Teleconsultation services: state of the art and questionnaire
development for measuring patient experiences
Master Thesis Medical Informatics
Esmée Tensen
2 Student:
Esmée Tensen
Student number: 10273638 Email: e.tensen@amc.uva.nl Places of the SRP project: KSYOS TeleMedical Center Professor J.H. Bavincklaan 2-4 1183 AT Amstelveen
Academic Medical Center (AMC) Department of Medical Informatics Meibergdreef 9
1105 AZ Amsterdam Mentors:
Prof. dr. Leonard Witkamp
Director of KSYOS TeleMedical Center
Email: l.witkamp@amc.uva.nl and l.witkamp@ksyos.org
Dr. Job van der Heijden
Head of Research and Development of KSYOS TeleMedical Center Email: j.vanderheijden@ksyos.org
Leonie Thijssing, MSc - PhD Student Department of Medical Informatics Email: l.thijssing@amc.uva.nl
Tutor:
Prof. dr. Monique Jaspers
Researcher, department of Medical Informatics Email: m.w.jaspers@amc.uva.nl
Period:
3
Table of content
Preface and acknowledgement ... 4
Summary ... 5
Samenvatting ... 6
Chapter I: Two decades of teledermatology: current status and integration in national healthcare systems ... 8
Introduction ... 8
Method ... 8
Search results ... 9
Actors ... 9
Purposes and subspecialties of teledermatology ... 9
Delivery modalities and technologies ... 10
Business models ... 11
Integration in national healthcare systems ... 12
Preconditions and requirements for implementation of teledermatology ... 12
Added value ... 14
Discussion ... 14
Conclusion ... 15
Chapter II: Patient’s Perspective on Quality of Teleconsultation Services ... 19
Introduction ... 19
Methods... 19
Results ... 20
Discussion ... 22
Chapter III: Validation and psychometric analysis of a questionnaire for measuring quality of teleconsultation services from the patients´ perspective ... 24
Introduction ... 24
Method ... 25
Results ... 28
Discussion ... 32
Conclusion ... 34
Appendix A: Experience questionnaire measuring patient’s perspective on quality of teleconsultation services ... 36
Appendix B: Importance questionnaire measuring patients’ perspective on quality of teleconsultation services ... 43
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Preface and acknowledgement
My Scientific Research Project took place at KSYOS TeleMedical Center and the Academic Medical Center in Amsterdam. First I conducted a literature study about the current status of teledermatology and the integration in national healthcare systems. This review is published in the Journal Current Dermatology Reports and is shown in chapter I. Secondly I submitted a Conference Paper for the Medical Informatics Europe (MIE) Conference 2016. This paper was accepted for oral presentation and presented in August in Munich (chapter II). Thirdly I conducted psychometric analyses to assess the reliability, validity and internal cohesion of a teleconsultation questionnaire to measure quality of care from the patients’ perspective. This research is described in chapter III. At last, I submitted an article about teledermatology and teledermatoscopy for a Dutch General Practitioners Journal called “Bijblijven”. This Dutch article is under publication and is not included in this thesis. Preliminary results of the data analyses of this study were shown at the 6th World Congress of Teledermatology in London. Besides the papers, I attended the Masterclass of the International Partnership in Health Informatics Education (IPHIE) in Salt Lake City, the Medical Informatics Europe Conference in Munich, the 6th World Congress of Teledermatology in London and I presented the preliminary results of my thesis in the eHealth module in the Master Medical Informatics.
I would like to thank Leonie Thijssing, Job van der Heijden, Leonard Witkamp and Monique Jaspers for their supervision and feedback during my scientific research project. Besides, I would like to thank my sisters, parents, family, friends, and fellow students who encouraged and supported me during my Master Medical Informatics.
5
Summary
Telemedicine is the use of communication technologies in healthcare for the exchange of medical information for diagnosis, treatment, prevention, research, evaluation and education over a distance. Teledermatology has been one of the first telemedicine services to see the light of day. Two decades of teledermatology research is published and summarized in chapter I. Search terms included “teledermatology”, “teledermoscopy”, “tele wound care”, “telederm*”, “(dermatology OR dermoscopy OR wound care OR skin) AND (telemedicine OR ehealth or
mhealth OR telecare OR teledermatology OR teledermoscopy)”. Inclusion criteria were (i) Dutch
or English written papers and (ii) publication year from 2011 to present or (iii) (systematic) reviews with publication year before 2011. One hundred fourteen publications and 14 (systematic) reviews were included for full text reading. Focus of this review is on the following outcomes: (i) actors (primary, secondary, tertiary), (ii) purposes (consultation, triage, follow-up, education) and subspecialties (tele-wound care, burn care, teledermoscopy (teledermatoscopy), teledermatopathology, and mobile teledermatology), (iii) delivery modalities and technologies (store and forward, real-time interactive and hybrid modalities using web-based systems, email, mobile phones, tablets or videoconferencing equipment), (iv) business models, (v) integration of teledermatology into national healthcare systems, (vi) preconditions and requirements for implementation (security, ethical issues, responsibility, reimbursement, user satisfaction, technique, and technology standards), and (vii) added value. To conclude, teledermatology is an efficient and effective healthcare service compared to in-person care. Teledermatology reduces patients’ travel time and waiting time, avoids (unnecessary) dermatologic visits, and improves access of care to underserved patients.
As described in chapter I, teleconsultation applied in the right setting improves quality of care, is more efficient and at lower costs compared to face-to-face care. Despite these benefits of teleconsultation, experiences of patients should be taken into account while implementing a teleconsultation program. Patient satisfaction with teleconsultation services can increase the acceptance and improves the implementation of these services. Validated and standardized questionnaires to measure the quality aspects of teleconsultation relevant from the patients’ perspective are not available yet. We aim to develop such a questionnaire. First, a systematic literature search was performed and focus groups were held to acquire quality aspects of teleconsultations patients perceive as important. Thirty-seven unique quality aspects distilled from these activities, were used for questionnaire. This research was presented at the Medical Informatics Europe conference and is shown in chapter II.
Chapter III describes the validation and psychometric analysis of this concept questionnaire. The questionnaire was sent to patients who experienced a telecardiology, telepulmonology or teledermatology consultation in the 7 months prior to the study and after permission of the GP. We conducted psychometric data analyses to assess the reliability, validity and internal cohesion of the questionnaire. Another optional questionnaire measuring the importance of quality aspects was used to measure how patients rated the importance of these aspects. Data of a total of 90 of the 402 respondents could be used for statistical analyses (response rate: 22.4%). The psychometric analyses and explorative factor analysis resulted in three reliable scales with high internal consistency (α=0.737-α=0.839): communication and information,
organization of care and cost and compensation. Most patients were satisfied about their
teleconsultation and would recommend it to other patients. Preliminary psychometric results show that the teleconsultation questionnaire consists of three reliable and internally consistent scales but further research with a larger population is needed to determine reliability and validity of the questionnaire for measuring patients’ experiences with teleconsultation services. Keywords: Teleconsultation, Patients’ perspective, Questionnaire validation
6
Samenvatting
Telemedicine kan gedefinieerd worden als het gebruik van communicatie technologie in de gezondheidszorg voor het uitwisselen van medische informatie. Telemedicine kan worden gebruikt voor het bepalen van een diagnose, opstellen van een behandelplan, preventie, onderzoek, evaluatie en educatie over een afstand. Teledermatologie is een van de eerste telemedicine services. Teledermatologie onderzoek van de laatste twee decennia is gepubliceerd in hoofdstuk I. Gebruikte zoektermen zijn: “teledermatology”, “teledermoscopy”, “tele wound care”, “telederm*”, “(dermatology OR dermoscopy OR wound care OR skin) AND
(telemedicine OR ehealth or mhealth OR telecare OR teledermatology OR teledermoscopy)”.
Inclusie criteria waren (i) Nederlands of Engels geschreven papers, (ii) publicatie jaar vanaf 2011 tot nu, (iii) (systematische) reviews met publicatiejaar voor 2011. Honderd-veertien publicaties en 14 (systematische) reviews zijn geïncludeerd om volledig gelezen te worden. Deze review focust op de volgende uitkomsten: (i) actoren (primair, secundair en tertiair), (ii) doeleinden (consultatie, triage, follow-up, educatie) en sub specialismen (tele-wondzorg, brandwonden zorg, teledermoscopie (teledermatoscopie), teledermatopathologie en mobile teledermatologie), (iii) methodes en technieken (store-and-forward, real-time interactief en hybride methodes die gebruik maken van web-based systemen, email, mobiele telefoons, tablets of videoconferentie benodigdheden), (iv) business modellen, (v) integratie van teledermatologie in de nationale gezondheidszorg, (vi) randvoorwaarden en eisen voor implementatie (beveiliging, ethische kwesties, verantwoordelijkheden, vergoedingen, gebruikstevredenheid, technieken en technologie standaarden), en (vii) de meerwaarde van teledermatologie. Teledermatologie is een efficiënte en effectieve manier om zorg te leveren vergeleken met de reguliere zorg. Teledermatologie vermindert de reistijd en wachttijd, vermindert het aantal (onnodige) bezoeken aan de dermatoloog en verbetert de toegankelijkheid van de zorg bij patiënten in afgelegen gebieden.
Zoals beschreven in hoofdstuk I, verbetert het op de juiste manier toepassen van teleconsultatie de kwaliteit van de zorg en is het efficiënter tegen lagere kosten vergeleken met de reguliere zorg. Ondanks deze voordelen moeten de ervaringen van patiënten meegenomen worden voor de implementatie van teleconsultatie. Patiënten die tevreden zijn met teleconsultatie kunnen de acceptatie vergroten en de implementatie verbeteren. Gevalideerde en gestandaardiseerde vragenlijsten die nodig zijn om de kwaliteitsaspecten van teleconsultatie te meten vanuit het perspectief van de patiënt zijn nog niet ontwikkeld. Het doel van dit onderzoek is om een dergelijke vragenlijst te ontwikkelen. Eerst is er een systematische literatuur studie gedaan en zijn focus groepen gehouden met patiënten om kwaliteitsaspecten te verkrijgen die belangrijk zijn vanuit het perspectief van de patiënt. Dit resulteerde in 37 kwaliteitsaspecten die zijn gebruikt voor de vragenlijst ontwikkeling. De resultaten van dit onderzoek zijn gepresenteerd op het Medical Informatics Europe congres en zijn weergegeven in hoofdstuk II.
Hoofdstuk III beschrijft de validatie en psychometrische analyse van deze concept vragenlijst. De vragenlijst was verstuurd naar patiënten die in de 7 maanden voorafgaand aan het onderzoek een telecardiologie, telepulmonologie of teledermatologie consult hadden gehad en waarvoor de huisarts toestemming had gegeven. Psychometrische analyses waren uitgevoerd om de validiteit, betrouwbaarheid en de interne samenhang van de vragenlijst te bepalen. Een optionele vragenlijst mat hoe belangrijk de kwaliteitsaspecten waren volgens de patiënten. Data van 90 van de 402 respondenten kon gebruikt worden voor statistische analyses (response: 22,4%). De psychometrische analyses en exploratieve factor analyses resulteerde in drie betrouwbare schalen met hoge interne samenhang (α=0,737-α=0,839): communicatie en
7 tevreden over het teleconsult en zouden het bij andere patiënten aanbevelen. De eerste psychometrische resultaten laten zien dat de vragenlijst uit drie betrouwbare schalen bestaat met interne samenhang maar verder onderzoek met een grotere populatie is nodig om de betrouwbaarheid en validiteit van de vragenlijst te bepalen om patiënt ervaringen met teleconsultatie services te meten.
8
Chapter I:
Two decades of teledermatology: current status and integration in national
healthcare systems
Published in Current Dermatology Reports, Volume 5, Issue 2, June 2016 E.Tensen1, J.P. van der Heijden2, M.W.M. Jaspers1, L. Witkamp1,2
1
Department of Medical Informatics, Academic Medical Center, The Netherlands
2
KSYOS Health Management Research, Amstelveen, The Netherlands
Introduction
Telemedicine, as defined by the World Health Organization, is the use of communication technologies in healthcare for the exchange of medical information for diagnosis, treatment, prevention, research, evaluation and education over a distance (1). Teledermatology is a mature and frequently used form of telemedicine. The first publications about teledermatology listed in PubMed were published in 1995 (2-5) and the number has grown exponentially. At the end of the year 2015, the number of publications in PubMed with search term “teledermatology” evolved to 477 publications.
The visual character of dermatology makes it well-suited for telemedicine. Colors of the skin and distribution of skin lesions provide indications and clues in accurate diagnosing lesions and rashes (6•). Teledermatology has proven to be comparable in accuracy rates to in person conventional care concerning diagnosis, management, and clinical outcomes (7•), clearing many of the barriers mentioned when teledermatology was first implemented. However, some barriers in teledermatology remain, e.g., security, privacy and legal issues, and the absence of palpation of the skin (8, 9), but can be solved relatively easy through selection of patients by the GP, education, and proper implementation of the service.
Teledermatology is currently applied throughout all kinds of medical settings, e.g., in hospital and primary care, nursing homes, home care settings and is applicable in underserved and remote areas to deliver care over a distance. Furthermore, it is applied in countries (e.g., Switzerland, the Netherlands and the United States) known for their long patient waiting times and/or capacity limits for dermatologic consultation. Teledermatology has been used during wars, in military and maritime settings and reduced the number of medical evacuations (10, 11). Finally, it provides care to patients in developing countries who have no access to (dermatologic) care (12•).
The aim of this narrative review is to give an overview of the current status of teledermatology concerning 1) the actors of teledermatology, 2) the purposes and subspecialties of teledermatology research, 3) the delivery modalities and technologies used, 4) business models used, 5) the integration of teledermatology in national health infrastructures, 6) preconditions and requirements for implementation of teledermatology, and 7) surplus merits of teledermatology.
Method
A literature search was conducted in PubMed. Search terms included “teledermatology”, “teledermoscopy”, “tele wound care”, “telederm*”, “(dermatology OR dermoscopy OR wound
care OR skin) AND (telemedicine OR ehealth or mhealth OR telecare OR teledermatology OR teledermoscopy)”. Inclusion criteria were i) Dutch or English written papers and ii) publication
year from 2011 to present or iii) (systematic) reviews with publication year before 2011. First, all titles were scanned and all duplicates were removed. Titles that contained
9 “teledermatology” or had a relevant focus were included. Secondly, titles and abstracts were scanned and included if they met the review questions. All papers without an abstract were scanned quickly and were included if they focused on teledermatology. Unavailable publications and publications focusing solely on teledermatopathology were excluded. Finally, one reviewer read all remaining publications and completed a data abstraction form with publication characteristics and relevance for every publication. Results discussed in this review were based on this final selection of the publications and any additional publications that were cited in one of the publications and met the inclusion criteria, but were not in the original search result.
Search results
The literature search, as conducted in November 2015, resulted in 787 references and after removal of the duplicates 430 unique publications remained. After title selection, 265 publications were included for abstract selection and 114 publications were included for full text reading. Furthermore, 60 (systematic) reviews, published before 2011 were found and 14 of those reviews remained for full reading after title and abstract selection.
Actors
There are different instances of teledermatology in which actors are involved. An overview of different actors in teledermatology is presented in figure 1. Primary teledermatology includes direct communication between the patient and the primary healthcare provider (i.e., General Practitioner (GP), general nurse) or dermatologists for first diagnosis or referral (6•). Most common is secondary teledermatology. Patients visit the GP and the GP communicates or exchanges medical information of the patient with the dermatologists. Secondary teledermatology is used by primary care providers to receive advice for triage of patient and consults (6•). Other secondary actors who are not explicitly mentioned in the literature are health insurance companies and healthcare institutions, e.g., burn care centers, nursing homes and emergency departments. Tertiary teledermatology concerns the collaboration and communication among dermatologists (13). Finally, patient-assisted teledermatology is a form of teledermatology in which the patient interacts directly with a healthcare professional, for example in follow-up care in which the patients interacts with a (public health) nurse or wound-care nurse.
Figure 1. Actors teledermatology
Purposes and subspecialties of teledermatology
Pak defines the goal of teledermatology as: “to provide the highest quality of dermatologic care
more efficiently by moving patient information rather than patients” (14). Teledermatology can
be classified by the different purposes it serves: consultation, triage, follow-up and education. Likewise, it is used for screening (of melanoma), wound treatment, (international) knowledge exchange between healthcare professionals, second opinion, and referrals prevention.
The systematic review of van der Heijden et al. (13) found different purposes of tertiary teledermatology. Tertiary teledermatology could be used for receiving an expert opinion from a more specialized colleague (e.g., academic dermatologist) or a second opinion. Furthermore, it could be used for resident training and ongoing medical education (13).
10 Teledermatopathology, teledermoscopy (teledermatoscopy), and tele-wound care are subspecialties of teledermatology. Tele-wound care is a subspecialty used in chronic wound care. A study of Litzinger et al. found that 83% of the nurses improved their productivity and efficiency by using video conferencing in tele-wound care (15). Tele-wound care reduces (transportation and staff) costs, improves quality of life for chronic wound patients and is equally effective to conventional care (16, 17). Teledermoscopy could be used in the examination of pigmented skin lesions, for the early detection of skin cancer and for triage. Coates et al. summarize an accuracy of teledermoscopic diagnoses, ranging from 75% to 95% (18•). A new application of teledermoscopy concerns the use of mobile teledermoscopy. Burn care telemedicine makes it possible to get expertise from a healthcare professional of a specialized burn center. It has been shown to be technically and clinically feasible to provide burn care telemedicine (19).
Delivery modalities and technologies
Teledermatology can be delivered by 3 different modalities: store and forward (SAF), real-time (RT) interactive, and hybrid. Choice of a modality depends on the structure of the local health care system, decisions of stakeholders, like hospital management and physicians as prospective users of the service, payers such as health insurance companies, and the competences of the referring physician (12•). Store and forward is the most offered and used modality in teledermatology (7•, 11, 12, 20). As described in the literature, the use of store and forward telehealth is increasing and real-time use is decreasing (21).
Table 1 summarizes the advantages and disadvantages of store and forward and real-time interactive technologies. Store and forward and real-time interactive modes of teledermatology have in common that they are independent of space. These modes are especially beneficial in low-resource settings and the United States with large distances between the patient and the dermatologists. By use of these delivery modalities, dermatologists in other geographic areas could be reached (7•, 8, 12•, 22).
SAF technology includes the exchange of high-quality digital images between a general or nurse practitioner and a dermatologist or between two dermatologists. Distinctive for a store and forward mode is that it can be used time independent, making it more flexible in practice, fitting in daily workflow, and applicable for the exchange of information between different time zones. However, direct interaction between actors is not possible. Use of SAF technology for delivering teledermatology services shortens the consultation time compared to real-time and conventional care, which makes it a lower-cost intervention (9). However, responses are delayed, and patients have to wait for the advice of the dermatologist (8, 22).
The real-time (RT) interactive modality uses video conferencing equipment during a teledermatology consultation. Use of this modality makes delivery of teledermatology services location independent but not time independent. RT allows direct interaction between the general practitioner (GP), patient, and dermatologists. They should all be available at the same time, which makes RT consultation scheduling logistically challenging. Furthermore, RT is time consuming, interrupts the routine workflow and is more expensive (9, 12•, 14, 22). The duration of the videoconference is mostly as long as the conventional consultation and is not cost-effective in case of short travel distances.
Hybrid modalities combine features from SAF and RT. Direct interaction between healthcare professionals and additionally viewing high-quality images is possible by use of hybrid modalities (7•).
11 Table 1. Advantages and disadvantages store and forward and real-time
Store and forward Real-time interactive
Digital images Video conferencing
Asynchronous:
space and time independent, flexible
Synchronous:
independent of space, dependent on time, less flexible
No or minimal interaction possible Direct interaction possible sender and recipient (GP, patient, dermatologist) Consultation time is short Time consuming
Low costs Expensive and not cost-effective short
distance Medical history and images stored and
transferred, standardized
More clinical (in depth) and complete information acquired from patient Response delayed:
Wait between consultation and advice dermatologist
Immediate response:
Advice dermatologist and diagnosis can be obtained immediately during consultation High resolution digital images Lower resolution images
Fits better in daily workflow Interferes with daily workflow
Technologies which are used for SAF and RT are web-based systems or email and videoconferencing equipment. Furthermore, mobile phones and tablets could be used for capturing and sending images. Image quality of these devices has been improved and is no longer a barrier in teledermatology (9). Mobile teledermatology and mobile teledermoscopy are specialties that use mobile devices (i.e., phones, tablets) while performing teledermatology. Smartphones and tablets can be used by patients to capture images and transfer them to their healthcare provider or by GP’s to send images for advice to a dermatologist.
Business models
Teledermatology has many advantages over current conventional care modes. However, many teledermatology implementations fail when the business models behind the service are either not well understood and subsequently poorly implemented or not implemented at all. Challenges and issues that should be considered in business modeling concern, e.g., technology, security and privacy, legal risks, ethical issues and reimbursement.
Pak (23) describes five important steps for integrating teledermatology into a well-defined business process and model: “1) understanding how the organization delivers care, 2) analyzing
the alternatives including cost-benefit analysis, 3) obtaining organizational support, 4) formulating an execution plan, 5) training staff and monitoring the process”. Defining a good
business and reimbursement model depends on the teledermatology modality used (SAF, real-time, hybrid), consultation, follow-up, and referral process. If teledermatology is implemented in the appropriate setting, it could increase the access and quality of care while decreasing costs (23).
A survey (2011) among teledermatology programs in the United States (20) concluded that 12 of the surveyed programs (33%) accepted payments from Medicare, Medicaid, Health Maintenance Organizations (HMO), private payers and self-payers. Furthermore, eight teledermatology programs (22%) received federal funding from the Veterans Administration or United States military and two programs (6%) provided teledermatology as a voluntary service. Teledermatology programs were reimbursed by private payers (N=25, 69%), by self-payers (N=22, 61%), Medicaid (N=20, 56%), Medicare (N=19, 53%) and by HMO (N=17, 47%). Thirty-nine states in the United States receive some reimbursement for telehealth services provided
12 by Medicaid (24). Reimbursement of other countries and business models were not found in our literature search.
In The Netherlands, teledermatology is fully reimbursed and integrated in the national healthcare system. Teledermatology was introduced during the first five years of this century in small pilots together with innovating dermatologists and general practitioners on a regional basis as a part of clinical research, thus building clinical evidence and broad basic support among future users. From 2005, health institutions (e.g., KSYOS TeleMedical Center) that solely focused on providing telemedicine and eHealth services, actively implemented teledermatology in the existing health infrastructure. Pivotal factors in the successful implementation have been the focus on change management among and continuous support of future users in the field. GPs were approached to start with teledermatology when the local dermatologists were already on board and could act as local drivers of this new service. Health workers have been trained and supported during the process of implementation. The health institutions providing teledermatology took full responsibility for the entire process including medical responsibility. They contracted medical specialists and general practitioners as well as health insurers and were responsible for quality control. These parties provided safe and user-friendly transmural electronic health records that facilitated the process of teledermatology. Finally, from 2005, the health insurers have reimbursed teledermatology, leading to further increase of its use. This has led to a steady increase in general practitioners using tele consultation services in various fields (e.g., dermatology, ophthalmology, cardiology, and mental health) from 120 in 2005 to an estimated 5,500 in 2015 (60% of all GP’s in the Netherlands).
Integration in national healthcare systems
In 2009, the eHealth survey of the World Health Organization (WHO) showed that a teledermatology service was established in only 16% of the 114 responding countries (25). Less is published about the integration of teledermatology in national healthcare systems. In the beginning of 2012, thirty-seven teledermatology programs were active in the United States (20). Reimbursement is often an obstacle for the implementation of telemedicine into (national) health care systems (26). The Veterans Health Administration (VHA) has designed one of the largest teledermatology programs in the United States (21). Furthermore, teledermatology has been broadly integrated in the Dutch Healthcare system since 2006 and is fully reimbursed. In 2014, more than 12% of the GP visits in the Netherlands was related to dermatological care (27), and in total 27.2 per 1000 patients in GP practice were referred to a dermatologist (27). KSYOS TeleMedical Center (28) provides specialized tele-medical care in the Netherlands. In 2015, KSYOS TeleMedical Center provided 14,900 teledermatology (store-and-forward) consultations in which 3,421 GPs and 247 dermatologists were involved. Since the introduction of teledermatology in 2006, a total of 130,531 teledermatology consultations have been performed by KSYOS TeleMedical Center in The Netherlands.
Preconditions and requirements for implementation of teledermatology
Perceived barriers and incentives for implementation of teledermatology services differ for primary care physicians and dermatologists and should be taken into account during the implementation. Equipment costs and management and staff training are implementation barriers as perceived by primary care physicians while medical legal liability, diagnostic reliability, and patient follow-up are barriers for academic dermatologists (29, 30). Both groups are concerned about the financial reimbursement of teledermatology (29, 30). In The Netherlands, lack of reimbursement was not an issue during the initial introduction among innovators. However, for the large-scale implementation that has happened in the Netherlands, reimbursement of dermatologists as well as general practitioners has been pivotal.
Various preconditions and requirements should be considered while implementing a teledermatology program. First of all, an important precondition for teledermatology is
13 assignment of persons responsible for the service as a whole, by extension for (in)correct diagnosing and prescribing the associated treatment, and reflecting on the legal risks (31, 32). Secondly, there are some legal and ethical issues. If images of a patients are sent to the dermatologists, instead of the patient itself, a physical physician-patient relationship does not exist according to regulations in some countries (32). Each country has its own laws and regulations that influence implementation. For example, some states in the United States impose restrictions in providing teledermatology to other states in which the physician is not working and licensed, and in the Netherlands teledermatology between patient and dermatologist is only allowed when it concerns a follow up consultation and the physician-patient relationship has been established in the first face-to-face consultation. This implied that in order to implement teledermatology in the Netherlands, both general practitioner and dermatologist had to be contracted by the same health institution. Doing so, the patient is seen at least once physically by a health worker, in this case the general practitioner, contracted by the health institution. This is mandatory in the Netherlands in order to be able to receive reimbursement from the health care insurers.
Thirdly, security is an essential requirement for teledermatology implementation. Requirements for a secure teledermatology system described in the literature are privacy, availability, authentication, authorization, storage and network security, data encryption, confidentiality, and non-repudiation (9, 33). Data transmission should be reliable and the system should be continuously available, easily accessible and there should be a reliable and secure computer connection. Furthermore, the technical equipment used for making the pictures and sending the images should operate properly. Patients and health care providers should be authorized and verified by a unique authentication number. Confidential patient data should be protected, encrypted, and encoded by transmission. Additionally, the data flow should be logged and it should be documented which health care provider received which information and when. International Organization for Standardization (ISO) standards, like the ISO/TS 13131:2014 (34) on Telehealth services or the ISO/IEC 27001:2013 (35) on information technology security, can be very useful tools to address these issues.
Fourth, although images delivered through teledermatology provide a lot of information, additional (patient) information and medical history is needed for deciding on final diagnoses or treatments. Firstly, data on some patient demographics (e.g., identification number, name, gender, age etcetera) is required. Furthermore, the patient history (complaints and symptoms, allergies, medication use etcetera) and a description of the skin lesion (color, shape, borders, size, location, surface, number of lesions, distribution, and etcetera) could provide necessary clues (11, 22). A technological barrier concerns the interfacing of the teledermatology application with the existing Electronic Medical Record (32).
Furthermore, user satisfaction often is a barrier in the acceptance of technology and a key factor in the implementation of teledermatology. Orruño et al. (36) developed the teledermatology Technology Acceptance Model (based on the Technology Acceptance Model (TAM) of Davis (37)) and determined which factors affect the intention of physicians to use teledermatology. The teledermatology TAM describes the intention of physicians to use teledermatology and the acceptance of teledermatology in three different contexts: the individual (compatibility of technology, attitude), the technological (perceived usefulness of technology, perceived ease of use of technology and habits), and the organizational (facilitators, subjective norm) factors. Habits, compatibility, facilitators and subjective norm are additional dimensions to the original TAM. Habits encompass behavior which is now, with the use of teledermatology, automatized (36), e.g., do the individuals feel comfortable with the information and communication technology? The developers of the new teledermatology model found that facilitators (organizational infrastructure, training, and support) significantly influence the intention to use teledermatology (36). Training should include how teledermatology provides access to timely dermatologic care, how physicians should take
high-14 quality images and how to send images securely (38). Especially the organizational context of the teledermatology implementation is very important (36), do individuals believe that this organizational infrastructure provides support to use the system? So, implementation requirements for user acceptance of teledermatology are 1) full and continuous technical support to users, 2) training of physicians 3) and an appropriate organizational infrastructure. The last important factor which should be considered is the standardization of imaging and equipment of teledermatology services. There are no universal imaging standards developed and implemented in teledermatology yet (39). Therefore, Quigley et al. conducted a systematic review summarizing technology and technique imaging standards for acquiring digital dermatologic images (39).
Technology standards include spatial and color resolution, reproduction ratios, post acquisition image processing, color calibration, compression, image output, image archiving and storage and image security during transmission and storage. A study (1997) concluded that a resolution of 768 x 512 pixels suits teledermatology purposes as well (40). The American Telemedicine Association’s Practice Guidelines for teledermatology (2008) advised at least 24 bits of color which results in 16,777,216 available colors (41). The most recent American Telemedicine Association guideline (2012) recommended minimal 800 x 600 pixels and preferred a resolution of 1024 x 768 pixels for store-and-forward teledermatology (42).
Technique standards include environmental conditions (i.e., lighting, background, camera position), patient pose and standard view sets, patient consent, privacy, and confidentiality (39). Environmental conditions affect the quality, appearance and consistency of images (39). And privacy, security, and confidentiality standards depend on region specific laws and regulations.
Added value
One of the benefits of teledermatology is reduction of travel by patients. A systematic review by Wootton et al. summarized 18%-94% (mean 43%) of travel was avoided by teledermatology (43). Another advantage of teledermatology is the number of dermatologic visits averted and a reduction in unnecessary in-patient visits. A recent review by Whited (7•) summarizes that 13-81% (average 45.5%) of dermatologic visits is avoided while using store and forward, and 44.4%-82% (average 61.5%) of visits was averted with real time interactive teledermatology. As shown by Eminović et al. (44), teleconsultation reduces the number of unnecessary physical referrals to the dermatologist leading to lower costs and higher efficiency. Furthermore, van der Heijden et al. (45) conclude that teledermatology averts 74% of physical referrals and leads to an 18% cost reduction compared to in-patient dermatologic care. Teledermatology improves patient access to dermatologic expertise to patients who were underserved by dermatology care for geographic reasons (12•). It further reduces long patient waiting lists, streamlines patient care and allows shared decision-making with other physicians. Teledermatology consultation, applied in the right setting, provides care equal to but often more efficient and effective as physical patient care and at least does not negatively influence the quality of care delivered to the patient (45, 46). As described by Landow et al. (47) “teledermatology makes
three promises: better, cheaper and faster dermatologic care”.
Discussion
This narrative literature review of PubMed based on publications selected by one reviewer focused on the actors, purposes, subspecialties, delivery modalities and technologies, business models integration of teledermatology services into national healthcare systems, preconditions and requirements for implementation and added value of teledermatology.
Teledermatology is used by healthcare professionals for consultation of other colleagues, triage and, follow-up of patients and education of more junior healthcare professionals. It enables direct digital communication between the patient and primary health care provider or dermatologist, between general practitioners and dermatologists or amongst dermatologists. Teledermatology can be delivered by three different modalities: store and forward, real-time
15 interactive and hybrid. As pointed out in the literature, teledermatology has some advantages and could be beneficial for patient care. Teledermatology reduces patient travel time, avoids unnecessary referrals, lowers costs, and improves efficiency of care. More importantly, teledermatology has proven to be at least equally effective as physical patient care and does not negatively influence the quality of care delivered to the patient.
Despite the benefits of teledermatology, experiences of patients should be taken into account while implementing a teledermatology program. Because of methodological deficiencies in the evidence currently available, satisfactory explanations of the underlying reasons for patient satisfaction or dissatisfaction with telemedicine are not available (48). Besides, reliable and validated instruments to measure satisfaction and quality aspects of teledermatology from a patients’ perspective has not been developed yet (7•). In the Netherlands, the Consumer Quality Index (CQ-Index) (49), a standardized method for developing surveys and measuring healthcare quality from the patients’ perspective, was introduced in 2006 in order to promote patient-centered care. To measure the quality of care delivered through telemedicine from a patients’ perspective, we are developing a valid and reliable questionnaire, based on the framework of the CQ-Index. The responses on such a validated CQ-Index for teleconsultation could be used to enhance the quality of care delivered by telemedicine, give choice information to healthcare consumers, advocacy information for patients and patient organizations to inform their members about the quality of care of telemedicine services. Additionally, the results could be used by different stakeholders: by patients to decide about their healthcare provider; by the public health inspection to measure the quality of care; by the health insurance companies to decide about reimbursement; and by the government to monitor quality of healthcare. Furthermore, as indicated by Whited (50) there is a “research gap” on the effect of teledermatology on patients’ quality of life. Quality of life is an important outcome measure for skin diseases and teledermatology may have a positive effect on quality of life of patients. Patients do for example not have to visit the dermatologists physically but can visit their GP nearby. Especially for chronic patients, patient-assisted follow-up care at home avoids travelling to a physician and long appointments during work time. Patients can capture images with their smartphone (when they have time) and send the images to their healthcare provider.
There are yet some issues that should be considered before implementing a teledermatology program, e.g., technology, security and privacy, legal risks, ethical issues, and reimbursement. Teledermatology has been fully reimbursed and integrated in The Netherlands and some states in the USA. Reimbursement has a positive influence on the integration in national health systems and the number of teleconsultations conducted in the Netherlands. However, less is published about the integration of teledermatology in healthcare systems of other countries. Due to its merits, we yet expect teledermatology becoming integrated in more healthcare systems in the future. Nami et al. (51) for example believe that teledermatology will become more and more integrated in national health services and clinical practice as smartphones are integrated in our lives. The number of smartphone users is increasing exponentially and will enable us to perform teledermatology via mobile applications. Therefore, we expect that the number of teledermatology services will increase as well.
There are some shortcomings of this review. First, the search was conducted in one database only (PubMed) and no searches were performed in other databases, e.g., MEDLINE and EMBASE. Secondly, publications were selected and included by one reviewer, only which could have resulted in selection bias.
Conclusion
In conclusion, teledermatology provides care, which is of similar quality compared to conventional care but often more efficient and effective. It is a promising technique for geographically underserved patients and in countries with long patient wait lists. It reduces costs, wait times, travel time and the number of unnecessary referrals. In the future, more research is needed on the impact of teledermatology on the quality of life and on validated
16 methods for measuring experiences of patients to ensure that teledermatology services are viewed as beneficial from the patient perspective.
References
Papers of particular interest, published recently, have been highlighted as: • Of importance
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6. ● Bashshur RL, Shannon GW, Tejasvi T, Kvedar JC, Gates M. The Empirical Foundations of Teledermatology: A Review of the Research Evidence. Telemed J E Health.
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emerging techniques of the modern era: part I: History, rationale, and current practice. J Am Acad Dermatol. 2015;72(4):563-74; quiz 75-76. Article summarizes history, rationale and current practice of teledermatology.
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19
Chapter II:
Patient’s Perspective on Quality of Teleconsultation Services
Conference Paper Medical Informatics Europe, Munich 2016. Accepted for oral presentation. Leonie Thijssing1,, Esmée Tensen1 and Monique Jaspers1
1
Department of Medical Informatics, Academic Medical Center, The Netherlands
Introduction
Teleconsultation services are a means of delivering care over a distance in different fields, such as dermatology, cardiology and pulmonology. Teleconsultation can lead to better, more efficient care at lower cost when compared to face-to-face care (1). Patients’ satisfaction with these services is important in their acceptance of teleconsultation services (2) and can be crucial for the successful implementation of teleconsultation on a large scale. Such a questionnaire is available for dermatological care but not for teleconsultation yet (3). The goal of this study is to develop a validated and standardized questionnaire to measure the quality aspects of teleconsultation from a patients’ perspective.
Methods
The Consumer Quality Index (CQ-Index) (4), a standardized framework from the Dutch Center for Consumer Experiences in Healthcare, consisting of three phases, was used for questionnaire development. This study reports on the first phase: the assessments of quality aspects of teleconsultation important to patients by conducting a systematic literature review and patient focus groups. The results were used as input to a concept questionnaire which was pre-validated among different stakeholders.
Systematic literature study
A systematic literature study was conducted in PubMed and PsychINFO (5). Search terms related to the categories (A) Teleconsultation services (Telemedicine, Telehealthcare, Telehealth,
Telediagnostic, Remote consultation, Teleconsultation, Teledermatology, Telecardiology, Telepulmonology, Teleopthalmology, Teleradiology, Telenursing, Telepharmacy, Telerehabilitation, Telepsychiatry and Teleneurology), (B) Patients’ perspective (Patient acceptance of healthcare, Consumer satisfaction, Patient perspective, Patient satisfaction and Patient experience) and (C) Quality of Healthcare (Quality assurance health care, Delivery of health care and Quality of health care).In PubMed keywords within a category were searched
with “OR” and between categories with “AND”. Searches in PsychINFO were restricted to all keywords of category (A) separately combined with patient experience OR patient satisfaction. The selection on title and abstract was conducted by two reviewers. Inter-reliability of the two reviewers was calculated using Cohen’s kappa coefficient (6). Following the selection on title and abstract a full-text analysis was performed and quality aspects were extracted by two reviewers. Inclusion criteria were: availability of the abstract and full text, English written articles, original articles, articles focusing on teleconsultation services, articles exploring patients’ satisfaction or patients’ experiences with teleconsultations, articles reporting on quality-assessment or aspects concerning teleconsultation which patients indicated as relevant. Focus groups
This study was assessed by the Medical Ethical Commission of the Academic Medical Center (AMC) in the Netherlands and further Medical Ethical approval was not needed. Patients who had experienced a teledermatology, telepulmonology or telecardiology teleconsultation in the nine months prior to the start of this study, were 18 years or older, lived near Amsterdam and for whom their GP gave permission to contact them were eligible to participate in this study and received an invitation letter for the focus groups. The aim of the focus groups with five (first) and six (second) patients was to gain insight in patients’ positive and negative
20 experiences with store-and-forward teleconsultation. During the focus groups, patients wrote down, brainstormed about, clustered positive and negative experiences of teleconsultations, clustered their statements in categories and rated each of these statements on importance on a Likert scale from 1 (not important) to 5 (very important). Concept mapping was used to structure the results of the focus group.
Mapping quality aspects systematic review and focus groups
A list of unique quality aspects was distilled from the results of the systematic literature study and the focus groups. The quality aspects were then categorized according to the themes of the CQ-Index: i) access to care, ii) communication and information, iii) interpersonal conduct, iv) patient management role, v) competence, vi) organization of care, vii) continuity of care, viii) effective and safe care, ix) costs and compensation. The concept questionnaire was pre-validated during interviews with stakeholders of teleconsultation services, namely patients who experienced teleconsultation, GPs who performed teleconsultation, specialists who receive and answer teleconsultations, and the providers of the teleconsultation services.
Results
Systematic literature study
The literature search derived 1474 publications, of which duplicates were removed (N=88) and titles and abstract of the remaining publications analyzed (N=1386). Full text of the remaining articles (N=37) were read. Reasons for exclusion were: the abstract or full text was not available (N=130), not written in English or not the original article (N=49), the subject of the article was not about teleconsultation services (N=96), patient satisfaction nor patient experiences with teleconsultation were reported (N=610), quality aspects of teleconsultation were not reported by patients (N=25), no quality- assessment or aspects concerning teleconsultations were reported (N=427), it was not clear on which quality aspects the patients were satisfied (N=42). The Cohen’s kappa between the two reviewers for the title and abstract selection was moderate (Kappa=0.508) and for the full-text analysis substantial (Kappa=0.637). Seven publications were finally included. Quality aspects were extracted from these publications, based on consensus between two reviewers and were mapped onto the nine themes of the CQ-Index (table 1). In total 22 quality aspects were revealed in the systematic literature review, of which two were excluded that specifically focused on videoconferencing. No quality aspects concerned i) interpersonal conduct, ii) continuity of care and iii) effective and safe care.
21 Table 1. Quality aspects from the systematic literature study
Themes Quality aspects
Access to care - Teleconsultation provided convenient appointment times (8,12) - Patients do not need to travel to see a healthcare provider (11,13) - Teleconsultation provides a reduction of travel time (7,10,12) Communication and information - The healthcare provider was informative (10)
- All question asked by the patients were addressed properly (10) - Explanation given by the healthcare provider was clear (10) Patient management role - The healthcare provider provided sufficient privacy (7,8,11)
- Patients are less reliant on others for transport to the healthcare provider (13)
- Patients felt more at ease discussing issues (7)
- Teleconsultation diminished the level of trust in the information provided(10)
- Teleconsultation was not a disruption of patients daily life (11)
Competence - Healthcare providers or patients experienced technical difficulties during teleconsultation (7,9,10)
- Patients felt like physical exam was not possible through
teleconsultation(12)
Organization of care - There is a smaller queue at the GP’s office than to go to the specialist physically (13)
- Teleconsultation saves time for the patients (11) - Patients do not have to wait in clinical waiting rooms (7) - There is less time devoted to the appointment of the consult (13) - Convenient for minor problems (7,8,12)
Costs and compensations - Patients experienced cost saving through teleconsultation (7,10,11,12) - Patients have less travel expenses (11)
- Patients have less accommodation costs (10,11) - Patients loses less time off work hours (11,13)
Italic statements were too specific focusing on videoconferencing and were removed
Focus groups
For the first and second focus group respectively 216 and 186 patients were invited, with five (first) and six (second) patients participating in the focus group on the chosen date. Eight patients experienced telecardiology and three teledermatology. One patient cancelled last minute for the first focus group and five patients for the second. In total 22 quality aspects were derived from the focus groups. Thirteen of these aspects concerned a positive (+) experience and nine of these aspects were negative (-) experiences. Table 2 displays the quality aspects with their importance ratings (mean: 3.4-5.0): quality aspects similar to those from the literature study highlighted in bold.
Table 2. Quality aspects from the focus groups, positive or negative experience, mean and SD of importance
Quality aspects Mean SD
+ Safety increase through additional check from specialist 4.2 1.1
- Healthcare provider provided information about the deductible costs 4.2 1.79
+ Patients experience cost saving through use of teleconsultation
- There is a chance that patients would still need to be seen physically by the specialist - Patient missed the face- to-face contact with healthcare provider
- Patient was not satisfied with the outcome of the teleconsultation
+ Patient avoids waiting in clinical waiting rooms
+ Patients do not have to see the healthcare provider physically - Patients have clear insight in consequential costs of teleconsultation + The assessment of the teleconsultation was fast
+ There is a short waiting time for the (1st) appointment + Patients do not have to travel to see the specialist physically
- Patients missed being direct involved in the teleconsultation between the GP and the specialist.
+ Teleconsultation saved time for patients
- The communication of results to the patient depends on the availability of the GP - Patients have doubts about if the pictures were of sufficient quality.
- Teleconsultation result from the specialist took too long
+ Teleconsultation provides short lines of communication between healthcare providers + Teleconsultation provides additional support to the GP’s
+ The referral to the specialist after the use of teleconsultation was rapid
4.4 3.4 4 3.8 4.2 3.8 3.8 4.9 4.6 4 5 4.6 4.5 3.8 4.3 4 4.7 0.55 1.52 0.71 1.64 0.84 0.84 1.64 0.3 0.55 0.71 0.0 0.7 0.5 1.0 0.8 1.1 0.8
22
+ Patients were helped quickly by the specialist through the use of teleconsultation + The communication between healthcare providers was fast
4.7 4.8 5 0.5 0.4 0.0
Bold statements were also revealed from the systematic literature study
Mapping results
The quality aspects of the systematic literature study were mapped onto the results of the focus groups, resulting in 37 unique quality aspects. These quality aspects and the general questions of the CQ-Index framework were used to develop the concept questionnaire and was pre-validated by different stakeholders. The final concept questionnaire consisted of questions about i) introduction (2), ii) access to care (3), iii) communication and information (5), iv) interpersonal conduct (5), v) patient management (8), vi) competence (3), vii) organization of care (6), viii) continuity of care (3), ix) effective and safe care (2), x) costs and compensation (6),
xi) general judgement (2), and xii) background characteristics of patients (11).
Discussion
We aim at developing a questionnaire, based on the CQ-Index framework, for measuring the quality of care delivered through teleconsultations as perceived by patients. In this study we identified quality aspects using a systematic literature study and focus groups and categorized them into nine themes of the CQ-Index. This resulted in a concept questionnaire, pre-validated by different stakeholders. There are some limitations to this study. First, four of the seven studies included in the systematic literature study had a sample size smaller than twenty patients and the limited number of patients participating in focus group 1 may have resulted in missing quality aspects and less group interaction among participants. However, the mixed mode of both the literature study and focus group revealed 37 unique quality aspects. Secondly, selection bias could have occurred because the patients invited for the focus group lived near Amsterdam and were willing to participate. The questionnaire is essential to gain insight in patients’ experiences and perspectives on teleconsultation and to improve patient satisfaction with teleconsultations. In future research, we will test the comprehensiveness, relevance, unambiguousness, reliability and internal cohesion of the questionnaire. Furthermore, psychometric, multilevel, and subgroup analyses, will be performed to assess the psychometric and discriminating power of the questionnaire. The final questionnaire could be used by healthcare centers to improve the quality of their teleconsultation services; by patients to decide about their healthcare provider; by the public health inspection and government to measure and monitor the quality of care; and by the health insurance companies to decide about reimbursement.
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