Telemedizin in der Intensivmedizin – die Betrachtung eines Anwendungsfalls im Rahmen der Ergebnisse eines Scoping Reviews

Die steigende Zahl kritisch kranker Patienten mit komplexen Krankheitsverläufen stellt eine zunehmende Belastung des Gesundheitssystems dar. Krankenhäuser stehen dabei vor der Herausforderung, die Qualität der Behandlung auf höchstem Niveau zu halten. In diesem Zusammenhang wurden vielerorts telemedizinische Intervention umgesetzt, welche mithilfe audiovisueller Systemen ärztliches und pflegerisches Personal einer Intensivstation mit einem räumlich entfernten Zentrum verbinden. Sowohl die medizinischen als auch die ökonomischen Ergebnisse früherer Untersuchungen waren in einigen Fällen positiv, aber insgesamt heterogen, wobei eine Reihe von Faktoren und Barrieren identifziert wurden, die die Effektivität telemedizinischer Interventionen beeinflussen. Ziel dieser Studie war es, das Verständnis für diese Faktoren und Barrieren zu verbessern. Aufbauend auf den publizierten Ergebnissen einer Literaturrecherche wurde in diesem Manteltext der Anwendungsfall ERIC untersucht. ERIC stellt eine an der Charité – Universitätsmedizin Berlin implementierte telemedizinische Intervention auf einer Intensivstation dar, die im Lichte der aktuellen wissenschaftlichen Evidenz diskutiert wurde. Die vorliegende Arbeit folgte der Scoping-Review-Methode. Zunächst wurde ein Protokoll publiziert, welches die Strategie der Literaturrecherche, die Schritte zur Auswahl relevanter Studien, die Extraktion von Daten aus diesen Studien und schließlich die Darstellung und Analyse der extrahierten Daten beschrieb. Die Synthese der Daten führte zur Definition von Anwendungsfällen für Telemedizin in der Intensivmedizin. Die ERIC-Intervention wurde in den Anwendungsfall Improving Compliance eingeordnet. Die Intervention in diesem Anwendungsfall zielt darauf ab, die Anwendung von Best Practices und eine Verbesserung Patientensicherheit und Behandlungsqualität zu erreichen. Es existiert umfassende Evidenz, dass Telemedizin in der Intensivmedizin die Compliance wirksam verbessert. Es wurden jedoch mehrere Implementationsbarrieren festgestellt, die der Entfaltung des vollen Potentials telemedizinischer Maßnahmen entgegen stehen. Als eines dieser Hindernisse wurde die fehlende Interoperabilität der Systeme idenfiziert, die die Fähigkeit der Systeme zur Kommunikation untereinander einschränkt. Die Akzeptanz des Personals wurde als weitere wichtige Determinante für den Erfolg telemedizinischer Maßnahmen genannt. Verschiedene Maßnahmen, um die Auswirkungen dieser Hindernisse abzumildern, können zur Anwendung kommen, darunter gezielte Kommunikation, Schulung und Definition von Prozessen für die beteiligten Teams Es sollte Gegenstand zukünftiger Studien sein, die Wirksamkeit dieser Maßnahmen zu untersuchen.The increase in the number of critically-ill patients with complex medical history is expected to be a strain on available intensive care resources, with hospitals facing multiple challenges in maintaining an adequate level of intensive care service and quality. In this context, telemedicine interventions have been used to address some of these challenges. Such interventions rely on audio-visual systems connecting bedside staff at the ICU with a remotely-located care team. The medical and economical results of prior analyses have been in some cases positive but overall heterogeneous. A range of contextual factors and barriers exists that influences the effectiveness of telemedical interventions. The objective of this thesis was to advance the understanding of these factors and barriers by investigating evidence about intensive care telemedicine. Building on the published results of a literature review, this synopsis brings into the focus the use case of ERIC, a tele ICU intervention implemented at Charité – Universitätsmedizin Berlin, which is discussed in light of current scientific evidence. The thesis followed the scoping review method. First, a research protocol was published in a peer-review journal. The protocol described the literature search strategy and the steps for selecting relevant studies, extracting data from these studies, and finally charting and analyzing the extracted data. Once the protocol was published, the review was completed. Synthesis of the data resulted in the definition of use cases for telemedicine in critical care. The ERIC intervention was classified in the use case Improving Compliance. Interventions in this use case aim at enhancing the adoption of best practices and improving both patient safety and quality of care. A robust body of evidence exists that intensive care telemedicine is effective at improving compliance. However, several implementation barriers were identified that may prevent telemedical interventions from fulfilling their full potential. The lack of system interoperability, which limits the ability of systems to communicate with one another, was highlighted as one of such barriers. Staff acceptance was identified as another key determinant of the success of telemedical interventions. Several strategies are available to mitigate the impact of these barriers which include targeted communication, training and definition of processes for the involved teams. Fu-ture research should help define how to effectively implement them

Telemedicine in Intensive Care Units: Scoping Review

Background: The role of telemedicine in intensive care has been increasing steadily. Tele-intensive care unit (ICU) interventions are varied and can be used in different levels of treatment, often with direct implications for the intensive care processes. Although a substantial body of primary and secondary literature has been published on the topic, there is a need for broadening the understanding of the organizational factors influencing the effectiveness of telemedical interventions in the ICU. Objective: This scoping review aims to provide a map of existing evidence on tele-ICU interventions, focusing on the analysis of the implementation context and identifying areas for further technological research. Methods: A research protocol outlining the method has been published in JMIR Research Protocols. This review follows the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews). A core research team was assembled to provide feedback and discuss findings. Results: A total of 3019 results were retrieved. After screening, 25 studies were included in the final analysis. We were able to characterize the context of tele-ICU studies and identify three use cases for tele-ICU interventions. The first use case is extending coverage, which describes interventions aimed at extending the availability of intensive care capabilities. The second use case is improving compliance, which includes interventions targeted at improving patient safety, intensive care best practices, and quality of care. The third use case, facilitating transfer, describes telemedicine interventions targeted toward the management of patient transfers to or from the ICU. Conclusions: The benefits of tele-ICU interventions have been well documented for centralized systems aimed at extending critical care capabilities in a community setting and improving care compliance in tertiary hospitals. No strong evidence has been found on the reduction of patient transfers following tele-ICU intervention

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

Adoption of telemedicine: from pilot stage to routine delivery

<p>Abstract</p> <p>Background</p> <p>Today there is much debate about why telemedicine has stalled. Teleradiology is the only widespread telemedicine application. Other telemedicine applications appear to be promising candidates for widespread use, but they remain in the early adoption stage. The objective of this debate paper is to achieve a better understanding of the adoption of telemedicine, to assist those trying to move applications from pilot stage to routine delivery.</p> <p>Discussion</p> <p>We have investigated the reasons why telemedicine has stalled by focusing on two, high-level topics: 1) the process of adoption of telemedicine in comparison with other technologies; and 2) the factors involved in the widespread adoption of telemedicine. For each topic, we have formulated hypotheses. First, the advantages for users are the crucial determinant of the speed of adoption of technology in healthcare. Second, the adoption of telemedicine is similar to that of other health technologies and follows an S-shaped logistic growth curve. Third, evidence of cost-effectiveness is a necessary but not sufficient condition for the widespread adoption of telemedicine. Fourth, personal incentives for the health professionals involved in service provision are needed before the widespread adoption of telemedicine will occur.</p> <p>Summary</p> <p>The widespread adoption of telemedicine is a major -- and still underdeveloped -- challenge that needs to be strengthened through new research directions. We have formulated four hypotheses, which are all susceptible to experimental verification. In particular, we believe that data about the adoption of telemedicine should be collected from applications implemented on a large-scale, to test the assumption that the adoption of telemedicine follows an S-shaped growth curve. This will lead to a better understanding of the process, which will in turn accelerate the adoption of new telemedicine applications in future. Research is also required to identify suitable financial and professional incentives for potential telemedicine users and understand their importance for widespread adoption.</p

Organizational structure of telehealth care : an examination of four types of telemedicine systems

The purpose of this study is to make recommendations for a sustainable telemedicine system by examining the structural attributes of telemedicine across and within different types of organizations. A survey instrument with two categories, background questions and evaluation questions, was developed and used as a guide to interview eight key informants from four different types of telehealth systems. The eight transcribed interviews were coded using NUD*IST qualitative software. Research publications, archival documents, and government reports were collected to triangulate, or cross check, interview data. Multi-case study methodology was used as a guide to design the research, analyze date, compare results, and make recommendations. A telehealth typology is proposed as well as a simplified conceptual telehealth model and a diffusion of telemedicine model. While there are some structural differences among the different types of programs, there are many more similarities. All receive funding fiom multiple sources, and all employ a combination of full and part-time employees. Three core staff categories include administrative, medical, and technical support. Additional categories may include evaluation researchers and project coordinators

Telemedicine

Telemedicine is a rapidly evolving field as new technologies are implemented for example for the development of wireless sensors, quality data transmission. Using the Internet applications such as counseling, clinical consultation support and home care monitoring and management are more and more realized, which improves access to high level medical care in underserved areas. The 23 chapters of this book present manifold examples of telemedicine treating both theoretical and practical foundations and application scenarios

A History of Diabetic Retinopathy: An obscure entity becomes an international public health dillemma

Diabetic retinopathy is a disorder that was unknown until the late 19th century and that did not become important until at least the 1940’s. This study describes the disorder’s history and provides support for the thesis that most of the world’s health care systems have responded inadequately to the subsequent epidemics of diabetic retinopathy and its cause, diabetes mellitus, particularly in view of the well documented availability of evidence-based management strategies that have been developed over decades. The global distribution of health care systems to combat these disorders is exceptionally limited, and although contemporary exemplary plans are available in most corners of the world, they are limited in the percentages of populations that can be appropriately managed. In general, optimal systems are available only in environments containing sophisticated equipment and personnel in which only patients with appropriate medical insurance or funding are managed. Many caregivers remain unable to provide exemplary support because of inadequate access to patients, funding, or education, and few patients are genuinely compliant in managing their diabetes. Each of these factors is amplified in regions of relative poverty and poor hygiene. It currently appears that most of the world’s diabetic patients with retinopathy will remain underserved

Success and failure in eHealth

Introduction In the field of eHealth, there seems to be a gap between promising research and clinical reality. This master thesis aims to give insight in patterns that can be found regarding the possible outcome in terms of success and/or failure. An in-depth review of workflow will be done, to get an understanding of the implications of eHealth on workflow. Methods Using a systematic article search, papers have been collected regarding the subject of this thesis. Through multiple search strategies, one final search string has been formulated. This final search string led to 903 papers. These papers have been assessed on relevance using qualitative methods. This resulted in 258 papers, which have been categorised by topic, entity and success or failure. After categorisation, the topic of workflow has been selected for an additional in-depth full-text review. Results The categorisation led to 27 categories. The categories are separated among the following entities: patient, health professional, health system and all. The first three have been separated in terms of success and failure as well. This led to a quantitative overview of different categories, for different actors in terms of success and failure. Workflow appeared to be essential for the possible success or failure of eHealth implementations. It is important to include workflow in the design of the tool as well. Conclusion Different categories show a unique combination in success and failure, and to what entity they belong. The category costs appeared to be mostly based on the health system and is attributed to failure. Therefore it is a pre-requisite for the implementation of eHealth. Other categories like quality healthcare and user expectations seem to target on success. The category legal was smaller than anticipated, which could have been caused by categories that are closely linked to each other