The Ethical Implications of Telemedicine and the Internet for Home Healthcare

Information and communication technologies, such as the Internet, are transforming our business, education, and leisure practices. The healthcare industry is no exception to this trend and the burgeoning field of home-based telemedicine is evidence of this. As with many technological innovations in healthcare, assessments of homebased telemedicine and correlative policies are being driven by economic and technological criteria that emphasize cost reduction and technologic efficiency. These are important considerations, but these assessments neither identify the ethical values involved in home-based telemedicine nor address its possible ethical implications. Since the economic and technologic viability of home-based telemedicine is not identical with its ethical appropriateness and justification, this is a serious oversight. Hence, the use of telemedicine and the Internet in home healthcare invite a discussion about their ethical implications for the traditional goals and moral ideals of healthcare practice. The purpose of this study is to argue that the ethical implications of telemedicine and the Internet for home healthcare should be better understood and incorporated into future home-based telemedicine research and policy development. To this end, this study reviews the home-based telemedicine literature and examines the normative connections between home-based telemedicine and the following: (1) provider-patient relationships, (2) healthcare privacy and confidentiality, (3) distributive and family justice, and (4) informed consent. This study concludes that given the traditional values and goals of healthcare, information and communication technologies present both possible harms and benefits for home healthcare recipients and providers, but that on balance the benefits are more likely to outweigh the harms. However, because the exact benefits and harms of homebased telemedicine are unknown at this time, additional empirical research and outcome studies are needed. Finally, as part of a general technology assessment of home-based telemedicine, future research should include an ethical evaluation of all information and communication technologies that will be employed. If this is not done, home-based telemedicine policies will be inadequately informed and many of the possible harms of home-based telemedicine that could be prevented will not be prevented

User-centered visual analysis using a hybrid reasoning architecture for intensive care units

One problem pertaining to Intensive Care Unit information systems is that, in some cases, a very dense display of data can result. To ensure the overview and readability of the increasing volumes of data, some special features are required (e.g., data prioritization, clustering, and selection mechanisms) with the application of analytical methods (e.g., temporal data abstraction, principal component analysis, and detection of events). This paper addresses the problem of improving the integration of the visual and analytical methods applied to medical monitoring systems. We present a knowledge- and machine learning-based approach to support the knowledge discovery process with appropriate analytical and visual methods. Its potential benefit to the development of user interfaces for intelligent monitors that can assist with the detection and explanation of new, potentially threatening medical events. The proposed hybrid reasoning architecture provides an interactive graphical user interface to adjust the parameters of the analytical methods based on the users' task at hand. The action sequences performed on the graphical user interface by the user are consolidated in a dynamic knowledge base with specific hybrid reasoning that integrates symbolic and connectionist approaches. These sequences of expert knowledge acquisition can be very efficient for making easier knowledge emergence during a similar experience and positively impact the monitoring of critical situations. The provided graphical user interface incorporating a user-centered visual analysis is exploited to facilitate the natural and effective representation of clinical information for patient care

Defining the effect and mediators of two knowledge translation strategies designed to alter knowledge, intent and clinical utilization of rehabilitation outcome measures: a study protocol [NCT00298727]

BACKGROUND: A substantial number of valid outcome measures have been developed to measure health in adult musculoskeletal and childhood disability. Regrettably, national initiatives have merely resulted in changes in attitude, while utilization remains unacceptably low. This study will compare the effectiveness and mediators of two different knowledge transfer (KT) interventions in terms of their impact on changing knowledge and behavior (utilization and clinical reasoning) related to health outcome measures. METHOD/DESIGN: Physical and occupational therapists (n = 144) will be recruited in partnership with the national professional associations to evaluate two different KT interventions with the same curriculum: 1) Stakeholder-Hosted Interactive Problem-Based Seminar (SHIPS), and 2) Online Problem-Based course (e-PBL). SHIPS will consist of face-to-face problem-based learning (PBL) for 2 1/2 days with outcome measure developers as facilitators, using six problems generated in consultation with participants. The e-PBL will consist of a 6-week web-based course with six generic problems developed by content experts. SHIPS will be conducted in three urban centers in Canada. Participants will be block-allocated by a minimization procedure to either of the two interventions to minimize any prognostic differences. Trained evaluators at each site will conduct chart audits and chart-stimulated recall. Trained interviewers will conduct semi-structured interviews focused on identifying critical elements in KT and implementing practice changes. Interviews will be transcribed verbatim. Baseline predictors including demographics, knowledge, attitudes/barriers regarding outcome measures, and Readiness to Change will be assessed by self-report. Immediately post-intervention and 6 months later, these will be re-administered. Primary qualitative and quantitative evaluations will be conducted 6-months post-intervention to assess the relative effectiveness of KT interventions and to identify elements that contribute to changing clinical behavior. Chart audits will determine the utilization of outcome measures (counts). Incorporation of outcome measures into clinical reasoning will be assessed using an innovative technique: chart-stimulated recall. DISCUSSION: A strategy for optimal transfer of health outcome measures into practice will be developed and shared with multiple disciplines involved in primary and specialty management of musculoskeletal and childhood disability

Performance Validity Assessment Of Bona Fide And Malingered Traumatic Brain Injury Using Novel Eye-Tracking Systems

Purposeful presentation of neurocognitive impairment (i.e., dissimulation) in assessment of brain injury is a primary pitfall to accurate psychological assessment, especially among individuals seeking compensation. Current methods used to evaluate effort test failure (EFT; Webb et al., 2012) and dissimulation in brain injury assessment has advanced over the past few decades, but remains unacceptably inaccurate. In diagnostic decision-making, current methods identify obvious cases of purposefully poor performance, but they are considerably less accurate in subtle cases typically seen clinically; more important, they are vulnerable to coaching. Oculomotor behavior during visual tasks may be a promising avenue in the assessment of performance validity. Oculomotor patterns observed after brain injury have been well documented, and patterns characteristic of normal decision-making have been studied in healthy adults, but findings from these endeavors have not been applied to performance validity assessment. Accordingly, this study evaluated contributions of oculomotor patterns to detection of purposeful poor performance using state-of-the-science eye-tracking equipment by studying the predictive ability of a gold-standard performance validity test: The Test of Memory Malingering (TOMM). The study examined 39 adults with moderate to severe traumatic brain injury (TBI), 42 healthy adults coached to simulate memory impairment (SIM), and 50 healthy adults providing full effort (HC). The results supported the main hypothesis: One index derived using oculomotor patterns of performance provided a reliable increase to the predicative accuracy of the TOMM in differentiating bona fide TBI from simulated TBI. Numerous other oculomotor indexes showed promise, both in their relationships to key cognitive constructs and in their ability to differentiate dissimulation from healthy adults and bona fide TBI. The predicative ability of these measures was insignificant, however, due to an underpowered sample size and violations of the assumptions of pivotal statistical models. As such, future research is needed to replicate these findings and should strive to increase sample sizes to more accurately assess those visual patterns that showed predictive potential

The effect of faculty performance measurement systems on student retention

Institutions of higher learning have been tracking student course-drop rates as a measure of student success along with faculty performance data. However, there is a lack of understanding as to how faculty performance data influences drop rates. The purpose of this study was to determine whether faculty knowledge of performance data creates a difference in drop rates. This study combined theories of performance measurement, decision support, self-determination theory (SDT), and personal decision making (PDM) as a conceptual foundation that linked faculty knowledge to student success. The specific research question addressed if data can be used to assist faculty efforts in reducing student attrition. This experimental longitudinal study tested the effect of faculty knowledge of personal performance measures on student course-drop rates. A sample of 32 subjects from a major university were randomly selected and assigned to equivalent-groups that included an experimental group, which received performance feedback and instruction, and an uninformed control group. Paired sample t-tests indicated a significant 32.8% reduction in student attrition for faculty in the experimental group, compared to a 10.3% increase in attrition observed for the control group faculty. Results suggest that providing faculty access to performance data via a decision support system will result in a reduction of student course drop rates. The key social value for this study is to provide a blueprint in collecting, structuring, and disseminating data that assist faculty and institutions in addressing student persistence. Students who persist in their courses have a greater potential of completing their studies and thus gaining access to better paying careers, higher levels of self-esteem, and an overall improved quality of life

Designing Motivational Interviewing Instruction Employing the First Principles of Instruction

Indiana University-Purdue University Indianapolis (IUPUI)Health care reform emphasizes prevention of chronic disease through the reduction of modifiable risk factors as a way to reduce health care costs, morbidity, and mortality. Motivational interviewing (MI) is an effective method of health behavior counseling. It has been used successfully applied in health related behavior change and self- management of chronic disease. The knowledge, skills, and attitude of MI are acquired through learning as other techniques used in the health professions. Nurse practitioner faculty need guidance on how to design instruction in MI that incorporates competencies and utilizes innovative strategies. Prescriptive instructional design theory utilizes knowledge from educational research to establish the steps in the design process. The purpose of this research was to apply prescriptive instructional theory to the design of effective, efficient, and engaging instruction in MI resulting in beginning proficiency in the NP students. A formative design was used for this study. The First Principles of Instruction served as the prescriptive design theory used in the design of instruction in MI. Data sources included the researcher’s design journal, observation during interaction with the instance, demographics of authentic users, authentic user reaction, and knowledge testing. Four cycles of design-redesign were completed. Results of the study point to improvements in the First Principles of Instruction. The instruction was effective, based on the improved scores from pretest to posttest on the Helpful Response Questionnaire. The improved scores also indicated an increase in knowledge of MI. Efficiency was not improved from pretest to posttest. The definition of efficiency as less time to completion of the task did not apply to MI communication skills. The First Principles of Instruction were useful in the design of the techniques of MI. However, there is little guidance for the affective component of MI such as empathy. The prescriptions of the First Principles of Instruction were useful in designing the instruction in MI. NP students indicated in post instruction interviews that engagement in the instruction was related to the relevance of the subject matter to practice and interactive exercises

Evaluator-blinded trial evaluating nurse-led immunotherapy DEcision Coaching In persons with relapsing-remitting Multiple Sclerosis (DECIMS) and accompanying process evaluation: Study protocol for a cluster randomised controlled trial

License:Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0)Background: Multiple sclerosis is a chronic neurological condition usually starting in early adulthood and regularly leading to severe disability. Immunotherapy options are growing in number and complexity, while costs of treatments are high and adherence rates remain low. Therefore, treatment decision-making has become more complex for patients. Structured decision coaching, based on the principles of evidence-based patient information and shared decision-making, has the potential to facilitate participation of individuals in the decision-making process. This cluster randomised controlled trial follows the assumption that decision coaching by trained nurses, using evidence-based patient information and preference elicitation, will facilitate informed choices and induce higher decision quality, as well as better decisional adherence. Methods/Design: The decision coaching programme will be evaluated through an evaluator-blinded superiority cluster randomised controlled trial, including 300 patients with suspected or definite relapsing-remitting multiple sclerosis, facing an immunotherapy decision. The clusters are 12 multiple sclerosis outpatient clinics in Germany. Further, the trial will be accompanied by a mixed-methods process evaluation and a cost-effectiveness study. Nurses in the intervention group will be trained in shared decision-making, coaching, and evidence-based patient information principles. Patients who meet the inclusion criteria will receive decision coaching (intervention group) with up to three face-to-face coaching sessions with a trained nurse (decision coach) or counselling as usual (control group). Patients in both groups will be given access to an evidence-based online information tool. The primary outcome is ‘informed choice’ after six months, assessed with the multi-dimensional measure of informed choice including the sub-dimensions risk knowledge (questionnaire), attitude concerning immunotherapy (questionnaire), and immunotherapy uptake (telephone survey). Secondary outcomes include decisional conflict, adherence to immunotherapy decisions, autonomy preference, planned behaviour, coping self-efficacy, and perceived involvement in coaching and decisional encounters. Safety outcomes are comprised of anxiety and depression and disease-specific quality of life. Discussion: This trial will assess the effectiveness of a new model of patient decision support concerning MS-immunotherapy options. The delegation of treatment information provision from physicians to trained nurses bears the potential to change current doctor-focused practice in Germany

Feasibility and Acceptability of a Digital Intervention to Support Shared Decision-making in Children's and Young People's Mental Health: Mixed Methods Pilot Randomized Controlled Trial

BACKGROUND: Interventions to involve parents in decisions regarding children's and young people's mental health are associated with positive outcomes. However, appropriately planning effectiveness studies is critical to ensure that meaningful evidence is collected. It is important to conduct pilot studies to evaluate the feasibility and acceptability of the intervention itself and the feasibility of the protocol to test effectiveness. OBJECTIVE: This paper reports the findings from a feasibility and acceptability study of Power Up for Parents, an intervention to promote shared decision-making (SDM) and support parents and caregivers making decisions regarding children's and young people's mental health. METHODS: A mixed method study design was adopted. In stage 1, health care professionals and parents provided feedback on acceptability, usefulness, and suggestions for further development. Stage 2 was a multicenter, 3-arm, individual, and cluster randomized controlled pilot feasibility trial with parents accessing services related to children's and young people's mental health. Outcome measures collected data on demographics, participation rates, SDM, satisfaction, and parents' anxiety. Qualitative data were analyzed using thematic analysis. Google Analytics estimates were used to report engagement with the prototype. Outcomes from both stages were tested against a published set of criteria for proceeding to a randomized controlled trial. RESULTS: Despite evidence suggesting the acceptability of Power Up for Parents, the findings suggest that recruitment modifications are needed to enhance the feasibility of collecting follow-up data before scaling up to a fully powered randomized controlled trial. On the basis of the Go or No-Go criteria, only 50% (6/12) of the sites successfully recruited participants, and only 38% (16/42) of parents completed follow-up measures. Nonetheless, health care practitioners and parents generally accessed and used the intervention. Themes describing appearance and functionality, perceived need and general helpfulness, accessibility and appropriateness, and a wish list for improvement emerged, providing valuable information to inform future development and refinement of the intervention. CONCLUSIONS: Owing to the high attrition observed in the trial, proceeding directly to a full randomized controlled trial may not be feasible with this recruitment strategy. Nonetheless, with some minor adjustments and upgrades to the intervention, this pilot study provides a platform for future evaluations of Power Up for Parents. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN) 39238984; http://www.isrctn.com/ISRCTN39238984. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/14571