Fenne Verhoeven

The Contribution of Teleconsultation and Videoconferencing to Diabetes Care: A Systematic Literature Review

Background A systematic literature review was carried out to study the benefits of teleconsultation and videoconferencing on the multifaceted process of diabetes care. Previous reviews focused primarily on usability of technology and considered mainly one-sided interventions. Objective The objective was to determine the benefits and deficiencies of teleconsultation and videoconferencing regarding clinical, behavioral, and care coordination outcomes of diabetes care. Methods Electronic databases (Medline, PiCarta, PsycINFO, ScienceDirect, Telemedicine Information Exchange, ISI Web of Science, Google Scholar) were searched for relevant publications. The contribution to diabetes care was examined for clinical outcomes (eg, HbA1c, blood pressure, quality of life), behavioral outcomes (patient-caregiver interaction, self-care), and care coordination outcomes (usability of technology, cost-effectiveness, transparency of guidelines, equity of care access). Randomized controlled trials (RCTs) with HbA1c as an outcome were pooled using standard meta-analytical methods. Results Of 852 publications identified, 39 met the inclusion criteria for electronic communication between (groups of) caregivers and patients with type 1, type 2, or gestational diabetes. Studies that evaluated teleconsultation or videoconferencing not particularly aimed at diabetes were excluded, as were those that described interventions aimed solely at clinical improvements (eg, HbA1c). There were 22 interventions related to teleconsultation, 13 to videoconferencing, and 4 to combined teleconsultation and videoconferencing. The heterogeneous nature of the identified videoconferencing studies did not permit a formal meta-analysis. Pooled results from the six RCTs of the identified teleconsultation studies did not show a significant reduction in HbA1c (0.03%, 95% CI = - 0.31% to 0.24%) compared to usual care. There was no significant statistical heterogeneity among the pooled RCTs (χ 2 7= 7.99, P = .33). It can be concluded that in the period under review (1994-2006) 39 studies had a scope broader than clinical outcomes and involved interventions allowing patient-caregiver interaction. Most of the reported improvements concerned satisfaction with technology (26/39 studies), improved metabolic control (21/39), and cost reductions (16/39). Improvements in quality of life (6/39 studies), transparency (5/39), and better access to care (4/39) were hardly observed. Teleconsultation programs involving daily monitoring of clinical data, education, and personal feedback proved to be most successful in realizing behavioral change and reducing costs. The benefits of videoconferencing were mainly related to its effects on socioeconomic factors such as education and cost reduction, but also on monitoring disease. Additionally, videoconferencing seemed to maintain quality of care while producing cost savings. Conclusions The selected studies suggest that both teleconsultation and videoconferencing are practical, cost-effective, and reliable ways of delivering a worthwhile health care service to diabetics. However, the diversity in study design and reported findings makes a strong conclusion premature. To further the contribution of technology to diabetes care, interactive systems should be developed that integrate monitoring and personalized feedback functions.

Asynchronous and Synchronous Teleconsultation for Diabetes Care: A Systematic Literature Review

Aim: A systematic literature review, covering publications from 1994 to 2009, was carried out to determine the effects of teleconsultation regarding clinical, behavioral, and care coordination outcomes of diabetes care compared to usual care. Two types of teleconsultation were distinguished: (1) asynchronous teleconsultation for monitoring and delivering feedback via email and cell phone, automated messaging systems, or other equipment without face-to-face contact; and (2) synchronous teleconsultation that involves real-time, face-to-face contact (image and voice) via videoconferencing equipment (television, digital camera, webcam, videophone, etc.) to connect caregivers and one or more patients simultaneously, e.g., for the purpose of education. Methods: Electronic databases were searched for relevant publications about asynchronous and synchronous teleconsultation [Medline, Picarta, Psychinfo, ScienceDirect, Telemedicine Information Exchange, Institute for Scientific Information Web of Science, Google Scholar]. Reference lists of identified publications were hand searched. The contribution to diabetes care was examined for clinical outcomes [e.g., hemoglobin A1c (HbA1c), dietary values, blood pressure, quality of life], for behavioral outcomes (patient–caregiver interaction, self-care), and for care coordination outcomes (usability of technology, cost-effectiveness, transparency of guidelines, equity of access to care). Randomized controlled trials with HbA1c as an outcome were pooled using standard meta-analytical methods. Results: Of 2060 publications identified, 90 met inclusion criteria for electronic communication between (groups of) caregivers and patients with type 1 and 2 or gestational diabetes. Studies that evaluated teleconsultation not particularly aimed at diabetes were excluded, as were those that described interventions aimed solely at clinical improvements (e.g., HbA1c or lipid profiles). In 63 of 90 interventions, the interaction had an asynchronous teleconsultation character, in 18 cases interaction was synchronously (videoconferencing), and 9 involved a combination of synchronous with asynchronous interaction. Most of the reported improvements concerned clinical values (n = 49), self-care (n = 46), and satisfaction with technology (n = 43). A minority of studies demonstrated improvements in patient–caregiver interactions (n = 28) and cost reductions (n = 27). Only a few studies reported enhanced quality of life (n = 12), transparency of health care (n = 7), and improved equity in care delivery (n = 4). Asynchronous and synchronous applications appeared to differ in the type of contribution they made to diabetes care compared to usual care: Asynchronous applications were more successful in improving clinical values and self-care, whereas synchronous applications led to relatively high usability of technology and cost reduction in terms of lower travel costs for both patients and care providers and reduced unscheduled visits compared to usual care. The combined applications (n = 9) scored best according to quality of life (22.2%). No differences between synchronous and asynchronous teleconsultation could be observed regarding the positive effect of technology on the quality of patient–provider interaction. Both types of applications resulted in intensified contact and increased frequency of transmission of clinical values with respect to usual care. Fifteen of the studies contained HbA1c data that permitted pooling. There was significant statistical heterogeneity among the pooled randomized controlled trials (χ2 = 96.46, P < 0.001). The pooled reduction in HbA1c was not statically significant (weighted mean difference −0.10; 95% confidence interval −0.39 to 0.18). Conclusion: The included studies suggest that both synchronous and asynchronous teleconsultations for diabetes care are feasible, cost-effective, and reliable. However, it should be noted that many of the included studies showed no significant differences between control (usual care) and intervention groups. This might be due to the diversity and lack of quality in study designs (e.g., inaccurate or incompletely reported sample size calculations). Future research needs quasi-experimental study designs and a holistic approach that focuses on multilevel determinants (clinical, behavioral, and care coordination) to promote self-care and proactive collaborations between health care professionals and patients to manage diabetes care. Also, a participatory design approach is needed in which target users are involved in the development of cost-effective and personalized interventions. Currently, too often technology is developed within the scope of the existing structures of the health care system. Including patients as part of the design team stimulates and enables designers to think differently, unconventionally, or from a new perspective, leading to applications that are better tailored to patients needs.

Factors affecting health care workers’ adoption of a website with infection control guidelines

GOALnTo identify factors that could affect health care workers (HCWs) adoption of a website for communicating infection control guidelines.nnnMETHODSnIn total, 20 semi-structured interviews were conducted with HCWs in 5 different occupational groups and 4 different hospitals in the Netherlands and Germany. A website communicating guidelines for the prevention and control of Methicillin Resistant Staphylococcus aureus served as a casus. The HCWs, the majority of whom had prior experience with the website, were asked to give their opinions about factors that hinder or facilitate adoption of the website in practice. The interviews were based on the PRECEDE (Predisposing, Reinforcing, and Enabling Causes in Educational Diagnosis and Evaluation) model complemented by quality criteria for health-related websites. This model encompasses different categories of factors relevant to technology adoption in health care.nnnRESULTSnA total of 361 interview statements were relevant to the four main categories of the PRECEDE model, yielding the following observations: (1) Technological factors (72 statements): The usability, design, and relevance of the website were positively valued. The website enabled HCWs to access contextually relevant information quickly. The websites credibility was evaluated rather negatively, as respondents perceived that the websites guidelines were not in concurrence with the best available evidence and it was not clear to HCWs who created the website. (2) Individual factors (85 statements): Respondents, particular infection control professionals, showed individual resistance to the website because they preferred to use their personal knowledge and experience (and communication with colleagues) over online sources. (3) Work-related factors (53 statements): Respondents perceived high work pressure during working hours as an impediment to consulting the website. In contrast, respondents thought the website might lower work pressure for infection control professionals, as they will receive fewer questions from HCWs. (4) Organizational factors (131 statements): Interpersonal (face-to-face) communication between HCWs from different occupational groups in both a formal (training) and informal (feedback) manner was seen as the most stimulating factor behind website use. The respondents identified infection control nurses as the most important opinion leaders.nnnCONCLUSIONnFactors from multiple categories determine HCWs adoption of web-based guidelines, but the organization appeared to be a paramount reinforcer of initiation and maintenance of technology adoption among HCWs. In order eliminate resistance and create ownership among HCWs toward the website, leading to a willingness to integrate the website into routine care, it is essential to more actively involve HCWs in the early phases of the design process.

From expert-driven to user-oriented communication of infection control guidelines

Currently, infection control guidelines in hospitals and other health care institutions are more expert-driven than user-oriented. In order to enhance the usability of the expert-driven guideline format, we developed a website for the communication of existing guidelines that better fit the practical information needs of health care workers (HCWs). We employed a user-centered design process that involved two studies. In the initial study, 28 HCWs were asked to solve tasks using existing, paper-based infection control guidelines. In order to detect their strategies and problems, the participants were asked to think aloud. Usability problems occurred due to poorly structured information, insufficient quality of information, and a mismatch between experts and HCWs vocabulary. To overcome these shortcomings, three design principles were applied for communicating infection control guidelines: better navigation (the guidelines should be searchable in several ways); multimodality (the guidelines should not be presented as text only), and action-orientation (the guidelines should be presented as HCWs behaviors). A website was developed to meet these principles. In the second study, the same 28 HCWs completed tasks identical to those of the first study while thinking aloud, but this time using the website. The percentage of correctly completed tasks increased and the mean time for task completion decreased significantly. Also, respondents were more satisfied with the website than the paper-based guidelines. The number of problems due to poor information quality and a mismatch in vocabulary declined, although the number of structural problems increased. This can probably be explained by the fact that the navigation structure was user-generated (using Card Sort), in contrast to a standardized answer format based on common usability principles. Overall, we found that involving HCWs in the development process is important to create a sense of ownership and to foster the implementation of the guidelines, which might eventually result in compliance and reduce health care-associated infections. This paper outlines concrete steps for how to involve HCWs in the design process.

How nurses seek and evaluate clinical guidelines on the Internet

AIMnThis paper is a report of a study conducted to assess nurses information-seeking strategies and problems encountered when seeking clinical guidelines on the Internet, and to investigate the criteria they apply when evaluating the guidelines and the websites communicating the guidelines.nnnBACKGROUNDnAs nurses are increasingly taking on clinical responsibilities, they should be able to use the Internet to access up-to-date clinical guidelines. Currently, nurses information-seeking skills remain rather limited.nnnMETHODnIn 2008, a convenience sample of 20 nurses solved scenario-based tasks using the Internet to seek clinical guidelines regarding methicillin-resistant Staphylococcus aureus while thinking aloud.nnnRESULTSnGeneral background information and universal precautions were successfully identified by participants, in contrast to more specific precautions. Nurses information-seeking skills appeared rather basic, as they employed a limited number of search terms and consulted a limited number of websites. Ineffective searches were mainly caused by a mismatch between the guidelines and nurses tacit knowledge. Perceived practical relevance and information completeness were the most frequently applied quality criteria. Accuracy and disclosures, which are emphasized in existing e-health literature, were considered less important. As long as information matched nurses practical and experiential wisdom, they were satisfied.nnnCONCLUSIONnNurses appeared to rely predominantly on tacit knowledge during the search process and while evaluating the retrieved guidelines. This is dangerous because nurses reliance on inaccurate information might result in inadequate behaviour. It is therefore essential to expand nurses current information base by tailoring both navigation structure and the guideline communication to dovetail with nurses tacit knowledge.

Discount user-centered e-health design: a quick-but-not-dirty method

The philosophy of discount usability engineering perfectly fits the health care setting, where cost-cutting is ubiquitously present. We adapted Nielsens discount usability approach for the health care setting by combining traditional thinking aloud (n=18) and Card Sorting (n=18) with online prototyping (n=5) and simplified thinking aloud (n=5). We used the approach to design an efficient and effective website with infection control guidelines for nursing home staff leading to high levels of satisfaction within a time frame of three months for the total cost of €7195. Based on our experiences, we would advocate using this discount user-centered approach for the design of e-health applications. Future research should concentrate on integrating the principles of creative co-design methods and online research into the discount usability approach.

The Development of a Web-Based Tool for Compliance with Safe Work Practices; a Case Study about Methicillin-Resistant Staphylococcus aureus

This paper describes the design process of a web-based tool for compliance with safe work practices in cross-border care settings, focusing on infection control of Methicillin-resistant Staphylococcus aureus. The tool should facilitate health care workers (HCWs) with applicable evidence-based guidelines and best-practices that enhance the decision making process and enable them to deliver safe health care. A user-centered design approach was used comprising five different methods: Document analysis; scenario testing; survey; Card Sort Task, and prototyping. The approach provided insights in HCWs thinking and acting in practice which helped to fully adapt the tool to HCWs needs. Moreover, it was found that involving HCWs is important to create ownership and to foster the applicability of the tool, even as to ensure that the tool’s content is in accordance with existing guidelines.