Telemedicine journal : the official journal of the American Telemedicine Association最新文献

The videoconferencing link between the Royal Adelaide Hospital Cancer Centre in South Australia and the Royal Darwin Hospital in the Northern Territory was established to allow Darwin clinicians to discuss cases in multidisciplinary oncology meetings at the tertiary referral center. This was evaluated by questionnaires distributed to the 20 health professionals involved and a group of 8 patients with breast cancer whose case histories had been discussed via videoconferencing. All clinicians found the telemedicine link to be either useful or very useful in at least one aspect of their practice. The major benefit was cited as enabling remote area clinicians to participate in multidisciplinary cancer meetings. Three of the 5 remote clinicians who practiced solely in the Northern Territory found that the telemedicine consultation increased their workload, while only 2 of 13 clinicians who practiced solely in South Australia reported an increase over their normal activities, the others reporting no difference. Benefits identified included better support of isolated clinicians, decreased travel, and enhanced education and peer review. Perceived difficulties were technical problems, the impersonal nature of the interaction, inability to examine the remote patient and lack of reimbursement for the consultation. Seven of the eight patients surveyed were satisfied or very satisfied with the telemedicine consultation. Four patients wished to have access to videotape of the multidisciplinary meeting. Of those requiring travel for treatment, all believed that the telemedicine consultation influenced their care and shortened their time away from home.

The objectives of this project were to examine how members of a colocated rehabilitation engineering team communicate during their work and hence deduce the implications of these communications for the design of video-based technologies to support communication among members of a virtual rehabilitation engineering team. Twenty-four assessment clinic sessions conducted by rehabilitation engineering team were recorded on videotape over a period of 3 years. These tapes were analyzed in considerable detail using a schema to identify and classify the talk and actions of the team members. Combining talk and actions with artifacts is a mechanism used by designers to develop ideas and communicate them to others. Speakers rely on actions to support and make their talk lucid. Cooperation based on sharing artifacts is a strength of face-to-face interaction. Participants can experience artifacts and observe others using the artifacts. Tools such as videoconferencing to support virtual rehabilitation teams will have to provide the participants with the ability to see often quite subtle gestures and actions if they are to grasp the meaning of the talk. Increased understanding how a team communicates visually complex data may (1) aid development of next generation videoconferencing equipment to better support distributed designers and rehabilitation engineers and (2) guide development of techniques to enhance the quality of visual data presentation in current videoconferencing systems.

Objective: This study compares the costs of offering outpatient care to primarily orthopedic and dermatology patients via live, interactive telemedicine to the estimated costs of direct face-to-face care for the same patients.

Materials and methods: A simple, yet detailed methodology was used to evaluate the cost of adding telemedicine to a health care delivery system, using a "hub-and-spoke" model located in Minnesota. The costs and cost savings of telemedicine were evaluated from the perspectives of patients, providers, insurers, employers, and society as a whole. Sensitivity analysis was used to investigate the impact of various factors on the model.

Results: The variable cost of a telemedicine referral was $144, versus an estimated face-to-face referral cost of $183. Reductions in patient travel costs and in lost employee productivity were the principal benefits of the system. The break-even point, where total costs equal total cost savings, equalled 1,449 consultations annually. Sensitivity analyses indicated that the breakeven point varies from a low of 152 telemedicine consultations for a "best case" scenario to no possible breakeven point for a "worst case" scenario.

Conclusions: At the system's current level of 300 consultations per year, the telemedicine system is estimated to add $45,000 to society's costs of providing medical care for these patients. The additional cost is primarily due to personnel expenses and an increase in the volume of specialty care. Patients see specialists more often due to improved access to care and lower transportation costs. Providers bear the cost while patients and employers enjoy substantial savings.

Objectives: Glaucoma is a major cause of blindness. More than 80,000 Americans suffer permanent vision loss from the disease. Widespread screening is fundamental in limiting the incidence of glaucoma-associated blindness. This pilot study explored the use of stereo digital images taken at a primary care center for telemedicine review by an off-site specialist as a means of screening for glaucoma.

Materials and methods: Thirty-two diabetic patients were screened at a family medicine clinic. None had previously been diagnosed with glaucoma. A senior optometry student took stereoscopic digital and 35-mm optic disc photographs with a nonmydriatic retinal camera. The digital images were forwarded to a remote ophthalmologist for review. The conventional color stereo slide pairs of the same eyes were subsequently reviewed for comparison. Agreement on signs of glaucomatous disc changes between the two imaging systems was analyzed.

Results: Twenty-six of 32 eyes' digital and 35-mm photographs were analyzed. Six of 32 eyes (18.8%) could not be compared due to lack of matching 35-mm slides or digital images. Out of 26 eyes, lamina cribosa visibility was undeterminable in 8 eyes' digital images and 3 other eyes' 35-mm slides. Agreement among digital images and 35-mm slides of the remaining eyes was: 100%-vertical elongation, barring of vessels, bayoneting of vessels, and drance hemorrhage; 96.2%-focus notching of rim and rim pallor; 93.3%-lamina cribosa visability; 92. 3%-overpass cupping; 88.5%-focal enlargement; 84.6%-parapapillary halo; 80%-nerve fiber visibility; 65.4%-parapapillary atrophy. Parapapillary halo (p = 0.046) and nerve fiber layer visibility (p = 0.18) were detected on some 35-mm slides but not seen on matching digital views.

Conclusion: Evaluations of cup-to-disc ratio (C/D) using both methods were in general agreement. However, some digital images were noted as too dark for assessing fine glaucomatous disc changes. Stereo digital images taken with a nonmydriatic camera by nonophthalmic photographers is a promising alternative for glaucoma screening in primary care settings. Telemedicine offers efficient communications with off-site glaucoma specialists. A larger study population is necessary to determine the overall effectiveness of using stereo digital imagery and teleophthalmology for glaucoma screening.

When a student is away from school for an extended time due to illness, he/she is provided with a tutor or access to in-hospital classrooms to keep up with his/her studies. This isolates the child from normal classroom experiences. A remote-control videoconferencing system (VCS), P.E.B.B.L.E.S.trade mark (Providing Education by Bringing Learning Environments to Students), was developed to allow a student access to his/her regular classroom from the hospital. Remote control is provided by a game pad, which allows the student to direct the system. The first iteration, P.E.B. B.L.E.S. I, tested feasibility. The design of P.E.B.B.L.E.S. II provides an integrated version of the system with user interface aimed at children. Four studies examined its efficacy in allowing a student to participate in typical classroom activities and in providing him/her a sense of presence in the classroom. Results indicate that the system can be used with relatively few errors when set to perform the majority of required activities. The study-participants reported positive experiences using the system, and remote users appeared to have a sense of presence in the classroom.

Objective: To determine what information sources are used during a remote diagnosis task.

Materials and methods: Experienced trauma care providers viewed segments of videotaped initial trauma patient resuscitation and airway management. Experiment 1 collected responses from anesthesiologists to probing questions during and after the presentation of recorded video materials. Experiment 2 collected the responses from three types of care providers (anesthesiologists, nurses, and surgeons). Written and verbal responses were scored according to detection of critical events in video materials and categorized according to their content. Experiment 3 collected visual scanning data using an eyetracker during the viewing of recorded video materials from the three types of care providers. Eye-gaze data were analyzed in terms of focus on various parts of the videotaped materials.

Results: Care providers were found to be unable to detect several critical events. The three groups of subjects studied (anesthesiologists, nurses, and surgeons) focused on different aspects of videotaped materials.

Conclusion: When the remote events and activities are multidisciplinary and rapidly changing, experts linked with audio-video-data connections may encounter difficulties in comprehending remote activities, and their information usage may be biased. Special training is needed for the remote decision-maker to appreciate tasks outside his or her speciality and beyond the boundaries of traditional divisions of labor.

Objective: A telepathology connection between Richmond VAMC and Beckley VAMC using dynamic robotic telepathology to provide pathology services remotely was established.

Materials and methods: This study reports a 14-month experience using telepathology to diagnose surgical specimens obtained from patients at the Beckley VA Medical Center and viewed in Richmond 250 miles away. Over 14 months, 2325 slides representing 1000 cases were viewed.

Results: Discrepancies were observed in 20 of 2325 slides, or 0.86% of the total. None of the patients, where a discrepancy was found, were adversely affected by the preliminary report given.

Conclusions: This study demonstrates that telepathology is a reliable and cost-effective alternative to on-site pathology services and reviews advantages and disadvantages of the system.

This paper presents the results of experiments examining the performance of a telesurgeon and an assistant local to the patient performing simulated laparoscopic tasks under a variety of time-delay conditions. Of particular interest is a comparison between the surgeon provided with audio/video and force feedbck synchronously with various time delays, and the surgeon performing asynchronously, where video is delayed relative to force feedback. These conditions are relevant since current telecommunication systems have limited bandwidth, and video signals must be compressed for efficient transmission. This produces a time lag between the video camera and the surgeon's monitor, Force feedback and position commands from a surgical teleoperator require much lower bandwidth, and can be transmitted in near-real time. In the first of two series of experiments, two laparoscopic training tasks were performed under different time-delay conditions, with force and video feedback delayed by equal amounts. In the second series, using the same tasks, the force feedback was more immediate, while the video delay lagged by the time required for compression and decompression. In both experiments, there were various role assignments in terms of whether the telesurgeon or the assistant controlled the laparoscope and/or the various surgical tools required. The three most striking results are that (1) nontrivial time delays significantly degraded the performance of the surgical tasks, (2) asynchronous force feedback resulted in significantly faster task-performance than did synchronous performance when the surgeon operated the laparoscopic tools, and (3) there was no difference between synchrony and asynchrony when the remote surgeon operated the laparoscope and gave commands while the local assistant operated the surgical tools.

Objective: To determine the effect of degraded digital image resolution (as viewed on a monitor) on the accuracy and confidence of dermatologic interpretation.

Materials and methods: Eight dermatologists interpreted 180 clinical cases divided into three Logical Competitor Sets (LCS) (pigmented lesions, non-pigmented lesions, and inflammatory dermatoses). Each case was digitized at three different resolutions. The images were randomized and divided into (9) 60-image sessions. The physicians were completely blinded concerning the image resolution. After 60 seconds per image, the viewer recorded a diagnosis and level of confidence. The resultant ROC curves compared the effect of LCS, level of clinical difficulty, and resolution of the digital image. One-way analysis of variance (ANOVA) compared the curves.

Results: The areas beneath the ROC curves did not demonstrate any consistently significant difference between the digital image resolutions for all LCS and levels of difficulty. The only significant effect observed was amongst pigmented lesions (LCS-A) where the ROC curve area was significantly smaller in the easy images at high resolution compared to low and medium resolutions. For all other ROC curve comparisons within LCS-A, at all other levels of difficulty, as well as within the other LCS at all levels of difficulty, none of the differences was significant.

Conclusion: A 720 x 500 pixel image can be considered equivalent to a 1490 x 1000 pixel image for most store-and-forward teledermatology consultations.