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1.  Feasibility and Effectiveness of Remote, Telephone-Based Delivery of Cardiac Rehabilitation 
Abstract
Objectives: Cardiac rehabilitation (CR) provides significant benefit for persons with cardiovascular disease. However, access to CR services may be limited by driving distance, costs, need for a driver, time away from work, or being a family primary caregiver. The primary aim of the project was to test the reach (i.e., patient and provider uptake), effectiveness (safety and clinical outcomes), and implementation (time and costs) of a remote telephone-based Phase 2 CR program. A secondary aim was to compare outcomes between patients attending the remote program (home-CR) and those attending an on-site program (comparison group). Subjects and Methods: Subjects were given a choice of the remote or face-to-face program. Remote CR participants (n=48) received education and assessment during 12 weekly by telephone calls. Data were compared with those for face-to-face CR program participants (n=14). Independent t tests and chi-squared tests were used for continuous and categorical variables, respectively. Repeated-measures analysis of covariance models were used to assess differences in outcomes. Costs were analyzed using a cost-minimization analysis. Results: Of 107 eligible patients, 45 refused participation, 5 dropped out, and 1 died unrelated to the study. Participants had a mean age of 64 (standard deviation 7.5) years. Remote CR participants were highly satisfied with their care and had a higher completion rate (89% of authorized sessions versus 73% of face-to-face). Costs for each program were comparable. There were no significant changes over time in any measured outcome between groups at 12 weeks except medication adherence, which decreased over time in both groups; face-to-face patients reported a greater decrease (p=0.05). Conclusions: This is the first study to test a remote CR program in a population of older Veterans. Many hospitals do not provide comprehensive CR services on-site; thus remote CR is a viable alternative to bring services closer to the patient.
doi:10.1089/tmj.2013.0079
PMCID: PMC3880057  PMID: 24161003
telecommunications; cardiology/cardiovascular disease; home health monitoring
2.  A Pilot Project to Improve Access to Telepsychotherapy at Rural Clinics 
Abstract
Background: The U.S. Department of Veterans Affairs (VA) has pioneered telemental health (TMH) with over 500,000 TMH encounters over the past decade. VA community-based outpatient clinics were established to improve accessibility of mental healthcare for rural Veterans. Despite these clinics clinics and increased availability of TMH, many rural Veterans have difficulty receiving mental healthcare, particularly psychotherapy. Materials and Methods: Twelve therapists participated in a pilot project using TMH technologies to improve mental healthcare service delivery to rural Veterans treated at six community clinics. Therapists completed online training, and study staff communicated with them monthly and clinical leaders every other month. Therapists completed two questionnaires: before training and 10 months later. This article describes barriers and facilitators to the implementation of the project, as well as therapists' knowledge, confidence, and motivation regarding TMH. Results: Two clinicians were offering telepsychotherapy after 10 months. At all six sites, unanticipated organizational constraints and administrative barriers delayed implementation; establishing organizational practices and therapists' motivation helped facilitate the process. Adopters of the project reported more positive views of the modality and did not worry about staffing, a concern of nonadopters. Conclusions: Despite barriers to implementation, lessons learned from this pilot project have led to improvements and changes in TMH processes. Results from the pilot showed that therapists providing telepsychotherapy had increased confidence, knowledge, and motivation. As TMH continues to expand, formalized decision-making with clinical leaders regarding project goals, better matching of therapists with this modality, and assessment of medical center and clinic readiness are recommended.
doi:10.1089/tmj.2013.0085
PMCID: PMC3880058  PMID: 24168721
military medicine; telehealth; telepsychiatry
3.  Mobile Health Is Worth It! Economic Benefit and Impact on Health of a Population-Based Mobile Screening Program in New Mexico 
Abstract
Background: HABITS for Life was a 3-year initiative to broadly deliver a statewide biometric and retinal screening program via a mobile unit throughout New Mexico at no charge to participants. The program goal—to identify health risk and improve population health status—was tested over a 3-year period. Value to participants and impact to the healthcare system were measured to quantify impact and value of investing in prevention at the community level. Materials and Methods: We used the Mobile Health Map Return-on-Investment Calculator, a mobile screening unit, biometric screening, retinography, and community coordination. Our systems included satellite, DSL, and 3G connectivity, a Tanita® (Arlington Heights, IL) automated body mass index–measuring scale, the Cholestec® (Alere™, Waltham, MA) system for biomarkers and glycosylated hemoglobin, a Canon (Melville, NY) CR-1 Mark II camera, and the Picture Archiving Communication System. Results: In this report for the fiscal year 2011 time frame, 6,426 individuals received biometric screening, and 5,219 received retinal screening. A 15:1 return on investment was calculated; this excluded retinal screening for the under-65 year olds, estimated at $10 million in quality-adjusted life years saved. Statistically significant improvement in health status evidenced by sequential screening included a decrease in total cholesterol level (p=0.002) (n=308) and an increase in high-density lipoprotein level after the first and second screening (p=0.02 andp=0.01, respectively), but a decrease in mean random glucose level was not statistically significant (p=0.62). Retinal results indicate 28.4% (n=1,482) with a positive/abnormal finding, of which 1.79% (n=93) required immediate referral for sight-threatening retinopathy and 27% (n=1,389) required follow-up of from 3 months to 1 year. Conclusions: Screening programs are cost-effective and provide value in preventive health efforts. Broad use of screening programs should be considered in healthcare redesign efforts. Community-based screening is an effective strategy to identify health risk, improve access, provide motivation to change health habits, and improve physical status while returning significant value.
doi:10.1089/tmj.2013.0080
PMCID: PMC3880062  PMID: 24237397
business administration/economics; telemedicine; ophthalmology; extreme environments; information management
4.  Telemedicine in Alentejo 
Abstract
Alentejo covers a third of Portugal, yet it is home to only 5% of the population. Residents of the region are poorer, older, and less educated than the rest of the country. There is a shortage of physicians in several specialties. The low population density, a concentration of specialized services, and a poor public transportation network all create barriers to access. Telemedicine was introduced in 1998 to help address these challenges. In this article, we provide an overview of the program and its current status, focusing on infrastructure, services, and activity volume. We also discuss the impact the program has had from the perspectives of patients and healthcare professionals. From 1998 to 2011, there were 132,546 episodes of service using telemedicine, including real-time teleconsultations, teleradiology, teleultrasound, and telepathology. At present, the network includes 20 primary care units and five hospitals, covering almost 30,000 km2 and 500,000 people. Units have high-resolution videoconferencing equipment, access to patients' clinical records, an image archive, and peripherals, such as electronic dermatoscopes and phonendoscopes. Teleconsultations are available in 15 medical specialties and areas, ranging from neurology to pediatric surgery. In 2008, regional health authorities started a tele-education program, and by the end of 2011, 876 healthcare professionals, across 52 locations, had participated in remote learning sessions. More than a decade since telemedicine was introduced in Alentejo, it is now an integral part of everyday service provision. A comprehensive assessment of the costs and consequences of the program is currently underway.
doi:10.1089/tmj.2012.0308
PMCID: PMC3880063  PMID: 24180419
telemedicine; teleradiology; distance learning
5.  Barriers to Using Text Message Appointment Reminders in an HIV Clinic 
Abstract
Introduction: Failure to attend medical appointments among persons living with human immunodeficiency virus (HIV) has been associated with poor health outcomes. Text message appointment reminders are a novel tool to potentially improve appointment attendance, but the feasibility of this tool among persons living with HIV in the United States is unknown. Subjects and Methods: We conducted a randomized, controlled trial of text message reminders in a large HIV clinic. Patients who declined enrollment were asked for reasons for declining. For all patients randomized, demographic and clinical data were collected from medical records. Results: Of 94 patients screened for the study, 42 (45%) did not elect to participate; the most common reason for declining participation was the lack of either a cell phone or text messaging service. Cost, comfort with text messaging, and privacy were other major barriers to study enrollment. Among the 25 subjects randomized to receive text messages, 6 (24%) had their phones disconnected prior to the appointment reminder date. Ultimately, there were no differences in clinic attendance rates between the group that received text reminders versus the group that did not (72% versus 81%, p=0.42) in an intention-to-treat analysis. Conclusions: Although text message reminders may be successful in certain groups of patients, barriers must be addressed before they are used as a universal approach to improve clinic attendance.
doi:10.1089/tmj.2012.0275
PMCID: PMC3880106  PMID: 24160900
human immunodeficiency virus; text message appointment reminder; mobile phone; clinic attendance
6.  The Impact of Mobile Health Interventions on Chronic Disease Outcomes in Developing Countries: A Systematic Review 
Abstract
Introduction: Rates of chronic diseases will continue to rise in developing countries unless effective and cost-effective interventions are implemented. This review aims to discuss the impact of mobile health (m-health) on chronic disease outcomes in low- and middle-income countries (LMIC). Materials and Methods: Systematic literature searches were performed using CENTRAL, MEDLINE, EMBASE, and LILACS databases and gray literature. Scientific literature was searched to identify controlled studies evaluating cell phone voice and text message interventions to address chronic diseases in adults in low- or middle-income countries. Outcomes measured included morbidity, mortality, hospitalization rates, behavioral or lifestyle changes, process of care improvements, clinical outcomes, costs, patient–provider satisfaction, compliance, and health-related quality of life (HRQoL). Results: From the 1,709 abstracts retrieved, 163 articles were selected for full text review, including 9 randomized controlled trials with 4,604 participants. Most of the studies addressed more than one outcome. Of the articles selected, six studied clinical outcomes, six studied processes of care, three examined healthcare costs, and two examined HRQoL. M-health positively impacted on chronic disease outcomes, improving attendance rates, clinical outcomes, and HRQoL, and was cost-effective. Conclusions: M-health is emerging as a promising tool to address access, coverage, and equity gaps in developing countries and low-resource settings. The results for m-health interventions showed a positive impact on chronic diseases in LMIC. However, a limiting factor of this review was the relatively small number of studies and patients enrolled, highlighting the need for more rigorous research in this area in developing countries.
doi:10.1089/tmj.2012.0328
PMCID: PMC3880111  PMID: 24205809
chronic disease; mobile health; short message service; cellular phone; developing countries; systematic review
7.  Remote Patient Monitoring Based on ZigBee: Lessons from a Real-World Deployment 
Abstract
Aim: This work presents detailed experimental performance results from tests executed in the hospital environment for Health Monitoring for All (HM4All), a remote vital signs monitoring system based on a ZigBee® (ZigBee Alliance, San Ramon, CA) body sensor network (BSN). Materials and Methods: Tests involved the use of six electrocardiogram (ECG) sensors operating in two different modes: the ECG mode involved the transmission of ECG waveform data and heart rate (HR) values to the ZigBee coordinator, whereas the HR mode included only the transmission of HR values. In the absence of hidden nodes, a non–beacon-enabled star network composed of sensing devices working on ECG mode kept the delivery ratio (DR) at 100%. Results: When the network topology was changed to a 2-hop tree, the performance degraded slightly, resulting in an average DR of 98.56%. Although these performance outcomes may seem satisfactory, further investigation demonstrated that individual sensing devices went through transitory periods with low DR. Other tests have shown that ZigBee BSNs are highly susceptible to collisions owing to hidden nodes. Nevertheless, these tests have also shown that these networks can achieve high reliability if the amount of traffic is kept low. Contrary to what is typically shown in scientific articles and in manufacturers' documentation, the test outcomes presented in this article include temporal graphs of the DR achieved by each wireless sensor device. Conclusions: The test procedure and the approach used to represent its outcomes, which allow the identification of undesirable transitory periods of low reliability due to contention between devices, constitute the main contribution of this work.
doi:10.1089/tmj.2013.0059
PMCID: PMC3880127  PMID: 24229401
e-health; remote patient monitoring; body sensor network; ZigBee; telemedicine
8.  Comparing the Effectiveness of Telemedicine and Traditional Surveillance in Providing Diabetic Retinopathy Screening Examinations: A Randomized Controlled Trial 
Telemedicine Journal and e-Health  2013;19(12):942-948.
Abstract
Objective: To determine the effectiveness of telemedicine for providing diabetic retinopathy screening examinations compared with the effectiveness of traditional surveillance in community health clinics with a high proportion of minorities, including American Indian/Alaska Natives. Subjects and Methods: We conducted a multicenter, randomized controlled trial and assigned diabetic participants to one of two groups: (1) telemedicine with a nonmydriatic camera or (2) traditional surveillance with an eye care provider. For those receiving telemedicine, the criteria for requiring follow-up with an eye care provider were (1) moderate nonproliferative diabetic retinopathy or higher, (2) presence of clinically significant macular edema, or (3) “unable to grade” result for diabetic retinopathy or macular edema. Results: The telemedicine group (n=296) was more likely to receive a diabetic retinopathy screening examination within the first year of enrollment compared with the traditional surveillance group (n=271) (94% versus 56%, p<0.001). The overall prevalence of diabetic retinopathy at baseline was 21.4%, and macular edema was present in 1.4% of participants. In the telemedicine group, 20.5% would require further evaluation with an eye care provider, and 86% of these referrals were because of poor-quality digital images. Conclusions: Telemedicine using nonmydriatic cameras increased the proportion of participants who obtained diabetic retinopathy screening examinations, and most did not require follow-up with an eye care provider. Telemedicine may be a more effective way to screen patients for diabetic retinopathy and to triage further evaluation with an eye care provider. Methods to decrease poor quality imaging would improve the effectiveness of telemedicine for diabetic retinopathy screening examinations.
doi:10.1089/tmj.2012.0313
PMCID: PMC3850428  PMID: 24102102
ophthalmology; telemedicine; telehealth; diabetic retinopathy; retinopathy screening
9.  Low-Cost Tele-assessment System for Home-Based Evaluation of Reaching Ability Following Stroke 
Telemedicine Journal and e-Health  2013;19(12):973-978.
Abstract
Objective: Tele-assessment techniques can provide healthcare professionals with easily accessible information regarding patients' clinical progress. Recently, kinematic analysis systems have been used to assess rehabilitative outcomes in stroke patients. Kinematic systems, however, are not compatible with tele-assessment. The objective of our study was to develop a tele-assessment system for acquiring kinematic data of forward reaching movements in stroke patients, with an emphasis on cost-effectiveness, portability, and ease of use. Materials and Methods: We selected four healthy control participants and eight hemiplegic stroke patients for our study. The stroke patients were classified as Brunnstrom stage III, stage IV, or stage V. Our tele-assessment system used two three-axes accelerometers, a potentiometer, a multifunctional data acquisition card, and two computers. A standardized kinematic system was applied simultaneously to validate the measurements recorded by our tele-assessment system during five repetitions of forward reaching movements. Results: The correlation coefficients of the reaching displacement, velocity, and acceleration measurements obtained using our tele-assessment system and the standardized kinematic system were 0.956, 0.896, and 0.727, respectively. Differences in the maximum reaching distance and the maximum reaching velocity of forward reaching movements were observed among the study groups. There were no significant differences in the time required to complete the testing session among the study groups. Conclusions: Our tele-assessment system is valid for the evaluation of upper-extremity reaching ability in stroke patients. Further research is needed to investigate the feasibility of the use of the tele-assessment system in patients' homes.
doi:10.1089/tmj.2012.0300
PMCID: PMC3850429  PMID: 24138613
tele-assessment; stroke; upper extremity function
10.  A Web Search on Environmental Topics: What Is the Role of Ranking? 
Telemedicine Journal and e-Health  2013;19(12):967-972.
Abstract
Background: Although the Internet is easy to use, the mechanisms and logic behind a Web search are often unknown. Reliable information can be obtained, but it may not be visible as the Web site is not located in the first positions of search results. The possible risks of adverse health effects arising from environmental hazards are issues of increasing public interest, and therefore the information about these risks, particularly on topics for which there is no scientific evidence, is very crucial. The aim of this study was to investigate whether the presentation of information on some environmental health topics differed among various search engines, assuming that the most reliable information should come from institutional Web sites. Materials and Methods: Five search engines were used: Google, Yahoo!, Bing, Ask, and AOL. The following topics were searched in combination with the word “health”: “nuclear energy,” “electromagnetic waves,” “air pollution,” “waste,” and “radon.” For each topic three key words were used. The first 30 search results for each query were considered. The ranking variability among the search engines and the type of search results were analyzed for each topic and for each key word. The ranking of institutional Web sites was given particular consideration. Results: Variable results were obtained when surfing the Internet on different environmental health topics. Multivariate logistic regression analysis showed that, when searching for radon and air pollution topics, it is more likely to find institutional Web sites in the first 10 positions compared with nuclear power (odds ratio=3.4, 95% confidence interval 2.1–5.4 and odds ratio=2.9, 95% confidence interval 1.8–4.7, respectively) and also when using Google compared with Bing (odds ratio=3.1, 95% confidence interval 1.9–5.1). Conclusions: The increasing use of online information could play an important role in forming opinions. Web users should become more aware of the importance of finding reliable information, and health institutions should be able to make that information more visible.
doi:10.1089/tmj.2013.0051
PMCID: PMC3850430  PMID: 24083368
e-health; information management; policy
11.  A Randomized Controlled Trial Comparing Health and Quality of Life of Lung Transplant Recipients Following Nurse and Computer-Based Triage Utilizing Home Spirometry Monitoring 
Telemedicine Journal and e-Health  2013;19(12):897-903.
Abstract
Background: Lung transplantation is now a standard intervention for patients with advanced lung disease. Home monitoring of pulmonary function and symptoms has been used to follow the progress of lung transplant recipients in an effort to improve care and clinical status. The study objective was to determine the relative performance of a computer-based Bayesian algorithm compared with a manual nurse decision process for triaging clinical intervention in lung transplant recipients participating in a home monitoring program. Materials and Methods: This randomized controlled trial had 65 lung transplant recipients assigned to either the Bayesian or nurse triage study arm. Subjects monitored and transmitted spirometry and respiratory symptoms daily to the data center using an electronic spirometer/diary device. Subjects completed the Short Form-36 (SF-36) survey at baseline and after 1 year. End points were change from baseline after 1 year in forced expiratory volume at 1 s (FEV1) and quality of life (SF-36 scales) within and between each study arm. Results: There were no statistically significant differences between groups in FEV1 or SF-36 scales at baseline or after 1 year.: Results were comparable between nurse and Bayesian system for detecting changes in spirometry and symptoms, providing support for using computer-based triage support systems as remote monitoring triage programs become more widely available. Conclusions: The feasibility of monitoring critical patient data with a computer-based decision system is especially important given the likely economic constraints on the growth in the nurse workforce capable of providing these early detection triage services.
doi:10.1089/tmj.2013.0049
PMCID: PMC3850431  PMID: 24083367
home health monitoring; telehealth; telemedicine; m-health; transplantation
13.  Walk-In Telemental Health Clinics Improve Access and Efficiency: A 2-Year Follow-Up Analysis 
Telemedicine Journal and e-Health  2013;19(12):938-941.
Abstract
Introduction: Telemedicine has demonstrated potential to improve access and quality of mental health services in underserved areas. Use of telemedicine to deliver health services may enable a range of synergistic innovations in care practices, but such innovations will require rigorous evaluation. Materials and Methods: We evaluated a telemental health program designed to increase access by eliminating clinician travel time in a multisite rural community mental health center. The program included both traditionally scheduled and “open scheduled” clinics provided via telemedicine. An initial 13-month evaluation showed better access, quality, and sustainability compared with similar services delivered using traditional methods available elsewhere within the organization. A 24-month follow-up analysis was undertaken to determine if initial findings remained consistent. Results: Telemedicine clinics continued to show remarkably consistent advantages in both access and quality compared with traditional services. Cost-efficiency gains were also robust, maintaining a 20-percentage-point advantage in conversion of scheduled time to billable time over traditional clinics. Much of this advantage was attributable to the 20% of clinic volume that was open-scheduled or “walk-in” in nature. Conclusions: This study confirms earlier findings that telemedicine technology can support synergistic innovations in service format (such as “open scheduling”) and maintain measurable advantages in access and quality along with cost-efficiencies past the initial implementation period.
doi:10.1089/tmj.2013.0076
PMCID: PMC3850444  PMID: 24050609
telehealth; telemedicine; rural; mental health; cost-effectiveness; evaluation
14.  Adapting the Content of Cancer Web Sites to the Information Needs of Patients: Reliability and Readability 
Telemedicine Journal and e-Health  2013;19(12):956-966.
Abstract
Background: People who use the Internet to research health topics do not usually find all the information they need and do not trust what they read. This study was designed to assess the reliability, accessibility, readability, and popularity of cancer Web sites in Spanish and to analyze the suitability of Web site content in accordance with the specific information needs of cancer patients. Materials and Methods: This was a two-phase, cross-sectional, descriptive study. The first phase involved data gathering through online searches and direct observation. The second phase involved individual structured interviews with 169 patients with breast, prostate, bladder, and kidney cancer. Spearman rank correlations were calculated between variables. Results: Most sites belonged to nonprofit organizations, followed by universities or medical centers (14%). Thirty-one percent of the Web sites had quality seals, 59% provided details of authorship, 62% provided references to bibliographic sources, 38% identified their funding sources, and 54% showed the date of their last update. Twenty-one percent of the Web sites did not meet the minimum accessibility criteria. With regard to readability, 24% of the texts were considered to be “quite difficult.” Patients' information needs vary depending on the type of cancer they have, although all patients want to know about the likelihood of a cure, survival rates, the side effects, and risks of treatment. Conclusions: The health information on cancer available on the Internet in Spanish is not very reliable, accessible, or readable and is not necessarily the information that breast, kidney, prostate, and bladder cancer patients require. The content of cancer Web sites needs to be assessed according to the information needs of patients.
doi:10.1089/tmj.2013.0050
PMCID: PMC3850662  PMID: 24073899
e-health; information management; telemedicine
15.  Intelligent Classification of Heartbeats for Automated Real-Time ECG Monitoring 
Telemedicine Journal and e-Health  2014;20(12):1069-1077.
Abstract
Background: The automatic interpretation of electrocardiography (ECG) data can provide continuous analysis of heart activity, allowing the effective use of wireless devices such as the Holter monitor. Materials and Methods: We propose an intelligent heartbeat monitoring system to detect the possibility of arrhythmia in real time. We detected heartbeats and extracted features such as the QRS complex and P wave from ECG signals using the Pan–Tompkins algorithm, and the heartbeats were then classified into 16 types using a decision tree. Results: We tested the sensitivity, specificity, and accuracy of our system against data from the MIT-BIH Arrhythmia Database. Our system achieved an average accuracy of 97% in heartbeat detection and an average heartbeat classification accuracy of above 96%, which is comparable with the best competing schemes. Conclusions: This work provides a guide to the systematic design of an intelligent classification system for decision support in Holter ECG monitoring.
doi:10.1089/tmj.2014.0033
PMCID: PMC4270110  PMID: 25010717
heartbeat detection; heartbeat classification; decision tree; electrocardiography monitoring
16.  Young Women's Experience with Using Videoconferencing for the Assessment of Sexual Behavior and Microbicide Use 
Telemedicine Journal and e-Health  2013;19(11):866-871.
Abstract
Background: Videoconferencing (VC) systems are increasingly recognized as a viable means of enhancing communication across different geographic regions and have been used within multiple settings. Until now, despite increased use and diverse applications, VC has received relatively little attention as a data collection tool in qualitative research. The literature on preferred data collection methods for sensitive topics offers different perspectives, with no clear consensus on the best approach for collecting sensitive data. We sought to determine if VC is a feasible tool for eliciting sexual history from participants in a vaginal microbicide study. Subjects and Methods: Fifty-nine young women who participated in a Phase 1 microbicide safety and acceptability study at three sites (Tampa, FL; Pittsburgh, PA; and San Juan, Puerto Rico) were interviewed through VC from New York City. During the third VC session, participants gave feedback on their experience using the method. Results: Most of the participants reported that they preferred VC to phone-only interviews. Participants noted that because of the sensitive nature of the interviews, geographical distance from the interviewer facilitated disclosure. Despite some technical problems, such as the time delay in video transmission and occasional loss of connection, participants expressed a high degree of satisfaction with using VC. Conclusions: VC seems to be a feasible alternative form of conducting in-depth interviews on sensitive topics. VC enables data collection from geographically dispersed research participants without the cost and time burden of traveling to sites or developing local interviewer capabilities when the number of interviews is small.
doi:10.1089/tmj.2013.0008
PMCID: PMC3810614  PMID: 24050616
videoconferencing; interview; qualitative research; microbicide; sexual behavior
17.  Utilization of the American Telemedicine Association's Clinical Practice Guidelines 
Telemedicine Journal and e-Health  2013;19(11):846-851.
Abstract
Background: The American Telemedicine Association (ATA) Standards and Guidelines Committee develops practice standards and guidelines. Key to the Committee's mission is dissemination so the standards can be used in the practice of telemedicine. Over a 2-year period, when a standards document was accessed from the ATA Web site, a short survey was completed, but it did not assess how the documents were used once downloaded. A more formal survey was conducted to determine the impact ATA standards and guidelines are having on healthcare delivery via telemedicine. Materials and Methods: A survey was developed and distributed via SurveyMonkey to 13,177 ATA members and nonmembers in November 2011. Results were compiled and analyzed after a 90-day open period for responses to be submitted. Results: The majority of respondents (96%) believe the practice of telemedicine/telehealth should have standards and guidelines and that the ATA and other professional societies/associations should be responsible for developing them. The top uses of guidelines include guidance for clinical practice, training, gaining reimbursement, and research. Respondents indicating a need for standards and guidelines said the ATA (78.7%) and other professional societies/associations (74.5%) should be responsible for development. When asked to list specific practice guidelines or standards they are using for telehealth, the majority (21.5%) are using in-house (e.g., hospital, company)-developed guidelines, followed by those from professional associations/societies (20.4%) and those developed by the ATA (18.2%). Conclusions: Overall, the survey results indicate guidelines documents developed by the ATA and other professional societies and those developed in-house are being regularly accessed and used in both public and private sectors. Practitioners of telemedicine believe that standards and guidelines are needed for guidance for clinical practice, training, gaining reimbursement, and research, and they are to use those developed by professional organization such as the ATA as well as those developed by their own institutions.
doi:10.1089/tmj.2013.0027
PMCID: PMC3810615  PMID: 24050615
standards; guidelines; American Telemedicine Association; utilization
18.  Comparative Effectiveness Study to Assess Two Examination Modalities Used to Detect Dental Caries in Preschool Urban Children 
Telemedicine Journal and e-Health  2013;19(11):834-840.
Abstract
Background: Dental caries affecting the primary dentition of U.S. children continues to be the most prevalent chronic childhood disease. Preventive screening for dental caries in toddlers by dental professionals is labor-intensive and costly. Studies are warranted to examine innovative screening modalities that reduce cost, are less labor-intensive, and have the potential to identify caries in high-risk children. Subjects and Methods: Two hundred ninety-one children were randomized into two groups: Group 1 received a traditional, visual tactile examination initially and follow up-examinations at 6 and 12 months, and Group 2 received a teledentistry examination initially and follow-up examinations at 6 and 12 months. The mean primary tooth decayed and filled surfaces (dfs) scores were calculated for all children at baseline and 6 and 12 months. Results: At baseline, the mean dfs score for children examined by means of teledentistry was 2.19, and for the children examined by means of the traditional method, the mean was 1.27; the means were not significantly different. At the 12-month examination, the mean dfs score for the children examined by means of teledentistry was 3.02, and for the children examined by means of the clinical method, the mean dfs was 1.70; the means were not significantly different. At 12 months the mean fillings score for the children examined by means of teledentistry was 1.43 and for the children examined by means of the clinical method was 0.51; the means were statistically significantly different (p<0.001). Conclusions: These results suggest that the teledentistry examinations were comparable to clinical examinations when screening for early childhood caries in preschool children. The data further showed that color printouts of teeth with cavities provided to parents of children who received teledentistry screenings promoted oral healthcare utilization, as children from the teledentistry study group received more dental care than children from the clinical study group.
doi:10.1089/tmj.2013.0012
PMCID: PMC3810618  PMID: 24053114
telehealth; e-health; telemedicine
19.  Health Monitors for Chronic Disease by Gait Analysis with Mobile Phones 
Telemedicine Journal and e-Health  2014;20(11):1035-1041.
Abstract
We have developed GaitTrack, a phone application to detect health status while the smartphone is carried normally. GaitTrack software monitors walking patterns, using only accelerometers embedded in phones to record spatiotemporal motion, without the need for sensors external to the phone. Our software transforms smartphones into health monitors, using eight parameters of phone motion transformed into body motion by the gait model. GaitTrack is designed to detect health status while the smartphone is carried during normal activities, namely, free-living walking. The current method for assessing free-living walking is medical accelerometers, so we present evidence that mobile phones running our software are more accurate. We then show our gait model is more accurate than medical pedometers for counting steps of patients with chronic disease. Our gait model was evaluated in a pilot study involving 30 patients with chronic lung disease. The six-minute walk test (6MWT) is a major assessment for chronic heart and lung disease, including congestive heart failure and especially chronic obstructive pulmonary disease (COPD), affecting millions of persons. The 6MWT consists of walking back and forth along a measured distance for 6 minutes. The gait model using linear regression performed with 94.13% accuracy in measuring walk distance, compared with the established standard of direct observation. We also evaluated a different statistical model using the same gait parameters to predict health status through lung function. This gait model has high accuracy when applied to demographic cohorts, for example, 89.22% accuracy testing the cohort of 12 female patients with ages 50–64 years.
doi:10.1089/tmj.2014.0025
PMCID: PMC4229704  PMID: 24694291
home health monitoring; chronic obstructive pulmonary disease; mobile phones; gait analysis; health monitors; m-health
20.  Measurement of Self-Monitoring Web Technology Acceptance and Use in an e-Health Weight-Loss Trial 
Telemedicine Journal and e-Health  2013;19(10):739-745.
Abstract
Background: Research on technology acceptance and use in e-health weight-loss interventions is limited. Using data from a randomized controlled trial of two e-health interventions, we evaluated the acceptance and use of a self-monitoring Web site for weight loss. Materials and Methods: We examined eight theoretical constructs about technology acceptance using adapted 5-point Likert scales and the association of measured Web site usage and weight loss. Results: All scales had high internal consistency (Cronbach's alpha=0.74–0.97) in both interventions and at 3 and 15 months (end of intensive and maintenance intervention, respectively). From 3 to 15 months mean scores changed unfavorably for two constructs (compatibility and behavioral intention) among coach-led intervention participants, who received ongoing feedback on their self-monitoring entries. Among self-directed intervention participants, who received minimal coach support, mean scores changed unfavorably for five constructs (usefulness, ease of use, concern, compatibility, and behavioral intention). At 3 months, usefulness, ease of use, effect, compatibility, and behavioral intention in the coach-led group (Pearson r=0.33–0.5) and usefulness and affect in the self-directed group (r=0.43–0.46) were significantly correlated with Web site usage, which was correlated with weight loss (β=−0.02, p≤0.001 for both interventions). From 3 to 15 months, mean score changes for usefulness and behavioral intention correlated significantly with Web site usage in the coach-led group. Conclusions: The adapted acceptance measures showed acceptable psychometric properties and significant associations with actual Web site use, which correlated with weight loss. Better understanding of technology acceptance and use in e-health weight-loss interventions may improve participant adherence and outcome.
doi:10.1089/tmj.2013.0009
PMCID: PMC3787321  PMID: 23952787
e-health; telehealth; technology
21.  Telemedicine: A Cost-Reducing Means of Delivering Psychotherapy to Rural Combat Veterans with PTSD 
Telemedicine Journal and e-Health  2013;19(10):754-759.
Abstract
Background: Although effective psychotherapies for posttraumatic stress disorder (PTSD) exist, high percentages of Veterans in need of services are unable to access them. One particular challenge to providing cost-effective psychological treatments to Veterans with PTSD involves the difficulty and high cost of delivering in-person, specialized psychotherapy to Veterans residing in geographically remote locations. The delivery of these services via clinical videoteleconferencing (CVT) has been presented as a potential solution to this access to care problem. Materials and Methods: This study is a retrospective cost analysis of a randomized controlled trial investigating telemedicine service delivery of an anger management therapy for Veterans with PTSD. The parent trial found that the CVT condition provided clinical results that were comparable to the in-person condition. Several cost outcomes were calculated in order to investigate the clinical and cost outcomes associated with the CVT delivery modality relative to in-person delivery. Results: The CVT condition was significantly associated with lower total costs compared with the in-person delivery condition. The delivery of mental health services via CVT enables Veterans who would not normally receive these services access to empirically based treatments. Additional studies addressing long-term healthcare system costs, indirect cost factors at the patient and societal levels, and the use of CVT in other geographic regions of the United States are needed. Conclusions: The results of this study provide evidence that CVT is a cost-reducing mode of service delivery to Veterans with PTSD relative to in-person delivery.
doi:10.1089/tmj.2012.0298
PMCID: PMC3787338  PMID: 23931729
medicine; military medicine; telehealth; telepsychiatry
22.  Using Mobile Phone Technology to Provide Recovery Support for Women Offenders 
Telemedicine Journal and e-Health  2013;19(10):767-771.
Abstract
Background Mobile technology holds promise as a recovery tool for people with substance use disorders. However, some populations who may benefit the most may not have access to or experience with mobile phones. Incarcerated women represent a group at high risk for recidivism and relapse to substance abuse. Cost-effective mechanisms must be in place to support their recovery upon release. This study explores using mobile technology as a recovery management tool for women offenders residing in the community following release from jail. Subjects and Methods: This study surveyed 325 minority women offenders with substance use disorders to determine whether or not they use cell phones, their comfort with texting and search features, and the social networks that they access from mobile phones. Results: We found that 83% of survey subjects had cell phones; 30% of those were smartphones. Seventy-seven percent of the women reported access to supportive friends, and 88% had close family members they contacted regularly using mobile technology. Results indicated that most of the women were comfortable using a mobile phone, although the majority of them had prepaid minutes rather than plans, and most did currently use smartphones or have the capability to download applications or access social networks via their phones. Most women reported that they would be comfortable using a mobile phone to text, e-mail, and answer surveys. Conclusions: The high rate of adoption of mobile technology by women offenders makes them a promising target for recovery support delivered via mobile phone.
doi:10.1089/tmj.2012.0309
PMCID: PMC3787367  PMID: 23931730
e-health; telehealth; technology
23.  Older Adults' Perceptions of Home Telehealth Services 
Telemedicine Journal and e-Health  2013;19(10):786-790.
Abstract
The success of home telemedicine depends on end-user adoption, which has been slow despite rapid advances in technological development. This study focuses on an examination of significant factors that may predict the successful adoption of home telemedicine services (HTS) among older adults. Based on previous studies in the fields of remote patient monitoring, assisted living technologies, and consumer health information technology acceptance, eight factors were identified as a framework for qualitative testing. Twelve focus groups were conducted with an older population living in both urban and rural environments. The results reveal seven predictors that play an important role in perceptions of HTS: perceived usefulness, effort expectancy, social influence, perceived security, computer anxiety, facilitating conditions, and physicians' opinion. The results provide important insights in the field of older adults' acceptance of HTS, with guidelines for the strategic planning, developing, and marketing of HTS for the graying market.
doi:10.1089/tmj.2012.0272
PMCID: PMC3787386  PMID: 23931702
home telehealth services; older adults; telehealth adoption predicting factors
24.  Changes to CMS Reimbursement Rules for Intraoperative Neurophysiological Monitoring: Implications for Telemedicine 
Telemedicine Journal and e-Health  2013;19(10):791-793.
Abstract
Intraoperative neurophysiological monitoring (IONM) is used as an adjunct for surgeries that pose risk to nervous system structures. IONM is performed by a technologist in the operating room and is overseen by a highly trained fellowship-trained physician clinical neurophysiologist. Telemedicine has allowed the professional oversight component to be done remotely, with reimbursement for multiple simultaneous cases. Recent changes to Current Procedure Terminology coding and Medicare reimbursement policies provide options only for exclusive 1:1 technologist:oversight physician billing. This policy change may create profound repercussions in the practice of telemedicine by actively discouraging the leveraging of highly specialized and scarce expertise through on-site physician extenders.
doi:10.1089/tmj.2013.0004
PMCID: PMC3787403  PMID: 23952785
telemedicine; policy; telesurgery
25.  New Hospital Telemedicine Services: Potential Market for a Nighttime Telehospitalist Service 
Telemedicine Journal and e-Health  2014;20(10):902-908.
Abstract
Background: A critical shortage in the supply of physicians in the United States has necessitated innovative approaches to physician service delivery. Telemedicine is a viable service delivery model for a variety of physician and health services. Telemedicine is most effective when applied where physician resources are scarce, patient care is time sensitive, and service volume may be distributed across a network. Shortages in critical care and neurology specialists have led to the use of tele-intensive care unit and telestroke services in hospital settings. These hospital-based telemedicine services have gained acceptance and recommendation. Hospitalist staffing shortages may provide an opportunity to apply similar telemedicine models to hospitalist medicine. This study assesses the potential market for a nighttime telehospitalist service. Materials and Methods: An analysis of the Florida state hospital discharge dataset investigated the potential market for a new nighttime telehospitalist service. Admissions were filtered and stratified for common hospitalist metrics, time of day, and age of patients. Admissions were further expressed by hour of day and location. Results: Nineteen percent of common hospitalist admissions occurred between 7:00 p.m. and 7:00 a.m., with a range of 17%–27% or 0.23–10.09 admissions per night per facility. Eighty percent of admissions occurred prior to midnight. Nonrural facilities averaged 6.69 hospitalist admissions per night, whereas rural facilities averaged 1.35 admissions per night. Conclusions: The low volume of nighttime admissions indicates an opportunity to leverage a telehospitalist physician service to deliver inpatient medical admission services across a network. Lower volumes of nighttime admissions in rural facilities may indicate a market for telehospitalist solutions to address the dilemma of hospitalist staffing shortages.
doi:10.1089/tmj.2013.0344
PMCID: PMC4188377  PMID: 24660844
business administration/economics; telemedicine; telehealth; commercial telemedicine

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