Journal of Telemedicine and Telecare

This commentary examines the impact and limitations of existing legal policy as it relates to tele-monitoring, and considers the extent to which it serves to promote or impede remote monitoring technologies in the context of chronic illness.

Telemedicine conducted via prerecorded interaction is more convenient than that using realtime interaction. On the other hand, a realtime consultation allows an immediate result to be obtained and there is likely to be a strong educational component for the remote practitioner. The use of the telephone is under-rated in telemedicine. Telephones have been used in outpatient follow-up, mental health, help lines and support groups. Telephones (fixed and mobile) have also been used for data transfer (e.g. for transmission of electrocardiograms). Realtime transfer of still images has been used in telepathology for many years, and more recently for rapid assessment of injuries. Realtime transfer of video images has been widely explored, perhaps most successfully in telepsychiatry. Some realtime telemedicine applications have been taken up with enthusiasm, even if formal evidence of cost-effectiveness may be lacking. Teleradiology and telepsychiatry are two examples where widespread adoption is beginning to occur. Other forms of realtime telemedicine represent 'niche' applications. That is, they appear to be both successful and sustainable in the centres where they were pioneered, but have not been adopted elsewhere. Teledialysis and teleoncology are examples of this type. The patchy diffusion of telemedicine is something that is not yet well understood.

We assessed the feasibility of telemedicine for home monitoring of 45 patients with chronic respiratory failure (CRF) discharged from hospital. The patients transmitted pulsed arterial saturation (pSat) data via a telephone modem to a receiving station where a nurse was available for a teleconsultation. A respiratory physician was also available. Scheduled and ad hoc appointments were conducted. Thirty-five patients were on home mechanical ventilation, 13 with invasive and 22 with non-invasive devices. The main diagnosis was chronic obstructive pulmonary disease (COPD). The follow-up period was 176 days (SD 69). In all, 376 calls for scheduled consultations were received and 83 ad hoc consultations were requested by the patients. The actions taken were: 55 therapy modifications, 19 hospitalizations in a respiratory department for decompensated CRF, three hospitalizations in an intensive care unit (ICU), 22 requests for further investigations, 25 contacts with the general practitioner (GP), 66 demands for respiratory consultations and 10 calls for the emergency department. The mean time recorded for the 459 calls was 16 min/patient/week. In 82% of calls, a pSat recording was received successfully. The nurse time required to train the users in the operation of the pSat instrument was high (mean time 30 min). However, the results showed that home monitoring was feasible, and useful for titration of oxygen, mechanical ventilation setting and stabilization of relapses.

We compared telemedicine with a conventional outpatient continence service (CS) in community-dwelling older women with urge or stress incontinence. After an initial biofeedback-assisted pelvic floor muscle training session, subjects were randomized to behavioural training for eight weeks via the CS (n = 27) or a telemedicine continence programme (TCP) (n = 31). Participants in both treatment groups experienced significant improvement in their symptoms, namely, a reduction in the number of daily incontinence episodes (P<0.001) and voiding frequency (P<0.001), while the volume of urine at each micturition increased (P<0.005). Pelvic floor muscle strength as measured by the Oxford Score also improved (P<0.005). There were no significant differences in outcomes between the two groups. Thus our findings suggest that videoconferencing is as effective as conventional methods in the management of urinary incontinence.

We developed an online system for estimating dietary nutritional content. It also had the function of assessing the accuracy of the participating dieticians and ranking their performance. People who wished to have their meal estimated (i.e. clients) submitted images of their meal taken by digital camera to the server via the Internet, and dieticians estimated the nutritional content (i.e. calorie and protein content). The system assessed the accuracy of the dieticians and if it was satisfactory, the results were sent to the client. Clients received details of the calorie and protein content of their meals within 24 h by email. A total of 93 dieticians (71 students and 22 licensed practitioners) used the system. A two-way analysis of variance showed that there was a significant variation (P=0.004) among dieticians in their ability to estimate both calorie and protein content. There was a significant difference in values of both calorie (P=0.02) and protein (P<0.001) estimation accuracy between student dieticians and licensed dieticians. The estimation accuracy of the licensed nutritionists was 85% (SD 10) for calorie content and 78% (SD 17) for protein content.

The island of Jersey is located 160 km south of Britain and 23 km from northwest France. The island has well-established primary and secondary mental health services, but tertiary services have to be purchased from UK mainland service providers. A pilot study of telepsychiatry was conducted, using videoconferencing to access tertiary mental health services from the UK. During a six-month study period, five patient consultations and six specialist presentations were carried out. The total cost of using videoconferencing to deliver tertiary mental health services not ordinarily available in Jersey was £3483.06. The costs of using the traditional model instead would have been £12,975.00. The threshold at which videoconferencing became cheaper than travel was between five and six telemedicine episodes per year; the actual workload during the pilot study was 22 episodes per year. The study suggests that telemedicine is cost-effective for providing tertiary mental health services not ordinarily available in Jersey.

We tested the feasibility of Universal Mobile Telephone System (UMTS) mobile phones for video consultations in the home. Five patients with diabetic foot ulcers were included in the study. Each of them was offered three video consultations instead of visits to the hospital outpatient clinic. The consultations took from 5 to 18 min. In all 15 consultations, the hospital experts were able to assess the ulcer in cooperation with the visiting nurse and to decide on the treatment. However, technical problems sometimes made it difficult for them. Connectivity problems occurred in seven of the 15 consultations. Also, the audio signal was rather unstable at times. In all situations except one, however, the clinicians were able to reach a decision that the expert felt confident about, and after all consultations the atmosphere and participants' attitudes were very positive.

The Alberta Telehealth Network uses a provincial scheduling system, which allows use of the network to be monitored via reporting procedures. We developed a province-wide costing model for videoconferencing in Alberta, including administrative, clinical and educational activities. In 2003, there were 212 different videoconferencing sites. During the year, 5766 videoconferencing sessions were provided and in these sessions the sites were connected to the network a total of 21,596 times. About 27% of the connections were from providing sites and about 73% of the connections were from receiving sites. On average, one site in the telehealth system was connected to another site about 100 times, and the average videoconferencing session included about 3.8 sites, varying from mainly two sites in clinical sessions to 4.2 sites in administrative sessions and 6.1 sites in educational sessions. The total cost of videoconferencing in Alberta for administrative, clinical and educational activities was about CA &dollar;5.74 million in 2003. About 52% of the annual cost was for educational sessions, 34% for administrative meetings and 14% for clinical consultations. The average cost of videoconferencing at a single site ranged from &dollar;223.48 (for providing clinical consultations) to &dollar;278.57 (for receiving educational sessions). The costing model provides information for decision-makers about the cost of videoconferencing activities and can be used in the development of a sustainable telehealth system in Alberta.

We conducted a pilot study of the feasibility of an Internet-based weight loss programme using videoconferencing to emulate face-to-face situations and a Web service to support self-monitoring. A pre–post test design was used to compare changes in bodyweight, metabolic variables and attendance rate. Nine subjects lost on average 5.9 kg (6.0% of body weight, P<0.001) over the course of the 12-week programme. Waist circumference was reduced significantly (10.2 cm, P=0.03). Total cholesterol, aspartate transferase (AST) and alanine transferase (ALT) significantly decreased. Eight participants completed a questionnaire after the intervention. Overall, responders were satisfied with the protocol and considered the Internet weight loss programme to be helpful to them. One technical problem was that Internet congestion could reduce the quality of audio and video. The Internet appears to hold promise as a medium to facilitate communication in weight loss programmes.

A 14-month-old child with a central corneal scar underwent rotational autografting of his cornea to clear his visual axis. This was accomplished through eccentric trephination and 180 degree rotation of the central cornea. A preoperative image of the patient's cornea was manipulated digitally using a common commercial image-processing software package. This allowed accurate prediction of the best trephine size and location prior to surgery. Digital imaging played an important role in preoperative surgical planning and demonstrates the potential for tele-ophthalmology.