Telemedicine and e-Health

Background: The integration of telecommunications and information systems in healthcare is not new or novel; indeed, it is the current practice of medicine and has been an integral part of medicine in remote locations for several decades. The U.S. Government has made a significant investment, measured in hundreds of millions of dollars, and therefore has a strong presence in the integration of telehealth/telemedicine in healthcare. However, the terminologies and definitions in the lexicon vary across agencies and departments of the U.S. Government. The objective of our survey was to identify and evaluate the definitions of telehealth/telemedicine across the U.S. Government to provide a better understanding of what each agency or department means when it uses these terms. Methodology: The U.S. Government, under the leadership of the Health Resources and Services Administration in the U.S. Department of Health and Human Services, established the Federal Telemedicine (FedTel) Working Group, through which all members responded to a survey on each agency or department's definition and use of terms associated with telehealth. Results and Conclusions: Twenty-six agencies represented by more than 100 individuals participating in the FedTel Working Group identified seven unique definitions of telehealth in current use across the U.S. Government. Although many definitions are similar, there are nuanced differences that reflect each organization's legislative intent and the population they serve. These definitions affect how telemedicine has been or is being applied across the healthcare landscape, reflecting the U.S. Government's widespread and influential role in healthcare access and service delivery. The evidence base suggests that a common nomenclature for defining telemedicine may benefit efforts to advance the use of this technology to address the changing nature of healthcare and new demands for services expected as a result of health reform.

Introduction: Cognitive behavioral therapy (CBT) for child anxiety, although efficacious, typically requires 16–20 weekly sessions with a therapist. Brief CBT (BCBT; eight sessions) for child anxiety is promising but may have less favorable outcomes owing to reduced session time. Mobile health (m-health) has the potential to improve BCBT efficacy by delivering ecological momentary intervention to engage youth in learning and practicing CBT skills in their everyday lives (in vivo). Materials and Methods: We developed an m-health platform entitled SmartCAT (Smartphone-enhanced Child Anxiety Treatment). SmartCAT consists of (1) a smartphone application (app) that cues youth to use the CBT skills taught in sessions, (2) an online portal that allows therapists to monitor skill use, to send cues and treatment-related materials, to engage youth in real-time via secure messages, and to manage rewards, and (3) a communication protocol that allows real-time bidirectional exchange between the app and the portal. A pilot study with nine youth (9–14 years old) examined the platform's feasibility as an adjunct to BCBT. Results: SmartCAT was found to be capable of supporting BCBT for child anxiety and received positive feedback from both therapists and youth patients. Patients rated the app as highly usable (mean=1.7 on a 1–7 scale, with 1=“easy”). Patients completed 5.36 skills coach entries per session (standard deviation=1.95) and took an average of 3.14 min (standard deviation=0.98 min) to complete the entries. Conclusions: A smartphone app is feasible within CBT for child anxiety. Users found SmartCAT both acceptable and easy to use. Integrating an m-health platform within BCBT for anxious children may facilitate involvement in treatment and dissemination of effective procedures.

Objective: Remote monitoring technology (RMT) may enhance healthcare quality and reduce costs. RMT adoption depends on perceptions of the end-user (e.g., patients, caregivers, healthcare providers). We conducted a systematic review exploring the acceptability and feasibility of RMT use in routine adult patient care, from the perspectives of primary care clinicians, administrators, and clinic staff. Materials and Methods: We searched the databases of Medline, IEEE Xplore, and Compendex for original articles published from January 1996 through February 2013. We manually screened bibliographies of pertinent studies and consulted experts to identify English-language studies meeting our inclusion criteria. Results: Of 939 citations identified, 15 studies reported in 16 publications met inclusion criteria. Studies were heterogeneous by country, type of RMT used, patient and provider characteristics, and method of implementation and evaluation. Clinicians, staff, and administrators generally held positive views about RMTs. Concerns emerged regarding clinical relevance of RMT data, changing clinical roles and patterns of care (e.g., reduced quality of care from fewer patient visits, overtreatment), insufficient staffing or time to monitor and discuss RMT data, data incompatibility with a clinic's electronic health record (EHR), and unclear legal liability regarding response protocols. Conclusions: This small body of heterogeneous literature suggests that for RMTs to be adopted in primary care, researchers and developers must ensure clinical relevance, support adequate infrastructure, streamline data transmission into EHR systems, attend to changing care patterns and professional roles, and clarify response protocols. There is a critical need to engage end-users in the development and implementation of RMT.

Background: To compare access time and cycle time between an “in-house” teleglaucoma program and in-person glaucoma consultation. Patients and Methods: This was a prospective comparative study of 71 patients seen through the teleglaucoma program (eligible patients were glaucoma suspects or early-stage open-angle glaucoma) and 63 patients seen via a traditional in-person exam with a physician present. Access time was calculated as the time from the patient being referred to the date of a booked visit for either a teleglaucoma or in-person exam. Cycle time was defined as the time from registration until departure during the visit to the hospital; it was calculated for the subset of patients from each study group who completed activity logs on the day of their visit. Results: The mean access time was significantly shorter for patients seen through teleglaucoma compared with in-person exam: 45±22 days (range, 13–121 days) (n=68) versus 88±47 days (range, 27–214 days) (n=63), respectively (p<0.0001). The cycle time was also reduced for patients seen through teleglaucoma, compared with in-person assessment: 78±20 min (range, 40–130 min) (n=39) versus 115±44 min (range, 51–216 min) (n=39), respectively (p<0.001). The mean percentage time spent in the waiting room was also significantly reduced for patients seen through teleglaucoma versus in-person assessments: 19±13% versus 41±24% (n=39), respectively (p<0.01). Conclusions: Teleglaucoma improves access to care and is a more efficient way of managing glaucoma suspects and patients with early-stage glaucoma compared with in-person assessment.

Background: Telemedicine holds great potential to improve access to care and to reduce barriers to treatment for military populations with posttraumatic stress disorder (PTSD). This study sought to integrate the use of telemedicine mental health treatment services by a community healthcare provider to military populations residing in a rural location and to compare the equivalency of cognitive behavioral therapy (CBT) administered via telemedicine and traditional face-to-face therapy. Subjects and Methods: Study subjects were men or women 18 years of age or older who had served in Operation Enduring Freedom (OEF) and/or Operation Iraqi Freedom (OIF) and were diagnosed with PTSD. The 18 study subjects were randomized and provided 10 weekly therapy sessions of CBT. Pre- and post-intervention assessments were conducted using the Clinician Administered PTSD Scale (CAPS), Hamilton Anxiety Rating Scale (HAM-A), Montgomery-Asberg Depression Rating Scale (MADRS), Life Events Checklist, and SF-36v2^® (QualityMetric, Lincoln, RI) Health Survey. Results: The CAPS, HAM-A, and MADRS each demonstrated lower scores, signifying improvement, and 69% of subjects experienced a clinically significant change in the CAPS. Patient satisfaction results indicated greater satisfaction for telemedicine as opposed to traditional face-to-face treatment. Conclusions: Findings reveal a trend expressing the equivalence of telemedicine and face-to-face therapy when treating OEF/OIF veterans with PTSD among rural populations by a community provider. It further demonstrates the successful collaboration between a community healthcare provider and the military healthcare system.

Background: The Kinect™ (Microsoft™, Redmond, WA) sensor, originally developed for gaming purposes, may have interesting possibilities for other fields such as posture and motion assessment. The ability of the Kinect sensor to perform biomechanical measurements has previously been studied and shows promising results. However, interday repeatability of the device is still not known. Materials and Methods: This study assessed the intra- and interday repeatability of the Kinect sensor compared with a standard stereophotogrammetric device during posture assessment for measuring segment lengths. Forty subjects took part in the study. Five motionless captures were performed in one session to assess posture. Data were simultaneously recorded with both devices. Results: Similar intraclass correlations coefficient (ICC) values were found for intraday (ICC=0.94 for the Kinect device and 0.98 for the stereophotogrammetric device) and interday (ICC=0.88 and 0.87, respectively) repeatability. Conclusions: Results of this study suggest that a cost-effective, easy-to-use, and portable single markerless camera offers the same repeatability during posture assessment as an expensive, time-consuming, and nontransportable marker-based device.

Objective: The primary goal of this study was to examine which characteristics differentiated patients who highly engaged with a computerized recovery support program after alcohol/drug treatment from those who did not engage with the program. Materials and Methods: The program delivered individually tailored clinical content in a multimedia format over 18 months following residential treatment. A key component of the program was access to a recovery coach, a licensed drug and alcohol counselor. Posttreatment logins to the program, the amount of clinical content accessed, and the number of recovery coach contacts were measured. Results: Several factors were found to predict program engagement, including several demographic variables, the number of recovery coach contacts, motivation to be in recovery, and attendance at 12-step groups. Conclusions: These findings, combined with others in the literature, suggest that low engagement with computerized health programs is a widespread problem. Because many of these programs show therapeutic promise, future studies should continue to increase understanding of factors associated with high engagement so that efforts to increase engagement may be applied more effectively.

Objective: To construct a clinical decision support system (CDSS) for undergoing surgery based on domain ontology and rules reasoning in the setting of hospitalized diabetic patients. Materials and Methods: The ontology was created with a modified ontology development method, including specification and conceptualization, formalization, implementation, and evaluation and maintenance. The Protégé–Web Ontology Language editor was used to implement the ontology. Embedded clinical knowledge was elicited to complement the domain ontology with formal concept analysis. The decision rules were translated into JENA format, which JENA can use to infer recommendations based on patient clinical situations. Results: The ontology includes 31 classes and 13 properties, plus 38 JENA rules that were built to generate recommendations. The evaluation studies confirmed the correctness of the ontology, acceptance of recommendations, satisfaction with the system, and usefulness of the ontology for glycemic management of diabetic patients undergoing surgery, especially for domain experts. Conclusions: The contribution of this research is to set up an evidence-based hybrid ontology and an evaluation method for CDSS. The system can help clinicians to achieve inpatient glycemic control in diabetic patients undergoing surgery while avoiding hypoglycemia.

Background: Delivery of specialty healthcare to rural citizens in the United States remains largely unmet. The Veterans Health Administration is in a unique position to deliver specialty care to rural Veterans because it is mandated to deliver medical care to all eligible Veterans regardless of residence. To accomplish this, the VHA developed large national telehealth networks that provided over 1 million episodes of care in 2012. We investigated whether clinical video telehealth technologies can provide quality efficient neurologic follow-up care to Veterans living in the rural southwest United States. Patients and Methods: Veterans with chronic neurologic conditions living remotely in New Mexico, southern Colorado, eastern Arizona, and western Texas were offered follow-up teleneurology care at 11 rural community-based outpatient clinics following initial evaluation at the Albuquerque, NM, neurology outpatient clinic. Results: Over a 2-year period, 87% of 354 consecutive patients returned a performance improvement satisfaction questionnaire. Ninety percent of the patients were fully satisfied with their visit, and 92% felt teleneurology saved them time and money. We calculated an average time savings of 5 h and 325 miles driven, plus at least $48,000 total cost savings. Ninety-five percent reported they wanted to continue their neurologic care by teleneurology. Conclusions: Our study confirms earlier pilot studies of successful follow-up care through telemedicine. Our patients were highly satisfied with the convenience and quality of their teleneurology visit, and the neurology providers were convinced that neurologic care to both teleneurology and clinic follow-up patients was equivalent. Teleneurology to rural Veterans can provide quality neurologic care and overwhelming patient satisfaction and save considerable time and money.

Background: In 2000, Manitoba began utilizing telehealth services for the assessment, diagnosis and follow-up of fetal alcohol spectrum disorders (FASDs). Since that time, the use of telehealth in Manitoba has expanded to the delivery of education and support to families caring for children with FASD in rural and remote areas of the province. The purpose of this study was to expand on a previous evaluation through a focus on the participant experience. Our objectives were thus to explore the experience of families with the telehealth process and to examine the use of telehealth in diagnostic assessment as well as follow-up post-clinical assessment. Materials and Methods: Sixteen semistructured interviews were conducted with families who had participated in at least one diagnostic assessment and/or individual or group follow-up via telehealth offered through the Manitoba FASD Centre. Results: The majority of participants reported being happy with their experience(s) using telehealth for assessment, diagnosis, and/or follow-up support. Two general themes emerged from the data. The first theme is focused on the value of telehealth use for families with children living with FASD, whereas the second theme presents various needs of this client group. Conclusions: This study provides support for the use of telehealth as an effective technology beyond diagnosis for individuals with FASD and their families. Families support the utilization of this technology and, despite its minor shortcomings, appreciate the flexibility of telehealth, which allows them to remain in their home communities, connected to their families and support systems.

Introduction: Telemedicine has been utilized in various healthcare areas to achieve better patient outcomes, lower costs of providing services, and increase patient access to care. Tele-intensive care unit (ICU) technology has been introduced as a way to provide effective ICU services to patients with reduced access, as well as to decrease costs and improve patient care. Materials and Methods: The methodology for this qualitative study was a literature search and review of case studies. The search was limited to sources published in the last 10 years (2003–2013) in the English language. In total, 55 references were used for this research exploration inquiry. Results: Tele-ICU was found to be an effective way to use technology to decrease costs of providing intensive care, while improving patient outcomes such as mortality and length of stay. Several case studies supported the use of telemedicine in ICUs to provide intensive care to patients who lived in rural areas and lacked access to traditional ICUs. Furthermore, it was noted that, although the initial costs for tele-ICU startup were significant, as much as $100,000 per bed, the benefits of the utilization of this technology can offset those costs by reducing costs by 24% via decreased length of stay for patients. Conclusions: The findings of this study have suggested that the implementation of tele-ICU may have been more beneficial than costly, and it may have provided healthcare organizations the opportunity to increase quality of care and decrease mortality, while it might have decreased costs of delivering ICU services in both rural and urban areas.

Medical surveillance data from all government health clinics in Vietnam are currently collected through a slow, paper-driven process. Short message service (SMS) technology delivered through mobile phones offers a simple solution to improving the speed through which disease surveillance information can be collected. Identifying health concerns earlier with this mobile-based disease surveillance system has the potential to improve the care for patients seen at community health clinics as well as predict more quickly that a medical emergency, such as a pandemic, will occur. Thus, we piloted the feasibility of an SMS-based disease surveillance system designed for healthcare workers in Vietnam to directly report disease information on diarrhea and influenza-like illness to a central data repository using their mobile phones and an intuitive, user-friendly platform. This article reports data from 1,579 patient data entries in 20 Vietnamese health clinics during a 6-month period.

Background: Australians in rural and remote areas live with far poorer health outcomes than those in urban areas. Telehealth services have emerged as a promising solution to narrow this health gap, as they improve the level and diversity of health services delivery to rural and remote Australian communities. Although the benefits of telehealth services are well studied and understood, the uptake has been very slow. Materials and Methods: To understand the underpinning issues, we conducted a literature review on barriers to telehealth adoption in rural and remote Australian communities, based on the published works of Australian clinical trials and studies. Results: This article presents our findings using a comprehensive barrier matrix. This matrix is composed of four stakeholders (governments, technology developers and providers, health professionals, and patients) and five different categorizations of barriers (regulatory, financial, cultural, technological, and workforce). We explain each cell of the matrix (four stakeholders×five categories) and map the reported work into the matrix. Conclusions: Several exemplary barrier cases are also described to give more insights into the complexity and dilemma of adopting telehealth services. Finally, we outline recent technological advancements that have a great potential to overcome some of the identified barriers.