Telemedicine Center Research Articles

Use of Telemedicine in Surgical Education: A Seven-Year Experience

Uniformity in surgical education is challenging because surgical experience is based on rotation assignments. With work hour restrictions, the likelihood of residents being exposed to rare or unusual cases is diminished. Telemedicine may create a new learning paradigm for surgical education and supplement exposure for rare or unusual cases. A retrospective review (2010-2016) of teleconferences involving trauma centers worldwide was conducted. Participating hospitals included centers from underdeveloped countries to first world nations. Trauma cases were discussed among surgeons with different levels of experience and resource availability. Data collected included types of cases, anatomic injury patterns, hospital location, and the number of telemedicine centers and viewers participating. Seventy-three hospitals in 64 cities, spanning 27 countries, participated in 276 telemedicine grand round conferences. Cases discussed included penetrating trauma (47%), blunt trauma (42%), and blast injury (4%). The anatomic regions included were the thorax (28%), abdomen (26%), thoracoabdominal region (13%), neck (7%), and pelvis (6%). The most common injury discussed was vascular in nature (18%), followed by the lung, liver, diaphragm, and heart. The most common vascular lesion was in the aorta (18%), followed by the iliac vessels (8%) and the vena cava (7%). Telemedicine is a valuable tool, allowing the dissemination of diverse experiences. Most cases presented evaluated rare injuries or complex surgical approaches, which are not commonly seen on trauma sites. Learning different approaches in the management of complex trauma will make surgeons more prepared to deal with challenging cases.

TELEMEDICINE IN THE CONTEXT OF ACCESSIBILITY OF MEDICAL AID IN RUSSIA

The urgency of the topic is determined by the need to significantly increase the level of accessibility of medical services, first of all — of an innovative nature. The purpose of the article is to identify and characterize the development of telemedicine in contemporary Russia and therefore, propose the tools to improve accessibility of telemedicine services to the population.. Management decisions and organizational and economic relations that arise within the development of telemedicine are the subject of the study. The main results are: analysis of accessibility of medical services to the population as a whole was conducted; directions of using telemedicine technologies as an instrument for increasing access to medical care were identified; problems in the development of the domestic telemedicine market were outlined; differentiated accessibility of telemedicine services by different criteria were identified; directions for solving identified problems were suggested. The author suggests development of network cooperation between medical prevention centers, telemedicine centers and educational institutions located in rural areas. The materials of the article can be useful both for further scientific substantiation of ways for development of healthcare and for elaboration of practical solutions for the development of the market of innovative medical services.

Building clinical trials around patients: Evaluation and comparison of decentralized and conventional site models in patients with low back pain.

Clinical trials are slow and costly, built around the research centers that study local participants. Building clinical trials around patients in their homes and community through remote visits and monitoring could enhance recruitment and increase convenience for participants. This study evaluated different trial settings, a decentralized arm via telemedicine center (virtual study conduct), a conventional arm via health clinic (onsite study conduct) and a mixed model arm. Acute low-back pain patients (20–65 years) were recruited to this non-interventional trial in Switzerland. The study consisted of a screening period and a 2-week data collection period using direct data capture (eSource), electronic informed consent form (eICF), electronic diary (eDiary) and wearable actigraphy sensor.A higher number of patients were enrolled in the decentralized arm (N = 18) compared to the conventional arm (N = 5) and none in the mixed model arm. The decentralized arm consisted of a diverse population with increased participation from rural areas. In the decentralized arm 89% of enrolled patients completed the study compared to 60% in the conventional arm. All the patients reported satisfaction with the use of eICF, eDiary and remote visits; whereas patients reported a lower level of satisfaction with the wearable sensor.The decentralized setting was operationally feasible and well accepted by patients. Faster recruitment and improved access to patients was observed in the decentralized arm. This study supports broader adoption of the decentralized model in clinical trials, though further investigations in larger interventional trials are needed to confirm the benefits from this patient-centric approach.

An economic cost analysis of an expanding, multi-state behavioural telehealth intervention

Introduction In this paper the economic costs associated with a growing, multi-state telepsychiatry intervention serving rural American Indian/Alaska Native populations were compared to costs of travelling to provide/receive in-person treatment. Methods Telepsychiatry costs were calculated using administrative, information-technology, equipment and technology components, and were compared to travel cost models. Both a patient travel and a psychiatrist travel model were estimated utilising ArcGIS software and unit costs gathered from literature and government sources. Cost structure and sensitivity analysis was also calculated by varying modeling parameters and assumptions. Results and Discussion It is estimated that per-session costs were $93.90, $183.34, and $268.23 for telemedicine, provider-travel, and patient-travel, respectively. Restricting the analysis to satellite locations with a larger number of visits reduced telemedicine per-patient encounter costs (50 or more visits: $83.52; 100 or more visits: $80.41; and 150 or more visits: $76.25). The estimated cost efficiencies of telemedicine were more evident for highly rural communities. Finally, we found that a multi-state centre was cheaper than each state operating independently. Conclusions Consistent with previous research, this study provides additional evidence of the economic efficiency associated with telemedicine interventions for rural American Indian/Alaska Native populations. Our results suggest that there are economies of scale in providing behavioural telemedicine and that bigger, multi-state telemedicine centres have lower overall costs compared to smaller, state-level centres. Additionally, results suggest that telemedicine structures with a higher number of per-satellite patient encounters have lower costs, and telemedicine centres delivering care to highly rural populations produce greater economic benefits.

Application analysis of radiological imaging tele-consultation

Objective To investigate radiological imaging tele-consultation in clinical application. Methods All cases of the tele-consultation analyzed retrospectively came from the Hospital′s telemedicine center from January to December of 2015. The statistical analysis covered the level of applying hospital, modality type of imaging, inspection area, as well as the timing and purpose of the consultation. Results A total of 179 medical institutions required image consultation in 2015, most of which secondary hospitals, up to 58.66%. A total of 2 454 cases were consulted, including X-ray of 278 cases (11.33%), CT of 1 353 cases (55.13%), and MRI of 823 cases (33.54%). Purposes of tele-consultation vary from differential diagnosis of 1 602 cases (65.28%), definitive diagnosis of 766 cases (31.21%), and confirmative review of 86 cases (3.51%). 90.59% of the consultation cases were finished within 24 hours. Conclusions Radiological imaging tele-consultation could offer local hospitals with diagnosis efficiently effectively. On one hand, this service saves patients' costs and gains time for treatment. On the other, it makes primary hospitals more efficient in radiological imaging diagnosis. Key words: Tele-consultation; Medical imaging; Primary medical institutions; Requirement; Application

3D Integrated Tissue and Organ Printing System to Produce Human Body Parts with Structural Integrity

Tissue engineering and regenerative medicine strategies could offer new hope for patients with serious tissue injuries or end‐stage organ failure. Scientists are now applying the principles of cell transplantation, material science, and engineering to create biological substitutes that can restore and maintain normal function in diseased or injured tissues/organs. Among various three‐dimensional (3D) biofabrication technologies developed for the field of tissue engineering, 3D printing technology is one of the most attractive and powerful methods for use in constructing a structure that mimics native tissues, and thus many researchers are focusing on development of new printing technologies and applications. The hypothesis driving development of 3D bioprinting is that by precisely placing cells in relation to each other, an environment that encourages physiologically relevant cues both to and from these cells can be created, resulting in a tissue construct with functionality. Thus, we have developed 3D integrated tissue and organ printing (ITOP) system to allow construction of biological substitutes that mimic the structure and function of native tissues or organs. This system makes it possible to precisely place various cell types and biomaterials in a single 3D architecture. Our proof of concept experiments demonstrates the capabilities of our ITOP by fabricating structures of various tissue constructs of appropriate shape and size needed for clinical use. This novel organ printing system provides a leap forward in our ability to fabricate tissue constructs that could be used in translational applications.Support or Funding InformationThis work was supported, in part, by grants from the Armed Forces Institute of Regenerative Medicine (W81XWH‐08‐2‐0032), the Telemedicine and Advanced Technology Research Center at the US Army Medical Research and Material Command (W81XWH‐07‐1‐0718) and the Defense Threat Reduction Agency (N66001‐13‐C‐2027).

Telemedicine in Switzerland - the Example of Medgate

Telemedicine plays a central role in the acute medical care of patients in Switzerland. The Medgate Telemedicine Center has approximately 100 physicians, and for many patients has a function similar to that of a general practice as their first point of contact for medical concerns. Over 900 000 patients received telemedicine care in 2016. Patients can be treated entirely at a distance in about half of all cases. If this is not possible, the telemedicine physicians determine and coordinate further treatment. Telemedicine is also designed to reduce costs and duplication, while maintaining a high quality of patient care. Properly structured processes, evidence-based medical guidelines based on many years of experience as well as regular quality controls are essential in order to ensure high and uniform quality.

Teleconsultation on Skin Diseases: The Challenge of Providing Health Care to Isolated Populations in the Amazon Rainforest

This observational study was carried out in the state of Amazonas (Brazil), a huge and remote Rainforest area with only 2.2 inhabitants per square kilometer. This isolation is due to both geographical setting and ethnic-cultural barriers, with the indigenous population representing around 4% (20% of the entire indigenous population of Brazil, 60 ethnic groups and more than 40 languages). The lack of dermatology specialists encourages the few Primary Health Care Doctors (PCD) to apply for asynchronous support on skin disease occurrences through the portal of the Manaus-based Telemedicine and Telehealth Centre (TTC). Subsequently, the TTC counsels the PCD at a distance through his dermatologist-consultants (DC). The performance of such a teleconsultation system was audited by a TTC independent board of experts. They reviewed a 24 months continuous case series by focusing on the quality of PCD applications and DC counseling. The quality of anamnesis, description of physical signs and attached clinical documentation by the PCD was satisfactory in only 56/100, 44/100 and 53/100, respectively. A significantly negative trend (p<0.05) from the first to the second year was also observed. However, the PCD prompted presumptive diagnosis in 87/100, with a 72% of agreement with the DC’s final diagnosis. Indicators of good DC performance were: a) the response to the application within 72 h time occurring in 51/100, with a significantly improving trend (P<0.05); and b) the referrals to the health facilities of the capital of the state being recommended in only 13/100. Teleconsultation represents an opportunity for providing access to isolated populations and minorities. Although DC performance is improving, the high turnover of PCDs and the lack of training in e-health at the undergraduate level result in the poor quality of PCD applications. Thus, instruction in e-health tools should be added to the curriculum of the undergraduate program in medicine.

Treatment of Acute Coronary Syndrome by Telemedically Supported Paramedics Compared With Physician-Based Treatment: A Prospective, Interventional, Multicenter Trial

BackgroundPrehospital treatment of acute coronary syndrome (ACS) in German emergency medical services (EMSs) is reserved for EMS physicians due to legal issues.ObjectiveThe objective of this prospective, interventional, multicenter trial was to evaluate the quality of telemedically-delegated therapy and the possible complications in patients with ACS.MethodsAfter approval by the ethics committee and trial registration, a one-year study phase was started in August 2012 with 5 ambulances, telemedically equipped and staffed with paramedics, in 4 German EMS districts. The paramedics could contact an EMS-physician–staffed telemedicine center. After initiation of an audio connection, real-time data transmission was automatically established. If required, 12-lead electrocardiogram (ECG) and still pictures could be sent. Video was streamed from inside each ambulance. All drugs, including opioids, were delegated to the paramedics based on standardized, predefined algorithms. To compare telemedically-delegated medication and treatment in ACS cases with regular EMS missions, a matched pair analysis with historical controls was performed.ResultsTeleconsultation was performed on 150 patients having a cardiovascular emergency. In 39 cases, teleconsultation was started due to suspected ACS. No case had a medical complication. Correct handling of 12-lead ECG was performed equally between the groups (study group, n=38 vs control group, n=39, P>.99). There were no differences in correct handling of intravenous administration of acetylsalicylic acid, heparin, or morphine between both the groups (study group vs control group): acetylsalicylic acid, n=31 vs n=33, P=.73; unfractionated heparin, n=34 vs n=33, P>.99; morphine, n=29 vs n=27, P=.50. The correct handling of oxygen administration was significantly higher in the study group (n=29 vs n=18, P=.007).ConclusionsTelemedical delegation of guideline conform medication and therapy by paramedics in patients with ACS and was found to be feasible and safe. The quality of guideline-adherent therapy was not significantly different in both the groups except for the correct administration of oxygen, which was significantly higher in the study group.Trial RegistrationClinicaltrials.gov NCT01644006; http://clinicaltrials.gov/ct2/show/NCT01644006 (Archived by WebCite at http://www.webcitation.org/6mPam3eDy).

Nursing practice with triage decision making for COPD patients of a telemedicine centre – An ethnographic approach

Introduction: The collaboration reform has increased the responsibility of Norwegian municipalities for health care services for patients with chronic diseases; whereas chronic obstructive pulmonary disease (COPD) represents a large group [1]. This change, associated to the reform, requires establishing new clinical pathways. Telemedicine (TM) has demonstrated potential in advanced nursing practice in terms of efficacy and quality of care [2]. Through TM, nurses can determine patient’s health status and follow-up supported by a decision aid software program. To date, there is little research investigating how nurses working in municipal health care services make clinical decisions based on a triage to assess COPD patient’s health status. This research presents an ethnographic study with three nurses working in a telemedicine center (TMC) in Southern Norway as part of a European project, namely United4Health. Patients used a tablet at home with video camera for video consultations and a pulse oximeter device for transference of clinical measurements (oxygen saturation and heart rate). The aim of the study was to investigate how nurses in a TMC using video consultations made decisions on COPD patient’s health status using triage as part of the decision making process. Methods: The data collection was made through participatory observations, field notes and focus group interview including three nurses working in a TMC from October 2015 to February 2016 in southern Norway. The collected data is currently being analysed using qualitative content analysis [3]. Results and discussion: Preliminary results showed that nurses working in the TMC found the triage useful as part of the decision making process that allowed identifying health problems and prioritising the patients need for help. However, the nurses often used workarounds and made decisions according to their own knowledge and experience when interpreting the software recommendation; in these cases, the triage model was seen just as guidance. In addition, this interpretation was not only based on the daily triage assigned to each patient, but also on the content of past triaging and earlier nurses’ documentation for each patient. This indicated that triaging a chronic patient is complex, time consuming and relies on the nurses’ previous knowledge concerning both patients’ medical history and life. Furthermore, video consultation was important for the nurses as a visualisation of the patient, and it was a significant additional component to the triage recommendation and nurses’ own decision. Video consultation follow-up was often replaced by telephone calls because of frequent technical problems. This led to important visual information for the decision making process was not possible to be observed by nurses, which could have negatively influenced the decision outcome.

PHP129 - Analysis on the Regional Distribution of Telemedicine in China

Analyze the regional distribution of telemedicine in diferent districts. According to the directories of National Health Committee telemedicine center network hospitals , collecting the hospital ownership in different regions.And analyzing the circumstances of telemedicine from the view of population distribution in China. there are 1220 hospitals in the directories, which from 28 provinces ,it can be divided into three parts. 1.there are 13 region from the west of China, contained 760 medical units, accounting for 62.30%, Among the 760 hospitals, tertiary hospitals accounted for 11.84%,secondary hospitals accounted for 35.28%, community hospital accounted for 3.28%, unrated hospital accounted for 49.60%. And there are 471 hospitals in the poorest areas among 760 medical units, 8.5% are tertiary hospitals, secondary hospitals accounted for 22% ,community hospital accounted for 2.55%, unrated hospital accounted for 66.88% . 2. there are 6 provinces from the central and northeast old industrial regions regions,contained 135 hospitals and institutions, accounted for 11.06%.Among the 135 hospitals, tertiary hospitals accounted for 17.78% , secondary hospitals accounted for 40.74%, community hospital accounted for 20.74% ,unrated hospital accounted for 20.74%.3. there are 9 provinces from the economically developed regions,contained 327 hospitals and institutions,accounting for 26.8%.Among the 327 hospitals ,the ertiary hospitals accounted for 14.68% , secondary hospitals accounted for 45.87%, community hospital accounted for 4.28%, unrated hospital accounted for 35.17%. 1.Most of hospitals of the telemedicine are distributed in the west of China which are vast sparsely populated, and many of them are in the poorest and most extensive areas of west. 2.some of them are in the central and northeast old industrial areas ,3 .Less of them are distributed in economically developed regions. so, we predict telemedicine will have a better development in China.

Ethical aspects of Dhaka University Tele-medicine System

To provide basic health care services in rural areas is one of the major challenges for developing countries like Bangladesh because of lack of infrastructures and unavailability of qualified medical doctors in the villages. Telemedicine viewed as a new way of offering health care services that has the potential to overcome this problem. Author is a member of extended group at Dhaka University (DU) which has been developing telemedicine equipment and data acquisition software to promote telemedicine practice in Bangladesh. PC based ECG equipment, Digital stethoscope, Digital microscope, Digital X-ray view box and some other essential medical equipment was developed for telemedicine services. The data acquisition software establishes an easy and appropriate patients to doctor interaction through a trained operator in a remote center that involve management and arrangement of consultation of a chosen and agreeing doctor by a patient. Upon establishing audio-visual connection between patient and doctor relevant physiological data from different diagnostic instruments will be uploaded securely in a dedicated web server which can be viewed real time using unique patient/doctor ID and password. Recently the Telemedicine group of DU and a local NGO named SAMAMA with support from Service innovation fund (SIF) of Prime Minister Office (PMO) of Bangladesh took the initiative to establish eight rural telemedicine centers and one expert center for the field trial of telemedicine in Bangladesh. The aim of this paper is to examine the ethical challenges of such health care system and our effort to overcome those problem before starting the field trial.

Editorial Vol.6(3)

Editorial Vol.6(3)

ICU Telemedicine Comanagement Methods and Length of Stay

Studies have identified processes that are associated with more favorable length of stay (LOS) outcomes when an ICU telemedicine program is implemented. Despite these studies, the relation of the acceptance of ICU telemedicine management services by individual ICUs to LOS outcomes is unknown. This is a single ICU telemedicine center study that compares LOS outcomes among three groups of intensivist-staffed mixed medical-surgical ICUs that used alternative comanagement strategies. The proportion of provider orders recorded by an ICU telemedicine provider to all recorded orders was compared among ICUs that used a monitor and notify comanagement approach, a direct intervention with timely notification process, and ICUs that used a mix of these two approaches. The primary outcome was acuity-adjusted hospital LOS. ICUs that used the direct intervention with timely notification strategy had a significantly larger proportion of provider orders recorded by ICU telemedicine physicians than the mixed methods of comanagement group, which had a larger proportion than ICUs that used the monitor and notify method (P< .001). Acuity-adjusted hospital LOS was significantly lower for the direct intervention with timely notification comanagement strategy (0.68; 0.65-0.70) compared with the mixed methods group (0.70 [0.69-0.72]; P= .01), which was significantly lower than the monitor and notify group (0.83 [0.80-0.86]; P< .001). Direct intervention with timely notification strategies of ICU telemedicine comanagement were associated with shorter LOS outcomes than monitor and notify comanagement strategies.

Compression and Encryption of ECG Signal Using Wavelet and Chaotically Huffman Code in Telemedicine Application.

In mobile health care monitoring, compression is an essential tool for solving storage and transmission problems. The important issue is able to recover the original signal from the compressed signal. The main purpose of this paper is compressing the ECG signal with no loss of essential data and also encrypting the signal to keep it confidential from everyone, except for physicians. In this paper, mobile processors are used and there is no need for any computers to serve this purpose. After initial preprocessing such as removal of the baseline noise, Gaussian noise, peak detection and determination of heart rate, the ECG signal is compressed. In compression stage, after 3 steps of wavelet transform (db04), thresholding techniques are used. Then, Huffman coding with chaos for compression and encryption of the ECG signal are used. The compression rates of proposed algorithm is 97.72 %. Then, the ECG signals are sent to a telemedicine center to acquire specialist diagnosis by TCP/IP protocol.

Use of information technology to improve quality of healthcare: Kosova's telemedicine project and international virtual e-hospital as an example.

The idea to create the Telemedicine Project of Kosova and the International Virtual e-Hospital Network of Kosova, was presented at G8-Meeting, in Berlin May 4-5, 2000, by the senior author (RL) then Assistant Professor of Surgery at Virginia Commonwealth University, in Richmond, Virginia during the presentation, the "The anatomy of war and destruction of Kosova: The alumni view on reconstruction of heath in Kosova". Following wide spread acceptance by many countries and institutions around the world of the idea of creating a virtual e-hospital in Kosova,, became a reality. To ensure the creation of a telemedicine center and realization of the project in Kosova, the Telemedicine Association of Kosova was created in Prishtina, September 30, 2000. On February 2, 2001 a Memorandum of Understanding (MOU) for the implementation of TPK was signed between all stakeholders in health in Kosova. After extensive preparation, with the funding from the European Agency for Reconstruction, the Telemedicine Center of Kosova (TCK) was inaugurated on December 10, 2002, making way for the official beginning of the first phase of development of the TPK. This historical moment for Kosova and for the Balkan countries received extensive media coverage locally and abroad. Currently we are at the second year and phase of TPK realization. The Telemedicine Center of Kosova (TCK) is a state-of-the-art telemedicine center, the best in the Balkan and southeastern Europe. As such TCK is providing basic foundations for development of educational medical programs within the Kosova's medical system; as well it is establishing the standards of regional and international consultations and collaboration in the Balkan Peninsula. Furthermore, it is providing a solid basis for creation of human capacity that will lead and implement telemedicine program in the nine regional telemedicine centers of Kosova, for many years and decades to come.

Evaluation of telemedicine centres in Madhya Pradesh, Central India

In a developing country such as India, there is substantial inequality in health care distribution. Telemedicine facilities were established in Madhya Pradesh in 2007–2008. The purpose of this study was to evaluate the infrastructure, equipment, manpower, and functional status of Indian Space and Research Organisation (ISRO) telemedicine nodes in Madhya Pradesh. All district hospitals and medical colleges with nodes were visited by a team of three members. The study was conducted from December 2013–January 2014. The team recorded the structural facility situation and physical conditions on a predesigned pro forma. The team also conducted interviews with the nodal officers, data entry operator and other relevant people at these centres. Of the six specialist nodes, four were functional and two were non-functional. Of 10 patient nodes, two nodes were functional, four were semi-functional and four were non-functional. Most of the centres were not working due to a problem with their satellite modem. The overall condition of ISRO run telemedicine centres in Madhya Pradesh was found to be poor. Most of these centres failed to provide telemedicine consultations. We recommend replacing this system with another cost effective system available in the state wide area network (SWAN). We suggest the concept of the virtual out-patient department.

Incentives to create and sustain healthy behaviors: technology solutions and research needs.

Health-related technology, its relevance, and its availability are rapidly evolving. Technology offers great potential to minimize and/or mitigate barriers associated with achieving optimal health, performance, and readiness. In support of the U.S. Army Surgeon General's vision for a "System for Health" and its Performance Triad initiative, the U.S. Army Telemedicine and Advanced Technology Research Center hosted a workshop in April 2013 titled "Incentives to Create and Sustain Change for Health." Members of government and academia participated to identify and define the opportunities, gain clarity in leading practices and research gaps, and articulate the characteristics of future technology solutions to create and sustain real change in the health of individuals, the Army, and the nation. The key factors discussed included (1) public health messaging, (2) changing health habits and the environmental influence on health, (3) goal setting and tracking, (4) the role of incentives in behavior change intervention, and (5) the role of peer and social networks in change. This report summarizes the recommendations on how technology solutions could be employed to leverage evidence-based best practices and identifies gaps in research where further investigation is needed.

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.

Telemedicine Centers as a Venue for Attracting International Medical Tourists

Telemedicine Centers as a Venue for Attracting International Medical Tourists