Enablers and barriers in upscaling telemonitoring across geographic boundaries: a scoping review.

INTRODUCTION AND OBJECTIVE: Telemonitoring is a method to monitor a person's vital functions via their physiological data at distance, using technology. While pilot studies on the proposed benefits of telemonitoring show promising results, it appears challenging to implement telemonitoring on a larger scale. The aim of this scoping review is to identify the enablers and barriers for upscaling of telemonitoring across different settings and geographical boundaries in healthcare. METHODS: PubMed, Embase, Cinahl, Web of Science, ProQuest and IEEE databases were searched. Resulting outcomes were assessed by two independent reviewers. Studies were considered eligible if they focused on remote monitoring of patients' vital functions and data was transmitted digitally. Using scoping review methodology, selected studies were systematically assessed on their factors of influence on upscaling of telemonitoring. RESULTS: A total of 2298 titles and abstracts were screened, and 19 articles were included for final analysis. This analysis revealed 89 relevant factors of influence: 26 were reported as enabler, 18 were reported as barrier and 45 factors were reported being both. The actual utilisation of telemonitoring varied widely across studies. The most frequently mentioned factors of influence are: resources such as costs or reimbursement, access or interface with electronic medical record and knowledge of frontline staff. CONCLUSION: Successful upscaling of telemonitoring requires insight into its critical success factors, especially at an overarching national level. To future-proof and facilitate upscaling of telemonitoring, it is recommended to use this type of technology in usual care and to find means for reimbursement early on. A wide programme on change management, nationally or regionally coordinated, is key. Clear regulatory conditions and professional guidelines may further facilitate widespread adoption and use of telemonitoring. Future research should focus on converting the 'enablers and barriers' as identified by this review into a guideline supporting further nationwide upscaling of telemonitoring.

A cost minimisation analysis in teledermatology: model-based approach.

BACKGROUND: Although store-and-forward teledermatology is increasingly becoming popular, evidence on its effects on efficiency and costs is lacking. The aim of this study, performed in addition to a clustered randomised trial, was to investigate to what extent and under which conditions store-and-forward teledermatology can reduce costs from a societal perspective. METHODS: A cost minimisation study design (a model based approach) was applied to compare teledermatology and conventional process costs per dermatology patient care episode. Regarding the societal perspective, total mean costs of investment, general practitioner, dermatologists, out-of-pocket expenses and employer costs were calculated. Uncertainty analysis was performed using Monte Carlo simulation with 31 distributions in the used cost model. Scenario analysis was performed using one-way and two-way sensitivity analyses with the following variables: the patient travel distance to physician and dermatologist, the duration of teleconsultation activities, and the proportion of preventable consultations. RESULTS: Total mean costs of teledermatology process were €387 (95%CI, 281 to 502.5), while the total mean costs of conventional process costs were €354.0 (95%CI, 228.0 to 484.0). The total mean difference between the processes was €32.5 (95%CI, -29.0 to 74.7). Savings by teledermatology can be achieved if the distance to a dermatologist is larger (> = 75 km) or when more consultations (> = 37%) can be prevented due to teledermatology. CONCLUSIONS: Teledermatology, when applied to all dermatology referrals, has a probability of 0.11 of being cost saving to society.In order to achieve cost savings by teledermatology, teledermatology should be applied in only those cases with a reasonable probability that a live consultation can be prevented. TRIAL REGISTRATION: This study is performed partially based on PERFECT D Trial (Current Controlled Trials No. ISRCTN57478950).

Teledermatologic consultation and reduction in referrals to dermatologists: a cluster randomized controlled trial.

OBJECTIVE: To determine whether teledermatologic consultations can reduce referrals to a dermatologist by general practitioners (GPs). DESIGN: Multicenter cluster randomized controlled trial. SETTING AND PARTICIPANTS: We recruited 85 GPs from 35 general practices in 2 regions in the Netherlands (Almere and Zeist); 5 dermatologists from 2 nonacademic hospitals were also included in the study. Interventions The GPs randomized to the intervention used a teledermatologic consultation system to confer with a dermatologist, whereas those in the control group referred their patients according to usual practice. All patients, regardless of their condition, were seen in the office by a dermatologist after approximately 1 month. OUTCOME MEASURES: The main outcome measure was the proportion of office visits prevented by teledermatologic consultation, as determined by dermatologists at approximately the 1-month office visit. The secondary outcome measure was patient satisfaction, measured using the Patient Satisfaction Questionnaire III developed by Ware et al. RESULTS: The 85 study GPs enrolled 631 patients (46 intervention GPs, 327 patients; 39 control GPs, 304 patients). The 5 dermatologists considered a consultation preventable for 39.0% of patients who received teledermatologic consultation and 18.3% of 169 control patients, a difference of 20.7% (95% confidence interval, 8.5%-32.9%). At the 1-month dermatologist visit, 20.0% of patients who received teledermatologic consultation had recovered compared with 4.1% of control patients. No significant differences in patient satisfaction were found between groups. CONCLUSIONS: Teledermatologic consultation offers the promise of reducing referrals to a dermatologist by 20.7%. Providing teledermatologic consultation by GPs with more extended knowledge of dermatology may further reduce the need for dermatologist referrals. Trial Registration Current Controlled Trials No. ISRCTN57478950.

Evaluation of general practitioner's time investment during a store-and-forward teledermatology consultation.

BACKGROUND/OBJECTIVE: Introduction of teledermatology in general practice changes responsibilities and workloads of general practitioners (GPs) and dermatologists. We investigated the time investment of GPs as well as the relative share of the separate teledermatology activities during a store-and-forward teledermatology consultation. METHODS: Sixty-four teledermatology consultations (eight GPs x eight patients) were conducted in a laboratory setting. The starting and ending time of each consultation and of five separate teledermatology activities were recorded by independent observers. The impact of several GP, patient and consultation characteristics on the calculated durations was investigated with repeated measurements analysis. RESULTS: The mean duration of a teledermatology consultation was 11:32 min (range 7:02-26:44 min). The activity 'filling out electronic referral form' was the most time consuming teledermatology activity (3:12 min; 28%). Most time was spent on non-TD related consultation activities, e.g. taking medical history (4:43 min; 41%). The first of the eight consultations (p<0.001) and consultations with female patients (p=0.032) took on average more time than subsequent consultations (first consultations 13:42 min (male patients) and 17:03 min (female patients), and subsequent consultations 9:56 min (male patients) and 11:08 min (female patients)). CONCLUSIONS: Usage of store-and-forward teledermatology increases the average duration of a GP consultation with at least three and a half minutes. Further integration of teledermatology applications and electronic patients' records may reduce the total duration of a consultation and increase acceptance of teledermatology in general practice.

Ten years of teledermatology.

Using telemedicine health professionals can communicate with each other and with their patients over a distance. Teledermatology, dermatology application of telemedicine, is one of the most often applied telemedicine applications worldwide. Various studies have been performed to evaluate the effectiveness and efficiency of and satisfaction with teledermatology. Up to now no or limited valid scientific evidence has been found that teledermatology is beneficial for any group of users. This study aimed to perceive insight into the evolution of evaluation studies of teledermatology over the past ten years in terms of the telemedicine evaluation framework by Holle and Zahlmann consisting of four continuous phases. We added the phase "post implementation studies" that evaluate teledermatology as a fully integrated service in regular care. Retrieved literature from Medline was reviewed by two reviewers independently in order to include studies and classify them into the five phases. Ninety-nine studies out of 372 found unique references were included and classified into the phases. Most represented phase was phase II with 72 (72%) studies. The number of phase II studies is continuously growing since the introduction of evaluation in teledermatology. There were eight reported RCTs found (two in phase III, six in phase IV). The number of phase III and IV studies is too low to draw conclusions about the trends in their publication and stress the need for more such studies. Phase I and post implementations studies are probably under-represented as they might often not be published separately in scientific journal papers.

First evaluation of the NHS direct online clinical enquiry service: a nurse-led web chat triage service for the public.

BACKGROUND: NHS Direct is a telephone triage service used by the UK public to contact a nurse for any kind of health problem. NHS Direct Online (NHSDO) extends NHS Direct, allowing the telephone to be replaced by the Internet, and introducing new opportunities for informing patients about their health. One NHSDO service under development is the Clinical Enquiry Service (CES), which uses Web chat as the communication medium. OBJECTIVE: To identify the opportunities and possible risks of such a service by exploring its safety, feasibility, and patient perceptions about using Web chat to contact a nurse. METHODS: During a six-day pilot performed in an inner-city general practice in Coventry, non-urgent patients attending their GP were asked to test the service. After filling out three Web forms, patients used a simple Web chat application to communicate with trained NHS Direct triage nurses, who responded with appropriate triage advice. All patients were seen by their GP immediately after using the Web chat service. Safety was explored by comparing the nurse triage end point with the GP's recommended end point. In order to check the feasibility of the service, we measured the duration of the chat session. Patient perceptions were measured before and after using the service through a modified Telemedicine Perception Questionnaire (TMPQ) instrument. All patients were observed by a researcher who captured any comments and, if necessary, to assisted with the process. RESULTS: A total of 25 patients (mean age 48 years; 57% female) agreed to participate in the study. An exact match between the nurse and the GP end point was found in 45% (10/22) of cases. In two cases, the CES nurse proposed a less urgent end point than the GP. The median duration of Web chat sessions was 30 minutes, twice the median for NHS Direct telephone calls for 360 patients with similar presenting problems. There was a significant improvement in patients' perception of CES after using the service (mean pre-test TMPQ score 44/60, post-test 49/60; p=0.008 (2-tailed)). Patients volunteered several potential advantages of CES, such as the ability to re-read the answers from the nurse. Patients consider CES a useful addition to regular care, but not a replacement for it. CONCLUSIONS: Based on this pilot, we can conclude that CES was sufficiently safe to continue piloting, but in order to make further judgments about safety, more tests with urgent cases should be performed. The Web chat sessions as conducted were too long and therefore too expensive to be sustainable in the NHS. However, the positive reaction from patients and the potential of CES for specific patient groups (the deaf, shy, or socially isolated) encourage us to continue with piloting such innovative communication methods with the public.