Pascale Lehoux

A systematic review of clinical outcomes, clinical process, healthcare utilization and costs associated with telerehabilitation

Purpose. To identify clinical outcomes, clinical process, healthcare utilization and costs associated with telerehabilitation for individuals with physical disabilities. Method. Relevant databases were searched for articles on telerehabilitation published until February 2007. Reference lists were examined and key journals were hand searched. Studies that included telerehabilitation for individuals with physical impairments and used experimental or observational study designs were included in the analysis, regardless of the specific clientele or location of services. Data was extracted using a form to record methodological aspects and results relating to clinical, process, healthcare utilization and cost outcomes. Study quality of randomized clinical trials was assessed using the PEDro rating scale. Results. Some 28 articles were analysed. These dealt with rehabilitation of individuals in the community, neurological rehabilitation, cardiac rehabilitation, follow-up of individuals with spinal cord injuries, rehabilitation for speech-language impairments, and rehabilitation for varied clienteles. Clinical outcomes were generally improved following a telerehabilitation intervention and were at least similar to or better than an alternative intervention. Clinical process outcomes, such as attendance and compliance, were high with telerehabilitation although few comparisons are made to alternative interventions. Consultation time tended to be longer with telerehabilitation. Satisfaction with telerehabilitation was consistently high, although it was higher for patients than therapists. Few studies examined healthcare utilization measures and those that did reported mixed findings with respect to adverse events, use of emergency rooms and doctor visits. Only five of the studies examined costs. There is some preliminary evidence of potential cost savings for the healthcare facility. Conclusions. While evidence is mounting concerning the efficacy and effectiveness of telerehabilitation, high-quality evidence regarding impact on resource allocation and costs is still needed to support clinical and policy decision-making.

Technology Assessment and the Sociopolitics of Health Technologies

In a growing number of countries, health technology assessment (HTA) has come to be seen as a vital component in policy making. Even though the assessment of the social, political, and ethical aspects of health technology is listed as one of its main objectives, in practice, the integration of such dimensions into HTA remains limited. Recent social scientific research on the inherently political nature of technology strongly supports such a comprehensive approach. The growing claims by and on behalf of consumer groups also suggest that HTA should be informed by a broader set of perspectives. Using the example of the cochlear implant in children, this essay compares the professed objectives of HTA with typical practice and explores possible explanations for the discrepancies observed. A second example, home telemonitoring for elderly persons, demonstrates how the types of evidence considered by HTA and the process through which assessments are produced may be reconsidered. We argue for the formal integration of the sociopolitical dimensions of health care technologies into assessments. The ability of HTA to more fully address important issues from a public policy point of view will increase by making explicit the sociopolitical nature of health care technologies.

Involving patients in setting priorities for healthcare improvement: a cluster randomized trial

BackgroundPatients are increasingly seen as active partners in healthcare. While patient involvement in individual clinical decisions has been extensively studied, no trial has assessed how patients can effectively be involved in collective healthcare decisions affecting the population. The goal of this study was to test the impact of involving patients in setting healthcare improvement priorities for chronic care at the community level.MethodsDesign: Cluster randomized controlled trial. Local communities were randomized in intervention (priority setting with patient involvement) and control sites (no patient involvement). Setting: Communities in a canadian region were required to set priorities for improving chronic disease management in primary care, from a list of 37 validated quality indicators. Intervention: Patients were consulted in writing, before participating in face-to-face deliberation with professionals. Control: Professionals established priorities among themselves, without patient involvement. Participants: A total of 172 individuals from six communities participated in the study, including 83 chronic disease patients, and 89 health professionals. Outcomes: The primary outcome was the level of agreement between patients’ and professionals’ priorities. Secondary outcomes included professionals’ intention to use the selected quality indicators, and the costs of patient involvement.ResultsPriorities established with patients were more aligned with core generic components of the Medical Home and Chronic Care Model, including: access to primary care, self-care support, patient participation in clinical decisions, and partnership with community organizations (p < 0.01). Priorities established by professionals alone placed more emphasis on the technical quality of single disease management. The involvement intervention fostered mutual influence between patients and professionals, which resulted in a 41% increase in agreement on common priorities (95%CI: +12% to +58%, p < 0.01). Professionals’ intention to use the selected quality indicators was similar in intervention and control sites. Patient involvement increased the costs of the prioritization process by 17%, and required 10% more time to reach consensus on common priorities.ConclusionsPatient involvement can change priorities driving healthcare improvement at the population level. Future research should test the generalizability of these findings to other contexts, and assess its impact on patient care.Trial registrationThe Netherlands National Trial Register #NTR2496.

The Computer Based Patient Record: A Strategic Issue in Process Innovation

Reengineering of the workplace through Information Technology is an important strategic issue for todays hospitals. The computer-based patient record (CPR) is one technology that has the potential to profoundly modify the work routines of the care unit. This study investigates a CPR project aimed at allowing physicians and nurses to work in a completely electronic environment. The focus of our analysis was the patient nursing care process. The rationale behind the introduction of this technology was based on its alleged capability to both enhance quality of care and control costs. This is done by better managing the flow of information within the organization and by introducing mechanisms such as the timeless and spaceless organization of the work place, de-localization, and automation of work processes. The present case study analyzed the implementation of a large CPR project (

Feasibility and outcome evaluation of a telemedicine application in speech–language pathology

45 million U.S.) conducted in four hospitals in joint venture with two computer firms. The computerized system had to be withdrawn because of boycotts from both the medical and nursing personnel. User-resistance was not the problem. Despite its failure, this project was a good opportunity to understand better the intricate complexity of introducing technology in professional work where the usefulness of information is short lived and where it is difficult to predetermine the relevancy of information. Profound misconceptions in achieving a tighter fit (synchronization) between care processes and information processes were the main problems.

Creating a new articulation between research and practice through policy? The views and experiences of researchers and practitioners

This evaluative study assessed the feasibility and outcome of delivering speech–language services from a distance to children and adolescents who stutter. All six patients who formed the first cohort seen in the telespeech programme were included in the study. The results demonstrated that interactive videoconferencing can provide a feasible and effective care delivery model. Patient attendance was maintained throughout the intervention. All participants showed improved fluency. Stuttering ranged from 13% to 36% before treatment and 2% to 26% after treatment. All participants maintained at least part of their improved fluency during the six-month follow-up, when stuttering ranged from 4% to 32%. The study demonstrates that full assessment and treatment of stuttering in children and adolescents can be accomplished successfully via telemedicine.

The Computer-Based Patient Record Challenges Towards Timeless and Spaceless Medical Practice

Objectives In 1990, the Quebec Social Research Council - a body financing social research in Quebec, Canada -launched a new policy encouraging the development of social research units within health care organizations. Through financial incentives, it encouraged the implementation of long-term collaborations between researchers and practitioners with the purpose of transforming both scientific knowledge production and professional practices. This paper examines the perceptions of researchers and practitioners regarding the attributes and the usefulness of this collaborative research policy. Methods A self-administered survey was sent to all the researchers (n = 146; response rate 78.1%) and practitioners (n = 204; response rate 44.1%) involved in the 21 collaborative research teams funded in 1998. T-tests were performed in order to assess the difference between the perceptions of researchers and practitioners in five key dimensions of collaborative research. Results The results showed that, contrary to expectations, researchers and practitioners shared fairly similar views regarding the various dimensions of collaborative research. They both agreed that their involvement within collaborative research teams had contributed to the development of new skills and practices but had not facilitated their participation in external activities nor their involvement in networks and organizations that influence environments in which public policies and practices are deployed. They also both encountered some difficulties in putting the dimensions that they highly valued into practice. Conclusions Collaborative research within health care organizations succeeded in fostering the implementation of new modes of knowledge production and intervention. Nevertheless, special attention needs to be given to the development of strategies to reduce the discrepancies between values and practices.

What leads to better health care innovation? Arguments for an integrated policy-oriented research agenda

Although computerization is increasingly advocated as a means for hospitals to enhance quality of care and control costs, few studies have evaluated its impact on the day-to-day organization of medical work. This study investigated a large Computerized Patient Record (CPR) project (

What Are the Key Ingredients for Effective Public Involvement in Health Care Improvement and Policy Decisions? A Randomized Trial Process Evaluation

50 million U.S.) aimed at allowing physicians to work in a completely electronic record environment. The present multiple-case study analyzed the implementation of this project conducted in four hospitals. Our results show the intricate complexity of introducing the CPR in medical work. Profound obstructions to the achievement of a tighter synchronization between the care and information processes were the main problems. The presence of multiple information systems in one (Communication, Decision Support, and Archival record keeping) was overlooked. It introduced several misconceptions in the meaning and codification of clinical information that were then torn apart between information richness to sustain clinical decisions and concision to sustain care coordination.

Assessment of a computerized medical record system: disclosing scripts of use

This essay is based on the recognition that the current ‘downstream’ health services research and policy approach to innovation misses the mark on one crucial point. It has not addressed how to promote the design of innovations that are likely to be more valuable than others. Re-visiting the ways in which health services research could inform innovation processes, this paper suggests that three attributes make innovations especially compelling from a health care system perspective: relevance; usability; and sustainability. These could be used as a starting point for outlining a policy-oriented research agenda that could bridge upstream design processes, and downstream needs and priorities. Given the pace at which innovations come about and the complexity of health care systems, we believe that both research and policy should be able to contribute significantly to the shaping of socially valuable technological change in health care. Recognizing that such a long-term goal cannot be reached through a linear, rationalistic process, our paper offers preliminary arguments to start to reconcile the health policy and innovation agendas.