Monika Alise Johansen

An economic analysis of screening for diabetic retinopathy.

The costs of telemedicine screening for diabetic retinopathy were examined in a trial conducted in northern Norway, involving the University Hospital of Tromsø (UHT) and the primary care centre in Alta, approximately 400 km away. In Alta, specially trained nurses examined 42 diabetic patients using a digital camera to obtain images of the retina. The images were then sent by email to an eye specialist at the UHT. A cost-minimization analysis showed that at low workloads, for example 20 patients per annum, telemedicine was more expensive than conventional examination: NKr8555 versus NKr428 per patient. However, at higher workloads, telemedicine was cheaper. For example, at 200 patients per annum, telemedicine cost NKr971 and conventional examination cost NKr1440 per patient. The break-even point occurred at a patient workload of 110 per annum. Given that there are some 250 diabetic patients in Alta, telemedicine screening is the cheaper service for the public sector.

Electronic Symptom Reporting Between Patient and Provider for Improved Health Care Service Quality: A Systematic Review of Randomized Controlled Trials. Part 1: State of the Art

Background Over the last two decades, the number of studies on electronic symptom reporting has increased greatly. However, the field is very heterogeneous: the choices of patient groups, health service innovations, and research targets seem to involve a broad range of foci. To move the field forward, it is necessary to build on work that has been done and direct further research to the areas holding most promise. Therefore, we conducted a comprehensive review of randomized controlled trials (RCTs) focusing on electronic communication between patient and provider to improve health care service quality, presented in two parts. Part 2 investigates the methodological quality and effects of the RCTs, and demonstrates some promising benefits of electronic symptom reporting. Objective To give a comprehensive overview of the most mature part of this emerging field regarding (1) patient groups, (2) health service innovations, and (3) research targets relevant to electronic symptom reporting. Methods We searched Medline, EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials, and IEEE Xplore for original studies presented in English-language articles published from 1990 to November 2011. Inclusion criteria were RCTs of interventions where patients or parents reported health information electronically to the health care system for health care purposes and were given feedback. Results Of 642 records identified, we included 32 articles representing 29 studies. The included articles were published from 2002, with 24 published during the last 5 years. The following five patient groups were represented: respiratory and lung diseases (12 studies), cancer (6), psychiatry (6), cardiovascular (3), and diabetes (1). In addition to these, 1 study had a mix of three groups. All included studies, except 1, focused on long-term conditions. We identified four categories of health service innovations: consultation support (7 studies), monitoring with clinician support (12), self-management with clinician support (9), and therapy (1). Most of the research (21/29, 72%) was conducted within four combinations: consultation support innovation in the cancer group (5/29, 17%), monitoring innovation in the respiratory and lung diseases group (8/29, 28%), and self-management innovations in psychiatry (4/29, 14%) and in the respiratory and lung diseases group (4/29, 14%). Research targets in the consultation support studies focused on increased patient centeredness, while monitoring and self-management mainly aimed at documenting health benefits. All except 1 study aiming for reduced health care costs were in the monitoring group. Conclusion RCT-based research on electronic symptom reporting has developed enormously since 2002. Research including additional patient groups or new combinations of patient groups with the four identified health service innovations can be expected in the near future. We suggest that developing a generic model (not diagnosis specific) for electronic patient symptom reporting for long-term conditions may benefit the field.

Electronic Symptom Reporting Between Patient and Provider for Improved Health Care Service Quality: A Systematic Review of Randomized Controlled Trials. Part 2: Methodological Quality and Effects

Background We conducted in two parts a systematic review of randomized controlled trials (RCTs) on electronic symptom reporting between patients and providers to improve health care service quality. Part 1 reviewed the typology of patient groups, health service innovations, and research targets. Four innovation categories were identified: consultation support, monitoring with clinician support, self-management with clinician support, and therapy. Objective To assess the methodological quality of the RCTs, and summarize effects and benefits from the methodologically best studies. Methods We searched Medline, EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials, and IEEE Xplore for original studies presented in English-language articles between 1990 and November 2011. Risk of bias and feasibility were judged according to the Cochrane recommendation, and theoretical evidence and preclinical testing were evaluated according to the Framework for Design and Evaluation of Complex Interventions to Improve Health. Three authors assessed the risk of bias and two authors extracted the effect data independently. Disagreement regarding bias assessment, extraction, and interpretation of results were resolved by consensus discussions. Results Of 642 records identified, we included 32 articles representing 29 studies. No articles fulfilled all quality requirements. All interventions were feasible to implement in a real-life setting, and theoretical evidence was provided for almost all studies. However, preclinical testing was reported in only a third of the articles. We judged three-quarters of the articles to have low risk for random sequence allocation and approximately half of the articles to have low risk for the following biases: allocation concealment, incomplete outcome data, and selective reporting. Slightly more than one fifth of the articles were judged as low risk for blinding of outcome assessment. Only 1 article had low risk of bias for blinding of participants and personnel. We excluded 12 articles showing high risk or unclear risk for both selective reporting and blinding of outcome assessment from the effect assessment. The authors’ hypothesis was confirmed for 13 (65%) of the 20 remaining articles. Articles on self-management support were of higher quality, allowing us to assess effects in a larger proportion of studies. All except one self-management interventions were equally effective to or better than the control option. The self-management articles document substantial benefits for patients, and partly also for health professionals and the health care system. Conclusion Electronic symptom reporting between patients and providers is an exciting area of development for health services. However, the research generally is of low quality. The field would benefit from increased focus on methods for conducting and reporting RCTs. It appears particularly important to improve blinding of outcome assessment and to precisely define primary outcomes to avoid selective reporting. Supporting self-management seems to be especially promising, but consultation support also shows encouraging results.

Garbage in, garbage out: extracting disease surveillance data from epr systems in primary care

This paper presents an interpretive case study on extraction of disease surveillance data from Electronic Patient Records (EPRs) in primary care. The General Practitioners (GPs) use of the EPR system, and the effect this has on data content, such as symptoms reported by patients and diagnoses reported by GPs, is discussed. The paper contributes to greater understanding of sociotechnical issues related to disease surveillance, and contains illustrative examples of many issues important to CSCW. This includes how data collected in one context may be applied to a different context, and the delicate interplay between organizational and technical design challenges.

An exploratory study of disease surveillance systems in Norway.

We conducted a qualitative study of the system for contagious disease surveillance in Norway. Semi-structured interviews were held with five general practitioners (GPs), including one person responsible for informing GPs in their region about potentially serious disease outbreaks. The interviews suggested that the existing system had several limitations, making it of little relevance to local epidemics or daily medical practice. Specifically, it was difficult and time-consuming for physicians to locate relevant information, and there was a substantial delay between reported diagnoses and eventual feedback about outbreaks. This resulted in information that was too old to be of value. The interviews also investigated design matters related to future realtime disease surveillance systems. The GPs expressed interest in a distributed system for realtime extraction and presentation of data from electronic record systems. They required that any such system be customizable to the specific needs of the doctor in order to be relevant in day-to-day practice, and that correct interpretation of data would be possible in the minimum of time.

The potential of digital monochrome images versus colour slides in telescreening for diabetic retinopathy

Summary We explored the potential of digital monochrome images as an alternative to colour slides in screening for diabetic retinopathy. Twenty-eight patients with diabetes were recruited for the study and 20 actually participated. Using a fundus camera (Nikon 505AF) one set of three digital images and one set of three colour slides were taken per eye. Two independent ophthalmologists graded the colour slides and the digital images for diabetic retinopathy. The ophthalmologists spent about two minutes grading each set of images, suggesting that specialists could potentially screen a large number of patients. The agreement between the two screening methods was 0.95 and 0.89, with respect to disease or no disease. The agreement (κ) between the two ophthalmologists for grade of retinopathy was 0.47 when colour slides were employed and 0.61 when digital monochrome images were employed. The results indicate that digital red-free monochrome images represent a superior screening tool for diabetic retinopathy. Tele-screening may be beneficial when patients have to travel substantial distances to visit an ophthalmologist.

Difficulties in moving routine medical checks from the specialist level to the general practitioner level

We began a project to move routine medical checks for appropriate patients from the specialist level to the patients normal general practitioner (GP). The GPs analysis and conclusions would be checked by the specialist, using electronic messaging. The idea for the project came from the top level of the regional health authority. Despite that, the project was closed down before pilot testing began. We used stakeholder theory as a post-project evaluation to analyse what happened and where it went wrong. A common mistake in project planning is to focus the planning effort on system tasks and not to pay attention to a well-thought-out handling of the projects stakeholders. This was what happened in our project. Ideal objectives and good political intentions are not enough to implement a new e-health service.

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We investigated whether the parents of burns patients could capture suitable clinical images with a digital camera and add the necessary text information to enable the paediatric burns team to provide follow-up care via email. Four families were involved in the study, each of whom sent regular email consultations for six months. The results were very encouraging. The burns team felt confident that the clinical information in 30 of the 32 email messages (94%) they received was accurate, although in 11 of these 30 cases (37%) they stated that there was room for improvement (the quality was nonetheless adequate for clinical decision making). The study also showed that low-resolution images (average size 37 kByte) were satisfactory for diagnosis. Families were able to participate in the service without intensive training and support. The user survey showed that all four families found it easy and convenient to take the digital photographs and to participate in the study. The results suggest that the technique has potential as a low-cost telemedicine service in burns follow-up, and that it requires only modest investment in equipment, training and support.