Abstract Background Atopic eczema is a chronic inflammatory non-contagious skin disease characterised by intensive itch and inflamed skin. Due to its chronic and relapsing course atopic eczema imposes a great burden on affected families. Review articles about home care telemedicine have indicated advantageous effects of home telehealth. However, few studies have investigated how home care telemedicine applications affect the workload of the clinician. Methods The use of a web-based counselling system was recorded through computerised logging. The doctor who answered the requests sent via the Internet recorded the amount of time needed for reading and answering 93 consecutive requests. Results The time needed by the physician to read and answer a request was less than 5 minutes in 60% of the cases. The doctor spent significantly more time to answer requests that had photographs attached compared to requests without photographs (P = 0.005). The time needed to answer requests received during the winter season (October-March) was significantly longer than the rest of the year (P = 0.023). There was no correlation between the answering time and the age of the patient. Conclusions Individual web-based follow-up of atopic eczema patients at home is feasible. The amount of time needed for the doctor to respond to a request from the patient appears to be small. The answering time seems to depend on whether photographs are supplied and also on seasonal variations of disease activity. Since the management of atopic eczema is complex involving many different types of treatments and educational aspects, we expect this type of communication to be useful also to other chronic disease patients requiring close follow-up.</p

D McGeady

EA Krupinski

EJ O'Connell

H Andreassen

J Heinrich

JL Delli Fraine

LK Dotterud

M Bensink

M Wallwiener

RM Berghout

Roald Bolle

SM Borowitz

Terje Solvoll

Thomas RG Schopf

TS Bergmo

U Darsow

W Hersh

BMC Research Notes

English

PubMed

Springer - Publisher Connector

RESEARCH ARTICLE Open Access
The workload of web-based consultations with
atopic eczema patients at home
Thomas RG Schopf1*, Roald Bolle2, Terje Solvoll1
Abstract
Background: Atopic eczema is a chronic inflammatory non-contagious skin disease characterised by intensive itch
and inflamed skin. Due to its chronic and relapsing course atopic eczema imposes a great burden on affected
families. Review articles about home care telemedicine have indicated advantageous effects of home telehealth.
However, few studies have investigated how home care telemedicine applications affect the workload of the
clinician.
Methods: The use of a web-based counselling system was recorded through computerised logging. The doctor
who answered the requests sent via the Internet recorded the amount of time needed for reading and answering
93 consecutive requests.
Results: The time needed by the physician to read and answer a request was less than 5 minutes in 60% of the
cases. The doctor spent significantly more time to answer requests that had photographs attached compared to
requests without photographs (P = 0.005). The time needed to answer requests received during the winter season
(October-March) was significantly longer than the rest of the year (P = 0.023). There was no correlation between
the answering time and the age of the patient.
Conclusions: Individual web-based follow-up of atopic eczema patients at home is feasible. The amount of time
needed for the doctor to respond to a request from the patient appears to be small. The answering time seems to
depend on whether photographs are supplied and also on seasonal variations of disease activity. Since the
management of atopic eczema is complex involving many different types of treatments and educational aspects,
we expect this type of communication to be useful also to other chronic disease patients requiring close follow-
up.
Background
Atopic eczema (AE) is a chronic inflammatory non-con-
tagious skin disease characterised by intensive itch and
inflamed skin lesions with a typical distribution on the
skin surface. It is related to other atopic diseases, such
as bronchial asthma and hay fever. The incidence of AE
in Western countries has increased steadily during the
last decades[1]. In Norway it is one of the most com-
mon chronic diseases with a cumulative prevalence in
children of 20-25%[2]. Due to its chronic and relapsing
course with itching, scratching and impaired sleep, AE
imposes a great burden on affected families[3]. Manage-
ment of moderate to severe AE is a therapeutic chal-
lenge[4].
The University Hospital of North Norway in Tromsø
serves as the main specialist health care provider due to
the shortage of both dermatologists and paediatricians
in the northernmost health region. Some patients may
have to travel up to 400 km by aircraft to see a specia-
list. Regularly, these patients arrive in the evening the
day before they have an appointment at the clinic. Con-
sequently, there is a potential here for telemedicine to
improve access to specialist health care, as well as to
reduce travel and hotel costs. Studies have shown that
store-and-forward technology can be used for remote
diagnosis of skin diseases with a level of accuracy com-
parable with outpatient examinations[5,6]. Several
review articles about home care telemedicine have indi-
cated advantageous effects of home telehealth[7,8]. While
there is some evidence that patient-physician communi-
cation through e-mail and web messaging is time efficient
* Correspondence: Thomas.Roger.Schopf@telemed.no
1Norwegian Centre for Integrated Care and Telemedicine, University Hospital
of North Norway, Tromsø, Norway
Schopf et al. BMC Research Notes 2010, 3:71
http://www.biomedcentral.com/1756-0500/3/71
© 2010 Schopf et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
for the doctor, few studies have tried to assess the actual
time required to process web messages[9-12]. This report
is part of a randomised controlled trial designed to ana-
lyse the effects of web-based consultations for parents of
children with atopic eczema. One of the conclusions was
that such a service is feasible involving a moderate mes-
sage volume and that the majority of patients were satis-
fied with the service[13]. Therefore, we conducted an
analysis on the time needed by the doctor to process
patient messages.
Methods
Details of study procedures are described in a previous
publication[13]. Briefly, patients were consecutively
recruited from the paediatric and dermatological outpa-
tient units at the University Hospital of North Norway
in Tromsø and Hammerfest County Hospital between
August 2005 and September 2006. Children aged 0.5 -
12 years with moderate to severe AE with at least one
period of disease activity in the last 12 months were eli-
gible for inclusion. In the intervention group parents
were free to send requests via the Internet. They were
also allowed to see their primary physician at all times.
The Internet communication was accessible briefly after
randomisation. In addition to “free writing” parents
were asked to use a form showing extent and severity of
the eczema. Photographs of affected skin areas could be
attached but this was not mandatory. The parents could
send requests via the Internet to the specialist ward for
general advice at any time or when the eczema flared.
There were no limitations concerning the length or fre-
quency of requests provided they were dealing with AE.
All parents have given their informed consent.
Measures
The doctor who answered the requests sent via the
Internet recorded the amount of time needed for read-
ing and answering 93 consecutive requests received
between January 2007 and June 2008. Messages contain-
ing only “thank you” or brief notes were not recorded.
Time measurement was done by the use of an ordinary
wristwatch with stop-clock functionality. Time was
recorded in categories: Less than 5 minutes, 5-10 min-
utes, and more than 10 minutes. This approach was
chosen in order to ease data recording and processing.
All chronological data represent the work of one doctor.
Technical solution
The technical solution used in the project provides
functionality that includes a secure messaging system
which ensures the patients’ privacy while sending photo-
graphs and text to their provider via an ordinary web-
browser. The images were uploaded directly from the
camera leaving no sensitive data on the computer used
[13]. The system is based on patient initiated contact,
and the specialist usually replied within one working
day. One experienced resident in dermatology at the
University Hospital of North Norway answered the
requests, while two specially trained nurses answered
messages when the doctor was on leave or holiday.
When an answer was sent, the patient was informed
through SMS. There was no system for notifying the
health personnel about incoming requests. Daily login
was thus generally performed twice a day in order to
access requests.
Statistical analysis
SPSS 15.0 for Windows was used for the statistical analy-
sis. The doctor’s time data were analysed to determine if
handling requests that had photographs attached was a
more time-consuming process. The time of year when
the requests were received was also analysed. Requests
received from October to March were by definition
designated as winter period, the remainder being summer
period. Hereby the study period was divided into two
equally long time periods. Because the response time
data was very skewed (see also table 1), we categorised
and applied c2-tests for analysis. All given P values are
2-tailed, P < 0.05 indicates statistical significance.
Ethics
The Regional Committee for Medical Research Ethics in
North Norway and the Data Inspectorate of Norway
approved the study protocol.
Results
During the study period, 12 patients sent a total of 93
requests. While there was an even distribution of
requests throughout the period, the number of requests
per patient varied, see table 1.
Table 1 Requests per patient
No requests No requests with photographs
Patient 1 49 6
Patient 2 11 0
Patient 3 7 3
Patient 4 6 1
Patient 5 5 1
Patient 6 4 0
Patient 7 4 1
Patient 8 2 1
Patient 9 2 0
Patient 10 1 0
Patient 11 1 0
Patient 12 1 0
All 93 13
Schopf et al. BMC Research Notes 2010, 3:71
http://www.biomedcentral.com/1756-0500/3/71
Page 2 of 4
Workload
The doctor answered 93 consecutive requests received
between January 2007 and June 2008. Fifty-six out of
the 93 messages (60%) were answered within 5 minutes.
Thirty messages (32%) were answered in 5-10 minutes,
and 7 messages (8%) in more than 10 minutes. The
time needed to answer requests that had photographs
attached was significantly longer compared to requests
without photographs (P = 0.005). Also the time varied
according to the season. The doctor spent significantly
more time to answer those 47 requests received in the
winter season (October-March) than in the rest of the
year (P = 0.023). There was no correlation between the
answering time and the age of the patient. Table 2 sum-
marises the distribution of answering times for all
patients as well as the patient sending the highest num-
ber of requests (Patient 1).
Discussion
Several review articles about home care telemedicine
have indicated advantageous effects of home telehealth
[7,8]. A study by Andreassen et al indicated that 45% of
the population wish to use the Internet for communica-
tion with their doctor[14]. However, the majority of stu-
dies have focused on the transmission of laboratory
data, e.g., blood glucose data or spirometry data. Little is
known about communication involving “free text” writ-
ing via e-mail or web-based systems. In this study we
used a secure web-based system to exchange text mes-
sages and photographs in the follow-up of eczema
patients previously seen at our hospital. Our study
showed that follow-up of AE patients through the use of
home-based telemedicine is feasible. The amount of
time needed for the doctor to respond to a request from
the patient appears to be small compared to an ordinary
consultation at the hospital, not to mention compared
to the time needed by the patient to travel. This is con-
sistent with the findings of Borowitz et al[11]. The time
needed for the doctor to read and answer a request was
significantly longer during the winter season. This
appears to be due to the natural course of AE which
often improves in warm sunny weather while the condi-
tion worsens in the winter season. The answering time
was significantly longer when digital images were
attached to the request. Because of the visual nature of
dermatology, photographs obviously provide additional
information that needs to be processed by the doctor.
This result is thus not surprising. Because the manage-
ment of AE is complex, this type of web-based follow-
up seems applicable also to other patients with chronic
disease, e.g., epilepsy or psychiatric disorders. We
believe transmission of sensitive patient data should be
secure and therefore, the use of ordinary e-mail does
not appear to be adequate.
There are several limitations of this study. Time mea-
surement was performed by one single physician. We do
not know anything about the potential time investment
of other doctors. We chose to let one doctor do the
work to ensure that a good routine was established first
before starting time recordings. Another issue is the
self-reporting of time data. Ideally, another independent
person should have observed the doctor who handled
the requests. A similar method was used in a study
investigating time investment of general practitioners in
a teledermatology setting[12]. However, the study was
performed in a laboratory setting. We considered a simi-
lar approach inadequate in our case. We aimed at inves-
tigating in a busy and real hospital environment.
Furthermore, in a previous study about e-mail consulta-
tions Borowitz et al also used self-reported time data
obtained by a single physician[11]. The inhomogeneous
distribution of the number of requests per patient might
introduce bias, e.g., a trend towards shorter answering
times for patient 1 because the doctor could refer to
earlier responses to the same patient. However, the dis-
tribution of the response times did not seem to change
when patient 1 was excluded. Furthermore, when deal-
ing with atopic eczema, the inhomogeneous distribution
of requests does not seem surprising to us because of
the nature of the disease. It can be expected that the
need for consultations is variable in different patients
depending on the severity of the condition.
Conclusions
Individual web-based follow-up of AE patients at home
is feasible. The amount of time needed for the doctor to
respond to a request from the patient appears to be
small. The time for an answer seems to depend on
whether photographs are supplied and also on seasonal
variations of disease activity. Since the management of
AE is complex involving many different types of treat-
ments and educational aspects, we expect this type of
communication to be useful also to other chronic dis-
ease patients requiring close follow-up.
Acknowledgements
We thank Prof. Trond Flægstad at the Department of Paediatrics at the
University Hospital of North Norway for his advice, Bjørn Straume at the
University of Tromsø for his advice on the statistical analysis, Vera Igeland,
Torill Nystuen and the other nurses at the paediatric and dermatological
departments for their help, Dr. Cecilie Revhaug and her staff at Hammerfest
County Hospital for the kind cooperation and Helse Nord for funding this
Table 2 Distribution of requests (percentage)
< 5 min 5-10 min > 10 min
Patient 1 61 33 6
Patient 2-12 59 32 9
All 60 32 8
Schopf et al. BMC Research Notes 2010, 3:71
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Page 3 of 4
project. We also thank the patients and their parents for participating in the
trial, as well as Kevin Sunde Oppegaard and Jeremiah Scholl for helpful
comments.
Author details
1Norwegian Centre for Integrated Care and Telemedicine, University Hospital
of North Norway, Tromsø, Norway. 2Department of Paediatrics, University
Hospital of North Norway, Tromsø, Norway.
Authors’ contributions
TRGS had primary responsibility for protocol development, data analysis and
writing of the manuscript. RB contributed to protocol development, data
analysis and writing of the manuscript. TS had responsibility for the technical
solution and contributed to writing of the manuscript. All authors read and
approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 2 March 2010 Accepted: 12 March 2010
Published: 12 March 2010
References
1. Heinrich J, Hoelscher B, Frye C, Meyer I, Wjst M, Wichmann HE: Trends in
prevalence of atopic diseases and allergic sensitization in children in
Eastern Germany. Eur Respir J 2002, 19:1040-1046.
2. Dotterud LK: Allergy in North Norwegian schoolchildren: an
epidemiological study of atopic diseases among school children in Sør-
Varanger community in relation to environmental factors and with
particular reference to atopic dermatitis. PhD thesis University of Tromsø
1995.
3. O’Connell EJ: The burden of atopy and asthma in children. Allergy 2004,
59(Suppl):7-11.
4. Darsow U, Lübbe J, Taïeb A, Seidenari S, Wollenberg A, Calza AM, Giusti F,
Ring J: Position paper on diagnosis and treatment of atopic dermatitis. J
Eur Acad Dermatol Venereol 2005, 19:286-295.
5. Krupinski EA, LeSueur B, Ellsworth L, Levine N, Hansen R, Silvis N,
Sarantopoulos P, Hite P, Wurzel J, Weinstein RS, Lopez AM: Diagnostic
accuracy and image quality using a digital camera for teledermatology.
Telemed J 1999, 5:257-263.
6. Hersh W, Helfand M, Wallace J, Kraemer D, Patterson P, Shapiro S,
Greenlick M: A systematic review of the efficacy of telemedicine for
making diagnostic and management decisions. J Telemed Telecare 2002,
8:197-209.
7. Bensink M, Hailey D, Wootton R: A systematic review of successes and
failures in home telehealth: preliminary results. J Telemed Telecare 2006,
12:8-16.
8. Delli Fraine JL, Dansky KH: Home-based telehealth: a review and meta-
analysis. J Telemed Telecare 2008, 14:62-66.
9. McGeady D, Kujala J, Ilvonen K: The impact of patient-physician web
messaging on healthcare service provision. Int J Med Inform 2008,
77:17-23.
10. Wallwiener M, Wallwiener CW, Kansy JK, Seeger H, Rajab TK: Impact of
electronic messaging on the patient-physician interaction. J Telemed
Telecare 2009, 15:243-250.
11. Borowitz SM, Wyatt JC: The origin, content, and workload of e-mail
consultations. JAMA 1998, 280:1321-1324.
12. Berghout RM, Eminović N, de Keizer NF, Birnie E: Evaluation of general
practitioner’s time investment during a store-and-forward
teledermatology consultation. Int J Med Inform 2007, 76(Suppl 3):384-391.
13. Bergmo TS, Wangberg SC, Schopf TR, Solvoll T: Web-based consultations
for parents of children with atopic dermatitis: results of a randomised
controlled trial. Acta paediatr 2009, 98(2):316-320.
14. Andreassen H, Sandaune AG, Gammon D, Hjortdahl P: Use of Internet
health services in Norway. Tidsskr Nor Laegeforen 2002, 122:1640-1644,
(In Norwegian, abstract in English.).
doi:10.1186/1756-0500-3-71
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consultations with atopic eczema patients at home. BMC Research Notes
2010 3:71.
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