Eileen Brebner

Experience-based guidelines for the implementation of telemedicine services.

Many telemedicine projects fail to survive beyond the funded research phase. A review of seven Scottish telemedicine services was conducted to identify successes and failures. Qualitative interviews were conducted with key individuals in each project. All projects were partly successful. The main reasons associated with partial failure were: the service was not needs-driven; there was no commitment to provide the service; there was no suitable exit strategy after research funding expired; there was poor communication; there was a lack of training; there were technical problems; work practices were not updated; the protocols for use were poor or non-existent. Based on this, guidelines that might improve the chances of success in future projects were drawn up.

Evaluation of an accident and emergency teleconsultation service for north-east Scotland

We evaluated an accident and emergency teleconsultation service provided to 14 community hospitals in north-east Scotland. Each community hospital was equipped with a videoconferencing system and a document camera to allow transmission of radiographs. The network used 384 kbit/s ISDN connections. A total of 1392 teleconsultations were recorded during a 12-month study period. Seventy-seven per cent of patients (n = 1072) were managed locally and 23% (n = 320) were transferred to Aberdeen. The majority (95%) of teleconsultations were conducted on weekdays, and 90% of these occurred between the hours of 09:00 and 16:00. The mean delay in contacting a doctor was 9 min and the mean consultation time was 10 min. The majority of patients were suffering from fractures or suspected fractures of the limbs. Radiograph transmission was used in 75% of all teleconsultations. A high degree of satisfaction was recorded by all users of the service.

Accident and emergency teleconsultation for primary care - a systematic review of technical feasibility, clinical effectiveness, cost effectiveness and level of local management:

A systematic review of accident and emergency teleconsultation services was carried out. Studies (English language only) conducted worldwide and published between 1996 and 2003 were included. Evidence relating to technical feasibility, clinical effectiveness, cost effectiveness and level of local management was used as the main outcome measure. Thirty-one studies met the selection criteria. Only two studies were randomized controlled studies. All studies provided evidence that that the service was technically feasible. Of the studies, 97% suggested that the service was clinically effective; 48% (15) of the studies gave figures for the level of local management achieved. The range for local management was 35–100% with a mean of 76%. Only 23% of the studies provided evidence to suggest that the service was cost effective. The case for cost-effectiveness is far from proven and this area of research requires immediate attention if potential users are to be convinced of the value of telemedicine.

Evaluation of a Pilot Telemedicine Network for Accident and Emergency Work

A pilot accident and emergency teleconsulting service was established in Scotland. It was based at the accident and emergency department of the main hospital in Aberdeen. There were three peripheral sites in rural Grampian (Peterhead, Turriff and Huntly) and one in the Shetland Isles. The videoconferencing equipment used was connected by ISDN at 384 kbit/s. During the 15 months of the study, 1998 videoconference calls were made, of which 402 (20%) calls were made to the accident and emergency department for clinical consultations. The majority of the clinical calls (95%) were made between 09:00 and 17:00, and more than 90% were completed within 20 min. During the majority of calls (87%) one or more X-ray images were transmitted. The majority of patients (89%) received treatment without transportation to the main centre in Aberdeen. The present study demonstrated that accident and emergency teleconsultations can be technically reliable, effective in reducing the number of patient transfers and acceptable to the referring clinicians. As a result, approximately 1.5 million has been made available by the government to develop a national system for Scotland.

The diagnostic acceptability of lowbandwidth transmission for tele-ultrasound

Ultrasound recordings were made of 100 consecutive patients attending for obstetric examination in Peterhead and 100 patients attending for non-obstetric examination in Aberdeen. Two identical videoconferencing machines were used to transmit and receive the original ultrasound images at data rates of 384 kbit/s and 128 kbit/s, thus producing a total of three tapes for each case. Four experienced observers, who were blinded to the transmission bandwidth, each viewed 300 examinations and decided whether the images were acceptable or not for diagnosis. Almost 100% of the obstetric ultrasound images on the original recordings were considered diagnostically acceptable, compared with 93% of the 384 kbit/s transmissions and 44% of the 128 kbit/s transmissions. Similarly, 99% of the non-obstetric ultrasound images were considered acceptable, compared with 87% of the 384 kbit/s transmissions and 21% of the 128 kbit/s transmissions. For the obstetric ultrasound images the intra-observer diagnostic agreement was 93% (κ = 0.89) between the original and the 384 kbit/s transmissions, and 78% (κ = 0.63) between the original and the 128 kbit/s transmissions. For the non-obstetric ultrasound images the respective intra-observer diagnostic agreements were 77% (κ = 0.62) and 78% (κ = 0.63). The quality of dynamic ultrasound images transmitted at 384 kbit/s was diagnostically acceptable, but was unsatisfactory at 128 kbit/s.

A pilot study in medical education using interactive television

Medical students in the United Arab Emirates do not receive postmortem teaching. This is because postmortems are not normally carried out, for cultural reasons. In order to address this problem a collaborative project was established between the medical schools of Aberdeen University and the United Arab Emirates University to evaluate the feasibility, acceptability and effectiveness of telepathology teaching. A videoconferencing link was established between the UK and the Middle East using ISDN at a transmission speed of 384 kbit/s. Although some technical problems relating to line continuity were encountered, the results relating to feasibility, acceptability and effectiveness were very positive. Although expensive, this form of teaching may still be cost-effective in relation to the benefits.

Intercontinental postmortem studies using interactive television.

For cultural reasons, medical students in the United Arab Emirates UAE are not offered postmortem studies. In a collaborative project between the medical schools of Aberdeen University and the UAE University the feasibility, acceptability and effectiveness of telepathology teaching were evaluated. The transmission of postmortem video images at a quality high enough for teaching purposes was achieved at a data transmission speed of 384 kbit s. Videoconferencing as a method of presentation was viewed by the students as both interesting and useful. All students participating in the telepathology teaching sessions exceeded the minimum acceptable score of 60 in a multiple-choice examination. Although international videoconferencing at 384 kbit s is expensive, the costs involved in the telepathology project were small in relation to the educational benefits.

Low-bandwidth tele-ultrasound

We examined the acceptability and diagnostic accuracy of dynamic ultrasound images transmitted at 128 kbit/s and 384 kbit/s. The gold standard was the direct recording of 200 ultrasound examinations on video-tape. The taped images were later transmitted at both 128 kbit/s and 384 kbit/s and recorded, resulting in three tapes for each case. Four observers viewed each tape individually. Ninety per cent of images transmitted at 384 kbit/s were rated as diagnostically acceptable compared with 32% of images transmitted at 128 kbit/s. Diagnostic agreement between tapes transmitted at 384 kbit/s and the gold standard was 85%, compared with 78% for 128 kbit/s transmissions. Observers were not satisfied with low-bandwidth transmission of ultrasound images despite adequate diagnostic accuracy. Dynamic ultrasound images transmitted at 384 kbit/s were viewed as both diagnostically acceptable and accurate.

Video-hypnosis--the provision of specialized therapy via videoconferencing.

Hypnosis is not normally accessible to patients living in remote areas. We conducted a pilot study to evaluate the feasibility of providing hypnosis via videoconferencing, using ISDN at 384 kbit/s. Eleven of 15 patients invited to do so took part. Ten of the 11 stated that they were satisfied with the video-hypnosis session and all indicated that they would like to have further video-hypnosis sessions in the future. Sound quality and image quality were acceptable during nearly all sessions, in spite of some interference as a result of technical problems and weather conditions. The results suggest that hypnosis can be provided successfully via videoconferencing.

Tele-ultrasound for remote areas.

Summary We studied the introduction of a telemedicine service for the prenatal diagnosis and management of pregnant patients at a remote site in Scotland. During a 10-month study period, 85 videoconferences were carried out between the remote hospital in Elgin and the fetal medicine unit in Aberdeen. ISDN transmission at 384 kbit/s was used. There were technical problems in five calls (6%). The mean call duration was 40 min (range 5-60 min). Most calls (62%) were for educational reasons and 26% were for clinical purposes. The degree of satisfaction recorded by the remote health-care staff was high: the mean score on a five-point scale (1, very unsatisfied; 5, very satisfied) for general satisfaction with the clinical support was 4.2. The system was found to be both clinically useful and educationally beneficial.