Joseph C. Kvedar

Role for Telemedicine in Acute Stroke Feasibility and Reliability of Remote Administration of the NIH Stroke Scale

BACKGROUND AND PURPOSE Immediate access to physicians experienced in acute stroke treatment may improve clinical outcomes in patients with acute stroke. Interactive telemedicine can make stroke specialists available to assist in the evaluation of patients at multiple urban or remote rural facilities. We tested whether interrater agreement for the NIH Stroke Scale (NIHSS), a critical component of acute stroke assessment, would persist if performed over a telemedicine link. METHODS One bedside and 1 remote NIHSS score were independently obtained on each of 20 patients with ischemic stroke. The bedside examination was performed by a stroke neurologist at the patients bedside. The remote examination was performed by a second stroke neurologist through an interactive high-speed audio-video link, assisted by a nurse at the patients bedside. Kappa coefficients were calculated for concordance between bedside and remote scores. RESULTS Remote assessments took slightly longer than bedside assessments (mean 9.70 versus 6.55 minutes, P<0. 001). NIHSS scores ranged from 1 through 24. Based on weighted kappa coefficients, 4 items (orientation, motor arm, motor leg, and neglect) displayed excellent agreement, 6 items (language, dysarthria, sensation, visual fields, facial palsy, and gaze) displayed good agreement, and 2 items (commands and ataxia) displayed poor agreement. Total NIHSS scores obtained by bedside and remote methods were strongly correlated (r=0.97, P<0.001). CONCLUSIONS The NIH Stroke Scale remains a swift and reliable clinical instrument when used over interactive video. Application of this technology can bring stroke expertise to the bedside, regardless of patient location.

Connected Health: A Review Of Technologies And Strategies To Improve Patient Care With Telemedicine And Telehealth

With the advent of national health reform, millions more Americans are gaining access to a health care system that is struggling to provide high-quality care at reduced costs. The increasing adoption of electronic technologies is widely recognized as a key strategy for making health care more cost-effective. This article examines the concept of connected health as an overarching structure for telemedicine and telehealth, and it provides examples of its value to professionals as well as patients. Policy makers, academe, patient advocacy groups, and private-sector organizations need to create partnerships to rapidly test, evaluate, deploy, and pay for new care models that use telemedicine.

The Empirical Foundations of Telemedicine Interventions for Chronic Disease Management

The telemedicine intervention in chronic disease management promises to involve patients in their own care, provides continuous monitoring by their healthcare providers, identifies early symptoms, and responds promptly to exacerbations in their illnesses. This review set out to establish the evidence from the available literature on the impact of telemedicine for the management of three chronic diseases: congestive heart failure, stroke, and chronic obstructive pulmonary disease. By design, the review focuses on a limited set of representative chronic diseases because of their current and increasing importance relative to their prevalence, associated morbidity, mortality, and cost. Furthermore, these three diseases are amenable to timely interventions and secondary prevention through telemonitoring. The preponderance of evidence from studies using rigorous research methods points to beneficial results from telemonitoring in its various manifestations, albeit with a few exceptions. Generally, the benefits include reductions in use of service: hospital admissions/re-admissions, length of hospital stay, and emergency department visits typically declined. It is important that there often were reductions in mortality. Few studies reported neutral or mixed findings.

National telemedicine initiatives: essential to healthcare reform.

Contributing authors: Elizabeth A. Krupinski, Ph.D.,3 Jim Grigsby, Ph.D.,4 Joseph C. Kvedar, M.D.,5 Ronald S. Weinstein, M.D.,3 Jay H. Sanders, M.D.,6 Karen S. Rheuban, M.D.,7 Thomas S. Nesbitt, M.D.,8 Dale C. Alverson, M.D.,9 Ronald C. Merrell, M.D.,10 Jonathan D. Linkous,11 A. Stewart Ferguson, Ph.D.,12 Robert J. Waters, J.D.,13 Max E. Stachura, M.D.,14 David G. Ellis, M.D.,15 Nina M. Antoniotti, Ph.D.,16 Barbara Johnston, M.S.N.,17 Charles R. Doarn, M.B.A.,18 Peter Yellowlees, M.D.,19 Steven Normandin,20 and Joseph Tracy 21

The Role of Online Support Communities: Benefits of Expanded Social Networks to Patients With Psoriasis

OBJECTIVE To determine the demographics, usage patterns, attitudes, and experiences of online support site users. DESIGN Online survey. Patients A total of 260 subjects recruited from 5 online psoriasis support groups. MAIN OUTCOME MEASURES An exploratory analysis was performed to determine demographic and disease characteristics of online support site users. Perceived benefits were also documented. RESULTS The mean (SD) age of respondents was 40.1 (11.5) years (range, 18-75 years), most (75.7%) were white, female (60.4%), and college educated (84.3%). Key factors associated with use of online support sites included availability of resources (95.3%), convenience (94.0%), access to good advice (91.0%), and the lack of embarrassment when dealing with personal issues (90.8%). The most common activities were posting messages (65.0%) and searching for information (63.1%). Nearly half of all respondents perceived improvements in their quality of life (49.5%) and psoriasis severity (41.0%) since joining the site. Intensity of participation in online support activities was associated with improved quality of life (P = .002), but not with improvements in psoriasis severity. CONCLUSIONS Our data demonstrate that psoriasis virtual communities offer users both a valuable educational resource and a source of psychological and social support. Such benefits could be further enhanced by physician engagement within these communities.

An Internet-Based Virtual Coach to Promote Physical Activity Adherence in Overweight Adults: Randomized Controlled Trial

Background Addressing the obesity epidemic requires the development of effective, scalable interventions. Pedometers and Web-based programs are beneficial in increasing activity levels but might be enhanced by the addition of nonhuman coaching. Objectives We hypothesized that a virtual coach would increase activity levels, via step count, in overweight or obese individuals beyond the effect observed using a pedometer and website alone. Methods We recruited 70 participants with a body mass index (BMI) between 25 and 35 kg/m2 from the Boston metropolitan area. Participants were assigned to one of two study arms and asked to wear a pedometer and access a website to view step counts. Intervention participants also met with a virtual coach, an automated, animated computer agent that ran on their home computers, set goals, and provided personalized feedback. Data were collected and analyzed in 2008. The primary outcome measure was change in activity level (percentage change in step count) over the 12-week study, split into four 3-week time periods. Major secondary outcomes were change in BMI and participants’ satisfaction. Results The mean age of participants was 42 years; the majority of participants were female (59/70, 84%), white (53/70, 76%), and college educated (68/70, 97%). Of the initial 70 participants, 62 completed the study. Step counts were maintained in intervention participants but declined in controls. The percentage change in step count between those in the intervention and control arms, from the start to the end, did not reach the threshold for significance (2.9% vs –12.8% respectively, P = .07). However, repeated measures analysis showed a significant difference when comparing percentage changes in step counts between control and intervention participants over all time points (analysis of variance, P = .02). There were no significant changes in secondary outcome measures. Conclusions The virtual coach was beneficial in maintaining activity level. The long-term benefits and additional applications of this technology warrant further study. Trial Registration ClinicalTrials.gov NCT00792207; http://clinicaltrials.gov/ct2/show/NCT00792207 (Archived by WebCite at http://www.webcitation.org/63sm9mXUD)

American Telemedicine Association's practice guidelines for teledermatology

The ATA assembled a group of experts to develop practice guidelines for teledermatology. This document represents the body of work that this distinguished group assembled. It was approved by the ATA Board of Directors and is presented here in its entirety.

Isolation and characterization of a spontaneously arising long-lived line of human keratinocytes (NM1)

SummaryThe long-lived keratinocyte line, NM1, was isolated from the epidermis of a pool of foreskins obtained from apprently, normal neonates at the time of circumcision. Cultures were initiated in Dulbecco’s minimal essential medium containing 20% fetal bovine serum, 0.4 μg/ml hydrocortisone, 10−9M cholera, toxin, and 10 ng/ml epidermal growth factor using mitomycin C-treated 3T3 cells as a feeder layer. Unlike normal keratinocytes which survive for only 150 generations these cells have been in culture for more than a year and have been carried for more than 400 doublings. The cells seem to follow a pathway, of growth and differentiation that is very similar to normal keratinocytes. Cytokeratin fibrils, intercellular attachments, and cornified envelopes were observed. The keratin polypeptides isolated from the NM 1 cells were similar to those previously described in normal cultured, cells; the presence of profilaggrin and involucrin was demonstrated by sodium dodecyl sulfate electrophoresis and immunoblotting with monoclonal antibodies specific to these proteins. The NM 1 cells showed a reduced dependency on 3T3 feeder cells but did not form tumors when placed into athymic nude mice. Screening of the cells for SV40, BK, HPV 16, and HPV 18 viruses was negative. The NM1 cells showed trisomy of chromosome 8. The long-lived nature of these cells makes them a valuable model for studying growth and differentiation of kerationocytes.

Impact of Home-Based Monitoring on the Care of Patients with Congestive Heart Failure

Congestive heart failure (CHF) affects nearly 5 million people in the United States with an annual cost of

Telehealth Among US Hospitals: Several Factors, Including State Reimbursement And Licensure Policies, Influence Adoption

30 billion. Home-based telemonitoring is a therapeutic tool that may reduce costs and improve patient satisfaction. This article assesses the effectiveness of home telemonitoring in patients with class III or IV CHF recently discharged from the hospital. A cohort of patients (n=83) were provided home telemonitoring for a 2-month period following hospital discharge. Home visit frequency, patient rehospitalization rate, emergency department use, quality of life, and health care costs were compared to a similar usual care cohort (n=83). Patients in the telemonitor group transmitted their weight, blood pressure, and oxygen saturation daily to a telemonitor nurse who evaluated each patient with a follow-up telephone call. Daily home care telemonitoring reduced the frequency of home nursing visits, provided cost savings, and was associated with improved self-perceived quality of life.