Penny A. Jennett

The socio-economic impact of telehealth: A systematic review:

We reviewed the socio-economic impact of telehealth, focusing on nine main areas: paediatrics, geriatrics, First Nations (i.e. indigenous peoples), home care, mental health, radiology, renal dialysis, rural/remote health services and rehabilitation. A systematic search led to the identification of 4646 citations or abstracts; from these, 306 sources were analysed. A central finding was that telehealth studies to date have not used socioeconomic indicators consistently. However, specific telehealth applications have been shown to offer significant socio-economic benefit, to patients and families, health-care providers and the health-care system. The main benefits identified were: increased access to health services, cost-effectiveness, enhanced educational opportunities, improved health outcomes, better quality of care, better quality of life and enhanced social support. Although the review found a number of areas of socio-economic benefit, there is the continuing problem of limited generalizability.

Telemedicine approach to screening for severe retinopathy of prematurity: a pilot study

PURPOSE To evaluate the use of remote reading of digital retinal photographs in the diagnosis of severe (referral-warranted) retinopathy of prematurity (ROP) during longitudinal screening for ROP. STUDY DESIGN Prospective, longitudinal cohort study. SUBJECTS Forty-four consecutive premature infants at risk for ROP. METHODS All infants were examined longitudinally, over a series of examinations, by indirect ophthalmoscopy (gold standard) and digital photography using the RetCam-120 Digital Retinal Camera (Massie Research Laboratories Inc., Dublin, CA) equipped with an ROP lens. Images were stored and read remotely by a masked reader. Referral-warranted ROP was defined as ROP in zone 1, the presence of plus disease or the presence of any stage 3 ROP. We determined whether and when referral-warranted ROP was diagnosed for each eye, of each infant, on each examination, during the course of each of the infants screening. RESULTS Severe (referral-warranted) ROP was diagnosed in 23 eyes by indirect ophthalmoscopy during their series of examinations. Digital photography had a sensitivity of 100% and a specificity of 96% in detecting referral-warranted ROP. The positive predictive value of digital photography was 92%, and the negative predictive value was 100%. In 87% of eyes, referral-warranted ROP was diagnosed by digital photography before or at the same time as indirect ophthalmoscopy. CONCLUSIONS Longitudinal remote reading of digital photographs using the RetCam-120 system has excellent specificity and sensitivity in detecting referral-warranted ROP. This pilot study has shown that remote reading of digital photographs has promise for telemedicine strategies in ROP screening.

A study of a rural community's readiness for telehealth

A qualitative approach was used to explore the readiness of a rural community for the implementation of telehealth services. There were four domains of interest: patient, practitioner, public and organization. Sixteen semistructured telephone interviews (three to five in each domain) were carried out with key informants and recorded on audio-tape. Two community awareness sessions were held, which were followed by five audio-taped focus groups (with five to eight people in each) in the practitioner, patient and public domains. In addition, two in-depth interviews were conducted with community physicians. Analysis of the data suggested that there were four types of community readiness: core, engagement, structural and non-readiness. The level of readiness varied across domains. There were six main themes: core readiness; structural readiness; projection of benefits; assessment of risk; awareness and education; and intra-group and inter-group dynamics. The results of the study can be used to investigate the readiness of rural and remote communities for telehealth, which should improve the chance of successful implementation.

The effect of information technology on the physician workforce and health care in isolated communities: the Canadian picture.

The ratio of physicians to population in Canada peaked in the mid-1990s and is now falling. The decrease in the number of family physicians has had a disproportionate effect on rural and remote communities, and surveys have indicated that the availability of physicians and services is likely to deteriorate in rural and remote communities. Telemedicine is increasingly evident in every Canadian province and territory, and it could assist in more effective use of workforce resources by linking appropriate experts at central sites to patients and practitioners at remote sites. Positive effects on recruitment and retention of health providers and morale of the local workforce can be expected. In spite of national interest, evidence for the effect of telemedicine on staff distribution, roles and recruitment, use of health resources, health management and system integration is very limited. Telephone interviews were therefore conducted to collect information from 12 telehealth projects in Canada, one from each province or territory. The responses confirmed observations in the literature that telemedicine has positive outcomes for the workforce.

Policy Implications Associated with the Socioeconomic and Health System Impact of Telehealth: A Case Study from Canada

This research was undertaken to inform future telehealth policy directions regarding the socioeconomic impact of telehealth. Fifty-seven sources were identified and analyzed through a comprehensive literature search of electronic databases, the Internet, journals, conference proceedings, as well as personal communication with consultants in the field. The review revealed a focus on certain socioeconomic indicators such as cost, access, and satisfaction. It also identified areas of opportunity for further research and policy analysis and development (e.g., social isolation, life stress, poverty), along with various barriers and challenges to the advancement of telehealth. These included confidentiality, reimbursement, and legal and ethical considerations. To become fully integrated into the health care system, telehealth must be viewed as more than an add-on service. This paper offers 19 general and 20 subject-specific telehealth recommendations, as well as seven policy strategies.

Evaluation of a distance consulting service based on interactive video and integrated computerized technology.

Telemedicine equipment was installed at a rural site in Drumheller and at Calgary, 85 miles (136 km) away. It allowed consultation between health-care providers at Drumheller and specialists and subspecialists at the Faculty of Medicine in Calgary. The efficacy of the system in providing more equitable access to health care for persons living in geographically remote sites was evaluated during a 12-month pilot project. Seventy-five encounters were attempted during the study. A total of 55 encounters (42 clinical and 13 non-clinical) were completed. The completed clinical encounters were distributed across a wide spectrum of medical specialties. Users of the system reported favourably on the impact of the telemedicine system on access to health services for rural patients, on diagnostic, investigative and management decisions, on patient and physician travel times, on feelings of professional isolation and educational opportunities and on overall patient health status. The study provides new knowledge and demonstrates the success of the technology in this project. As expected, other problems were raised and addressed in a preliminary manner including: the potential for health-provider education; acquisition and retention of rural physicians; ethical, legal and patient confidentiality issues; minimum acceptable technology; and network management issues.

Telehealth readiness assessment tools

In planning a telehealth project, a readiness assessment can help to improve the chances of successful implementation by identifying the stakeholders and the factors that should be targeted. We conducted a literature search and identified six questionnaires on readiness that can be used when implementing telehealth projects. Only one of them was sufficiently generic to be used with all kinds of telehealth projects and with different groups of participants (patients and public, health-care practitioners and organization personnel like health-care managers and technical support managers), but it had rather limited psychometric evaluation. Two of them had had good psychometric evaluation but they were specific to particular telehealth projects and groups of stakeholders. All six published questionnaires were in English. We have developed and validated a French-Canadian version of the practitioner and organizational telehealth readiness assessment tool.

Preparing doctors for tomorrow: information management as a theme in undergraduate medical education

Summary. The evolving nature of medical knowledge and technology requires that the practitioners of tomorrow be able to develop practice management and computer skills in order to enhance quality patient care, ongoing education, and research. The paper describes how the discipline of medical informatics can be integrated into an undergraduate medical curriculum, not as a course or series of courses, but as a repeated theme throughout the 3‐year systembased curriculum. Recommendations specific to integrating medical informatics into an undergraduate curriculum are outlined with respect to: (1) content; (2) content organization; (3) management; and (4) evaluation. Six areas of information and computer management applications are discussed. These are computer‐assisted learning, retrieving and organizing information from computerised databases, the application of medical informatics tools to the critical appraisal of literature and associated statistical software packages, hospital ‐ and office‐based information systems, and electronic communications. Medical education has a history of resistance to change. Reference to guidelines and experiences of others who have negotiated information management and medical informatics changes into medical school environments can therefore be helpful. It is in this context that this paper is presented.

The Need for Economic Evaluation of Telemedicine to Evolve: The Experience in Alberta, Canada

Economic evaluation of telemedicine applications is required to provide decision makers in health care with appropriate information on costs and benefits of this information and communications technology. The level of economic evaluation should evolve as telemedicine applications mature. At the basic level, economic evaluation may include basic cost analysis and primarily observational data on nonmonetary benefits. The focus will change as telemedicine programs develop. At this intermediate level, practice patterns and workforce issues are addressed as they affect utilization and costs of telemedicine services. Longer-term economic evaluation, thus far not achieved in telemedicine assessment, should focus on assessment of health outcomes and economic impact. Alberta, Canada has made progress assessing telemedicine applications in psychiatry, radiology, rheumatology, and rehabilitation. Data availability and analytic resources continue to present challenges to economic assessment of telemedicine.

The Potential Effects of Telehealth on the Canadian Health Workforce: Where Is the Evidence?

The literature reports that telehealth holds the potential to positively alter the health workforce, yet there is little evidence to support and substantiate this commonly held belief. This qualitative study examines the anticipated and realized effects of telehealth on health workforce concerns. The six themes examined include the distribution of expertise of health professionals, effect on skills base, recruitment and retention of health professionals, staffing of telehealth initiatives, appropriate use of health care resources, and other workforce outcomes. Twelve telehealth initiatives were selected for study - one from each of Canadas provinces and territories. Projects included eight consultation applications, two administrative information systems, and two community-based programs. A questionnaire guided the initial and 6-month follow-up interviews with project coordinators. The six themes were independently validated for accuracy, interpretation, consistency, and saturation. Positive effects from...