Patient adherence to recommendations after teleconsultation: survey of patients from a telemedicine centre in Switzerland

We investigated patients' adherence to recommendations after telephone triage at the Swiss Centre for Telemedicine. We studied cases where the medical problem was assessed as not requiring an immediate face-to-face consultation. Two weeks after teleconsultation, follow-up telephone interviews were conducted with 1129 self-care patients. The patients were asked if they had adhered to the telephone recommendations and whether they had had a subsequent face-to-face consultation. A total of 1003 patients (88%) were available for the follow-up telephone interview. Of those, 85% reported that they had adhered to all self-care recommendations and 86% had followed the advice about further use of the health-care system. Overall, 28% of patients had attended a face-to-face consultation. Half of them were referred by the teleconsultation centre, and half of them had decided themselves not to follow the centre's recommendation. Since acceptance of self-care recommendations after teleconsultation was high, teleconsultation may be an efficient alternative to face-to-face consultations for some conditions.     

Cost implications of outpatient teleneurology

A randomized controlled trial was conducted to compare the costs of realtime teleneurology with the cost of conventional neurological care. Two district hospitals in Northern Ireland were equipped with videoconferencing units and were connected to the regional neurological centre by ISDN at 384 kbit/s. Of 168 patients randomized to the study, 141 kept their appointments (76 male, 65 female). Sixty-five patients were randomized to a conventional consultation while 76 were randomized to a teleconsultation. The average age was 44 years of those seen conventionally and 42 years of those seen by telemedicine. The groups had similar diagnoses. The telemedicine group required more investigations and reviews than the conventional group. The average cost of the conventional consultation was 49 pounds sterling compared with 72 pounds sterling for the teleconsultation. Realtime teleneurology was not as cost-effective as conventional care.     

The telemedicine network of the People's Liberation Army

In the early 1990s, the People's Liberation Army began to establish a telemedicine network for the non-emergency health-care of the personnel of military units and their families, as well as local civilian patients. All data were transferred over the ordinary telephone network. All the stations were uniformly equipped with PCs containing videoconferencing cards. The network comprised 13 management centres and 208 teleconsultation stations. To evaluate the telemedicine service, we conducted a survey with written questionnaires and telephone interviews. The questionnaire was sent to the person responsible for each telemedicine station. A total of 187 questionnaires were returned, a response rate of 85%. The survey showed that 1503 teleconsultation sessions had been conducted for military as well as civilian patients during the 18-month study period, and 1708 static images had been transferred across the network during these sessions.     

Patient satisfaction with teledermatology: quantitative and qualitative results from a randomized controlled trial

As part of a randomized controlled trial involving 208 dermatology patients, a quantitative and qualitative study was undertaken to explore patients' satisfaction with a specialist dermatological opinion and further management obtained through either a traditional outpatient consultation (control group) or an asynchronous teleconsultation (telemedicine group). There was a response rate of 71% to the quantitative patient satisfaction survey (148 replies from 208 distributed questionnaires). The responders comprised 80 of the 111 telemedicine patients (72%) and 68 of the 97 control patients (70%). Overall levels of patient satisfaction were high in both groups, and there was no significant difference between them. Ninety per cent of patients in the control group were satisfied with their overall care, compared with 81% in the telemedicine group, and 87% of patients in the control group were satisfied with their overall management, compared with 84% in the telemedicine group. Follow-up qualitative interviews with 30 of the participants also suggested that patients were generally positive about their care and management, regardless of group, age or gender. Receiving a diagnosis, treatment and cure, receiving adequate information and explanations, the need to be taken seriously, the need for individualized personal care, and the importance of a short waiting time for an appointment and treatment were all aspects of care and management most likely to result in patient satisfaction, regardless of modality.     

An integrated nursing and telemedicine approach to vascular care

We have developed a telemedicine approach to vascular care for patients being managed in primary care. District nurses visit patients in their homes. Clinical information and digital photographs can be sent by email to the vascular surgeon for assessment. Where appropriate a preliminary teleconsultation between the patient and a vascular surgeon, with the nurse in attendance, is held at the primary care centre and the management of the patient is agreed. This may include referral to surgery. Over eight months six patients with diabetes and peripheral ulcers participated in the vascular telemedicine clinic. The average consultation time was 12 min (SD 4), which included discussion of the case and negotiation of its management. Important outcomes of the new system were the ability to schedule patients for rapid referral and to have completed the management of the case during the teleconsultation.     

Patient referral by telemedicine: effectiveness and cost analysis of an Intranet system

The clinical effectiveness and costs of telemedicine in improving the referral process from primary to secondary care were examined in an eight-month prospective, comparative study with one-year follow-up. The internal-medicine outpatient clinics of two Finnish district hospitals were compared--Peijas Hospital (PH) with telemedicine and Hyvink?? Hospital (HH) without it. The three primary-care centres studied referred a total of 292 adult patients to the outpatient clinics. The population-based number of referrals to PH (7.5/1000) from primary-care centres was twice that to HH (3.8/1000). Thirty-seven per cent of referrals to PH included requests from general practitioners for on-line medical advice (teleconsultation). Forty-three per cent of the total number of intranet referrals resulted in outpatient visits at PH, compared with 79% in the outpatient clinic at HH. Only 18% of the patients receiving a teleconsultation ended up in the outpatient department of PH within one year. These visits were mainly due to progression of chronic disease. No deaths or missed diagnoses could be attributed to telemedicine, but one diagnosis was delayed. The direct costs of an outpatient clinic visit in internal medicine (EU211) were seven times greater per patient than for an e-mail consultation (EU32), with a marginal cost decrease of EU179 for every new intranet consultation. A cost-minimization analysis of the alternative interventions showed a net benefit of EU7876 in favour of the teleconsultation process. General practitioners sought an outpatient visit for 130 of their patients, and advice only for another 77. On-line advice was nonetheless given in 108 cases, and only 88 patient visits were arranged. Eleven referrals were declined. The cost difference between giving on-line medical advice for the 108 cases and a visit to the outpatient clinic for the other 88 was less costly (by EU4140) than investigating the 124 patients whose original clinic referrals to the PH were not declined. Productivity in the hospital increased over threefold by using e-mail consultations instead of traditional outpatient visits. The wide interactive use of the intranet referral system between secondary and primary care improved clinical effectiveness, lowered direct costs, increased productivity and was cost-effective.     

基于ATM网络架构的远程医学系统

远程医学系统目前在许多医院已开展并投入使用,基本通讯线路采用电话线,ISDN等窄带线路进行会诊,所以会诊应用效果一般,我院为提高 远程医学水平与省电信局合作开发建立了山东省远程医学网络,它基于山东电信ATM（非同步传送模式网络）公共数据网,遍布全省各地县,图像清晰度高,集远程会诊,远程教学,远程手术指导及观察于一体。     

军队远程医疗会诊环节规范化管理研究

目的：探讨军队远程医疗会诊规范化管理。方法：收集和检查了上海85医院远程会诊中心执行会诊的病历质量，并建立病案系统。结果：会诊中心4年共执行远程医疗会诊658例；其中传送会诊病历599例(91％)，影像图像392例(60％)，会诊意见单595例(90％)，采集了会诊实况录像203例(31％)。病历质量分析显示，58％的远程病历能被认可，1794幅放射影像图像中只有80％的影像图像被认为可阅读。结论：远程医疗会诊的最佳操作是远程病历应该预先传送，传输的病史应该完整，图像应该可阅读；为确保远程医学网络数据传递安全性和保密性，应采用专网专用的会诊软件；会诊资料收集多媒体化，病案标识和分类标准化，以及会诊病例管理信息化是远程医疗会诊规范操作的三个基本环节。     

Teleconsultation as a replacement for referral to an outpatient clinic

We conducted a randomized case control study of referrals from a primary care centre in Finland. All the consultations and referrals from seven general practitioners (GPs) dealt with by internists and surgeons at Satakunta Central Hospital in Pori and geriatricians at Satalinna Hospital in Harjavalta over five months were included. For patients in the control group, a conventional referral letter was sent to the hospital outpatient clinic. For patients in the intervention group, the GPs had to decide whether they wanted an electronic consultation with the hospital or wanted to refer the patient (i.e. to transfer responsibility for treatment). Communication with the hospital specialist was then via a secure Web-based system. Ninety-three patients consented to participate in the study. None refused, although there were 15 non-attenders. Satisfaction data were collected from questionnaires completed by the patients and doctors. All the patients treated by teleconsultation said that they wanted the same procedure in future and 63% of the control group said they would prefer a teleconsultation next time. The doctors quickly learned to exploit the telemedicine model successfully. The responsibility for treatment was maintained in the health centre in 52% of cases using teleconsultation, without any visit to hospital being required. The GPs and the hospital doctors agreed on the follow-up treatment. Telereferral increased the possibility of the GP maintaining responsibility for the treatment. The reduced number of hospital visits in the telemedicine model should produce significant cost savings.     

Perceptions of Local Health Care Quality in 7 Rural Communities with Telemedicine

CONTEXT: Rural health services are difficult to maintain because of low patient volumes, limited numbers of providers, and unfavorable economies of scale. Rural patients may perceive poor quality in local health care, directly impacting the sustainability of local health care services. PURPOSE: This study examines perceptions of local health care quality in 7 rural, underserved communities where telemedicine was implemented. This study also assesses factors associated with travel outside of local communities for health care services. METHODS: Community-based pretelemedicine and posttelemedicine random telephone surveys were conducted in 7 northern California rural communities assessing local residents' perceptions of health care quality and the frequency of travel outside their community for health care services. Five-hundred rural residents were interviewed in each of the pretelemedicine and posttelemedicine surveys. Between surveys, telemedicine services were made available in each of the communities. FINDINGS: Residents aware of telemedicine services in their community had a significantly higher opinion of local health care quality (P =.002). Satisfaction with telemedicine was rated high by both rural providers and patients. Residents with lower opinions of local health care quality were more likely to have traveled out of their community for medical care services (P =.014). CONCLUSIONS: The introduction of telemedicine into rural communities is associated with increases in the local communities' perception of local health care quality. Therefore, is it possible that telemedicine may result in a decrease in the desire and need for local patients to travel outside of their community for health care services.     

Telehealth consultations in rheumatology: cost-effectiveness and user satisfaction

We conducted a feasibility study to assess user satisfaction with and the cost-effectiveness of a rheumatology telehealth clinic in northern Alberta. Six telehealth clinics were organized between a rural health centre and the specialist rheumatology centre, which was about a 4 h drive away. Fifty-two new patients were seen. Their median age was 54 years (range 7-81 years). After the teleconsultation, no patient required a conventional face-to-face consultation. Overall, patients agreed that the teleconsultation met their needs and that the care they received was as good as conventional care. The physicians involved in the study thought the process practical and effective. The total costs of service delivery would be equal for teleconsultation and for traditional consultation at a workload of 247 consultations a year.     

A cost-effectiveness analysis of interactive paediatric telecardiology

We analysed the cost-effectiveness of a teleconsultation service after five years of operation. The service provides diagnostic consultation at a distance for children suffering from cardiac pathologies. A retrospective study was performed with all 78 infants who had received a paediatric cardiology teleconsultation over a four-year period from January 1998. The cost-effectiveness of telecardiology was compared with that of the conventional means of providing services. Teleconsultation proved to be an effective and reliable method of enhancing access to tertiary care. The number of patient journeys (both emergency transfers and semi-urgent or elective visits to the tertiary care centre) was reduced by 42%. However, the cost analysis demonstrated that teleconsultation did not result in overall cost savings: the total cost of telecardiology was C dollars 272,327 and the total cost of conventional care would have been C dollars 157,212. There were direct savings for patients but not for the health-care system, because of the high cost of the equipment and telecommunication fees. Telemedicine therefore represented a supplementary cost of C dollars 1500 per patient. In summary, telemedicine added to cost but increased effectiveness. The incremental cost-effectiveness ratio of teleconsultation was estimated to C dollars 3488 per patient journey avoided.     

区域远程病理学会诊网络平台的构建

远程医学会诊网络系统基本包括三大系统,一是远程疑难病会诊系统;二是远程影像学会诊系统;三是远程病理学会诊系统。而后两项系统的设计构建水平,对保证远程会诊的准确性具有决定性意义。本文重点论述远程病理学会诊系统的设计、构建和实施。远程病理学作为远程医学的一个重要分支,目前在国内外的发展及应用已逐渐被重视,通过远程病理会诊为远地医疗单位或病人提供咨询服务,做出正确的病理诊断是切实可行的。     

区域远程病理学会诊网络平台的构建

远程医学会诊网络系统基本包括三大系统,一是远程疑难病会诊系统;二是远程影像学会诊系统;三是远程病理学会诊系统。而后两项系统的设计构建水平,对保证远程会诊的准确性具有决定性意义。本文重点论述远程病理学会诊系统的设计、构建和实施。远程病理学作为远程医学的一个重要分支,目前在国内外的发展及应用已逐渐被重视,通过远程病理会诊为远地医疗单位或病人提供咨询服务,做出正确的病理诊断是切实可行的。     

The legal and ethical aspects of telemedicine. 4: Product liability and jurisdictional problems.

The use of telemedicine brings with it the risk that the human factor--the teleconsultant--will fail to reach the standard of care that the law requires of medical professionals. It also brings the risk that the telemedical equipment or system will fail at a crucial moment. Such risks, of course, are inherent in many aspects of medical care but in telemedicine, at the interface between communications technology and health care, one must consider not only who is liable for failure, but under which country's laws will that liability be determined. This final review article describes the challenges facing manufacturers and their customers in providing safe, properly endorsed telemedicine systems. The problem of which country's laws should apply to a cross-border teleconsultation is also reviewed.     

A follow-up study of remote trauma teleconsultations

We conducted a follow-up study of patients who had attended a nurse-led minor accident and treatment service (MATS) and who had participated in a teleconsultation. Over three and a half years, 31,510 patients had attended the MATS unit and 1854 patients (5.9%) of these had participated in a teleconsultation. Of the 1854 telemedicine patients, 1199 had been referred to hospital or clinic and 1153 had actually attended. Retrospective examination of the relevant hospital records showed that in 25 cases (2%) the original telediagnosis was considered incorrect at face-to-face review and that treatment was either begun or changed in 264 cases (23%). All patients, including those discharged home after the teleconsultation, were sent a questionnaire about any changes to their injury. Of the 655 patients discharged home, a questionnaire response was obtained from 598 (91%). Following discharge, 43 of these patients had sought help from another health-care provider (the majority from their general practitioner). Of the 46 patients referred to hospital who did not keep their follow-up appointments, questionnaire results were obtained from 35 (76%). Nine of these patients had sought help from another health-care provider (the majority from their general practitioner) but there had been no change in diagnosis or treatment. Our findings suggest that teleconsultations are an effective means of delivering minor injuries care.     

Patient satisfaction with telemedicine in a prison environment.

Prison inmates were surveyed about their perceptions of the use of videoconferencing in clinical consultations. A 14-item questionnaire was used to assess satisfaction with the patient-physician clinical interaction. Of the 299 inmates surveyed immediately after their teleconsultations, 221 completed questionnaires that were suitable for analysis (74%). Only 9% of patients indicated that they were not satisfied with the teleconsultation. They rated the telemedicine context well above the midpoint of the scale (16) on both an information-exchange and a patient-comfort dimension, with means of 29 and 24, respectively. There was a significant difference (P < 0.01) in the patient-comfort dimension in terms of the location of the prisoners. No significant differences were found in patient satisfaction related to the specialty of the physician. The results suggest that many contextual factors must be considered to understand the communicative implications of patient satisfaction with telemedicine.     

Physician perceptions of the effect of telemedicine on rural retention and recruitment

We conducted a postal survey of 140 family and community specialist physicians in a predominantly rural area which had received clinical telemedicine services and videoconferenced continuing medical education (CME) for two years. The questionnaire contained 46 items. The response rate was 47%. Most respondents (83%) reported having attended videoconferenced CME sessions and 45% reported having referred patients for teleconsultation. Physicians in more rural areas used these services more frequently. Ratings of two statements assessing the value of telemedicine in community support were significantly and positively correlated with the number of videoconferenced CME sessions attended and the number of telemedicine services used. In relation to their decision to stay in their community for at least one year, respondents rated telemedicine lower in importance than all but one of 17 other factors expected to influence physician recruitment and retention in rural communities. The influences on physician rural recruitment and retention are complex. However, telemedicine was used more frequently by the more rural physicians, and there was a relationship between higher usage and higher ratings of its value as a community support.