Choosing to live with home dialysis-patients' experiences and potential for telemedicine support: a qualitative study.

BACKGROUND: This study examines the patients' need for information and guidance in the selection of dialysis modality, and in establishing and practicing home dialysis. The study focuses on patients' experiences living with home dialysis, how they master the treatment, and their views on how to optimize communication with health services and the potential of telemedicine. METHODS: We used an inductive research strategy and conducted semi-structured interviews with eleven patients established in home dialysis. Our focus was the patients' experiences with home dialysis, and our theoretical reference was patients' empowerment through telemedicine solutions. Three informants had home haemodialysis (HHD); eight had peritoneal dialysis (PD), of which three had automated peritoneal dialysis (APD); and five had continuous ambulatory peritoneal dialysis (CAPD). The material comprises all PD-patients in the catchment area capable of being interviewed, and all known HHD-users in Norway at that time. RESULTS: All of the interviewees were satisfied with their choice of home dialysis, and many experienced a normalization of daily life, less dominated by disease. They exhibited considerable self-management skills and did not perceive themselves as ill, but still required very close contact with the hospital staff for communication and follow-up. When choosing a dialysis modality, other patients' experiences were often more influential than advice from specialists. Information concerning the possibility of having HHD, including knowledge of how to access it, was not easily available. Especially those with dialysis machines, both APD and HHD, saw a potential for telemedicine solutions. CONCLUSIONS: As home dialysis may contribute to a normalization of life less dominated by disease, the treatment should be organized so that the potential for home dialysis can be fully exploited. Pre-dialysis information should be unbiased and include access to other patients' experiences. Telemedicine may potentially facilitate a communication-based follow-up and improve safety within the home setting, making it easier to choose and live with home dialysis.

Challenges in telemedicine and eHealth: lessons learned from 20 years with telemedicine in Tromsø.

The Norwegian Centre for Telemedicine (NST) has, over the past two decades, contributed to the development and implementation of telemedicine and ehealth services in Norway. From 2002, NST has been a WHO Collaboration Center for telemedicine. In August 1996, Norway became the first country to implement an official telemedicine fee schedule making telemedicine services reimbursable by the national health insurer. Telemedicine is widely used in Northern Norway. Since the late 1980's, the University Hospital of North-Norway has experience in the following areas: teleradiology, telepathology, teledermatology, teleotorhinolaryngology (remote endoscopy), remote gastroscopy, tele-echocardiography, remote transmission of ECGs, telepsychiatry, teleophthalmology, teledialysis, teleemergency medicine, teleoncology, telecare, telegeriatric, teledentistry, maritime telemedicine, referrals and discharge letters, electronic delivery of laboratory results and distant teaching for healthcare personnel and patients. Based on the result achieved, the health authority in North-Norway plans to implement several large-scale telemedicine services: Teleradiology (incl. solutions for neurosurgery, orthopedic, different kinds of surgery, nuclear medicine, acute traumatic and oncology), digital communication and integration of patient data, and distant education. In addition, the following services will also be considered for large-scale implementation: teledialysis, prehospital thrombolysis, telepsychiatry, teledermatology. Last in line for implementation are: pediatric, district medical center (DMS), teleophthalmology and ear-nose-throat (ENT).

Difficulties in moving routine medical checks from the specialist level to the general practitioner level.

We began a project to move routine medical checks for appropriate patients from the specialist level to the patient's normal general practitioner (GP). The GP's analysis and conclusions would be checked by the specialist, using electronic messaging. The idea for the project came from the top level of the regional health authority. Despite that, the project was closed down before pilot testing began. We used stakeholder theory as a post-project evaluation to analyse what happened and where it went wrong. A common mistake in project planning is to focus the planning effort on system tasks and not to pay attention to a well-thought-out handling of the project's stakeholders. This was what happened in our project. Ideal objectives and good political intentions are not enough to implement a new e-health service.

Telemedicine in haemodialysis: a university department and two remote satellites linked together as one common workplace.

A common workplace was established between the renal unit at the University Hospital of North Norway and two satellite dialysis centres, in Alta and Hammerfest. A 2 Mbit/s ATM network was employed for IP-based videoconferencing. A common electronic medical record system and dialysis monitoring software were used. During an eight-month study period, nine patients were enrolled and 225 videoconferences were performed for daily visits and regular rounds. A bandwidth of 768 kbit/s was required for satisfactory teledialysis. Although technical (28%) and logistical problems (10%) were frequent, five hospitalizations and one-third of the planned visiting rounds were avoided. An economic analysis showed that annual savings amounted to US$46,613, while annual costs were US$79,489. Despite the technical difficulties in about 30% of conferences, the nurses were satisfied with the videoconferencing system. Digital X-rays were communicated without problems. The pilot study indicates that satellite units may be incorporated into the daily management at the central institution by telemedicine.

[May heart murmurs be assessed by telemedicine?]. / Kan hjertebilyder evalueres med telemedisin?

BACKGROUND: Children often have heart murmurs; referral to a specialist is common. A service for remote auscultation of heart murmurs was established in which heart sounds and short texts were sent as attachment to e-mails. Our aim was to assess the quality of this method. MATERIAL AND METHODS: Heart sounds from 47 patients with no murmur (n = 7), innocent murmurs (n = 20), or with pathological murmurs (n = 20) were recorded using a sensor-based stethoscope and e-mailed to a computer. The sounds were repeated giving 100 cases, randomly distributed on a CD. Four specialists categorised the cases as having "no murmur", "innocent murmur", or "pathological murmur", recorded assessment time, degree of certainty, and need for referral. RESULTS: On average 2.1 minutes were spent on each case. Mean sensitivity and specificity were 90% and 98%, respectively. Inter- and intra-observer variability were low (kappa 0.81 and 0.87). 93% of cases with a pathological murmur and 13% with an innocent murmur were recommended for referral. INTERPRETATION: Telemedical referral of children with heart murmurs to a cardiologist is safe, reduces travelling, and saves time. Skilled auscultation is adequate to detect those with innocent murmurs.