Journal of Telemedicine and Telecare

We conducted a qualitative study to examine users' perceptions of a web-based screening and referral system for young adults with health-related social problems. The first 50 patients who used the system also took part in semi-structured interviews. There were 20 patients aged 15–17 years and 30 aged 18–25 years. Completing the web-based screening process took an average of 25 min. Ninety percent of participants reported at least one major health-related social problem and a total of 134 referrals were selected for further assistance. Ninety-six percent of participants said they would recommend the system to a friend or peer, and 80% supported its use for annual screening. Perceived strengths of the system were novelty, privacy, ease of use, relevance, motivation, variety and proximity of referrals, and clinic staff support. Perceived shortcomings were length, sensitivity, navigation challenges and agency availability. The system complemented provider visits and preserved privacy while improving attention to patient needs. Computerized screening and referral tools have potential to improve the quality of care in vulnerable young adults.

We developed an instrument to measure the satisfaction of lung transplant recipients with home monitoring. The survey comprised 15 items, each scored on a five-point Likert-type scale (from strongly disagree to strongly agree). Three additional free-text items enabled subjects to provide comments. The survey had a scoring range of 15–75. In a test group of 43 patients, the internal consistency (Cronbach's alpha) was 0.93 overall for all questions. The intra-class correlation for scores from the same 27 patients approximately 2.5 months apart was 0.77 for the total score. The survey was used to evaluate subject satisfaction in a randomized controlled trial of a computerized algorithm for triaging lung transplant recipients. Surveys were mailed to 50 study subjects and were returned by 32 (64% return rate). Ninety percent of respondents were satisfied with the home monitoring programme and would recommend it to other patients.

Telemedicine is useful in monitoring patients, and in particular those, such as lung transplant recipients, suffering from chronic illnesses. This prospective cohort study was conducted on 15 lung transplant recipients. The patients provided physicians with data from spirometry as well as their clinical respiratory symptoms via SMS messages. In cases where spirometry results or clinical symptoms required follow-up, the monitoring physician contacted the patient according to guidelines and gave appropriate instructions. Qualitative assessment of satisfaction showed that the sense of increased support from medical staff was rated highest (92.9%). Telespirometry is an efficient method of monitoring lung transplant recipients which leads to patient satisfaction, compliance, adherence to study and sense of security. Nevertheless, for optimal implementation of this method, thorough training of both medical staff and patients is required.

Summary

Sixteen patients with cystic fibrosis were randomized to either telemedicine or standard care alone. All patients were terminally ill. Patients in the telemedicine group had an ISDN line installed in their home and were given a videoconferencing unit connected to their home television set. Eleven subjects completed the baseline assessment and seven patients completed the study (4 on telemedicine and 3 in the control arm). Telemedicine patients had weekly videoconferences from home for a clinical assessment, psychological support and the opportunity for discussion with any member of the multidisciplinary team. A total of 71 home videoconferences were conducted during the study. Anxiety levels were measured before and after the conferences. After six months there were no significant differences in quality of life, anxiety levels, depression levels, admissions to hospital or clinic attendances, general practitioner calls or intravenous antibiotic use between the two groups. However, there was a significant improvement in perception of body image for those in the telemedicine group and the patients liked and valued the service. The use of telemedicine can enhance the support that a specialist unit can provide for the patient and their family, and may reduce outpatient clinic attendances.

A qualitative approach was used to explore the readiness of a rural community for the implementation of telehealth services. There were four domains of interest: patient, practitioner, public and organization. Sixteen semistructured telephone interviews (three to five in each domain) were carried out with key informants and recorded on audio-tape. Two community awareness sessions were held, which were followed by five audio-taped focus groups (with five to eight people in each) in the practitioner, patient and public domains. In addition, two in-depth interviews were conducted with community physicians. Analysis of the data suggested that there were four types of community readiness: core, engagement, structural and non-readiness. The level of readiness varied across domains. There were six main themes: core readiness; structural readiness; projection of benefits; assessment of risk; awareness and education; and intra-group and inter-group dynamics. The results of the study can be used to investigate the readiness of rural and remote communities for telehealth, which should improve the chance of successful implementation.

We reviewed the methodology used in telemedicine research concerning patients with postural and movement disorders. Literature searches were performed using various computerized databases through to October 2005. Twenty-two studies met the criteria for review. Two broad models of telemedicine delivery were represented in the literature: (1) telemedicine between health-care professionals at each telemedicine site ( n = 16) and (2) telemedicine between health-care professionals and a patient at a remote site ( n = 6). Disparate research methodologies were used to investigate these two models. Most studies were limited to investigating the technical feasibility and acceptability of a telemedicine service rather than focusing on the overall effect of introducing the telemedicine service into routine health care. Nonetheless, it is possible to conclude that telemedicine is acceptable for both patients and professionals when used in rehabilitation. Since the two models of telemedicine evaluation tend to explore different outcomes (diagnostic accuracy versus health status), it is recommended that separate methodologies should be used. In contrast to evaluations of telemedicine model 2, randomized controlled trials appear to be less valuable for telemedicine model 1.

In telemedicine and telehealth, the perception of success is complex, varies according to time and context, and depends on the perspective of the observer. Several reviews of the evaluation literature have been undertaken in recent years. These reviews identify common methodological shortcomings. Telehealth services continue to be funded as short-term projects. While it is essential to address methodology issues, it is important to understand that studies of pilot projects provide only interim findings about the feasibility of such applications, not how well they operate as mature applications. This represents something of a conundrum: evaluation is expected to establish the long-term value of telehealth using criteria which are specific to short-term projects. A useful approach would be to develop frameworks enabling all similar studies (e.g. diabetic home care) to be examined in order to extract commonalities and differences. This would enable us to draw conclusions about where telehealth is effective, as well as what variables demonstrate ‘success’

A change in evaluation methodology, from a strictly technical approach to a more comprehensive one, would result in better and less biased decision making in connection with the introduction of information technology in health care. To reach this goal, guidelines are required for building and refining contextual frames, taking qualitative considerations into account. We used primary health care as an example. A literature search produced over 200 relevant articles, from which 76 were selected which explicitly referred to evaluation in connection with health-care information systems. Text analysis allowed us to classify them into three groups. This allowed the development of a contextual frame and emphasized the human dimension as a possible problem area when using medical information systems.

A literature review was conducted to obtain a high-level view of the value of telemedicine in the management of five common chronic diseases (asthma, COPD, diabetes, heart failure, hypertension). A total of 141 randomised controlled trials (RCTs) was identified, in which 148 telemedicine interventions of various kinds had been tested in a total of 37,695 patients. The value of each intervention was categorised in terms of the outcomes specified by the investigators in that trial, i.e. no attempt was made to extract a common outcome from all studies, as would be required for a conventional meta-analysis. Summarizing the value of these interventions shows, first, that most studies have reported positive effects ( n = 108), and almost none have reported negative effects ( n = 2). This suggests publication bias. Second, there were no significant differences between the chronic diseases, i.e. telemedicine seems equally effective (or ineffective) in the diseases studied. Third, most studies have been relatively short-term (median duration 6 months). It seems unlikely that in a chronic disease, any intervention can have much effect unless applied for a long period. Finally, there have been very few studies of cost-effectiveness. Thus the evidence base for the value of telemedicine in managing chronic diseases is on the whole weak and contradictory.