Preparing for success: readiness models for rural telehealth.

BACKGROUND: Readiness is an integral and preliminary step in the successful implementation of telehealth services into existing health systems within rural communities. METHODS AND MATERIALS: This paper details and critiques published international peer-reviewed studies that have focused on assessing telehealth readiness for rural and remote health. Background specific to readiness and change theories is provided, followed by a critique of identified telehealth readiness models, including a commentary on their readiness assessment tools. RESULTS: Four current readiness models resulted from the search process. The four models varied across settings, such as rural outpatient practices, hospice programs, rural communities, as well as government agencies, national associations, and organizations. All models provided frameworks for readiness tools. Two specifically provided a mechanism by which communities could be categorized by their level of telehealth readiness. DISCUSSION: Common themes across models included: an appreciation of practice context, strong leadership, and a perceived need to improve practice. Broad dissemination of these telehealth readiness models and tools is necessary to promote awareness and assessment of readiness. This will significantly aid organizations to facilitate the implementation of telehealth.

Policy implications associated with the socioeconomic and health system impact of telehealth: a case study from Canada.

This research was undertaken to inform future telehealth policy directions regarding the socioeconomic impact of telehealth. Fifty-seven sources were identified and analyzed through a comprehensive literature search of electronic databases, the Internet, journals, conference proceedings, as well as personal communication with consultants in the field. The review revealed a focus on certain socioeconomic indicators such as cost, access, and satisfaction. It also identified areas of opportunity for further research and policy analysis and development (e.g., social isolation, life stress, poverty), along with various barriers and challenges to the advancement of telehealth. These included confidentiality, reimbursement, and legal and ethical considerations. To become fully integrated into the health care system, telehealth must be viewed as more than an add-on service. This paper offers 19 general and 20 subject-specific telehealth recommendations, as well as seven policy strategies.

The socio-economic impact of telehealth: a systematic review.

We reviewed the socio-economic impact of telehealth, focusing on nine main areas: paediatrics, geriatrics, First Nations (i.e. indigenous peoples), home care, mental health, radiology, renal dialysis, rural/remote health services and rehabilitation. A systematic search led to the identification of 4646 citations or abstracts; from these, 306 sources were analysed. A central finding was that telehealth studies to date have not used socio-economic indicators consistently. However, specific telehealth applications have been shown to offer significant socio-economic benefit, to patients and families, health-care providers and the health-care system. The main benefits identified were: increased access to health services, cost-effectiveness, enhanced educational opportunities, improved health outcomes, better quality of care, better quality of life and enhanced social support. Although the review found a number of areas of socio-economic benefit, there is the continuing problem of limited generalizability.

Addressing oral disease--the case for tobacco cessation services.

There is strong scientific evidence from clinical and epidemiological studies that tobacco use, particularly cigarette smoking, is linked to periodontal disease as well as other serious but less common oral health diseases. Given the strength of this evidence, dentists must include tobacco cessation services (TCS) as part of their routine care. This paper describes barriers to the adoption of TCS as identified by Alberta dentists participating in a randomized intervention trial and discusses strategies for overcoming these barriers. As well, suggestions are made to professional associations and educational institutes on ways to increase the incorporation of tobacco cessation into professional practice standards.

Telehealth: 'real life' implementation issues.

This paper addresses the practical issues specific to the successful integration of telehealth into the Canadian health system at national, regional, provincial and territorial levels. Five key issues for optimal implementation were readiness of the environment; needs analysis/strategic business plans/diverse partnerships; equipment and Information Technology (IT) vendors; staged implementation; and evaluation. Strong professional, as well as technical policy standards, were also required. Recognizing the importance of human factors and workforce implications, the change process, and the changing culture were also viewed as critical to successful implementation. The importance of 'best practices', 'lessons learned', 'buy-in', inter-connectivity, inter-operability, and sustainability issues was noted. Lastly, ongoing systemic evaluation was seen to be key to sustained telehealth programs.

Canadian experiences in telehealth: equalizing access to quality care.

The Canadian Conference "TExpo'98: Interactive Health" focused on four telehealth themes: community needs, Canadian experiences, industry perspectives, and access/security/interoperability issues. Health and socioeconomic needs have been the driving force behind telehealth initiatives; telelearning is one of the major Canadian initiatives. To encourage Canadian telehealth initiatives, the federal government is building a national health infrastructure. One element in this framework is concerned with empowering the public, strengthening health care services, and ensuring accountability. Technological advancements and innovative partnerships among health communities, government, users, professional bodies, and industry are critical to continued growth. Key issues including access, evaluation, implementation, privacy, confidentiality, security, and interoperability are of universal concern to participants. Research that examines the benefits and costs of telehealth is needed.

Video-capture teleradiology for the after-hours reading of computerized tomography scans.

We evaluated the after-hours support that radiologists could provide from their homes to an urban hospital for reading emergency computerized tomography (CT) scans. During a six-month study period, 36 CT scans were acquired using a video-capture card in a PC and transmitted via an ordinary telephone line. The teleradiology interpretation and the formal report (from the hard copy) were compared with a reference or gold standard interpretation made by a radiologist and an emergency physician for 31 of the 36 cases. In comparison with the gold standard, there were 26 correct diagnoses by teleradiology (84%) and five incorrect (16%). Head CT scans accounted for 74% of the transmitted scans and all five of the cases with discrepant diagnoses. The cause of the single clinically relevant discrepancy was found to be unrelated to the use of teleradiology. In comparison with the formal report, the accuracy of the teleradiologist was not significantly different for all categories combined or for head CT scans alone. Video-capture technology provided a reliable means of transmitting CT scans for after-hours interpretation in emergency cases.

Telelearning in health: a Canadian perspective.

OBJECTIVE: This project identified telelearning projects associated with the 13 established Canadian telehealth centers in order to describe the nature of their activities, outline enablers and barriers to these activities, and present key action plans to move the Canadian agenda on telelearning in health forward. MATERIALS AND METHODS: Data were collected by a one-page questionnaire sent to the Canadian telehealth centers. Recipients were asked to identify current partners in such activities and to indicate if such partners should complete a separate questionnaire. Forty-nine questionnaires were distributed. Reported enablers, barriers, and action plans were placed in categories and analyzed. Data from 37 questionnaires, referencing 101 projects, formed the basis of the analysis. RESULTS: More than half of the telelearning programs were developed for health providers, approximately one third for undergraduate or graduate students, and a small percentage for patients or the private sector. The most frequently used communication mode was two-way audio/video conferencing. Enabling conditions were grouped into four categories: Canada as a country, timing, infrastructure, and collaboration and support. Five categories of barriers were cited: lack of sustainable funding, insufficient infrastructure and resources for sustainable programs, absence of the required culture change, lack of standardization and defined policies, and unavailability of valid and reliable evaluation frameworks. Eight broad constructive action steps were suggested. CONCLUSIONS: The reported enablers can create momentum to carry telelearning into a position of prominence. The Canadian telehealth community recommends action steps that could facilitate the removal of barriers and maximize current opportunities.

The Medical Skills Centre at the University of Calgary Medical School.

The aim of the Medical Skills Centre at the University of Calgary is to provide a predictable learning environment and standardized teaching methods in the area of clinical skills teaching. The centre uses volunteer patients and trained actors for all levels of medical education and evaluation. A computer database enables easy access to groups of patients and varying medical issues. This article describes the organization and operation of the Medical Skills Centre and notes a variety of courses which use the unique facilities of the centre.

Preparing our future physicians: integrating medical informatics into the undergraduate medical education curriculum.

This paper describes how two medical schools have integrated "medical informatics" into their undergraduate medical education programs with the aim of preparing their students for future practice. It describes the components or elements of the informatics programs, how learning opportunities have been integrated into the curricula, how the informatics programs have evolved, and future directions. The medical schools approached the task of introducing informatics in a parallel way. Following needs identification, similar topic areas, goals, and specific informatics learning objectives were developed. These were used as a basis for implementation and evaluation. In general, the topic areas selected are: computer literacy, communications, information retrieval and management, computer-aided learning, patient management, office practice management, and hospital information systems. Learning opportunities in informatics were integrated for the above goals, in accordance with how the curriculum was organized in each school. These opportunities, and the support activities provided will be described.

Technology-based dissemination.

Health care reform and restructuring, changes in the scope and definitions of 'health', 'health care' and 'health research', along with a continued emphasis on multidisciplinary health promotion and prevention, all indicate the need for information dissemination, exchange and management. Technology can be a tool to help meet this need, as it can help us disseminate, as well as understand the process of dissemination. Rapid advances in, and reduced costs of technology, permit the integration of this tool. This paper provides a definition for dissemination, along with a background and rationale as to why now is the time and place to harness technology to assist with the dissemination process. In addition, it presents well-designed studies on the effective use of technology as an aid to dissemination. Concrete examples of innovative technology that are being tested are also examined. Finally, the challenge and strategies for technology integration are addressed.

The use of advanced computer technology to enhance access to health care and to respond to community needs: the results of the evaluation of a technology-based clinical consultation service.

This paper describes a long distance, high tech, two-way interactive video pilot system that supports teleconsultations between primary health care givers at a rural site and specialists and subspecialists at the Faculty of Medicine, University of Calgary. Evaluation results from the 12-month trial are presented. The underlying philosophy behind the telemedicine outreach pilot program was to provide equal access to health services for those currently in under-served areas. The advanced technology system offered multiple clinical services in emergency, urgent, and elective situations. The impact of the telemedicine consultative service on health care delivery, patients, providers, and costs were evaluated. Findings from the 12-month trial demonstrate that quality care and access to care can be offered in spite of the disparate location of patients and health care providers. Some limitations and constraints to the implementation of the technology are noted and reviewed.

Evaluation of a distance consulting service based on interactive video and integrated computerized technology.

Telemedicine equipment was installed at a rural site in Drumheller and at Calgary, 85 miles (136 km) away. It allowed consultation between health-care providers at Drumheller and specialists and subspecialists at the Faculty of Medicine in Calgary. The efficacy of the system in providing more equitable access to health care for persons living in geographically remote sites was evaluated during a 12-month pilot project. Seventy-five encounters were attempted during the study. A total of 55 encounters (42 clinical and 13 non-clinical) were completed. The completed clinical encounters were distributed across a wide spectrum of medical specialties. Users of the system reported favourably on the impact of the telemedicine system on access to health services for rural patients, on diagnostic, investigative and management decisions, on patient and physician travel times, on feelings of professional isolation and educational opportunities and on overall patient health status. The study provides new knowledge and demonstrates the success of the technology in this project. As expected, other problems were raised and addressed in a preliminary manner including: the potential for health-provider education; acquisition and retention of rural physicians; ethical, legal and patient confidentiality issues; minimum acceptable technology; and network management issues.

A practical approach to lifestyle change counselling in primary care.

Many contemporary medical conditions have been found to be the consequence of lifestyle choices. These adverse habit patterns have their origin in the individuals family and/or natural social network. Primary care practitioners frequently interact with their patients for the purpose of helping them resolve medical problems by clarifying issues or presenting different options. In lifestyle related conditions, the initiation and maintenance of possible behaviour changes is usually the optimal resolution. How people intentionally change well-established behaviour patterns is still not well understood, and most clinicians are not confident in their ability to help patients alter adverse behaviours. Several studies provide support for a 'stage-matched framework' of behaviour change that integrates readiness for change with intervention processes from various theoretical models. This article provides a brief overview of the current thinking with respect to self-initiated and professionally facilitated behaviour change, and then describes a generic five-step approach to individualized lifestyle counselling for use in primary care clinical settings.

Comparing peer and faculty evaluations in an internal medicine residency.

PURPOSE: To compare in-training evaluations of residents by their peers with evaluations by faculty preceptors in an internal medicine residency. METHOD: The study group consisted of 22 residents enrolled in the core (three-year) internal medicine program at the University of Calgary in 1989-90 and 1990-91. At the end of each rotation, ratings of the residents were requested from faculty preceptors and from peers for several categories of clinical competence. The peer ratings were paired with faculty ratings, for a total of 74 pairs of ratings. The Wilcoxon matched-pair signed-rank procedure was used to compare the paired ratings. One-way analysis of variance was used to compare the peer and faculty ratings with the residents' scores on three other kinds of evaluation used by the residency. RESULTS: While there was no significant difference between peer and faculty ratings for overall competence or for several components of competence, there were significant differences for some components, with faculty tending to rate higher than peers. The latter components were physical examination, team relationships, industriousness and enthusiasm, teaching, physician-patient relationships, and case presentations. External validation of the ratings by comparing them with other kinds of evaluation yielded little meaningful information. CONCLUSION: That the faculty ratings were significantly higher than the peer ratings for some components of clinical competence suggests that there were differences in the quality of evaluation between the peers and faculty, or differences in the standards or expectations of the two groups.

Advanced training in biomedical ethics: a curriculum in clinical specialty programmes.

Medical ethics play an essential role in the practice of medicine, in the care of individual patients, in the allocation of health care resources, and in the formulation of health care policy. A specific body of knowledge, 'biomedical ethics', has developed which applies ethical theory to biomedical practice. This has provided doctors with tools systematically to integrate rational ethical analysis into clinical decision-making. Training in the discipline of biomedical ethics is now required for all doctors in Canada. The goals, content areas, learning objectives, and learning methods considered appropriate for advanced training in this field for medical specialists are provided in this paper. Six topic areas are discussed: introduction to ethical theory, clinical ethics, professional ethics, ethics of human experimentation, ethics of health policy, and independent study. Ways this curriculum could be organized and evaluated are also offered.

Gender, family status, and career patterns of graduates of the University of Calgary Faculty of Medicine.

In 1986 the authors sent a questionnaire to 745 physicians who had graduated between 1973 and 1985 from The University of Calgary Faculty of Medicine. The survey obtained information on the graduates' status as parents, the "breaks" they had taken from their practices, and the hours per week they devoted to direct patient care, in order to observe what relationship the graduates' gender and status as parents had on the other variables. The women were far more likely to have taken breaks for parental leave, but the differences in the frequencies of breaks taken by the men and the women for other reasons were less striking. The women were working fewer hours in direct patient-care settings, and those women who were parents and under 35 years old spent fewer hours on patient care than did the men (from all age groups) who were parents. The authors discuss their findings in terms of the impacts of age and cohort effects and the possible lessening of gender-based differences in present-day physicians' practices.