Nationwide Telemedicine Research Articles

Abstract 4136776: Prognostic Value of Resting Heart Rate and Heart Rate Variability in the 12-lead Electrocardiogram: Mortality Data From the CODE Nationwide Database

Introduction: Resting Heart Rate (HR) and Heart Rate Variability (HRV) reflect autonomic control, and are implicated as prognostic factors. We aimed to evaluate the prognostic value of HR and HRV in a cohort from a nationwide telemedicine network. Methods: We assessed unique ECGs recorded from patients ≥16 years-old, from the tele-ECG database of the Telehealth Network of Minas Gerais, Brazil, between 2010 and 2017. Variables of interest were HR and standard deviation of normal RR intervals (SDNN). Self-informed data were collected: sex, age, risk factors (hypertension, dyslipidemia, diabetes, smoking) and comorbidities (myocardial infarction, Chronic Obstructive Pulmonary Disease, and Chagas disease). Outcomes of interest were all-cause and cardiovascular mortality, assessed by ICD codes reported in death certificates, through linkage with the Mortality Information System. Cox regression was applied to evaluate the association between HR and HRV and the outcomes, in 4 models: 1. Unadjusted; 2. Adjusted for sex and age; 3. Model 2 + risk factors + clinical comorbidities; 4. Model 3 + HRV or HR, respectively. Results: At total 992.611 individuals were included, median age of 55 years, 60% women. In 6 years, there were 33.292 deaths (3,37%), 21% due to cardiovascular causes. Patients who died had higher prevalence of all risk factors and comorbidities, as well as higher HR: 76 (IQR 66-87) vs. 74 (IQR 65-83) bpm, p<0.001 and lower HRV: 84 (IQR 51-127) vs. 114 (IQR 74-153), p<0.001. After adjustments (model 4), all HR quartiles were independently associated a progressively increased risk of all-cause mortality, being 88% higher for the 4 th quartile (HR=1.88 (95%CI 1.77–1.89). Similarly, the 1 st and 2 nd HRV quartiles remained associated with increased all-cause mortality (1 st quartile HR=1.42 (95%CI 1.37–1.47) in the final model. For cardiovascular mortality, HR was also an independent predictor, with a progressively higher risk, with a 77% increase (HR=1.77 95%CI 1.65–1.91) in the 4 th quartile. HRV was also an independent predictor of cardiovascular death, with a 33% risk increase (HR=1.33, 95%CI 1.23–1.44) for the 1 st quartile. Male gender, age, and all risk factors and comorbidities were also independent predictors of all-cause and cardiovascular mortality. Conclusions: In a large cohort of Brazilian adults, baseline HR and HRV were independent predictors of all-cause and cardiovascular mortality, after adjustment for clinical variables and autonomic indexes.

Examining the Effectiveness of Telephone Clinics: A Review of a Telephone Foot and Ankle Orthopaedic Clinic in a District General Hospital in the United Kingdom.

Since the outbreak of COVID-19, significant value has been placed on preventative methods for pathogen spread.One suchmethod is the use of telemedicine via telephone clinics (TC). This article is designedto study TCin a District General Hospital in the United Kingdom. This clinical audit aims to evaluate the use of a TC in the United Kingdom and assess its effectiveness. It also aims to assess the use of a clinician-led triaging system to select patients who would receive subsequent telephone follow-ups (TFU). Two cycles were conducted. The first cycle was conducted in 2020 and the second cycle in 2022. Inbetween the two cycles, a clinician-led triage system was implemented to reduce the number of patients being called back for a face-to-face (FTF) appointment. Data was collected regarding the outcomes of the appointments and compared between the two cycles. Chi-squared test statistical test was employed with a p-value < 0.05 deeming significance. Overall, more discharges were made for 2022 outcomes compared to 2020 outcomes (30% vs 19%; p = 0.03) after employing the clinician-led triage. The number of patients listed for a TFU increased when comparing the 2020 versus 2022 datasets (21% vs 12%; p = 0.026), and the overall number of patients not attending appointments decreased when comparing the 2020 versus 2022 datasets (9% vs 17%; p = 0.033). This articleshows that for this particular clinic, an orthopaedic clinician-led triaging system allows for a greater number of patients to be discharged, lessened need for FTF consultations, and increased adherence to appointments by patients. However, much work is yet to be done concerning the long-term consequences and issues of rolling out nationwide telemedicine.

837-P: Improved Outcomes across Socioeconomically Advantaged and Disadvantaged Communities—A Real-World Study

Socioeconomic conditions of one's community have been attributed to disparities in diabetes outcomes and management practices. Among a random sample (n=19955) of people with type 2 diabetes receiving care at a nationwide telemedicine clinic utilizing a carbohydrate restricted nutritional approach and continuous remote care model (CR-CRCM), we explored A1c and medication utilization by area deprivation index quintile (Q). Upon enrollment, patients residing in more disadvantaged areas (Q4, Q5) had higher A1c compared to the least disadvantaged area (Q1; 7.8% vs 7.7%, p&amp;lt;0.01), and insulin (INS) and sulfonylureas (SU), but not other medication classes, were prescribed to a greater proportion of patients living in Q5 (25% INS, 23% SU) compared to Q1 (18% INS, 18% SU) and Q2 (21% INS, 19% SU) after accounting for differences in age, sex, baseline BMI, baseline INS use (when appropriate), and race and ethnicity (p&amp;lt;0.05). After one year in clinic, no differences in the prescription of medication classes between Q were observed, except for INS, where greater use remained only in Q5 than Q1 (14% vs 10%, p=0.011); among those remaining on INS, dose was reduced by 49-58% across all Q (p&amp;lt;0.001). Differences in SU use were no longer present; 77-83% fewer SU were prescribed across Q. Differences in A1c between Q4 (6.6%) and Q5 (6.7%) vs Q1 (6.5%) remained (p&amp;lt;0.001), though all groups achieved significant reductions in A1c of 1.1-1.2% (all p&amp;lt;0.001) concurrent with reduced prescription of all diabetes medication (from 1.7-1.8 to 1.1-1.2 medication classes per person). Across all levels of socioeconomic disadvantage, patients achieved clinically and statistically meaningful reductions in A1c and medication. Higher rates of SU use among patients residing in more disadvantaged areas were mitigated through a CR-CRCM to improve glycemia. Further, these data suggest a CR-CRCM may overcome financial barriers to optimal diabetes management through reduced need for medication. Disclosure A.L.Mckenzie: Employee; Virta Health Corp., Stock/Shareholder; Virta Health Corp. S.J.Athinarayanan: Employee; Virta Health Corp.

Telemedical Interdisciplinary Care Team Evaluation and Treatment of People With Low Back Pain: A Retrospective Observational Study

ObjectiveTo evaluate the effects of an interdisciplinary care team (ICT) model delivered by telemedicine on patients with low back pain (LBP). DesignRetrospective analysis of deidentified pre-existing data. SettingRetrospective observational study of patients presenting with LBP to a nationwide telemedicine practice using an ICT model. ParticipantsOver a 9-month period all patients with a diagnosis related to LBP and who had an ICT evaluation (medical doctor, advanced practice provider, health coach, and physical therapist) were included in the study (n=36). A minimum of 2 follow-up physical therapy visits were required for inclusion. InterventionsPatients were evaluated for LBP, received a diagnosis, and were offered a multidisciplinary treatment plan. Additional real-time audio visual medical, health coaching, registered dietician, and physical therapy services were received as deemed clinically appropriate. Main Outcome MeasuresBaseline, 30 day, and final pain (mean 81 day) measurements via numerical pain rating scale (NPRS). Baseline and final Patient-Reported Outcomes Measurement Information System (PROMIS)-10 Global Mental/Physical domains. Secondary Outcome MeasuresUse of prescription medication, referral for imaging, need for injections, or surgery. Results36 patients met criteria. Pain levels included mild (n=6, 16.7%), moderate (n=19, 52.8%), and severe (n=11, 30.6%). Clinically significant pain improvements were noted in 83.3% (n=25) of those with moderate or severe pain. PROMIS Mental and Physical Health categorization from Fair/Poor to Good/Excellent significantly improved over time. The initial 20% (n=7) in Fair/Poor Mental Health improved to 6.3% (n=2) at finish, while the 80% (n=28) in Good/Excellent Mental Health at start improved to 93.8% (n=30) at finish. Regarding Physical Health, 51.4% (n=18) rated Fair/Poor at start and 31.3% (n=10) at finish, while the 48.6% (n=17) rated Good/Excellent at start improved to 68.8% (n=22) at finish. The need for prescription medication was low (n=6, 16.7%) and spinal imaging orders were negligible (n=1, 2.8%). Injections were warranted in 11.4% (n=4) of patients and surgical referral with operative treatment in 2.8% (n=1). ConclusionInterdisciplinary care delivered through telemedicine can significantly improve pain and support improved health-related quality of life in patients with LBP, with low rates of imaging, prescription, and interventional use.

Abstract 11982: Clinical Outcomes of Outpatients With Suspected Covid-19 Treated With Chloroquine Compounds in Brazil: A Nationwide Telemedicine Study

Introduction: Following the inception of the COVID-19 pandemic, chloroquine compounds were proposed as potential therapeutic strategies, at the cost of a potential increase in cardiovascular risk. We aimed to evaluate clinical outcomes of patients with COVID-19, comparing those using chloroquine compounds to individuals without specific treatment. Methods: Outpatients with suspected COVID-19 in Brazil who had at least 1 ECG transmitted to a Telehealth Network, were prospectively enrolled in 2 arms (G1: treatment with chloroquine compounds and G2: without specific treatment) and G3: registry of other specific treatments. Outcomes were assessed through follow-up phone calls on days 3 and 14, and also administratively collected from national mortality and hospitalization databases. The primary outcome was composed of: hospitalization and all-cause death. The association between treatment groups and the primary outcome was evaluated by logistic regression. Significant variables (p&lt;0.10) were included in 4 multivariate models: 1: unadjusted; 2: adjusted for age and sex; 3: adjusted for model 2 plus cardiovascular risk factors and 4: adjusted for model 3 plus COVID-19 symptoms (when available from phone contact). Results: In 303 days, 712 (10.2%) patients were allocated in G1 (chloroquine), 3623 (52.1%) in G2 (control) and 2622 (37.7%) in G3 (other treatments). Median age was 49 (IQR 38 - 62) years, 57% women. Of these, 1969 had successful phone contacts (G1: 260; G2: 871; G3: 838). The primary outcome was more frequent in groups 1 and 3 compared to the control group, when assessed exclusively by phone (G1: 38,5% vs. G2: 18,0% vs. G3: 34,2%, p&lt;0,001) or combined with administrative data (G1: 19,5% vs. G2: 11,0% vs. G3: 18,2%, p&lt;0,001). In the adjusted models, chloroquine independently associated with a greater chance of the primary outcome: phone contact (model 4): OR=3.24 (95% CI 2.31 - 4.54), p&lt;0.001; phone + administrative data (model 3): OR=1.99 (95% CI 1.61 - 2.44), p&lt;0.001. Chloroquine also independently associated with higher mortality, as assessed by phone + administrative data (model 3): OR=1.67 (95% CI 1.20 - 2.28). Conclusion: Chloroquine compounds associated with a higher risk of poor outcomes in outpatients with COVID-19 compared to standard care.

Physician Gender and Its Association With Patient Satisfaction and Visit Length: An Observational Study in Telemedicine.

IntroductionFemale physicians conduct longer visits than male physicians, with negative implications for their compensation. Yet patients often report higher satisfaction with female physicians. It is unknown whether satisfaction scores for female physicians are associated with their visit lengths. Our objective was to characterize the role of the physician and patient gender with respect to visit length and patient satisfaction.MethodsWe conducted an observational cohort study with patients and physicians of a nationwide telemedicine service between 2016 and 2018. Visit length was measured by the telemedicine system. Patients rated physicians on scales of one to five stars, with five considered “top box” satisfaction. We used logistic regression to estimate differences in patient satisfaction and linear regression to estimate differences in visit length by the physician and patient gender. We tested interactions between physician and patient gender and accounted for clustering by the physician.ResultsAmong 102,664 visits with 405 physicians, the mean visit length was 5.8 minutes. Visits with male physicians were 1.11 minutes shorter than those with female physicians (95% CI:-1.58, -0.65). Controlling for visit length, male physicians were less likely than female physicians to receive top-box satisfaction scores (OR: 0.72; 95% CI: 0.61, 0.85). Visits between female physicians and male patients were the longest and visits between male physicians and female patients were the shortest. Female physicians had longer visits than male physicians but this did not explain their higher satisfaction scores.ConclusionsTo reduce inequity in compensation resulting from differences in visit length, female physicians could shorten their visits without negative consequences for their satisfaction ratings.

The epidemic within the pandemic: Behavioral health and substance use in the face of COVID-19

The epidemic within the pandemic: Behavioral health and substance use in the face of COVID-19

Telemedicine Experience of General Surgery Trainees: Impact on Patient Care and Education.

The COVID-19 pandemic has had a significant impact on patient care, including the increased utilization of contact-free clinic visits using telemedicine. We looked to assess current utilization of, experience with, and opinions regarding telemedicine by general surgery residents at an academic university-based surgical training program. A response-anonymous 19-question survey was electronically distributed to all general surgery residents at a single academic university-based general surgery residency program. University of Southern California (USC) general surgery residency participants: Voluntarily participating general surgery residents at the University of Southern California. The response rate from USC general surgery residents was 100%. A majority of residents (76%) had utilized either video- or telephone-based visits during their careers. No resident had undergone formal training to provide telemedicine, although most residents indicated a desire for training (57.1%) and acknowledged that telemedicine should be a part of surgical training (75.6%). A wide variety of opinions regarding the educational experience of residents participating in telemedicine visits was elicited. The COVID-19 pandemic brought telemedicine to the forefront as an integral part of future patient care, including for surgical patients. Additional investigations into nationwide telemedicine exposure and practice among United States general surgery residencies is imperative, and the impact of the implementation of telemedicine curricula on general surgery resident telemedicine utilization, comfort with telemedicine technology, and patient outcomes are further warranted. Practice-based learning, systems-based practice, interpersonal and communication skills.

Telemedicine Consultation as an Indicator of Local Telemedicine Champions' Contributions, Health Care System Needs or Both: Tales from Two Continents.

Background: Telemedicine systems increase access to care, particularly in remote and developing countries. Nationwide telemedicine programs in Cabo Verde and Albania have been built by the International Virtual e-Hospital Foundation (IVeH) and based on the effective Initiate-Build-Operate-Transfer (IBOT) strategy. The aim of this study was to compare the clinical results between the two programs and examine the relationship between the clinical teleconsultations as an indicator of health care system needs and the contribution of local telemedicine champions. Methods: Data were prospectively collected between 2014 and 2018 from Albania and Cabo Verde. Telemedicine champions were defined as programs, physicians, or hospitals who have contributed at least 100 telemedicine consultations during the study periods. Chi-squared test was utilized to analyze the data. Results: There were 2,442 teleconsultations in Cabo Verde and 2,724 teleconsultations in Albania during the study periods. Using the 100-consultation benchmark as the indicator of telemedicine champion, we identified radiology (n = 1,061), neurotrauma (n = 742), and general neurology or stroke (n = 489) as champion clinical disciplines in Albania. With the same method of 100 consultations, we identified eight champion clinical disciplines in Cabo Verde, including neurology (n = 720), cardiology (n = 313), orthopedics (n = 190), surgery (143), endocrinology (141), otolaryngology (n = 139), urology (n = 139), and dermatology (126). The patient transfer/nontransfer ratio was 0.5 in Cabo Verde and 0.3 in Albania (p < 0.001). Three hospitals in Albania and eight community hospitals/health care centers in Cabo Verde requested the majority of teleconsultations. Two main hospitals in Cabo Verde and Albania responded to the consultations. Conclusion: The successful implementation of a telemedicine program depends on many factors. However, physician champions, who eventually create clinical discipline champions, and represent the hospital champions, are the backbone of the sustainability and progress of any telemedicine program. The number of consultations reflects the lack of local specialty expertise to provide health care service and thus can be used for future planning and investment.

1959. Parent Satisfaction and Antibiotic Prescribing for Pediatric Respiratory Infections by Telemedicine

BackgroundRespiratory tract infections (RTIs) are a common reason for direct-to-consumer (DTC) telemedicine consultation. Antibiotic prescribing during video-only DTC telemedicine consults was explored for pediatric RTIs, focusing on correlates with visit duration and patient satisfaction.MethodsData on pediatric (age less than 19 years) RTI consults were obtained from a large DTC nationwide telemedicine platform and included patient, physician, and encounter characteristics. Mixed-effects regression was used to assess variation in antibiotic receipt by patient and physician factors, as well as the association between antibiotic receipt and visit length or patient satisfaction.ResultsOf 12,842 RTI visits with 560 physicians, 55% of patients received an antibiotic prescription. Antibiotic prescribing rates among telemedicine providers were high: sinusitis (92.1%), otitis media (96.0%), pharyngitis (76.7%), and bronchitis/bronchiolitis (62.0%). A provider was more likely to receive a 5-star satisfaction rating from the parent when the child was provided a prescription for an antibiotic (OR 3.38; 95% CI 2.84–4.02), an antiviral (OR 2.56; 95% CI 1.81–3.64) or a nonantibiotic (OR 1.93; 95% CI 1.58–2.36). Visit length (mean 6.4 minute) was associated with higher satisfaction only when no antibiotic was prescribed (OR 1.03 per 6 seconds; 95% CI 1.01–1.06). Compared with nonpediatricians, pediatric providers were less likely to prescribe antibiotics (OR 0.44; 95% CI 0.29–0.68); however, patients of pediatricians were more likely to be highly satisfied (OR 1.50; 95% CI 1.11–2.03).ConclusionDuring DTC telemedicine video consultations for RTIs, pediatric patients were frequently prescribed antibiotics, which correlated with visit satisfaction. Although pediatricians prescribed antibiotics at a lower rate than other physicians, their satisfaction scores were higher. Especially problematic, adherence to guideline-concordant criteria for diagnosing acute otitis media and streptococcal pharyngitis, which, respectively, require otoscopy and throat culture, is not possible during a video-only telemedicine consult. High rates of antibiotic prescribing to children with RTIs suggest a need for antimicrobial stewardship efforts during video-only telemedicine consultation.Disclosures All Authors: No reported Disclosures.

A direct-to-patient telemedicine abortion service in Australia: Retrospective analysis of the first 18 months

Telemedicine is increasingly recognized as a promising means for enhancing access to abortion. In 2015, the Tabbot Foundation in Australia launched the first known nationwide telemedicine service to legally offer abortion directly to patients without an in person visit to an abortion provider. We report observations from the first 18 months of this service.

Access to Specialized Care Through Telemedicine in Limited-Resource Country: Initial 1,065 Teleconsultations in Albania.

To analyze the initial experience of the nationwide clinical telemedicine program of Albania, as a model of implementation of telemedicine using "Initiate-Build-Operate-Transfer" strategy. This was a retrospective study of prospectively collected data from teleconsultations in Albania between January 1, 2014 and August 26, 2015, delivered synchronously, asynchronously, or a combination of both methods. Patient's demographics, mode of consultation, clinical specialty, hospitals providing referral and consultation, time from initial call to completion of consultation, and patient disposition following teleconsultation were analyzed. Challenges of the newly created program have been identified and analyzed as well. There were 1,065 teleconsultations performed altogether during the study period. Ninety-one patients with autism managed via telemedicine were not included in this analysis and will be reported separately. Of 974 teleconsults, the majority were for radiology, neurotrauma, and stroke (55%, 16%, and 10% respectively). Asynchronous technology accounted for nearly two-thirds of all teleconsultations (63.7%), followed by combined (24.3%), and then synchronous (12.0%). Of 974 cases, only 20.0% of patients in 2014 and 22.72% of patients in 2015 were transferred to a tertiary hospital. A majority (98.5%) of all teleconsultations were conducted within the country itself. The Integrated Telemedicine and e-Health program of Albania has become a useful tool to improve access to high-quality healthcare, particularly in high demanding specialty disciplines. A number of challenges were identified and these should serve as lessons for other countries in their quest to establish nationwide telemedicine programs.

"Initiate-build-operate-transfer" - a strategy for establishing sustainable telemedicine programs not only in the developing countries

Establishing sustainable telemedicine has become a goal of many developing countries around the world. Yet, despite initiatives from a select few individuals and on occasion from various governments, often these initiatives never mature to become sustainable programs. The introduction of telemedicine and e-learning in the Balkans has been a pivotal step in advancing the quality and availability of medical services in a region whose infrastructure and resources have been decimated by wars, neglect, lack of funding, and poor management. The concept and establishment of the International Virtual e-Hospital (IVeH) has significantly impacted telemedicine and e-health services in Kosova. The success of the IVeH in Kosova has led to the development of similar programs in other Balkan countries and other developing countries in the hope of modernizing and improving their healthcare infrastructure. A comprehensive, four-pronged strategy developed by IVeH "Initiate-Build-Operate-Transfer" (IBOT), may be a useful approach in establishing telemedicine and e-health educational services not only in developing countries, but in developed countries. The development strategy, IBOT, used by the IVeH to establish and develop telemedicine programs is described. IBOT includes assessment of healthcare needs of each country, the development of a curriculum and education program, the establishment of a nationwide telemedicine network, and the integration of the telemedicine program into the very core of healthcare infrastructure. The end point is the transfer of a sustainable telehealth program to the nation involved. By applying IBOT, a sustainable telemedicine program of Kosova and Albania has been established as an effective prototype for telemedicine in the Balkans. Once fully matured, the program is transitioned to the Ministry of Health, which ensures the sustainability and ownership of the program. Similar programs are being established in Macedonia, Montenegro and other countries around the world. The IBOT model has been effective in creating sustainable telemedicine and e-health integrated programs in the Balkans and may be a good model for establishing such programs in developing countries.

Telemedicine and eye examinations for diabetic retinopathy: a time to maximize real-world outcomes.

A fundamental aspect of eye care and the long-term prevention of vision loss for patientswith diabetesmellitus involves the identification of specific retinal pathologies and the subsequent determination of the severity of diabetic retinopathy. Traditionally, this has been accomplished through individualized assessments by experienced eye care professionals, preferably following pupillary dilation. However, given that it is estimated that there will be more than half a billionpersonswithdiabetesby2030,necessitatingnearly2000 eye examinations per minute just to evaluate those in need once every year, this approach to retinal evaluation is unlikely to be sustainable by health care systems globally. Furthermore, despite multiple national and international initiatives to increase access andpromote awareness regarding the need for eye examinations for all persons with diabetes, only approximately 18% to 60% of persons undergo examinations that attain the recommended ocular examination guidelines. Progress, however, is possible. One of the success stories in the fight against complications due to diabetic retinopathy comes from the UK National Health Service in England andWales, which reports that, for the first time in 5 decades, diabetic retinopathy is no longer the leading cause of blindness in the working age population.1 A large part of this success appears to be due to their introduction of a nationwide telemedicine program for diabetic retinopathy and to improved glycemic control. Similar studies2-4 across multiple countries and populations have demonstrated that the prevalence of blindness and visual impairment among patients with diabetes is lowest among populations with programs that provide retinal evaluations for all patients with diabetes. Largely achieved using telemedicine programs for diabetic retinopathy, the implementation of retinal evaluations for all patients with diabetes has been shown to reduce the incidence of blindness among patients with diabetes by as much as 95%.3 In this issue of JAMA Ophthalmology, Mansberger and colleagues5 report on the long-termeffectiveness of telemedicine comparedwith traditional eye examinations for diabetic retinopathy by an eye care professional. This study,5 with up to5yearsof follow-up, reports that telemedicine increased the percentage of diabetic retinopathy examinations, with diabetic retinopathyseverity remaininggenerally stable, thussupporting theuseof telemedicine to screen fordiabetic retinopathy and monitor for disease worsening over a long period in the primary care setting. This and the other studies cited suggest that a telemedicine approach for diabetic retinopathy evaluation can effectively increase the rates of eye examinations, thereby potentially reducing the rates of blindness and vision loss in thediabetic population.However,Daskivich and Mangione6 caution readers that the devilwill be in the details whenitcomestoprimarycare–basedscreeningfordiabetic retinopathy. Indeed, to ensure that the benefits of telemedicine are fully realized in the real world, there is a need for standardized image capture; validated methods for image evaluation and reporting; definedquality control andquality assurance metrics; and secure data transmission, storage, and retrieval. Toaid this endeavor, theAmericanTelemedicineAssociationhaspublished the secondeditionof thepractice recommendations forocular telehealthprograms fordiabetic retinopathy that discusses eachof these critical aspects indetail.7 Given the ever more firmly established benefit of telemedicineprogramsfordiabetic retinopathy,ouremphasismust now shift toward optimizing approaches that improve efficiency, maximize beneficial long-term outcomes, and promote sustainability. Keys to success are the ongoing efforts to develop accepted recommendations on quality control, qualityassurance, referralguidelines, andstandards forpatientcare and safety. Furthermore, as the electronicmedical record becomes more universally integrated within telemedicine programs, evaluationof longitudinal clinical datamayprovide information relevant to care recommendations that may not otherwise be readily discovered.8 The retinal imaging device remains a technological cornerstone of any telemedicine program for diabetic retinopathy. Retinal imaging devices must meet current recommendations of image resolution (20 pixels per degree with a resolution of at least 10-15 μm) andmust be validated against Early Treatment Diabetic Retinopathy Study standard 7-field photography in determining the ability to identify and determine diabetic retinopathy severity. The importance of image quality is highlighted in the study by Mansberger and colleagues,5 who reported that the rate of ungradable images was approximately 3%to 11% fordiabetic retinopathyand 13% to 22% for diabetic macular edema across the different time intervals. These ungradable images prompted traditional eye examinations (as opposed to telemedicine examinations) for approximately 19%to26%ofpersons.Becauseungradable images necessitate a traditional examination, 1 in 4 or 5 patients would require a referral, limiting the cost-effectiveness of any telemedicineprogram.Furthermore,supplemental imagingapproachesmaybeofconsiderablebenefit.Forexample, the rates of ungradable images for diabetic macular edema are almost always higher than the rates of ungradable images for retinopathy, suggesting that the supplemental use of optical coherence tomography or a combined optical coherence tomographic/photographic modality might improve community outreach programs. Given recent progress in the care of personswithdiabetic retinopathy, the futureadvancementof teleRelated article Telemedicine and Eye Examinations for Diabetic Retinopathy Invited Commentary

Implementation of a novel occupational and environmental medicine specialty teleconsultation service: the VHA experience.

Occupational and environmental medicine (OEM) physician specialty practices continue to grow in scope and intensity across the Veterans Health Administration. This study characterizes the implementation of a novel, nationwide telemedicine program that provides OEM specialty consultation to providers across the Veterans Health Administration. We examined provider requests and specialist responses for a 6-month pilot from May to October 2013. Characteristics of consult users, determinants of case complexity, and specific applications of OEM specialty expertise were identified. Over a 6-month period, employee occupational health providers consulted the OEM telemedicine pilot a total of 65 times. Employee occupational health providers without formal training repeatedly identified complex cases related to work and disability. The program has created a new system management solution to deliver expert, in-depth consultation and real-time provider education in OEM.

Telemedicine as an innovative model for rebuilding medical systems in developing countries through multipartnership collaboration: the case of Albania.

The U.S. Government and other developed nations provide billions of dollars annually in relief assistance to countries around the world. The long-term benefits of this aid, however, are often difficult to elucidate. The aim of this article is to present a model of a multipartnership collaboration among U.S. governmental, nongovernmental organizations, and academia to rebuild medical systems using telemedicine as a sustainable model of foreign aid. The International Virtual e-Hospital implemented the "initiate-build-operate-transfer" strategy to establish an effective telemedicine system in Albania that includes the National Telemedicine Center and 12 regional telemedicine centers. This nationwide telemedicine network has active clinical programs, virtual educational programs, and an electronic library that has substantially improved the access to care while advancing medical education. We propose that telemedicine is an optimal, sustainable, low-cost model for rebuilding medical systems of developing countries when implemented through a multipartnership approach.

Design and Development of a Low Cost Personal Computer Based ECG Monitor

ECG equipment is vital for diagnosis of cardiac problems. However, such equipment come from the rich Western countries at a huge cost in both procurement and maintenance, and therefore cannot offer services to a large population in the Third World countries. The only solution is to design and develop such equipment in individual countries by developing local expertise. With three decades of experience, the Dhaka University group has taken a step towards developing prototypes of ECG equipment for dissemination to the healthcare service providers. This paper presents the detailed design of an PC based ECG equipment where optimized choice of components and of the design have been made keeping the cost and maintenance in view, but not sacrificing the quality, and incorporating necessary safety features to protect the patient from known hazards. Both the hardware and the software have been developed locally and are detailed in this paper. Outputs obtained from human subjects are shown which are of reasonable good quality, and have been verified using standard ECG equipment. The PC based ECG system will allow digital post processing of signals for improved diagnosis through software. Besides, this can also become part of a nationwide telemedicine system. DOI: http://dx.doi.org/10.3329/bjmp.v4i1.14701 Bangladesh Journal of Medical Physics Vol.4 No.1 2011 115-125

Determinants of physicians’ technology acceptance for e-health in ambulatory care

BackgroundGermany is introducing a nation-wide telemedicine infrastructure that enables electronic health services. The project is facing massive resistance from German physicians, which has led to a delay of more than five years. Little is known about the actual burdens and drivers for adoption of e-health innovations by physicians. ObjectiveBased on a quantitative study of German physicians who participated in the national testbed for telemedicine, this article extends existing technology acceptance models (TAM) for electronic health (e-health) in ambulatory care settings and elaborates on determinants of importance to physicians in their decision to use e-health applications. MethodsThis study explores the opinions, attitudes, and knowledge of physicians in ambulatory care to find drivers for technology acceptance in terms of information technology (IT) utilization, process and security orientation, standardization, communication, documentation and general working patterns. We identified variables within the TAM constructs used in e-health research that have the strongest evidence to determine the intention to use e-health applications. ResultsThe partial least squares (PLS) regression model from data of 117 physicians showed that the perceived importance of standardization and the perceived importance of the current IT utilization (p<0.01) were the most significant drivers for accepting electronic health services (EHS) in their practice. Significant influence (p<0.05) was shown for the perceived importance of information security and process orientation as well as the documentation intensity and the e-health-related knowledge. ConclusionsThis study extends work gleaned from technology acceptance studies in healthcare by investigating factors which influence perceived usefulness and perceived ease of use of e-health services. Based on these empirical findings, we derive implications for the design and introduction of e-health services including suggestions for introducing the topic to physicians in ambulatory care and incentive structures for using e-health.

“Initiate–Build–Operate–Transfer”—A Strategy for Establishing Sustainable Telemedicine Programs in Developing Countries: Initial Lessons from the Balkans

Establishing sustainable telemedicine has become a goal of many developing countries around the world. Yet, despite initiatives from a select few individuals and on occasion from various governments, often these initiatives never mature to become sustainable programs. The introduction of telemedicine and e-learning in Kosova has been a pivotal step in advancing the quality and availability of medical services in a region whose infrastructure and resources have been decimated by wars, neglect, lack of funding, and poor management. The concept and establishment of the International Virtual e-Hospital (IVeH) has significantly impacted telemedicine and e-health services in the Balkans. The success of the IVeH in Kosova has led to the development of similar programs in other Balkan countries and other developing countries in the hope of modernizing and improving their healthcare infrastructure. A comprehensive, four-pronged strategy, "Initiate-Build-Operate-Transfer" (IBOT), may be a useful approach in establishing telemedicine and e-health educational services in developing countries. The development strategy, IBOT, used by the IVeH to establish and develop telemedicine programs, was discussed. IBOT includes assessment of healthcare needs of each country, the development of a curriculum and education program, the establishment of a nationwide telemedicine network, and the integration of the telemedicine program into the healthcare infrastructure. The endpoint is the transfer of a sustainable telehealth program to the nation involved. By applying IBOT, a sustainable telemedicine program of Kosova has been established as an effective prototype for telemedicine in the Balkans. Once fully matured, the program will be transitioned to the national Ministry of Health, which ensures the sustainability and ownership of the program. Similar programs are being established in Albania, Macedonia, and other countries around the world. The IBOT model has been effective in creating sustainable telemedicine and e-health integrated programs in the Balkans and may be a good model for establishing such programs in developing countries.

Telemedicine: What It Is, Where It Came From, and Where It Will Go

Health care delivery in the United States is experiencing a paradigm shift, from a provider-centered approach to a patient-centered management model that emphasizes patient satisfaction and choice to build and retain market share. The application and usage of telecommunication technology have provoked this paradigm shift in health care delivery. As a form of technology, telemedicine has tremendously impacted society and revolutionized health care delivery in the country. It has drastically expanded the body of health care information available and has changed health care delivery models. Rogers’s theory ( Diffusion of Innovations [2003]) is adopted to explore why and how telemedicine has been implemented, grown, and sustained in Tennessee. It is beneficial to investigate the infrastructure of several forms of telemedicine networks that have been identified and commonly accepted as successful in developing and using it to improve health care delivery. This essay analyzes how five active telemedicine programs in Tennessee retain the structural commonalities that emphasize the importance of making telemedicine convenient for health care professionals and also making it visible through the use of marketing and training. To develop, grow, and sustain a telemedicine initiative, this essay suggests developing state- and nationwide telemedicine networks, ensuring multiple funding sources, and establishing a telemedicine advisory commission.