hope promising a glorious future of health and prosperity, an easy solution to rely on when in need of medical assistance. But the question arises is E-health an absolute spotless option? In this paper we question the integrity with which e-health is being practised, is the code of ethics being diligently followed? And if not then is ethical e-health entirely impossible? It is of utmost importance to encourage the motivational thinkers who have taken the initiative to provide a better and quicker solution to all health problems by integrating health services and information technology. To do so it becomes necessary to remove the barriers in the way of ethical E-health.
This chapter is about the state of the art for the creation of a good and sharable in medical record. This kind of record should take into account the inception point; that means that it has to start with the first encounter with the patient, where his or her history has to be properly taken. To achieve such a result, the record is supposed to start with the prerequisites that come out from ethical, epistemological and logical consideration; it should not be in conflict with the data acquirement and should not create a medical record that aimed only to economise (that is the base of the critics where the medical record has been described as a disruptive innovation). That is a type of innovation that creates new networks and new organisational cultures involving new players” with a potential improvement of health, displacing “older systems and ways of doing things. This seems more a business and bureaucratic decision, rather than one guided by science.
Many new technological innovations are currently in use or under development to ensure the effectiveness of convenient care. This chapter will focus on reviewing some ways to enhance the quality of clinical care in mental health through technology innovations in the device area. We will go over some of the changing technologies that are not only affecting healthcare but also the daily lives of many people around the world. As mobile homes and mobile clinics are targeting patients in the comfort of their homes, many smartphones, tablets, and medical devices are also being targeted at the same group of patients.
The doctor-patient relationship is evolving and changing through the impact of many technological, social and environmental factors. These factors will be examined, especially the impact of changing attitudes among younger generations of physicians and patients who live in an information-driven networked world. Telepsychiatry is already over 50 years old and has a strong evidence base which suggests that it is a better form of practice compared with the traditional in-person consultation for certain patient groups. In particular, telepsychiatry encourages intimacy in relationships through the use of the 'virtual space' in the consultation, better collaboration between psychiatrists and primary care physicians, and improved patient satisfaction. The practice of psychiatry will change through the use of mobile devices, asynchronous consultations, and the opportunities that automated interpretation and translation bring to work across cultures. The future will likely bring many psychiatrists working increasingly in a hybrid model, both in-person, and online, using the strengths of both approaches to improve patient care.
The U.S. healthcare system is changing and is becoming more patient-centered and technology-supported, with greater emphasis on population health outcomes and team-based care. The roles of healthcare providers are changing, and new healthcare roles are developing such as that of the patient advocate. This article reviews the history of this type of role, the changes that have taken place over time, the technological innovations in service delivery that further enable the role, and how the role could increasingly be developed in the future. Logical future extensions of the current typical patient advocate are the appearance of a virtual or avatar-driven care navigator, using telemedicine and related information technologies, as healthcare provision moves increasingly in a hybrid direction, with care being given both in-person and online.
Certainly, there are several innovations that have disrupted the thinking of the day. Just think of Laennec and his stethoscope in the early 19th Century (1815) ushering in change in heart and lung auscultation. He was up against the “standard-of-care.” The “Establishment”! The established protocol! The same can be said about Semmelweis and hand washing. He was ridiculed by his colleagues for taking the advice of a midwife and instituting the concept of washing hands between obstetric patients. The “standard-of-care” at this period of time in history (1840s) did not include hand washing! According to an American physician in Philadelphia, Charles Meigs, “Doctors are gentleman and a gentleman's hands are always clean.” These two individuals clearly could be labeled as disruptors! What they tried to do was change the status quo to improve healthcare against some pretty stiff odds. Today, there is no real difference in only “disruptors,” people trying to implement change. Of course, the technology is much different. We must ask ourselves as policy makers, as manufacturers, as clinicians, or as administrators, “Is what we do about patient care or about paying the bills?” There is no question there is an underlying protectionist theme. Perhaps we must look at healthcare in a different way. What is best for the patient? That is a “disruptive” idea!
In a Harvard Business Review article, Christensen et al.² discussed where disruptive innovations can cure healthcare. They cited several highly effective, accurate, and inexpensive technologies that would add tremendous value to healthcare but that never see the light of day. Why? As Christensen et al.² put it, “It threatens their business model and their livelihoods.” Ever hear that one before? These authors posited that often innovation can and does provide low-cost alternatives and that once consumers become aware, the market forces, or more importantly consumerism, take over. In retrospect, the phone on the wall was a great device in the home until it became your phone and computing device that is in your pocket and with you all the time. This paradigm shift from home phone to mobile phone has resulted in a change in the communications industry. Christensen et al.² have developed an effective model of how innovation enters into the market at the lowest level, often while the industry leaders are busy improving their products. As they put it, “think of over-engineered computers.” When a technology leader focuses on improving what it perceives the consumer(s) want, disruptive technologies emerge that do the same thing at lower costs, more simply, and more conveniently. Sort of like letting the patients remain at home and be monitored from their location rather than travel to the physician's office. Christensen et al.² stated that the model indicates the innovation eventually takes over and replaces the “status quo.” The minute clinics that are being deployed in grocery stores, where consumers can get basic medical treatment, are really disruptive to the established practice of medicine. This model makes perfect sense.
E-health is a rising star that marks the collaboration of medical science and information technology, a ray of
hope promising a glorious future of health and prosperity, an easy solution to rely on when in need of medical
assistance. But the question arises is E-health an absolute spotless option? In this paper we question the
integrity with which e-health is being practised, is the code of ethics being diligently followed? And if not
then is ethical e-health entirely impossible? It is of utmost importance to encourage the motivational thinkers
who have taken the initiative to provide a better and quicker solution to all health problems by integrating
health services and information technology. To do so it becomes necessary to remove the barriers in the way
of ethical E-health.
Introduction:
The effectiveness of any new technology is typically measured in order to determine whether it successfully achieves equal or superior objectives over what is currently offered. Research in telemental health-in this article mainly referring to telepsychiatry and psychological services-has advanced rapidly since 2003, and a new effectiveness review is needed.
Materials and methods:
The authors reviewed the published literature to synthesize information on what is and what is not effective related to telemental health. Terms for the search included, but were not limited to, telepsychiatry, effectiveness, mental health, e-health, videoconferencing, telemedicine, cost, access, and international.
Results:
Telemental health is effective for diagnosis and assessment across many populations (adult, child, geriatric, and ethnic) and for disorders in many settings (emergency, home health) and appears to be comparable to in-person care. In addition, this review has identified new models of care (i.e., collaborative care, asynchronous, mobile) with equally positive outcomes.
Conclusions:
Telemental health is effective and increases access to care. Future directions suggest the need for more research on service models, specific disorders, the issues relevant to culture and language, and cost.
Store-and-forward telepsychiatry, or asynchronous telepsychiatry (ATP), which allows clinical data, including video to be collected to be reviewed at a later time by a specialist, has been described as a feasible alternative to real-time telepsychiatry, or synchronous telepsychiatry (STP), as a consultation model for primary care. In theory, ATP should be economically more cost-effective than STP due to the increased flexibility of patient data collection and the substitution of the time of specialists with that of lower-cost providers. The aim of this study was to conduct a retrospective cost-analysis comparing ATP with STP and traditional in-person psychiatric consultations in the primary care setting. One hundred and twenty five ATP consultations were performed and fixed and marginal costs were calculated for each model using inputs such as equipment costs, time spent by providers and support staff, and hourly salaries. The fixed costs were 20,000 for ATP and STP and marginal costs were 68.18, 107.50, and $96.36, respectively, for the three groups. STP was the most expensive of the three types of consultations. ATP became the most cost-effective of the three models beyond 249 consultations. The marginal cost savings of ATP were due to substitution of low-cost providers for specialists. ATP represents a potential disruptive healthcare process that could allow more affordable care to be delivered to a larger population of patients. A full accounting of ATP's efficiency will require further studies, including prospective cost-benefit analyses from the perspectives of the patient, provider, and society.
Machine learning techniques such as support vector machines, decision tree learners and neural networks are applied to a text classification task to determine mental health problems. Inputs are transcribed speech samples from a "structured-narrative task" and outputs are psychiatric categories such as schizophrenia. In a preliminary trial, subjects from three groups generated speech samples: those with clinically diagnosed schizophrenia (31 patients), clinically diagnosed mania (16 patients) and controls (9 subjects). Even though the structured narrative task resulted in the use of a limited vocabulary by all subjects (only a total of 1100 different words were used), a classification performance of close to 80% accuracy (SVMs), 88% precision and 82% recall (decision tree learners) was achieved for the schizophrenia vs. control task. It is expected that results improve further in experiments utilising free-speech samples.
Research was initiated to examine conjoint collaborative care in family practice, in which physicians and behavioral health providers meet together with patients. The goal of the research was to evaluate providers' perceptions of, and patients' satisfaction with, conjoint collaborative care. The 397 patients who participated in the research were seen by either a physician alone or a team of providers. Participants completed a satisfaction survey and a health self-assessment form. Structured group interviews were held with providers before and after the research. Results show that physicians, therapists, and patients supported the conjoint collaborative care model; however, providers questioned its cost effectiveness. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Latina mothers of infants and toddlers are at high risk for developing serious depressive symptoms if they are newly immigrated and have limited English proficiency (LEP). Depressive symptoms compromise these mothers and result in severe consequences for their U.S.-born children. A randomized clinical trial of a short-term, in-home psychotherapy intervention for symptomatic mothers in an area of the United States where bilingual mental health providers were scarce used teams of English-speaking advanced practice psychiatric mental health nurses and bilingual community interpreters who were trained in a conduit, consecutive model of interpretation. The article describes the development of a theoretically congruent interpreter model, the training program that supported it, the challenges that surfaced and lessons learned during successful implementation in the field. Future refinements in progress and uses of the model are discussed.
Federal regulations require that health care organizations provide language services to patients with limited English proficiency. The National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS standards) provide guidance on how to fulfill these regulations. It is not known how US hospitals have incorporated them into practice.
To assess how US hospitals are meeting federal regulations requiring provision of language services using CLAS as a measure of compliance.
Cross-sectional survey.
Hospital interpreter services managers (or equivalent position).
Degree of meeting each of the 4 language-related CLAS standards.
Many hospitals are not meeting federal regulations. The majority reported providing language assistance in a timely manner in their first, but not their third, most commonly requested language. Although hospitals reported that they informed patients of their right to receive language services, many did so only in English. A majority of hospitals reported the use of family members or untrained staff as interpreters. Few reported providing vital documents in non-English languages. Overall, 13% of hospitals met all 4 of the language-related CLAS standards, whereas 19% met none.
Our study documents that many hospitals are not providing language services in a manner consistent with federal law. Enforcement of these regulations is inconsistent, and thus does not motivate hospitals to comply. Compliance will likely come with new guidelines, currently being written, by many of the regulatory organizations. Our study reinforces the importance of these efforts and helps target interventions to improve the delivery and safety of care to limited English proficient patients.
Machine learning techniques such as support vector machines are applied to a text classification task to determine mental health problems. Inputs are transcribed speech samples from a “structured-narrative task” and outputs are psychiatric categories such as schizophrenia. In a preliminary trial, subjects from three groups generated speech samples: those with clinically diagnosed schizophrenia (31 patients), clinically diagnosed mania (16 patients) and controls (9 subjects). Even though the structured narrative task resulted in the use of a limited vocabulary by all subjects (only a total of 1100 different words were used), a classification performance approaching 80% accuracy was achieved for the schizophrenia versus control task. Classification performance at this level indicates that the method is suitable for diagnostic or screening purposes. It is expected that results improve further in experiments utilising free-speech samples. Diagnostic categories in psychiatry can be broad and heterogeneous, e.g. schizophrenia, which includes a range of very different symptoms. In further experiments, clustering techniques are used to extract task-relevant diagnostic categories from psychiatric reports. In these reports, psychiatrists typically include biographic, background and referral information, a description of symptoms and an opinion on treatment recommendations. At the task level, diagnostic reports are written for a specific audience or decision making body. In preliminary experiments, detailed and specific diagnostic categories have been extracted from psychiatric reports by use of unsupervised learning. These categories genuinely reflect the everyday practise of a mental health professional.
This study simultaneously assessed the inter‐rater reliability of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders Axis I (SCID I) and Axis II disorders (SCID II) in a mixed sample of n = 151 inpatients and outpatients, and non‐patient controls. Audiotaped interviews were assessed by independent second raters blind for the first raters' scores and diagnoses. Categorical inter‐rater reliability was assessed for 12 Axis I disorders of SCID I, while both categorical and dimensional inter‐rater reliability was tested for all Axis II disorders. Results revealed moderate to excellent inter‐rater agreement of the Axis I disorders, while most categorically and dimensionally measured personality disorders showed excellent inter‐rater agreement. Copyright © 2010 John Wiley & Sons, Ltd.
Key Practitioner Message:
• Elaborate training in administration of the Structured Clinical Interview for DSM disorders (SCID) is a crucial ingredient for valid use of the SCID.
• The more dimensionally the SCID II pathology is indexed, the higher inter‐rater reliability.
• Structural assessment of Axis I and Axis II pathology by means of SCID I and II is an essential ingredient for valid and reliable pathology assessment in clinical practice and in research.
Asynchronous telehealth captures clinically important digital samples (e.g., still images, video, audio, text files) and relevant data in one location and subsequently transmits these files for interpretation at a remote site by health professionals without requiring the simultaneous presence of the patient involved and his or her health care provider. Its utility in the health care system, however, still remains poorly defined. We conducted this scoping review to determine the impact of asynchronous telehealth on health outcomes, process of care, access to health services, and health resources.
A search was performed up to December 2006 of MEDLINE, CINAHL, HealthSTAR, the Database of Abstracts of Reviews of Effectiveness, and The Cochrane Library. Studies were included if they contained original data on the use of asynchronous telehealth and were published in English in a peer-reviewed journal. Two independent reviewers screened all articles and extracted data, reaching consensus on the articles and data identified. Data were extracted on general study characteristics, clinical domain, technology, setting, category of outcome, and results. Study quality (internal validity) was assessed using the Jadad scale for randomized controlled trials and the Downs and Black index for non-randomized studies. Summary data were categorized by medical specialty and presented qualitatively.
The scoping review included 52 original studies from 238 citations identified; of these 52, almost half focused on the use of telehealth in dermatology. Included studies were characterized by diverse designs, interventions, and outcomes. Only 16 studies were judged to be of high quality. Most studies showed beneficial effects in terms of diagnostic accuracy, wait times, referral management, and satisfaction with services. Evidence on the impact of asynchronous telehealth on resource use in dermatology suggests a reduction in the number of, or avoidance of, in-person visits. Reports from other clinical domains also described the avoidance of unnecessary transfer of patients.
A significant portion of the asynchronous telehealth literature involves its use in dermatology. Although the quality of many original studies remains poor, at least within dermatology, there is consistent evidence suggesting that asynchronous telehealth could lead to shorter wait times, fewer unnecessary referrals, high levels of patient and provider satisfaction, and equivalent (or better) diagnostic accuracy when compared with face-to-face consultations. With the exception of a few studies in pediatric asthma, the impact of this intervention on individual health outcomes remains unknown.
Optimal care of the injured patient requires an organized approach, dedicated resources and clinical expertise. Victims of major trauma, however, frequently present to rural and suburban hospitals regardless of whether a dedicated trauma system in place. Immediate consultation by a trauma expert could potentially expedite effective evaluation and management of trauma victims, reducing the occurrence of unnecessary transport and leading to efficient stabilization and transport when needed. Remote assessment of trauma patients must be assesses for feasibility, safety and efficacy before widespread implementation. This project represents the initial steps towards the development of a functional telemedicine system for trauma care.
This review's goal was to determine how differences between physicians and patients in race, ethnicity and language influence the quality of the physician-patient relationship.
We performed a literature review to assess existing evidence for ethnic and racial disparities in the quality of doctor-patient communication and the doctor-patient relationship.
We found consistent evidence that race, ethnicity; and language have substantial influence on the quality of the doctor-patient relationship. Minority patients, especially those not proficient in English, are less likely to engender empathic response from physicians, establish rapport with physicians, receive sufficient information, and be encouraged to participate in medical decision making.
The literature calls for a more diverse physician work force since minority patients are more likely to choose minority physicians, to be more satisfied by language-concordant relationships, and to feel more connected and involved in decision making with racially concordant physicians. The literature upholds the recommendation for professional interpreters to bridge the gaps in access experienced by non-English speaking physicians. Further evidence supports the admonition that "majority" physicians need to be more effective in developing relationships and in their communication with ethnic and racial minority patients.
Research amply documents that language barriers impede access to health care, compromise quality of care, and increase the risk of adverse health outcomes among patients with limited English proficiency. Federal civil rights policy obligates health care providers to supply language services, but wide gaps persist because insurers typically do not pay for interpreters, among other reasons. Health care financing policies should reinforce existing medical research and legal policies: Payers, including Medicaid, Medicare, and private insurers, should develop mechanisms to pay for interpretation services for patients who speak limited English.
Twenty-one million Americans are limited in English proficiency (LEP), but little is known about the effect of medical interpreter services on health care quality. Asystematic literature review was conducted on the impact of interpreter services on quality of care. Five database searches yielded 2,640 citations and a final database of 36 articles, after applying exclusion criteria. Multiple studies document that quality of care is compromised when LEP patients need but do not get interpreters. LEP patients' quality of care is inferior, and more interpreter errors occur with untrained ad hoc interpreters. Inadequate interpreter services can have serious consequences for patients with mental disorders. Trained professional interpreters and bilingual health care providers positively affect LEP patients' satisfaction, quality of care, and outcomes. Evidence suggests that optimal communication, patient satisfaction, and outcomes and the fewest interpreter errors occur when LEP patients have access to trained professional interpreters or bilingual providers.
This study examined the reliability of the Structured Clinical Interview for DSM-III-R (SCID) in the administration of psychiatric assessments by real-time videoconferencing compared to face-to-face assessment within a rural American Indian community.
The SCID was administered to 53 male American Indian veterans who were randomly assigned over two separate occasions by different interviewers to face-to-face and real-time interactive videoconferencing within 2 weeks. Comparisons were made with prevalences, the McNemar test, and the kappa statistic.
With the exception of past-year substance dependence and abuse/dependence combined, there were no significant differences between face-to-face and videoconference administration. The majority of kappas calculated (76%) indicated a good or fair level of agreement. Externalizing disorders tended to elicit greater concordance than internalizing disorders.
Overall, SCID assessment by live interactive videoconferencing did not differ significantly from face-to-face assessment in this population. Videoconferencing is a viable vehicle for clinical and research purposes.
Several factors - including the prevailing shortage of radiologists, the increasing use of advanced imaging methods, the consolidation of hospitals into regional delivery systems, and heightened expectations of patients find referring physicians for timely service - have fostered the increasing use of teleradiology.
The goals of improving quality and safety of health care are the major drivers for computer-based clinical decision support. Successful use of computers and information technology in the health care setting requires a thorough understanding of their limitations and advantages. This unique work presents a state-of-the-art examination of the derivation and application of medical knowledge to clinical decision support, focusing on approaches that may be integrated into information systems and delivered at the point of care for providers, or directly to patients at point of need. Among its unique features is the inclusion of case studies that review lessons learned from both successful and unsuccessful projects.
The Structured Clinical Interview for DSM-III-R [Diagnostic and Statistical Manual, Revised] (SCID) is a semistructured interview for making the major Axis I and Axis II diagnoses. It is administered by a clinician or trained mental health professional who is familiar with the DSM-III-R classification and diagnostic criteria (1). The subjects may be either psychiatric or general medical patients or individuals who do not identify themselves as patients, such as subjects in a community survey of mental illness or family members of psychiatric patients. The language and diagnostic coverage make the SCID most appropriate for use with adults (age 18 or over), but with slight modification, it may be used with adolescents. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Diabetic retinopathy is a common cause of blindness, and screening can identify the disease at an earlier, more treatable stage. However, rural individuals with diabetes may have limited access to needed eye care. The objective of this project was to demonstrate the feasibility of a diabetic retinopathy screening program using a state-of-the-art nonmydriatic digital fundus imaging system. The study involved a series of patients screened in primary care and public health locations throughout seven predominantly rural counties in eastern North Carolina. Images of each fundus were obtained and sent to a retinal specialist. The retinal specialist reviewed each image, recorded image quality, diagnosed eye disease and made recommendations for subsequent care. Of193 volunteers with a history of diabetes mellitus, 96.3 percent reported that they were very comfortable or comfortable with the camera. Eighty-five percent of images were rated as good or fair by the retinal specialist. The retinal specialist also reported being very certain or certain of the diagnosis in 84 percent of cases. Image quality correlated highly with the certainty of diagnosis (Spearman's rank order correlation coefficient =0.79; P<0.001). The average time since the previous examination by an eye care specialist for diabetic subjects was two years. Approximately 62 percent of diabetic patients had diagnosable eye conditions, the most common of which was diabetic retinopathy (40.9 percent). In this convenience sample, African Americans, despite similar age and disease duration, were more likely to have retinopathy. Digital imaging is a feasible screening modality in rural areas, may improve access to eye care, and may improve compliance with care guidelines for individuals with diabetes mellitus.
Store-and-forward telepsychiatry, or asynchronous telepsychiatry (ATP), which allows clinical data, including video to be collected to be reviewed at a later time by a specialist, has been described as a feasible alternative to real-time telepsychiatry, or synchronous telepsychiatry (STP), as a consultation model for primary care. In theory, ATP should be economically more cost-effective than STP due to the increased flexibility of patient data collection and the substitution of the time of specialists with that of lower-cost providers. The aim of this study was to conduct a retrospective cost-analysis comparing ATP with STP and traditional in-person psychiatric consultations in the primary care setting. One hundred and twenty five ATP consultations were performed and fixed and marginal costs were calculated for each model using inputs such as equipment costs, time spent by providers and support staff, and hourly salaries. The fixed costs were 20,000 for ATP and STP and marginal costs were 68.18, 107.50, and $96.36, respectively, for the three groups. STP was the most expensive of the three types of consultations. ATP became the most cost-effective of the three models beyond 249 consultations. The marginal cost savings of ATP were due to substitution of low-cost providers for specialists. ATP represents a potential disruptive healthcare process that could allow more affordable care to be delivered to a larger population of patients. A full accounting of ATP's efficiency will require further studies, including prospective cost-benefit analyses from the perspectives of the patient, provider, and society.
To describe the technical development of an asynchronous telepsychiatry application, the Psychiatric Video Archiving and Communication System.
A client-server application was developed in Visual Basic.Net with Microsoft(®) SQL database as the backend. It includes the capability of storing video-recorded psychiatric interviews and manages the workflow of the system with automated messaging.
Psychiatric Video Archiving and Communication System has been used to conduct the first ever series of asynchronous telepsychiatry consultations worldwide. A review of the software application and the process as part of this project has led to a number of improvements that are being implemented in the next version, which is being written in Java.
This is the first description of the use of video recorded data in an asynchronous telemedicine application. Primary care providers and consulting psychiatrists have found it easy to work with and a valuable resource to increase the availability of psychiatric consultation in remote rural locations.
The impact of language proficiency as a potential contributor to ethnic disparities in mental health care has received less attention than other factors. Data from the National Latino and Asian American Study were examined to assess the impact of limited English proficiency (LEP) on access to and quality of mental health care for community-dwelling Latino and Asian Americans with mental disorders.
English-proficient (EP) and LEP individuals with mental disorders were compared on lifetime use of healthcare services for a mental disorder, duration of untreated disorders, receipt of minimally adequate care, and barriers to treatment (eg, lack of identification of need for treatment, language barriers, and embarrassment or discomfort related to treatment).
Compared with EP individuals, LEP individuals with mental disorders were significantly less likely to identify a need for mental health services, experience longer duration of untreated disorders, and use fewer healthcare services for mental disorders, particularly specialty mental health care. Receipt of minimally adequate care did not differ significantly by language proficiency. Embarrassment and discomfort were not more common among LEP individuals. Perceived need for treatment predicted lifetime mental healthcare use, whereas embarrassment and discomfort did not.
Among Latino and Asian Americans with mental disorders, LEP contributes to disparities in access to care and longer duration of untreated disorders. Potential disparities in quality of care were difficult to detect in the context of low overall rates of mental healthcare use and quality of care among both LEP and EP individuals.
This study examined the feasibility of conducting psychiatric consultations using asynchronous, or store-and-forward, video-based telepsychiatry.
Video-recorded 20- to 30-minute assessments of 60 nonemergency, English-speaking adult patients in a medically underserved county in California were uploaded along with other patient data to a Web-based record. Two psychiatrists then used the record to provide psychiatric consultations to the referring primary care providers.
Eighty-five percent of patients received diagnoses of mood disorders, 32% diagnoses of substance use disorders, 53% diagnoses of anxiety disorders, and 5% other axis I diagnoses. Psychiatrists recommended short-term medication changes for 95% of the patients and provided guidelines for possible future changes.
This study-the first study of asynchronous telepsychiatry to be published-demonstrated the feasibility of this approach. This type of assessment should not replace the face-to-face psychiatric interview, but it may be a very helpful additional process that improves access to care and expertise.
Language barriers pose problems in mental health care for foreign-born individuals in the United States. Immigrants with psychiatric disorders may be at particular risk but are currently understudied. The purpose of this study was to examine the effect of limited English proficiency (LEP) on mental health service use among immigrant adults with psychiatric disorders. Drawn from the National Latino and Asian American Study (NLAAS), Latino and Asian immigrant adults aged 18-86 with any instrument-determined mood, anxiety, and substance use disorder (n = 372) were included in the present analysis. Results from hierarchical logistic regression analyses showed that having health insurance, poor self-rated mental health, and more psychiatric disorders were independently associated with higher probability of mental health service use in the Latino group. After controlling for all background characteristics and mental health need factors, LEP significantly decreased odds of mental health service use among Latino immigrants. None of the factors including LEP predicted mental health service use among Asian immigrants, who were also the least likely to access such services. LEP was a barrier to mental health service use among Latino immigrants with psychiatric disorders. This study suggests that future approaches to interventions might be well advised to include not only enhancing the availability of bilingual service providers and interpretation services but also increasing awareness of such options for at least Latino immigrants. In addition, further investigation is needed to identify factors that can enhance access to mental health care services among Asians.
The core doctor-patient relationship is changing and becoming more fluid. Many factors are causing the changes, but they are being underpinned by the current technological revolution, which has spawned terms such as e-patients, health 2.0, participatory medicine, and virtual medicine in cyberspace. The Internet is being used so creatively and commonly by both patients and doctors that it has become literally a "part" of the doctor-patient relationship. To explore how the psychiatrist-patient relationship is changing, five simple questions are examined: How are patient expectations and behaviors changing? Who is using the Internet for mental health care? What online mental health services are currently being offered? How are current and past models of the psychiatrist-patient relationship being affected by these changes? And what is the psychiatrist-patient relationship of the future likely to be? Psychiatrists working in this environment will need to make changes to their practices over time. It is likely that their relationships with patients will continuously change, gradually becoming more participatory and ubiquitous, as care is provided both face-to-face and online-and literally anytime, anywhere.
To test the impact of a novel psychosocial intervention to improve antidepressant adherence and depression outcomes among older adults prescribed pharmacotherapy by their primary care physician (PCP).
A randomized controlled pilot study was conducted to examine the usefulness of the Treatment Initiation and Participation (TIP) program as an intervention to improve antidepressant adherence and depression outcomes.
The study was conducted at two primary care clinics in New York city: one clinic served geriatric adults and the second clinic served a diverse group of mixed aged adults.
The sample consisted of adults aged 60 years and older with major depression who were recommended antidepressant therapy by their PCPs.
All participants were prescribed antidepressant therapy and randomly assigned to either the intervention (TIP) or the treatment as usual (TAU) group. The TIP intervention identifies and targets psychological barriers to depression care, especially stigma, as well as fears and misconceptions of depression and its treatment. TIP participants are encouraged to develop a treatment goal and create an adherence strategy.
Study participants were assessed at entry, 6, 12, and 24 weeks later. Adherence was measured based on self-report with chart verification. Depression severity was measured using the Hamilton Depression Rating Scale.
Participants in TIP were significantly more adherent to their antidepressant pharmacotherapy at all assessment time points and had a significantly greater decrease in depressive symptoms than older adults who received TAU.
The results provide support for the usefulness of TIP as a brief intervention to improve adherence to depression medication treatment provided in primary care settings.
Disruptive innovation has brought affordability and convenience to customers in a variety of industries. However, health care remains expensive and inaccessible to many because of the lack of business-model innovation. This paper explains the theory of disruptive innovation and describes how disruptive technologies must be matched with innovative business models. The authors present a framework for categorizing and developing business models in health care, followed by a discussion of some of the reasons why disruptive innovation in health care delivery has been slow.
A computerized ECG interpretation system was incorporated into a large ambulatory health care service. The central unit has several terminals located at various regional cardiological clinics. In each clinic 80--120 ECG's are taken daily, of which 56% are interpreted as normal tracings. The interpretation system is currently utilized to separate automatically normal from abnormal tracings. Normal tracings are not re-checked by a cardiologist and the report is delivered directly to the family physician. In order to evaluate the reliability of the computer interpretation of normal ECG's (i.e., the percent of false-negative readings), 500 tracings interpreted by the program as normal were selected at random and read independently by three cardiologists. It was found that in 4.6% of the cases additional remarks were supplemented to the computer statement by at least one of the cardiologists. Most of the computer-cardiologist disagreements were of limited clinical importance. It was concluded that this system could be used as an effective tool for simultaneously processing ECG's from several remote locations, serving large ambulatory populations. By using the assistance of the computer system, marked reduction in cardiologists' time and cost could be achieved.
A set of on-line computer programs has been designed and implemented for the acquisition and long-term storage, retrieval, and evaluation of Holter monitoring data. The physician interpreting Holter tapes enters his findings in the computer system using an on-line remote terminal located in the heart station. The programs are available practically around the clock and allow reviewing of individual cases, preparation of printed reports, and fast evaluation of the presence or absence of a number of common findings in the entire data base. Approximately 800 cases have been entered since the initiation of this project in early 1977.
This paper presents a general statistical methodology for the analysis of multivariate categorical data arising from observer reliability studies. The procedure essentially involves the construction of functions of the observed proportions which are directed at the extent to which the observers agree among themselves and the construction of test statistics for hypotheses involving these functions. Tests for interobserver bias are presented in terms of first-order marginal homogeneity and measures of interobserver agreement are developed as generalized kappa-type statistics. These procedures are illustrated with a clinical diagnosis example from the epidemiological literature.
A network of ECG telephone transmission has been established which uses simple and inexpensive equipment, and which is aimed particularly at arrhythmia monitoring. Hospitals in areas remote from major medical centers are able to transmit to the Toronto General Hospital for expert advice. 400 patients in their homes may transmit to any of these hospitals for monitoring of pacemaker function or intermittent cardiac arrhythmia. Any patients in the Toronto General Hospital not admitted for a cardiac problem may be monitored via telephone by the expert nurses in the coronary care unit if a cardiac arrhythmia should arise. Equipment for the system has been carefully designed to minimize cost and to make it simple to use, particularly for the old or infirm patients in their homes. Transmissions between hospitals meet American Heart Association specifications for ECG recording. Transmissions of arrhythmias from patients' homes are carried out with a reduced low-frequency response. Expert cardiologists find both transmissions acceptable for their particular purpose. Standards should be set for simple, economic transmission systems as well as for those meeting the most stringent criteria.
The Mini-International Neuropsychiatric Interview (M.I.N.I.) is a short structured diagnostic interview, developed jointly by psychiatrists and clinicians in the United States and Europe, for DSM-IV and ICD-10 psychiatric disorders. With an administration time of approximately 15 minutes, it was designed to meet the need for a short but accurate structured psychiatric interview for multicenter clinical trials and epidemiology studies and to be used as a first step in outcome tracking in nonresearch clinical settings. The authors describe the development of the M.I.N.I. and its family of interviews: the M.I.N.I.-Screen, the M.I.N.I.-Plus, and the M.I.N.I.-Kid. They report on validation of the M.I.N.I. in relation to the Structured Clinical Interview for DSM-III-R, Patient Version, the Composite International Diagnostic Interview, and expert professional opinion, and they comment on potential applications for this interview.
A Web-based electrocardiogram (ECG) monitoring service in which a longitudinal clinical record is used for management of patients, is described. The Web application is used to collect clinical data from the patient's home. A database on the server acts as a central repository where this clinical information is stored. A Web browser provides access to the patient's records and ECG data. We discuss the technologies used to automate the retrieval and storage of clinical data from a patient database, and the recording and reviewing of clinical measurement data. On the client's Web browser, ActiveX controls embedded in the Web pages provide a link between the various components including the Web server, Web page, the specialised client side ECG review and acquisition software, and the local file system. The ActiveX controls also implement FTP functions to retrieve and submit clinical data to and from the server. An intelligent software agent on the server is activated whenever new ECG data is sent from the home. The agent compares historical data with newly acquired data. Using this method, an optimum patient care strategy can be evaluated, a summarised report along with reminders and suggestions for action is sent to the doctor and patient by email.
Telemedicine has the potential to revolutionize the delivery of dermatologic care to underserved areas.
Our purpose was to compare diagnoses from two types of dermatology consultations: telemedicine using store-and-forward (SAF) technology, and traditional face-to-face (FTF) office visits.
Skin conditions were imaged with a consumer-grade digital camera. A standardized template was used to collect historical data. Information was stored in a secured database for access by 2 or 3 board-certified dermatologists. Results from the FTF visit were used to assess the accuracy of the SAF diagnoses.
A total of 106 dermatologic conditions in 92 patients were included. Concordance between FTF and SAF diagnoses was high, ranging from 81% to 89% for all 3 dermatologists. Clinically relevant disagreement occurred in only 4% to 8% of cases. Remaining disagreements did not affect patient care. Diagnostic confidence and image quality affected agreement. When cases of high confidence were analyzed separately, agreement increased to 88% to 100%. This increase was substantiated by means of a chi-square test between the high confidence and low confidence groups, which demonstrated statistical significance (P <. 005) for all dermatologists. Similarly, when cases of above average image quality were considered, agreement increased to 84% to 98%. Again this difference was substantiated by means of a chi-square test between adequate and poor images, with statistical significance for two dermatologists (P <.001). Accuracy was comparable between disease types with the exception of benign neoplasms, which demonstrated agreement of 22% to 46%.
These data support the use of existing digital technology to construct an accurate SAF teledermatology system. The inexpensive camera and widely available computer equipment make this an extremely affordable system. Furthermore, participating dermatologists appear well aware of system limitations, as reflected in the increased agreement for high confidence cases. Additional investigation of the accuracy of teledermatology for benign neoplasms is warranted.
We studied the views of 26 general practitioners (GPs) towards store-and-forward tele-dermatology before its introduction into their practices. A postal questionnaire was developed using Likert-type questions with respondents able to explain their answers in free text. Questions related to the GPs' knowledge, perceptions and expectations of tele-dermatology, as well as their attitudes towards being part of a research trial. Most of the GPs had limited prior knowledge of tele-dermatology. They perceived its role to relate to quicker access to specialist opinions, decreased referrals, increased convenience for patients, diagnosis, and education and teaching. There was an overwhelming view that any system needed to be quick, easy to use, efficient and reliable. Concerns were expressed about being part of the clinical trial, using new technology and an increased workload. The future of tele-dermatology was thought to depend on the clinical adequacy of the system.
Radiographs on a viewing box were photographed at a remote hospital in South Africa using a digital camera with a resolution of 1024 x 768 pixels at 24-bit colour depth. The resultant images were stored in JPEG format and transmitted as email attachments to be read on a PC monitor by radiologists in Durban and Cape Town. Twenty-seven images were received, of which 23 were of diagnostic quality (85%). The mean file size was 120 kByte. For quality control purposes, 100 chest radiographs were photographed at a base hospital and read by a radiologist blinded to the diagnosis. In this study 96 images were of diagnostic quality (96%) and the correct diagnosis was made in 90 cases (94%). Incorrect readings were made in six cases (6%): small pulmonary nodules (less than 1 cm in diameter) were missed in five cases and in one case early apical tuberculosis was missed. Digital camera technology permits simple, inexpensive telemedicine. Limited spatial resolution is a concern when reading chest images with small pulmonary nodules and infiltrates.
The United States is experiencing one of its largest migratory waves, so health providers are caring for many patients who do not speak English. Bilingual nurses who have not been trained as medical interpreters frequently translate for these patients. To examine the accuracy of medical interpretations provided by nurses untrained in medical interpreting, we conducted a qualitative, cross-sectional study at a multi-ethnic, university-affiliated primary care clinic in southern California. Medical encounters of 21 Spanish-speaking patients who required a nurse-interpreter to communicate with their physicians were videorecorded. Encounters were transcribed by blinded research assistants. Transcriptions were translated and analyzed for types of interpretive errors and processes that promoted the occurrence of errors. In successful interpretations where misunderstandings did not develop, nurse-interpreters translated the patient's comments as completely as could be remembered and allowed the physician to extract the clinically-relevant information. In such cases, the physician periodically summarized his/her perception of the problem for back-translation and verification or correction by the patient. On the other hand, approximately one-half of the encounters had serious miscommunication problems that affected either the physician's understanding of the symptoms or the credibility of the patient's concerns. Interpretations that contained errors that led to misunderstandings occurred in the presence of one or more of the following processes: (1) physicians resisted reconceptualizing the problem when contradictory information was mentioned; (2) nurses provided information congruent with clinical expectations but not congruent with patients' comments; (3) nurses slanted the interpretations, reflecting unfavorably on patients and undermining patients' credibility; and (4) patients explained the symptoms using a cultural metaphor that was not compatible with Western clinical nosology. We conclude that errors occur frequently in interpretations provided by untrained nurse-interpreters during cross-language encounters, so complaints of many non-English-speaking patients may be misunderstood by their physicians.
Critical issues facing the development of telemedicine today are described and analyzed as dilemmas or paradoxes. The technological dilemma involves the difficult choice between using the latest technology regardless of how well it fits specific needs on the one hand, and the reluctance to capitalize on the available technological capability to create efficient and effective organizations for expanding the reach of health care on the other hand. The evaluation paradox points to the disjuncture between policy making requirements and the scientific enterprise. This engenders the difficulty of producing scientifically valid and policy relevant results from programs that have not achieved maturity or a steady state of operation. The contextual hazards of limiting the scope of telemedicine to rural areas are discussed, as well as the potential for creating a second tier of care for the remote and isolated populations. Finally, professional maturation is addressed as it underscores the importance of self regulation and control.
The financial and personal burden of chronic cardiac disease is high. Costs are likely to increase over the next few decades. Promising applications of telehealth have appeared in the diagnosis and management of cardiac disease and there are indications that telehealth services can improve the management of chronic cardiac disease as well as extend services to remote and rural populations. Telehealth has been applied to the capture of symptoms of cardiac disease with electrocardiography and echocardiography, to the management and rehabilitation of recently discharged patients, and in peer-to-peer consultation where remote expertise can facilitate diagnosis. Telehealth promises cost reductions in service delivery, although there is a need for properly controlled cost-effectiveness trials to underpin telehealth with a firm evidence base.
Teledermatology is becoming an increasingly common means of delivering dermatologic healthcare worldwide and will almost certainly play a greater role in the future. The type of technology used distinguishes the 2 modes of teledermatology consultation. The store and forward technique uses still digital images generated by a digital camera. Consultations of this type are considered asynchronous since the images are obtained, sent, and reviewed at different times. In contrast, real-time interactive consultations are synchronous. Patients and clinicians interact in real-time through an audio-video communication link. Each modality has its advantages and disadvantages, and studies appear in the literature that assess both technologies. Although diagnostic reliability (precision) assessments for teledermatology are subject to limitations, existing information indicates that both store and forward and real-time interactive technology result in reliable diagnostic outcomes when compared with clinic-based evaluations. Less information regarding diagnostic accuracy is available; however, one evaluation that used store and forward technology found comparable diagnostic accuracy between teledermatology consultations and clinic-based examinations. Currently, little information is available regarding cost effectiveness and patient outcomes. Existing evidence, while inconclusive, suggests that teledermatology may be more costly than traditional clinic-based care, especially when using real-time interactive technology. Teledermatology has been shown to have utility as a triage mechanism for determining the urgency or need for a clinic-based consultation. Overall, patients appear to accept teledermatology and are satisfied with it as a means of obtaining healthcare. Clinicians have also generally reported positive experiences with teledermatology. Future studies that focus on cost effectiveness, patient outcomes, and patient and clinician satisfaction will help further define the potential of teledermatology as a means of dermatologic healthcare delivery.
Each day in the United States, health care workers try to communicate with patients who are deaf, hard of hearing, or limited-English proficient (LEP). According to government regulations, these patients are guaranteed access to language accommodations. The legal implications of these regulations will be discussed along with ways to facilitate communication with patients who are deaf, hard of hearing, or LEP and the requirements for those who act as interpreters for such patients. AORN J (Feb 2002) 305–308.
Teledermatology is the practice of dermatology across distances (and time) and involves the transfer of electronic information. To be effective and safe, the teledermatology process needs to demonstrate an acceptable level of accuracy and reliability. Accuracy is reflected by the degree of concordance (agreement) between the teledermatology and face-to-face diagnoses. Reliability is dependent on how consistently a set of results can be reproduced across different operators. Mean concordance (primary diagnoses) achieved by four dermatologists studying 53 store-and-forward diagnostic cases, originating from 49 referred patients, was 79% (range 73-85%). When the differential diagnoses were taken into account, the variation across individual dermatologists narrowed further, with a mean of 86% (range 83-89%). In contrast, the mean general practitioner (GP; n=11) concordance (GP face-to-face vs reference dermatologist store-and-forward diagnoses) was 49%. An interim review of all 49 teledermatology patients showed no adverse outcome at the end of 3 months. The ability to request face-to-face visits by dermatologists, combined with GPs maintaining primary care of the referred patient, serve as additional safeguards for patients using a telemedicine system. Our results indicate that teledermatology management of referred skin complaints is both accurate and reliable.
In a pilot project, telemedicine was used to conduct retinal examinations of diabetic patients in the Alta municipality of Norway. All health-care workers who were involved in the project were interviewed. The ophthalmologists found that the grading of the level of retinopathy was quicker with digital images than with slit-lamp examinations. Fifty patients with type II diabetes were invited to attend a telemedicine check-up and 42 did so. Patients were asked to complete a questionnaire after the telemedicine examination and we received 32 replies (a 76% response rate), of which 12 were from men and 20 from women. The patients expressed a high degree of satisfaction with the telemedicine examination. The results of the evaluation also clearly showed that trust between health personnel was of major importance in engendering positive attitudes. Confidence is the basis of good collaboration between the various professions in the health-care sector, between health-care levels and between patients and treatment providers - in terms not only of individuals' confidence but also of routines, procedures and the system as a whole.
Telepathology is the most recent addition to the diagnostic armory of the Pathologist. In spite of its relative limitations, as compared to Dynamic Telepathology, Static Telepathology has been widely accepted as a low-cost diagnostic and consultation tool, especially in those remote areas where expert opinions or second opinions on histopathology, cytopathology or haematopathology are not readily available to the reporting pathologist. For an accurate Telepathology performance, optimal quality of images is required. Knowledgeable use of available hardware and software have made it possible to produce high quality images, making Static Telepathology a reliable diagnostic tool.
To compare the accuracy of store and forward method of teledermatology with the traditional face-to-face consultation.
The comparison was done between Institute of Dermatology King Edward Medical College Lahore that served as teledermatology center and Dermatology Department of Pakistan Institute of Medical Sciences Islamabad from where patients were selected. Telmedpak provided the technical support. Thirty three patients were selected from outpatient department of PIMS and images were taken using a digital camera. Images were stored in computer and were sent to Institute of Dermatology via e-mail for Teleconsultation along with a short history and examination findings. Diagnosis of consultant after face-to-face consultation was then compared with the image based diagnosis that is after teleconsultation.
In 81% of the cases the diagnosis on face-to-face consultation was same (p < 0.05) while in 18% of the cases the two diagnoses differed. In 9% (n = 3) of the cases, image resolution was not good but out of these three, diagnosis was same in two and differed in one case.
This study concludes that store and forward method of teledermatology is reliable and can provide a means of increasing access to dermatological care in rural and under-served areas.
Teledermoscopy uses telecommunication technologies to transfer images of pigmented skin lesions via the Internet for teleconsultation.
Clinical and dermoscopic images of 66 and 43 pigmented skin lesions achieved in two consecutive studies were sent by e-mail to dermatologists with different degrees of experience in dermoscopy for a telediagnosis. All lesions included in these studies were surgically excised and diagnosed histopathologically.
The diagnostic concordance between the face-to-face diagnosis and the telediagnosis was 91% in the first study, whereas, in the second study, it varied from 76.7%-95.3%. The accuracy of the diagnoses in both studies was not related to the quality of the images, but did highly depend on the level of diagnostic difficulty of a given pigmented skin tumor and on the level of experience of each observer.
Teleconsultation of dermoscopic images of pigmented skin lesions via e-mail provides a similar degree of diagnostic accuracy as face-to-face diagnosis when the diagnosis is made by a dermatologist confident with dermoscopy.
We reviewed the socio-economic impact of telehealth, focusing on nine main areas: paediatrics, geriatrics, First Nations (i.e. indigenous peoples), home care, mental health, radiology, renal dialysis, rural/remote health services and rehabilitation. A systematic search led to the identification of 4646 citations or abstracts; from these, 306 sources were analysed. A central finding was that telehealth studies to date have not used socio-economic indicators consistently. However, specific telehealth applications have been shown to offer significant socio-economic benefit, to patients and families, health-care providers and the health-care system. The main benefits identified were: increased access to health services, cost-effectiveness, enhanced educational opportunities, improved health outcomes, better quality of care, better quality of life and enhanced social support. Although the review found a number of areas of socio-economic benefit, there is the continuing problem of limited generalizability.
To determine if professional medical interpreters have a positive impact on clinical care for limited English proficiency (LEP) patients.
A systematic literature search, limited to the English language, in PubMed and PsycINFO for publications between 1966 and September 2005, and a search of the Cochrane Library.
Any peer-reviewed article which compared at least two language groups, and contained data about professional medical interpreters and addressed communication (errors and comprehension), utilization, clinical outcomes, or satisfaction were included. Of 3,698 references, 28 were found by multiple reviewers to meet inclusion criteria and, of these, 21 assessed professional interpreters separately from ad hoc interpreters. Data were abstracted from each article by two reviewers. Data were collected on the study design, size, comparison groups, analytic technique, interpreter training, and method of determining the participants' need for an interpreter. Each study was evaluated for the effect of interpreter use on four clinical topics that were most likely to either impact or reflect disparities in health and health care.
In all four areas examined, use of professional interpreters is associated with improved clinical care more than is use of ad hoc interpreters, and professional interpreters appear to raise the quality of clinical care for LEP patients to approach or equal that for patients without language barriers.
Published studies report positive benefits of professional interpreters on communication (errors and comprehension), utilization, clinical outcomes and satisfaction with care.