A problem-oriented precepting method

An organized method of clinical precepting may increase preceptor effectiveness. Problem-oriented precepting is an organized teaching method directed not only at achieving high-quality care for the presented patient, but also at solving the problems of the medical provider that block that goal. The precepting method consists of the following steps: (1) identify initial impressions, (2) confirm or refute these impressions, (3) identify the problem, (4) develop teaching goals, (5) devise methods to achieve these goals, and (6) evaluate outcome. The use of this step-by-step process permits earlier definition of resident problems, which can improve the resident's problem-solving ability.     

Education through telemedicine networks: setting quality standards

Quality standards for educational programming have received limited attention in telemedicine. We selected five sets of standards from the distance education literature established by: (1) the American Council on Education; (2) the American Distance Education Consortium; (3) the Council of Regional Accrediting Commissions; (4) the Distance Education and Training Council; (5) the Innovations in Distance Education Project. The standards were reviewed to determine the purposes they were intended to serve and the process by which they were established. The content of the five sets of standards were summarized around the 'four commonplaces' of education: learner, teacher, curriculum and context. Four major findings emerged. First, none of the sets of standards addresses all of the issues that are potentially relevant to telemedicine education; all emphasize certain topics while neglecting others. Second, there are some important aspects of telemedicine that are not addressed at all, such as patient confidentiality. Third, the standards generally provide a framework for defining high quality in distance education, leaving to those at the local level the task of deciding how a standard applies in their setting. Finally, the standards reviewed have many elements that could potentially apply to telemedicine education. Setting quality standards for education through telemedicine requires a systematic approach and a means for continuous improvement of those standards.     

Partnering through telemedicine to improve the quality of health-care

In order to assist health-care reform in eastern Slovakia, a partnership was established with health-care institutions in Rhode Island. The aim of the partnership was to improve maternal and child health in Slovakia. Thirty-seven telemedicine sessions were conducted via a satellite link. A number of workshops, case studies, demonstrations and interactive discussions took place between various health-care professionals. The use of telemedicine accelerated the adoption of new procedures in Slovakia.     

The iPath telemedicine platform

An early, point-to-point telepathology system at the University of Basel developed into an open-source, Internet-based platform for telemedicine in 2001. The Internet Pathology Suite (iPath) is a Web-based telepathology platform that permits the online presentation and discussion of cases within user groups. It also allows realtime telemicroscopy across firewalls. After four years, the telepathology network has over 700 active users. More than 6,300 cases with a total of about 39,000 images have been diagnosed. The diagnostic workload of all these cases is not exclusively handled by the Department of Pathology in Basel, but by a growing number of independent groups who also use the server simply as a case repository. What started as a small project for hospitals in Switzerland has become a global network.     

Study quality and evidence of benefit in recent assessments of telemedicine

We carried out a systematic review of recent telemedicine assessments to identify scientifically credible studies that included comparison with a non-telemedicine alternative and that reported administrative changes, patient outcomes or the results of an economic assessment. From 605 publications identified in the literature search, 44 papers met the selection criteria and were included in the review. Four other publications were identified through references cited in one of the retrieved papers and from a separate project to give a total of 48 papers for consideration, which referred to 42 telemedicine programmes and 46 studies. Some kind of economic analysis was included in 25 (52%) of the papers. In considering the studies, we used a quality appraisal approach that took account of both study design and study performance. For those studies that included an economic analysis, a further quality-scoring approach was applied to indicate how well the economic aspects had been addressed. Twenty-four of the studies were judged to be of high or good quality and 11 of fair to good quality but with some limitations. Seven studies were regarded as having limited validity and a further four as being unacceptable for decision makers. New evidence on the efficacy and effectiveness of telemedicine was given by studies on geriatric care, intensive care and some of those on home care. For a number of other applications, reports of clinical or economic benefits essentially confirmed previous findings. Although further useful clinical and economic outcomes data have been obtained for some telemedicine applications, good-quality studies are still scarce.     

The Lancashire telemedicine ambulance.

An emergency ambulance was equipped with three video-cameras and a system for transmitting slow-scan video-pictures through a cellular telephone link to a hospital accident and emergency department. Video-pictures were trasmitted at a resolution of 320 x 240 pixels and a frame rate of 15 pictures/min. In addition, a helmet-mounted camera was used with a wireless transmission link to the ambulance and thence the hospital. Speech was transmitted by a second hand-held cellular telephone. The equipment was installed in 1996-7 and video-recordings of actual ambulance journeys were made in July 1997. The technical feasibility of the telemedicine ambulance has been demonstrated and further clinical assessment is now in progress.     

The Italian national telemedicine programme

The Italian national telemedicine programme included a broad range of research projects, but they all served the common purpose of bringing about improvements in health-care management and performance. The programme consisted of seven projects, each of which had specific research and training objectives, and a three-year duration. The systems developed in the course of the programme were not experimental prototypes:they were intended to be pre-commercial systems. The functional and clinical merits of the products and systems developed were evaluated, and their costs and benefits measured with reference to those already in use. The seven projects were completed in 1999. The Italian Ministry of Universities, Research and Technology granted research funds totalling 50,000,000 Euros for the whole programme. While the results of the research were promising, successful projects alone are not sufficient to reduce costs in health-care. Indeed, far more money can be saved simply by encouraging the uptake on a larger scale of many technologies and practices that already exist.