Evaluation of a remote training approach for teaching seniors to use a telehealth system

Objective

There has been a growth of home healthcare technology in rural areas. However, a significant limitation has been the need for costly and repetitive training in order for patients to efficiently use their home telemedicine unit (HTU). This research describes the evaluation of an architecture for remote training of patients in a telemedicine environment. This work examines the viability of a remote training architecture called REmote Patient Education in a Telemedicine Environment (REPETE). REPETE was implemented and evaluated in the context of the IDEATel project, a large-scale telemedicine project, focusing on Medicare beneficiaries with diabetes in New York State.

Methods

A number of qualitative and quantitative evaluation tools were developed and used to study the effectiveness of the remote training sessions evaluating: (a) task complexity, (b) changes in patient performance and (c) the communication between trainer and patient. Specifically, the effectiveness of the training was evaluated using a measure of web skills competency, a user satisfaction survey, a cognitive task analysis and an interaction analysis.

Results

Patients not only reported that the training was beneficial, but also showed significant improvements in their ability to effectively perform tasks. Our qualitative evaluations scrutinizing the interaction between the trainer and patient showed that while there was a learning curve for both the patient and trainer when negotiating the shared workspace, the mutually visible pointer used in REPETE enhanced the computer-mediated instruction.

Conclusions

REPETE is an effective remote training tool for older adults in the telemedicine environment. Patients demonstrated significant improvements in their ability to perform tasks on their home telemedicine unit.     

Implementing patient question-prompt lists into routine cancer care

Objective

To examine the feasibility and acceptability of routine provision of patient question prompt lists (QPLs) to promote patient participation and patient-clinician communication in medical consultations.

Methods

Four cancer centres across NSW, Australia (two rural, two urban) were invited to participate, involving distribution of QPLs to patients seeing a medical or radiation oncologist, or palliative care clinician. Patients rated their satisfaction after their next consultation. Cancer specialists provided their views at the end of the study.

Results

Sixty-four percent (389/606) of patients attending consultations received a QPL. Of patients offered a QPL (426), 91% accepted. Of 139 patients surveyed post-consultation, 89% reported reading the QPL and, of these, 44% referred to the QPL during the consultation at least once. All of 10 cancer specialists providing their views post-implementation reported that QPL implementation in routine practice was feasible and did not strain resources.

Conclusions

Cancer patients and cancer specialists showed support for routine dissemination of the QPL.

Practice implications

For successful implementation of evidence-based tools we recommend promotion by local clinical champions, negotiation with clinic staff about dissemination methods, raised patient awareness through on-site project facilitators, media, consumer and support groups, and availability of resources in hard copy and via online sources.     

An Evaluation of Patient-Physician Communication Style During Telemedicine Consultations

Background

The quality of physician-patient communication is a critical factor influencing treatment outcomes and patient satisfaction with care. To date, there is little research to document the effect of telemedicine (TM) on physician-patient communication.

Objective

The objectives of this study are to measure and describe verbal and nonverbal communication during clinical TM consultations and to compare TM with in-person (IP) consultations in terms of the quality of physician-patient communication.

Methods

Veteran patients (n = 19) requiring pulmonary medicine consultations were enrolled into the study. The study group included 11 patients from the Iron Mountain Veterans Affairs Hospital (VAMC) remote site. Patients had individual TM consultations with a pulmonary physician at the Milwaukee VAMC hub site. A control group of 8 patients had IP consultations with a pulmonary physician at the Milwaukee VAMC. Video recordings of medical consultations were coded for patient-physician verbal and nonverbal communication patterns using the Roter Interaction Analysis System (RIAS).

Results

There were no differences in the length of TM consultations (22.2 minutes) and IP consultations (21.9 minutes). Analysis of visit dialogue indicated that the ratio of physician to patient talk was 1.45 for TM and 1.13 for IP consultations, indicating physician verbal dominance. Physicians were more likely to use orientation statements during IP consultations (P = .047). There were greater requests for repetition from patients during TM consultations (P = .034), indicating perceptual difficulties.

Conclusions

The study findings indicate differences between TM and IP consultations in terms of physician-patient communication style. Results suggest that, when comparing TM and IP consultations in terms of physician-patient communication, TM visits are more physician centered, with the physician controlling the dialogue and the patient taking a relatively passive role. Further research is needed to determine whether these differences are significant and whether they have relevance in terms of health outcomes and patient satisfaction with care.     

Perspectives and expectations for telemedicine opportunities from families of nursing home residents and caregivers in nursing homes

Background

This study assessed current perspectives and expectations for telemedicine by nursing home caregivers and families of nursing home patients in Taipei, Taiwan.

Methods

A total of 116 interviews were conducted with family members (n = 37) and caregivers (n = 79) using an original, four-part questionnaire devised to assess the expectations and concerns related to prospective telemedicine opportunities, including consumer attitude, knowledge of and interest in medicine, concerns and worries about telemedicine, and anticipated benefits of telemedicine.

Results

Statistical significance between the two groups was observed in sex, age, and educational level (all p < 0.001). Most respondents had heard about telemedicine before participation and showed some interest in telemedicine implementation. More than 70.0% of subjects in both groups had perceptions of telemonitoring of patients, notifications of health abnormalities, teleconferencing between physicians and family members, obtaining test/exam results and face-to-face consultation through telenetworks. Both groups hoped for information and education through telemedicine. More caregivers were concerned about increased costs (p = 0.020), poor hardware quality (p < 0.001), poor security, confidentiality, and reliability (p = 0.036), inconvenience to patients (p = 0.006), associated moral and ethical issues (p = 0.006), and uncertainty about responsibility (p = 0.022). The two groups did not differ in expectations concerning benefits of telemedicine. More than 60% of family members or caregivers expected improved efficiency and quality of hospital and nursing home health care, greater rapport between nursing homes and either staff or patients, reduced overall medical costs of caregiving, and reduced staff/caregiver working hours. The acceptable cost was anything up to $15.30 USD per month.

Conclusions

Nursing home caregivers and families of nursing home patients are highly interested in telemedicine; however, they are only willing to pay a slightly higher cost of nursing care for this service. The challenge for the future in this industry is to balance peoples’ demands and telemedicine's associated costs. Results of this study suggest that caregivers and families of nursing home residents favour telemedicine implementation to provide enhanced care coordination in nursing homes when economic circumstances are favourable.     

The physical examination in telecardiology and televascular consultations: A study using conversation analysis

Objective

This paper describes communication in the physical examination phases of telemedicine consultations.

Methods

Using the method of conversation analysis, we draw on 10 telemedicine consultations (five telecardiology and five televascular) between primary and tertiary care in the UK.

Results

Physical examination is absent in telecardiology consultations. In televascular consultations the professionals try to compensate for the lack of physical proximity by getting involved in a form of collaboration that constitutes a novel environment for all. Separated from the patient by physical space, the specialist orchestrates the positioning of the patient, the camera and the primary care nurse's activity via the use of a video-link.

Conclusion

Telemedicine offers primary care nurses a unique opportunity to engage in active collaboration with hospital specialists. The nurses’ examination skills are recruited because physical examination is conducted from distance and the specialist cannot touch the patient or see parts of the body with ease. We speculate that difficulties with the physical examination may have contributed to the relatively slow adoption of telemedicine.

Practice implications

The analysis reveals some new communication practices that participants in telemedicine are called to adopt. This can be used to inform training interventions that focus both on patient and professional.     

Factors that promote and prohibit access to participants in the clinical setting: a review of response rates from a health communication intervention study

Objective

This report examines the factors that influence researchers’ abilities to recruit participants into health communication studies conducted within the clinical setting.

Method

Review of response rates over a 15 month data collection period for an intervention study on patient-physician communication, low health literacy, and diabetes management.

Results

Most patients were willing to participate (73%). The challenge was not fostering interest in the study, but rather being able to approach potential participants. Over the course of the study, patients with diabetes visited the clinic 1263 times yet interviewers were only able to approach patients 196 times for potential inclusion in the study. Confounding factors that affected recruiting participants included the interviewers’ availability and clinic schedule, as well as patient chief complaint and no show or rescheduling rates.

Conclusion

Researchers must engage in collaborative efforts with clinic staff during the research design phase, maximize their availability to approach potential patients, and capitalize on the insights of clinic staff to approach those patients who fit the study criteria and would be most willing to participate in the research project.

Practice implications

Researchers must learn about the clinic, reduce research burden, and be flexible to work within the constraints of the clinic setting.     

Measuring the impact of nurse cue-response behaviour on cancer patients’ emotional cues

Objective

This study aimed to explore the impact of nurse responses to patients’ and family members’ emotional cues and concerns during the chemotherapy education consultation.

Methods

51 cancer patients and 13 nurses participated in this study. Nurse-delivered chemotherapy education sessions were audio-recorded, and patients completed the EORTC QLQ-C30 V3.0 questionnaire before the education. The audio records were transcribed and coded.

Results

Patients expressed their emotions more than family members, but patients’ cues decreased when family were present. Patients with lower emotional wellbeing (greater psychological distress) prior to the consultation did not express more cues/concerns. Nurses responded to patients’ and families’ cues equally in a cue-facilitative fashion. Facilitative responses were associated with decreased patients’ cues.

Conclusion

Family presence appears to hinder patients’ cues/concerns. Nurses’ PS responses were associated with less cues/concerns by patients.

Practice implication

The current study challenges the common assumption that a higher number of cues is indicative of effective consultation, and indicates the influence of family in patients’ cues/concerns.     

Methodologies for assessing telemedicine: a systematic review of reviews

Background and objectives

Previous reviews have expressed concerns about the quality of telemedicine studies. There is debate about shortcomings and appropriate methodologies. The aim of this review of systematic reviews of telemedicine is to summarize methodologies used in telemedicine research, discuss knowledge gaps and recommendations and suggest methodological approaches for further research.

Methods

We conducted a review of systematic reviews of telemedicine according to a protocol listing explicit methods, selection criteria, data collection and quality assessment procedures. We included reviews where authors explicitly addressed and made recommendations for assessment methodologies. We did a qualitative analysis of the reviews included, sensitized by two broad methodological positions; positivist and naturalistic approaches. The analysis focused on methodologies used in the primary studies included in the reviews as reported by the review authors, and methodological recommendations made by the review authors.

Results

We identified 1593 titles/abstracts. We included 50 reviews that explicitly addressed assessment methodologies. One group of reviews recommended larger and more rigorously designed controlled studies to assess the impacts of telemedicine; a second group proposed standardisation of populations, and/or interventions and outcome measures to reduce heterogeneity and facilitate meta-analysis; a third group recommended combining quantitative and qualitative research methods; and others applying different naturalistic approaches including methodologies addressing mutual adaptations of services and users; politically driven action research and formative research aimed at collaboration to ensure capacity for improvement of services in natural settings.

Conclusions

Larger and more rigorous studies are crucial for the production of evidence of effectiveness of unambiguous telemedicine services for pre defined outcome measures. Summative methodologies acknowledging telemedicine as complex innovations and outcomes as partly contingent on values, meanings and contexts are also important. So are formative, naturalistic methodologies that acknowledge telemedicine as ongoing collaborative achievements and engage with stakeholders, including patients to produce and conceptualise new and effective telemedicine innovations.     

Why don't patients take their drugs? The role of communication, context and culture in patient adherence and the work of the pharmacist in HIV/AIDS

Objective

This study examined facilitators and barriers to adherence in four South African antiretroviral therapy (ART) clinic sites and explored context and communication factors in relation to the role of the pharmacist.

Methods

Data were collected from interviews and narratives of patients and health professionals around the issues of adherence and qualitatively analysed using principles of Thematic Content Analysis.

Results

Findings confirm the complex interplay between illness, communication, sociocultural, economic, context and systemic issues. Analysis suggests adherence is multifaceted and reinforces the critical role of communication factors in achieving concordance between patient and pharmacist.

Conclusion

Successful treatment of HIV/AIDS depends on pharmacists and healthcare teams understanding contextual and interactional factors which play a role in adherence.

Practice implications

The findings reinforce the importance of embedding a patient-centred approach in the training and everyday practice of pharmacists. The value of qualitative methods in understanding barriers to adherence and the potential value of the cultural broker in intercultural settings is discussed. Some suggestions are made as to how adherence counselling can be made relevant and effective.     

Shared decision making in medicine: The influence of situational treatment factors

Objective

Although shared decision making (SDM) has become increasingly important in bioethical discussions and clinical practice, it is not clear in which treatment situations SDM is suitable. We address this question by investigating social norms on the appropriateness of SDM in different situations.

Methods

We conducted qualitative expert interviews with patients, general practitioners, and health administration and research professionals.

Results

SDM was considered to be most important in severe illness and chronic condition. Furthermore, SDM was indicated to be required if there is more than one therapeutic option, especially if it is not clear which option is best. Interviewees classified end-of-life decisions and decisions about prevention as those that primarily should be made by informed patients. On the other hand a paternalistic decision was considered most appropriate in emergency situations and when the patient does not want to participate in decision making.

Conclusion

This study demonstrates that multiple situational factors and their interactions must be considered regarding the scope of SDM in medical consultation.

Practice implications

Research addressing this question will help physicians adjust their consultation style and allow implementations of SDM and decision aids to be tailored more appropriately to complex treatment situations.     

Finding the right balance of physical activity: A focus group study about experiences among patients with chronic fatigue syndrome

Objective

To explore contexts of experiences of physical activity perceived as beneficial or harmful for CFS patients.

Methods

A qualitative study with empirical data from two focus groups with purposive sampling. Mean age was 50, two of ten participants were male, and social demographics varied. Participants were invited to share stories of good as well as bad experiences concerning physical activity. Data were analysed with systematic text condensation.

Results

Participants were not averse to physical activity, but specific preconditions would determine how the activity was perceived. Physical activity was experienced as helpful and enjoyable, especially related to leisure activities where flexible and individual adaptation was feasible. Non-customized activity may precipitate set-backs giving patients the impression of losing control and being betrayed by their bodies. Strategies to review energy usage in daily life could adjust expectations, diminish stress load and assist in approaching a more appropriate priority and balance.

Conclusion

Self-management, body awareness and physical activity of choice combined with facilitation and advice from health care professionals is essential to achieve a positive outcome.

Practice implications

Exercise programmes should be adapted, paced, and self-managed in accordance with personal preferences and activity levels to be beneficial and empowering for CFS patients.     

Reliability associated with the Roter Interaction Analysis System (RIAS) adapted for the telemedicine context

Objective

This study's purpose was to adapt the Roter Interaction Analysis System (RIAS) for telemedicine clinics and to investigate the adapted measure's reliability. The study also sought to better understand the volume of technology-related utterance in established telemedicine clinics and the feasibility of using the measure within the telemedicine setting. This initial evaluation is a first step before broadly using the adapted measure across technologies and raters.

Methods

An expert panel adapted the RIAS for the telemedicine context. This involved accounting for all consultation participants (patient, provider, presenter, family) and adding technology-specific subcategories. Ten new and 36 follow-up telemedicine encounters were videotaped and double coded using the adapted RIAS. These consisted primarily of follow-up visits (78.0%) involving patients, providers, presenters, and other parties. Reliability was calculated for those categories with 15 or more utterances.

Results

Traditional RIAS categories related to socioemotional and task-focused clusters had fair to excellent levels of reliability in the telemedicine setting. Although there were too few utterances to calculate the reliability of the specific technology-related subcategories, the summary technology-related category proved reliable for patients, providers, and presenters. Overall patterns seen in traditional patient–provider interactions were observed, with the number of provider utterances far exceeding patient, presenter, and family utterances, and few technology-specific utterances.

Conclusion

The traditional RIAS is reliable when applied across multiple participants in the telemedicine context. Reliability of technology-related subcategories could not be evaluated; however, the aggregate technology-related cluster was found to be reliable and may be especially relevant in understanding communication patterns with patients new to the telemedicine setting. Use of the RIAS instrument is encouraged to facilitate comparison between traditional, face-to-face clinics and telemedicine; among diverse consultation mediums and technologies; and across different specialties. Future research is necessary to further investigate the reliability and validity of adding technology-related subcategories to the RIAS. The limited number of technology-related utterances, however, implies a certain degree of comfort with two-way interactive video consultation among study participants.

Practice implications

Telemedicine continues to increase access to healthcare. The technology-related categories of the adapted RIAS were reliable when aggregated, thereby providing a tool to better understand how telemedicine affects provider–patient communication and outcomes.     

Tele-health: lessons and strategies from specialists in poison information

Objective

The use of the telephone for providing healthcare is growing. The aim of this exploratory study was to describe tele-health lessons and strategies as discussed by specialists who provide information and recommendations on poison control hotlines.

Methods

Three focus groups of 25 participants who work as specialists in poison information in poison control centers were conducted. Group discussions were analyzed using qualitative content analysis.

Results

Themes that emerged from the data on strategies for telephone communication include: taking control of the call, developing a therapeutic relationship, tailoring communication to fit each caller, preventing information overload, confirming caller understanding, and hands-on training for the development of telephone communication skills.

Conclusion

Specialists in poison information identified challenges specific to communicating with patients over the telephone and reported several types of strategies they used to manage them.

Practice implications

Telephone communication training may be needed to assist health care providers in improving their communication skills.     

Promoting decision aid use in primary care using a staff member for delivery

Objective

To determine the feasibility and effectiveness of in-clinic decision aid distribution using a care assistant.

Methods

We identified potentially eligible patients scheduled for upcoming appointments in our General Internal Medicine Clinic (n = 1229). Patients were deemed eligible for two decision aids: prostate cancer screening and/or weight loss surgery. Patients were approached to view the decision aid in-clinic. Our primary measures were the proportion of decision aids distributed to eligible patients, and the proportion of decision aids viewed.

Results

Among 913 patients who attended their scheduled appointments, 58% (n = 525) were approached and eligibility was assessed by the staff member. Among the 471 who remained eligible, 57% (n = 268) viewed at least a portion of the target decision aid. The mean viewing time for patients who watched less than the complete decision aid was 13 min.

Conclusions

In clinic viewing of decision aids may be a feasible and effective distribution method in primary care.

Practice implications

In clinic distribution requires an electronic health information system to identify potentially eligible patients, and a staff member dedicated to DA distribution. Brief decision aids (less than 10 min) are needed so patients can complete their use prior to the visit to facilitate patient-physician decision making.     

Patients’ reaction to the disclosure of rare dreaded adverse events

Background

Physicians must frequently inform their patients of the risks of rare, but serious, adverse events (AEs).

Objective

To examine how patients react to the disclosure of rare AEs.

Methods

Outpatients viewed a video of a physician describing a medication associated with a rare AE. Subjects then rated their worry, perceived chance of developing the AE, and willingness to take the medication.

Results

Non-White men were more likely to perceive a greater chance of developing the AE compared to White men [Adjusted odds ratio (95% CI) = 3.37 (1.09-10.45)]; White women were more likely to be worried [2.00 (0.95-4.24)] and to perceive a greater chance of developing the [6.22 (2.50-15.50)], perceive a greater chance of developing the AE [6.27 (2.43-16.15)], and be less willing to take the medication [0.23 (0.09-0.59)], compared to White men.

Conclusions

Gender and ethnicity influence how patients react to disclosure of rare, but serious, AEs.

Practice implications

An improved understanding of patients’ risk perceptions is required to inform the development of best practices to improve risk communication.     

Opinions of patients with type 2 diabetes about responsibility, setting targets and willingness to take medication. A cross-sectional survey

Objective

To assess opinions and their determinants of patients with type 2 diabetes about responsibility for managing their diabetes, setting treatment targets and willingness taking medication.

Methods

Questionnaire survey carried out in general practices and outpatient clinics across the Netherlands. Outcomes: opinions about responsibility, targets and medication. Multinomial logistic regression analysis.

Results

Data of 994 consecutive persons were analysed (mean age 65 years; 54% males). Of these 62% agreed to take responsibility for their diabetes. In the opinion of 89% the setting of targets should be by or in cooperation with their physician or nurse and 40% were willing to take tablets until all targets were attained. Patients who perceived dysfunction by barriers to activity did not agree to take responsibility (OR 3.68; 1.65-8.19). Patients with complications preferred to set targets in cooperation with their physician or nurse (OR 1.98; 1.03-3.80). Males were more willing to take tablets until all targets were attained (OR 1.62; 1.17-2.25).

Conclusion

Not all patients want to take responsibility for their diabetes or taking all necessary tablets, especially those with barriers to activity or complications.

Practice implications

Doctors and nurses should ask for patients’ opinions about responsibility and treatment goals before starting education.