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1.  Feasibility of Remote Real-Time Guidance of a Cardiac Examination Performed by Novices Using a Pocket-Sized Ultrasound Device 
Background. The potential of pocket-sized ultrasound devices (PUDs) to improve global healthcare delivery is limited by the lack of a suitable imaging protocol and trained users. Therefore, we investigated the feasibility of performing a brief, evidence-based cardiac limited ultrasound exam (CLUE) through wireless guidance of novice users. Methods. Three trainees applied PUDs on 27 subjects while directed by an off-site cardiologist to obtain a CLUE to screen for LV systolic dysfunction (LVSD), LA enlargement (LAE), ultrasound lung comets (ULC+), and elevated CVP (eCVP). Real-time remote audiovisual guidance and interpretation by the cardiologist were performed using the iPhone 4/iPod (FaceTime, Apple, Inc.) attached to the PUD and transmitted data wirelessly. Accuracy and technical quality of transmitted images were compared to on-site, gold-standard echo thresholds. Results. Novice versus sonographer imaging yielded technically adequate views in 122/135 (90%) versus 130/135 (96%) (P < 0.05). CLUE's combined SN, SP, and ACC were 0.67, 0.96, and 0.90. Technical adequacy (%) and accuracy for each abnormality (n) were LVSD (85%, 0.93, n = 5), LAE (89%, 0.74, n = 16), ULC+ (100%, 0.94, n = 5), and eCVP (78%, 0.91, n = 1). Conclusion. A novice can perform the CLUE using PUD when wirelessly guided by an expert. This method could facilitate PUD use for off-site bedside medical decision making and triaging of patients.
doi:10.1155/2013/627230
PMCID: PMC3762173  PMID: 24024032
2.  Wireless Control of Smartphones with Tongue Motion Using Tongue Drive Assistive Technology 
Tongue Drive System (TDS) is a noninvasive, wireless and wearable assistive technology that helps people with severe disabilities control their environments using their tongue motion. TDS translates specific tongue gestures to commands by detecting a small permanent magnetic tracer on the users’ tongue. We have linked the TDS to a smartphone (iPhone/iPod Touch) with a customized wireless module, added to the iPhone. We also migrated and ran the TDS sensor signal processing algorithm and graphical user interface on the iPhone in real time. The TDS-iPhone interface was evaluated by four able-bodied subjects for dialing 10-digit phone numbers using the standard telephone keypad and three methods of prompting the numbers: visual, auditory, and cognitive. Preliminary results showed that the interface worked quite reliably at a rate of 15.4 digits per minute, on average, with negligible errors.
doi:10.1109/IEMBS.2010.5626294
PMCID: PMC3128806  PMID: 21096049
3.  Asynchronous and Synchronous Teleconsultation for Diabetes Care: A Systematic Literature Review 
Aim
A systematic literature review, covering publications from 1994 to 2009, was carried out to determine the effects of teleconsultation regarding clinical, behavioral, and care coordination outcomes of diabetes care compared to usual care. Two types of teleconsultation were distinguished: (1) asynchronous teleconsultation for monitoring and delivering feedback via email and cell phone, automated messaging systems, or other equipment without face-to-face contact; and (2) synchronous teleconsultation that involves real-time, face-to-face contact (image and voice) via videoconferencing equipment (television, digital camera, webcam, videophone, etc.) to connect caregivers and one or more patients simultaneously, e.g., for the purpose of education.
Methods
Electronic databases were searched for relevant publications about asynchronous and synchronous tele-consultation [Medline, Picarta, Psychinfo, ScienceDirect, Telemedicine Information Exchange, Institute for Scientific Information Web of Science, Google Scholar]. Reference lists of identified publications were hand searched. The contribution to diabetes care was examined for clinical outcomes [e.g., hemoglobin A1c (HbA1c), dietary values, blood pressure, quality of life], for behavioral outcomes (patient-caregiver interaction, self-care), and for care coordination outcomes (usability of technology, cost-effectiveness, transparency of guidelines, equity of access to care). Randomized controlled trials with HbA1c as an outcome were pooled using standard meta-analytical methods.
Results
Of 2060 publications identified, 90 met inclusion criteria for electronic communication between (groups of) caregivers and patients with type 1 and 2 or gestational diabetes. Studies that evaluated teleconsultation not particularly aimed at diabetes were excluded, as were those that described interventions aimed solely at clinical improvements (e.g., HbA1c or lipid profiles).
In 63 of 90 interventions, the interaction had an asynchronous teleconsultation character, in 18 cases interaction was synchronously (videoconferencing), and 9 involved a combination of synchronous with asynchronous interaction. Most of the reported improvements concerned clinical values (n = 49), self-care (n = 46), and satisfaction with technology (n = 43). A minority of studies demonstrated improvements in patient-caregiver interactions (n = 28) and cost reductions (n = 27). Only a few studies reported enhanced quality of life (n = 12), transparency of health care (n = 7), and improved equity in care delivery (n = 4). Asynchronous and synchronous applications appeared to differ in the type of contribution they made to diabetes care compared to usual care: asynchronous applications were more successful in improving clinical values and self-care, whereas synchronous applications led to relatively high usability of technology and cost reduction in terms of lower travel costs for both patients and care providers and reduced unscheduled visits compared to usual care. The combined applications (n = 9) scored best according to quality of life (22.2%). No differences between synchronous and asynchronous teleconsultation could be observed regarding the positive effect of technology on the quality of patient-provider interaction. Both types of applications resulted in intensified contact and increased frequency of transmission of clinical values with respect to usual care. Fifteen of the studies contained HbA1c data that permitted pooling. There was significant statistical heterogeneity among the pooled randomized controlled trials (χ2 = 96.46, P < 0.001). The pooled reduction in HbA1c was not statically significant (weighted mean difference -0.10; 95% confidence interval -0.39 to 0.18).
Conclusion
The included studies suggest that both synchronous and asynchronous teleconsultations for diabetes care are feasible, cost-effective, and reliable. However, it should be noted that many of the included studies showed no significant differences between control (usual care) and intervention groups. This might be due to the diversity and lack of quality in study designs (e.g., inaccurate or incompletely reported sample size calculations). Future research needs quasi-experimental study designs and a holistic approach that focuses on multilevel determinants (clinical, behavioral, and care coordination) to promote self-care and proactive collaborations between health care professionals and patients to manage diabetes care. Also, a participatory design approach is needed in which target users are involved in the development of cost-effective and personalized interventions. Currently, too often technology is developed within the scope of the existing structures of the health care system. Including patients as part of the design team stimulates and enables designers to think differently, unconventionally, or from a new perspective, leading to applications that are better tailored to patients' needs.
PMCID: PMC2901046  PMID: 20513335
chronic diseases; diabetes mellitus; telemedicine; remote consultation; teleconsultation; videoconferencing; telemonitoring
4.  Teledermatology 
The seemingly ubiquitous use and acceptance of mobile, Wi-Fi-enabled, camera-ready tablets are offering dermatological clinicians a new telemedicine tool and collaborative learning platform, which may come to replace the traditional practice of forwarding digital still photographs to colleagues for consultation. The decreased cost and the increased ease of use of newer generation tablets are removing some of the participation barriers previously experienced by some dermatology professionals. Prior to full clinical implementation within the authors’ practice in 2011, they tested the Health Insurance Portability and Accountability Act-approved Apple FaceTime® videoconference platform and found it to be an affordable, convenient, and effective collaboration and consultation tool that may augment andragogical postgraduate medical learning.
PMCID: PMC3509879  PMID: 23198011
5.  Telemedicine System Using a High-Speed Network: Past, Present, and Future 
Gut and Liver  2009;3(4):247-251.
There is no doubt that telecommunication saves a great deal of time and expense when exchanging information, and recent technological advances have increased its popularity in business and educational applications. Telemedicine is a rapidly developing application of clinical medicine in which medical information is transferred via the Internet or another communication network for the purpose of consultations, and sometimes also for remote medical procedures or examinations. A telemedicine system can also be applied to medical education. Many doctors and medical students could benefit from telementoring and tele-education based on videoconferencing systems. However, telemedicine in general has not yet become popular in clinical practice or medical education. In our university, we have used a telemedicine system to educate doctors and medical students since 2003. Since our first telemedical conference with Kyushu University Hospital on February 12, 2003 when we have regularly performed telemedical conferences. Here we introduce a general methodology for telemedicine, our experiences of medical conferencing using telemedicine, and future possible directions.
doi:10.5009/gnl.2009.3.4.247
PMCID: PMC2852732  PMID: 20431756
Telemedicine; Digital video transport system
6.  Telemedicine: a cautious welcome. 
BMJ : British Medical Journal  1996;313(7069):1375-1377.
Telemedicine is a major new development. Having become technically and economically feasible, it deserves proper investigation. Rushing into equipment purchase, however, is almost certain to prove counterproductive. Face to face contact is fundamental to health care and enthusiasts of telemedicine should recognise that it is not as good as the real thing (and unlikely ever to be). However, constraints on time and resources will make face to face consultation increasingly expensive, and telemedicine has the potential to produce major efficiencies in the diagnostic process. The goal of current research is therefore to marry medicine with technology, capitalising on the advantages of telemedicine and producing a robust system that delivers an acceptable service at an appropriate price.
Images
PMCID: PMC2352879  PMID: 8956707
7.  Otolaryngology consultations by real-time telemedicine. 
The Ulster Medical Journal  2002;71(1):26-29.
We aimed to assess the value of real-time telemedicine using low cost videoconferencing equipment for otorhinolaryngology consultations. A general practitioner, using low cost videoconferencing equipment, presented patients to an otorhinolaryngologist. After history taking and clinical examination, investigations were requested if required and a diagnosis and management plan formulated. The patients were then seen, by the same otorhinolaryngologist, for a conventional face-to-face consultation. Differences in the history, clinical examination and investigation requests were reported. The accuracy of diagnosis and correlation of management plans between the two consultations were analysed. Forty-three patients were admitted to the study but one, a young child, refused examination either by tele-link or the conventional approach and had to be excluded. There were thus 42 patients with 55 diagnoses included in the trial, 26 (62%) females and 16 (38%) males. Age range was 5 months to 70 years. There was no difficulty with any of the patients in obtaining an accurate history and ordering investigations, if required, via the telelink. Clinical examination during the tele-link consultation was inadequate for eight out of the first 20 patients, resulting in a wrong diagnosis in three patients and a missed diagnosis in five patients. All of the next 22 patients had a correct diagnosis and management plan. Comparison of data from the two types of consultation showed that a correct diagnosis and management plan was made in 34 patients. Low cost real-time telemedicine is a useful technique, providing reliable otorhinolaryngology consultations in a general practice setting. However initial difficulties due to inexperience in using the equipment need to be overcome.
PMCID: PMC2475361  PMID: 12137160
8.  MED5/355: Using Web-technology for Asynchronous Telemedicine Consulting 
Introduction
Common telemedicine consultations can be divided in two classes: real-time telemedicine consultations and asynchronous telemedicine consultations. The advantage of real-time consultations is obvious - this is a natural discussion between physicians, which may be realised on the basis of desktop videoconferences. But the problems are also obvious: the necessity of additional hardware and the elevated demands for channel bandwidth. Because of the latter, the use of asynchronous telemedicine consultations is more preferable in most cases.
Methods
We can consider asynchronous telemedicine consultations as a special form of a discussion forum, very familiar tool for users' collaboration in global networks. Currently, there exist many software products that facilitate the discussion forums using Web-technology and Internet standards. After a period of research and analysis, we have taken the decision to use as our development basis the Lotus Notes/Domino server. The following characteristics of Lotus Notes can explain our decision:
Ready-to-run discussion forum model
Mechanisms for access control,
Build-in integration with Web-technology,
Visual tools for database design.
Results
The first version of Web-server for telemedicine consultation "Telemedicine concilium" using Lotus Notes/Domino technology is already in use. The main form, describing clinical case description documents, has the two main parts: description of patient vital status/systems and section of multimedia upload files (attached files with clinical investigation data). The clinical cases database is currently containing about 30 clinical cases. Approximately 40 physicians not only from Moscow, but also from other regions of Russia and from other countries of ex-USSR were registered as users of server.
Discussion
The current operation of the Lotus Notes server has proven the efficiency and attraction of the proposed technology. However, some problems have been detected: the Web-interaction mode is not available for all users, while some of them prefer to use e-mail for information exchange. Also, the form for the clinical case descriptions must be differentiated for different clinical cases or diverse category of patients (adults, children).
doi:10.2196/jmir.1.suppl1.e48
PMCID: PMC1761838
Remote Consultation; Databases; Web Technology
9.  A Smartphone Client-Server Teleradiology System for Primary Diagnosis of Acute Stroke 
Background
Recent advances in the treatment of acute ischemic stroke have made rapid acquisition, visualization, and interpretation of images a key factor for positive patient outcomes. We have developed a new teleradiology system based on a client-server architecture that enables rapid access to interactive advanced 2-D and 3-D visualization on a current generation smartphone device (Apple iPhone or iPod Touch, or an Android phone) without requiring patient image data to be stored on the device. Instead, a server loads and renders the patient images, then transmits a rendered frame to the remote device.
Objective
Our objective was to determine if a new smartphone client-server teleradiology system is capable of providing accuracies and interpretation times sufficient for diagnosis of acute stroke.
Methods
This was a retrospective study. We obtained 120 recent consecutive noncontrast computed tomography (NCCT) brain scans and 70 computed tomography angiogram (CTA) head scans from the Calgary Stroke Program database. Scans were read by two neuroradiologists, one on a medical diagnostic workstation and an iPod or iPhone (hereafter referred to as an iOS device) and the other only on an iOS device. NCCT brain scans were evaluated for early signs of infarction, which includes early parenchymal ischemic changes and dense vessel sign, and to exclude acute intraparenchymal hemorrhage and stroke mimics. CTA brain scans were evaluated for any intracranial vessel occlusion. The interpretations made on an iOS device were compared with those made at a workstation. The total interpretation times were recorded for both platforms. Interrater agreement was assessed. True positives, true negatives, false positives, and false negatives were obtained, and sensitivity, specificity, and accuracy of detecting the abnormalities on the iOS device were computed.
Results
The sensitivity, specificity, and accuracy of detecting intraparenchymal hemorrhage were 100% using the iOS device with a perfect interrater agreement (kappa = 1). The sensitivity, specificity, and accuracy of detecting acute parenchymal ischemic change were 94.1%, 100%, and 98.09% respectively for reader 1 and 97.05%, 100%, and 99.04% for reader 2 with nearly perfect interrater agreement (kappa = .8). The sensitivity, specificity, and accuracy of detecting dense vessel sign were 100%, 95.4%, and 96.19% respectively for reader 1 and 72.2%, 100%, and 95.23% for reader 2 using the iOS device with a good interrater agreement (kappa = .69). The sensitivity, specificity, and accuracy of detecting vessel occlusion on CT angiography scans were 94.4%, 100%, and 98.46% respectively for both readers using the iOS device, with perfect interrater agreement (kappa = 1). No significant difference (P < .05) was noted in the interpretation time between the workstation and iOS device.
Conclusion
The smartphone client-server teleradiology system appears promising and may have the potential to allow urgent management decisions in acute stroke. However, this study was retrospective, involved relatively few patient studies, and only two readers. Generalizing conclusions about its clinical utility, especially in other diagnostic use cases, should not be made until additional studies are performed.
doi:10.2196/jmir.1732
PMCID: PMC3221380  PMID: 21550961
Acute stroke; teleradiology; computed tomography; mhealth; mobile phone
10.  Neural Adaptation and Perceptual Learning using a Portable Real-Time Cochlear Implant Simulator in Natural Environments 
A portable real-time speech processor that implements an acoustic simulation model of a cochlear implant (CI) has been developed on the Apple iPhone/iPod Touch to permit testing and experimentation under extended exposure in real-world environments. This simulator allows for both a variable number of noise band channels and electrode insertion depth. Utilizing this portable CI simulator, we tested perceptual learning in normal hearing listeners by measuring word and sentence comprehension behaviorally before and after 2 weeks of exposure. To evaluate changes in neural activation related to adaptation to transformed speech, fMRI was also conducted. Differences in brain activation after training occurred in the inferior frontal gyrus and areas related to language processing. A 15–20% improvement in word and sentence comprehension of cochlear implant simulated speech was also observed. These results demonstrate the effectiveness of a portable CI simulator as a research tool and provide new information about the physiological changes that accompany perceptual learning of degraded auditory input.
doi:10.1109/IEMBS.2011.6090268
PMCID: PMC3674485  PMID: 22254517
cochlear implants; fMRI; portable media players
11.  “Right on all Occasions?” – On the Feasibility of Laterality Research Using a Smartphone Dichotic Listening Application 
Most psychological experimentation takes place in laboratories aiming to maximize experimental control; however, this creates artificial environments that are not representative of real-life situations. Since cognitive processes usually take place in noisy environments, they should also be tested in these contexts. The recent advent of smartphone technology provides an ideal medium for such testing. In order to examine the feasibility of mobile devices (MD) in psychological research in general, and laterality research in particular, we developed a MD version of the widely used speech laterality test, the consonant-vowel dichotic listening (DL) paradigm, for use with iPhones/iPods. First, we evaluated the retest reliability and concurrent validity of the DL paradigm in its MD version in two samples tested in controlled, laboratory settings (Experiment 1). Second, we explored its ecological validity by collecting data from the general population by means of a free release of the MD version (iDichotic) to the iTunes App Store (Experiment 2). The results of Experiment 1 indicated high reliability (rICC = 0.78) and validity (rICC = 0.76–0.82) of the MD version, which consistently showed the expected right ear advantage (REA). When tested in real-life settings (Experiment 2), participants (N = 167) also showed a significant REA. Importantly, the size of the REA was not dependent on whether the participants chose to listen to the syllables in their native language or not. Together, these results establish the current MD version as a valid and reliable method for administering the DL paradigm both in experimentally controlled as well as uncontrolled settings. Furthermore, the present findings support the feasibility of using smartphones in conducting large-scale field experiments.
doi:10.3389/fpsyg.2013.00042
PMCID: PMC3566356  PMID: 23404376
laterality; dichotic listening; language lateralization; smartphone; mobile device; software application
12.  Impact of a Telemedicine System with Automated Reminders on Outcomes in Women with Gestational Diabetes Mellitus 
Abstract
Background
Health information technology has been proven to be a successful tool for the management of patients with multiple medical conditions. The purpose of this study was to examine the impact of an enhanced telemedicine system on glucose control and pregnancy outcomes in women with gestational diabetes mellitus (GDM).
Subjects and Methods
We used an Internet-based telemedicine system to also allow interactive voice response phone communication between patients and providers and to provide automated reminders to transmit data. Women with GDM were randomized to either the telemedicine group (n=40) or the control group (n=40) and asked to monitor their blood glucose levels four times a day. Women in the intervention group transmitted those values via the telemedicine system, whereas women in the control group maintained paper logbooks, which were reviewed at prenatal visits. Primary outcomes were infant birth weight and maternal glucose control. Data collection included blood glucose records, transmission rates for the intervention group, and chart review.
Results
There were no significant differences between the two groups (telemedicine vs. controls) in regard to maternal blood glucose values or infant birth weight. However, adding telephone access and reminders increased transmission rates of data in the intervention group compared with the intervention group in our previous study (35.6±32.3 sets of data vs.17.4±16.9 sets of data; P<0.01).
Conclusions
Our enhanced telemedicine monitoring system increased system utilization and contact between women with GDM and their healthcare providers but did not impact upon pregnancy outcomes.
doi:10.1089/dia.2012.0010
PMCID: PMC3389380  PMID: 22512287
13.  Telepointer technology in telemedicine : a review 
Telepointer is a powerful tool in the telemedicine system that enhances the effectiveness of long-distance communication. Telepointer has been tested in telemedicine, and has potential to a big influence in improving quality of health care, especially in the rural area. A telepointer system works by sending additional information in the form of gesture that can convey more accurate instruction or information. It leads to more effective communication, precise diagnosis, and better decision by means of discussion and consultation between the expert and the junior clinicians. However, there is no review paper yet on the state of the art of the telepointer in telemedicine. This paper is intended to give the readers an overview of recent advancement of telepointer technology as a support tool in telemedicine. There are four most popular modes of telepointer system, namely cursor, hand, laser and sketching pointer. The result shows that telepointer technology has a huge potential for wider acceptance in real life applications, there are needs for more improvement in the real time positioning accuracy. More results from actual test (real patient) need to be reported. We believe that by addressing these two issues, telepointer technology will be embraced widely by researchers and practitioners.
doi:10.1186/1475-925X-12-21
PMCID: PMC3610246  PMID: 23496940
Telepointer; Telemedicine; Cursor pointer; Hand pointer; Laser pointer; Sketching pointer
14.  Initial Experience with a Handheld Device Digital Imaging and Communications in Medicine Viewer: OsiriX Mobile on the iPhone 
Journal of Digital Imaging  2010;24(2):184-189.
Medical imaging is commonly used to diagnose many emergent conditions, as well as plan treatment. Digital images can be reviewed on almost any computing platform. Modern mobile phones and handheld devices are portable computing platforms with robust software programming interfaces, powerful processors, and high-resolution displays. OsiriX mobile, a new Digital Imaging and Communications in Medicine viewing program, is available for the iPhone/iPod touch platform. This raises the possibility of mobile review of diagnostic medical images to expedite diagnosis and treatment planning using a commercial off the shelf solution, facilitating communication among radiologists and referring clinicians.
doi:10.1007/s10278-010-9312-7
PMCID: PMC3056977  PMID: 20567992
Radiology; PACS; informatics; teleradiology; mobile phone; iPhone; PDA; medical images; health care; DICOM; smartphone
15.  Promoting Behavior Change from Alcohol Use through Mobile Technology: The Future of Ecological Momentary Assessment 
Background
Interactive and mobile technologies (i.e., smartphones such as Blackberries, iPhones, and palm-top computers) show promise as an efficacious and cost-effective means of communicating health-behavior risks, improving public health outcomes, and accelerating behavior change (Abroms and Maibach, 2008). The present study was conducted as a “needs assessment” to examine the current available mobile smartphone applications (e.g., apps) that utilize principles of ecological momentary assessment (EMA) -- daily self-monitoring or near real-time self-assessment of alcohol use behavior -- to promote positive behavior change, alcohol harm reduction, psycho-education about alcohol use, or abstinence from alcohol.
Methods
Data were collected and analyzed from iTunes for Apple iPhone©. An inventory assessed the number of available apps that directly addressed alcohol use and consumption, alcohol treatment, or recovery, and whether these apps incorporated empirically-based components of alcohol treatment.
Results
Findings showed that few apps addressed alcohol use behavior change or recovery. Aside from tracking drinking consumption, a minority utilized empirically-based components of alcohol treatment. Some apps claimed they could serve as an intervention, however no empirical evidence was provided.
Conclusions
More studies are needed to examine the efficacy of mobile technology in alcohol intervention studies. The large gap between availability of mobile apps and their use in alcohol treatment programs indicate several important future directions for research.
doi:10.1111/j.1530-0277.2011.01571.x
PMCID: PMC3221771  PMID: 21689119
Ecological momentary assessment; alcohol; intervention; cellular phones; behavior change; cell phones
16.  Facilitating Stroke Management using Modern Information Technology 
Journal of Stroke  2013;15(3):135-143.
Background and Purpose
Information technology and mobile devices may be beneficial and useful in many aspects of stroke management, including recognition of stroke, transport and triage of patients, emergent stroke evaluation at the hospital, and rehabilitation. In this review, we address the contributions of information technology and mobile health to stroke management.
Summary of Issues
Rapid detection and triage are essential for effective thrombolytic treatment. Awareness of stroke warning signs and responses to stroke could be enhanced by using mobile applications. Furthermore, prehospital assessment and notification could be streamlined for use in telemedicine and teleradiology. A mobile telemedicine system for assessing the National Institutes of Health Stroke Scale scores has shown higher correlation and fast assessment comparing with face-to-face method. Because the benefits of thrombolytic treatment are time-dependent, treatment should be initiated as quickly as possible. In-hospital communication between multidisciplinary team members can be enhanced using information technology. A computerized in-hospital alert system using computerized physician-order entry was shown to be effective in reducing the time intervals from hospital arrival to medical evaluations and thrombolytic treatment. Mobile devices can also be used as supplementary tools for neurologic examination and clinical decision-making. In post-stroke rehabilitation, virtual reality and telerehabilitation are helpful. Mobile applications might be useful for public awareness, lifestyle modification, and education/training of healthcare professionals.
Conclusions
Information technology and mobile health are useful tools for management of stroke patients from the acute period to rehabilitation. Further improvement of technology will change and enhance stroke prevention and treatment.
doi:10.5853/jos.2013.15.3.135
PMCID: PMC3859007  PMID: 24396807
Stroke; Information technology; Mobile health; Telemedicine
17.  Comparison of the glidescope®, flexible fibreoptic intubating bronchoscope, iPhone modified bronchoscope, and the Macintosh laryngoscope in normal and difficult airways: a manikin study 
BMC Anesthesiology  2014;14:10.
Background
Smart phone technology is becoming increasingly integrated into medical care.
Our study compared an iPhone modified flexible fibreoptic bronchoscope as an intubation aid and clinical teaching tool with an unmodified bronchoscope, Glidescope® and Macintosh laryngoscope in a simulated normal and difficult airway scenario.
Methods
Sixty three anaesthesia providers, 21 consultant anaesthetists, 21 registrars and 21 anaesthetic nurses attempted to intubate a MegaCode Kelly™ manikin, comparing a normal and difficult airway scenario for each device. Primary endpoints were time to view the vocal cords (TVC), time to successful intubation (TSI) and number of failed intubations with each device. Secondary outcomes included participant rated device usability and preference for each scenario. Advantages and disadvantages of the iPhone modified bronchoscope were also discussed.
Results
There was no significant difference in TVC with the iPhone modified bronchoscope compared with the Macintosh blade (P = 1.0) or unmodified bronchoscope (P = 0.155). TVC was significantly shorter with the Glidescope compared with the Macintosh blade (P < 0.001), iPhone (P < 0.001) and unmodified bronchoscope (P = 0.011). The iPhone bronchoscope TSI was significantly longer than all other devices (P < 0.001). There was no difference between anaesthetic consultant or registrar TVC (P = 1.0) or TSI (P = 0.252), with both being less than the nurses (P < 0.001). Consultant anaesthetists and nurses had a higher intubation failure rate with the iPhone modified bronchoscope compared with the registrars. Although more difficult to use, similar proportions of consultants (14/21), registrars (15/21) and nurses (15/21) indicated that they would be prepared to use the iPhone modified bronchoscope in their clinical practice. The Glidescope was rated easiest to use (P < 0.001) and was the preferred device by all participants for the difficult airway scenario.
Conclusions
The iPhone modified bronchoscope, in its current configuration, was found to be more difficult to use compared with the Glidescope® and unmodified bronchoscope; however it offered several advantages for teaching fibreoptic intubation technique when video-assisted bronchoscopy was unavailable.
doi:10.1186/1471-2253-14-10
PMCID: PMC3945614  PMID: 24575885
18.  ANALYSIS: Mobile Phones Integrated into Diabetes Management: A Logical Progression 
In this issue of Journal of Diabetes Science and Technology, the intervention described by D. Katz, “Novel Interactive Cell-Phone Technology for Health Enhancement,” uses cell phones to provide the rapid communication necessary for the support of intensive management of diabetes. Mobile technology is widely accepted in today's society and can be an effective tool for this cause. There have been numerous interventions using various communication tools, including cell phones, to manage chronic disease, which all propose that improved communication and feedback to patients would improve health status. Dr. Katz has taken the next step by giving semiautomated, real-time, immediate feedback on each data point all transmitted by cell phone.
PMCID: PMC2769702  PMID: 19885192
cell phone; diabetes; telemedicine
19.  The scope of teledermatology in India 
Telemedicine describes the application of information and communication technologies in the entire range of functions that involve the health sector. Several medical and surgical specialties utilize tele-consultation. Dermatology is the best clinical specialty in the use of communications technology because of its inherently visual nature in both diagnosis and follow-up, which makes it easily applicable to virtual medicine. Teledermatology embraces great potential for revolutionizing the delivery of dermatologic services to remote and distant locations by means of telecommunications and information technology. It encompasses consultations between a patient (and the primary healthcare provider) and a dermatologist for diagnosis and management advice. Teledermatology also covers dermatological education for health professionals and for consumers. Teleconsultations reduce time and increase the chances of access to one or more consultants as the patient or referring doctor desires, irrespective of the distance between the two. Its usefulness in the field of surgery and aesthetic surgery is immeasurable as there are only a few experts in the field of aesthetic surgery available currently in comparison to the dermatology population and the ever growing awareness and demand of the patients towards aesthetics. As the field of teledermatology is advancing in leaps and bounds the day is not far off when an aesthetic surgeon will be able to perform his skill from his own office on a patient in a distant locality with the help of a qualified and trained assistant. By adopting high-tech medical communication, high-performance computers, high-resolution cameras, and fiber-optic equipment's the entire world shrinks!
doi:10.4103/2229-5178.110579
PMCID: PMC3673398  PMID: 23741661
India; teledermatology; telemedicine
20.  Integration of Telemedicine in Graduate Medical Informatics Education 
An essential part of health informatics is telemedicine, the use of advanced telecommunications technologies to bridge distance and support health care delivery and education. This report discusses the integration of telemedicine into a medical informatics curriculum and, specifically, a framework for a telemedicine course. Within this framework, the objectives and exit competencies are presented and course sections are described: definitions, introduction to technical aspects of telemedicine, evolution of telemedicine and its impact on health care delivery, success and failure factors, and legal and ethical issues. The emphasis is on literature review tools, practical exposure to products and applications, and problem-based learning. Given the rapid advances in the telecommunication field, keeping the course material up to date becomes a challenge for the instructor who at the same time aims to equip students with the knowledge and tools they will need in their future role as decision makers to detect a need for, design, implement, maintain, or evaluate a telemedicine application.
doi:10.1197/jamia.M1280
PMCID: PMC181980  PMID: 12668696
21.  Design of a randomized, non-inferiority trial to evaluate the reliability of videoconferencing for remote consultation of diabetes 
Background
An estimated 366 million people are living with diabetes worldwide and it is predicted that its prevalence will increase to 552 million by 2030. Management of this disease and its complications is a challenge for many countries. Optimal glycaemic control is necessary to minimize complications, but less than 70% of diabetic patients achieve target levels of blood glucose, partly due to poor access to qualified health care providers. Telemedicine has the potential to improve access to health care, especially for rural and remote residents. Video teleconsultation, a real-time (or synchronous) mode of telemedicine, is gaining more popularity around the world through recent improvements in digital telecommunications. If video consultation is to be offered as an alternative to face-to-face consultation in diabetes assessment and management, then it is important to demonstrate that this can be achieved without loss of clinical fidelity. This paper describes the protocol of a randomised controlled trail for assessing the reliability of remote video consultation for people with diabetes.
Methods/Design
A total of 160 people with diabetes will be randomised into either a Telemedicine or a Reference group. Participants in the Reference group will receive two sequential face-to-face consultations whereas in the Telemedicine group one consultation will be conducted face-to-face and the other via videoconference. The primary outcome measure will be a change in the patient’s medication. Secondary outcome measures will be findings in physical examination, detecting complications, and patient satisfaction. A difference of less than 20% in the aggregated level of agreement between the two study groups will be used to identify if videoconference is non-inferior to traditional mode of clinical care (face-to-face).
Discussion
Despite rapid growth in application of telemedicine in a variety of medical specialities, little is known about the reliability of videoconferencing for remote consultation of people with diabetes. Results of this proposed study will provide evidence of the reliability of specialist consultation offered by videoconference for people with diabetes.
Trial registration number
Australian New Zealand Clinical Trials Registry ACTRN12612000315819.
doi:10.1186/1472-6947-14-11
PMCID: PMC3925960  PMID: 24528569
Diabetes; Telemedicine; Remote consultation; Videoconferencing; Video teleconsultation; Video consultation; Video visit
22.  Design and performance of a multi-centre randomised controlled trial and economic evaluation of joint tele-consultations [ISRCTN54264250] 
Background
Appropriate information flow is crucial to the care of patients, particularly at the interface between primary and secondary care. Communication problems can result from inadequate organisation and training, There is a major expectation that information and communication technologies may offer solutions, but little reliable evidence. This paper reports the design and performance of a multi-centre randomised controlled trial (RCT), unparalleled in telemedicine research in either scale or range of outcomes. The study investigated the effectiveness and cost implications in rural and inner-city settings of using videoconferencing to perform joint tele-consultations as an alternative to general practitioner referral to the hospital specialist in the outpatient clinic.
Methods
Joint tele-consultation services were established in both the Royal Free Hampstead NHS Trust in inner London, and the Royal Shrewsbury Hospitals Trust, in Shropshire. All the patients who gave consent to participate were randomised either to joint tele-consultation or to a routine outpatients appointment. The principal outcome measures included the frequency of decision by the specialist to offer a follow-up outpatient appointment, patient satisfaction (Ware Specific Questionnaire), wellbeing (SF12) and enablement (PEI), numbers of tests, investigations, procedures and treatments.
Results
A total of 134 general practitioners operating from 29 practices participated in the trial, referring a total of 3170 patients to 20 specialists in ENT medicine, general medicine (including endocrinology, and rheumatology), gastroenterology, orthopaedics, neurology and urology. Of these, 2094 patients consented to participate in the study and were correctly randomised. There was a 91% response rate to the initial assessment questionnaires, and analysis showed equivalence for all key characteristics between the treatment and control groups.
Conclusion
We have designed and performed a major multi-centre trial of teleconsultations in two contrasting centres. Many problems were overcome to enable the trial to be carried out, with a considerable development and learning phase. A lengthier development phase might have enabled us to improve the patient selection criteria, but there is a window of opportunity for these developments, and we believe that our approach was appropriate, allowing the evaluation of the technology before its widespread implementation.
doi:10.1186/1471-2296-3-1
PMCID: PMC65515  PMID: 11835692
23.  The Anatomy of Teleneurosurgery in China 
With its huge population and vast territory, China faces a great challenge in providing modern advanced health care services to all parts of the country. The advances of information communication technologies (ICTs) and the advent of internet have revolutionised the means in the delivery of healthcare via telemedicine to remote and underserved populations, which to a certain extent has been very well exploited in China, especially where 70% peasants residing in the rural areas. This paper reviews the latest development in telemedicine infrastructure in China with the focus on the development of teleneurosurgery, drawing from the results gained from a 3-year networking project between Europe and China on telemedicine (TIME, 2005–2007) funded by European Commission under Asia ICT programme, with an aim to shape up envisages of future medical care in China. Comparison with its counterparts in Europe is also addressed.
doi:10.1155/2011/353405
PMCID: PMC3177458  PMID: 21941536
24.  How effective is video consultation in clinical oncology? A systematic review 
Current Oncology  2010;17(3):17-27.
Background
Video-consultation (vc) is a specialized type of telemedicine that uses technology to provide real-time visual and audio patient assessment at a distance. In the present review, we set out to evaluate whether vc is feasible for the assessment, monitoring, and management of oncology patients.
Methods
A search strategy designed to capture studies that addressed the use of telemedicine to deliver cancer care identified relevant articles in the medline (1966 to September 2008) and PubMed (to 2008) databases. Articles were included if they described studies incorporating video-conferencing between patient and provider for assessment or monitoring,physicians or nurses as the care providers,cancer patients,consultation in real-time, andreporting of 1 or more outcomes.
Results
Of the more than three hundred articles retrieved, nineteen articles describing 15 unique patient populations involving 709 patients were inclusded in the analysis. No randomized trials were located. Eight studies included a control group; seven involved a case series. The most commonly reported outcomes were patient satisfaction (ten studies), cost to perform consultation (six studies), patient preference for vc compared with in-person consultation (five studies), provider satisfaction (four studies), and provider convenience (four studies). Of these outcomes, satisfaction on the part of patients and physicians has been positive overall, total costs were comparable to or less than those for in-person consultations, and patients valued having vc as an option for consultation. Outcomes evaluating the effect on clinical care were infrequently reported.
Conclusions
While there is evidence to suggest that vc is both feasible and effective for use in the clinical care of oncology patients, studies are generally small and methodologically weak, with limited power of inference.
PMCID: PMC2880899  PMID: 20567623
Telemedicine; teleconsultation; video consultation; remote consultation
25.  Telemedicine and Alzheimer’s Disease From Studio-Based Videoconferencing to Mobile Handheld Cell Phones 
Journal of Brain Disease  2009;1:39-43.
The use of Telemedicine in the assessment of cognitive impairment and Alzheimer’s Disease is evolving with advances in Information and Communication Technology. This article outlines the course of evolution in Western Australia, a large state with a sparse population outside of the capital city. The starting point of the evolution, video-conferencing in Telehealth studios, is reviewed as well as the next stage, use of desktop technology, which enables the physician to consult from the office or clinic. A pilot study currently being undertaken to assess the validity of the latest stage in evolution of Telehealth—the use of handheld mobile cell phone video calling that allows the physician and patient to interact at locations convenient to both parties. The pitfalls and implications of the use of this stage, should it prove to be a valid approach, are discussed.
PMCID: PMC3676370  PMID: 23818808
Alzheimer’s; telemedicine; information and communication technology

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