Requirements development for a patient computing system.
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Critical parts of the software development life cycle are concerned with eliciting, understanding, and managing requirements. Though the literature on this subject dates back for several decades, practicing effective requirements development remains a current and challenging area. Some projects flourish with a requirements development process (RDP) that is implicit and informal, but this approach may be overly risky, particularly for large projects that involve multiple individuals, groups, and systems over time. At Partners HealthCare System in Boston, Massachusetts, we have applied a more formal approach for requirements development to the Patient Computing Project. The goal of the project is to create web-based software that connects patients electronically with their physician's offices and has the potential to improve care efficiency and quality. It is a large project, with over 500 function points. Like most technological innovation, the successful introduction of this system requires as much attention to understanding the business needs and workflow details as it does to technical design and implementation. This paper describes our RDP approach, and key business requirements discovered through this process. We believe that a formal RDP is essential, and that informatics as a field must include proficiencies in this area. (+info)
Design and performance of a multi-centre randomised controlled trial and economic evaluation of joint tele-consultations [ISRCTN54264250].
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BACKGROUND: Appropriate information flow is crucial to the care of patients, particularly at the interface between primary and secondary care. Communication problems can result from inadequate organisation and training, There is a major expectation that information and communication technologies may offer solutions, but little reliable evidence. This paper reports the design and performance of a multi-centre randomised controlled trial (RCT), unparalleled in telemedicine research in either scale or range of outcomes. The study investigated the effectiveness and cost implications in rural and inner-city settings of using videoconferencing to perform joint tele-consultations as an alternative to general practitioner referral to the hospital specialist in the outpatient clinic. METHODS: Joint tele-consultation services were established in both the Royal Free Hampstead NHS Trust in inner London, and the Royal Shrewsbury Hospitals Trust, in Shropshire. All the patients who gave consent to participate were randomised either to joint tele-consultation or to a routine outpatients appointment. The principal outcome measures included the frequency of decision by the specialist to offer a follow-up outpatient appointment, patient satisfaction (Ware Specific Questionnaire), wellbeing (SF12) and enablement (PEI), numbers of tests, investigations, procedures and treatments. RESULTS: A total of 134 general practitioners operating from 29 practices participated in the trial, referring a total of 3170 patients to 20 specialists in ENT medicine, general medicine (including endocrinology, and rheumatology), gastroenterology, orthopaedics, neurology and urology. Of these, 2094 patients consented to participate in the study and were correctly randomised. There was a 91% response rate to the initial assessment questionnaires, and analysis showed equivalence for all key characteristics between the treatment and control groups. CONCLUSION: We have designed and performed a major multi-centre trial of teleconsultations in two contrasting centres. Many problems were overcome to enable the trial to be carried out, with a considerable development and learning phase. A lengthier development phase might have enabled us to improve the patient selection criteria, but there is a window of opportunity for these developments, and we believe that our approach was appropriate, allowing the evaluation of the technology before its widespread implementation. (+info)
The informatics response in disaster, terrorism, and war.
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The United States currently faces several new, concurrent large-scale health crises as a result of terrorist activity. In particular, three major health issues have risen sharply in urgency and public consciousness--bioterrorism, the threat of widespread delivery of agents of illness; mass disasters, local events that produce large numbers of casualties and overwhelm the usual capacity of health care delivery systems; and the delivery of optimal health care to remote military field sites. Each of these health issues carries large demands for the collection, analysis, coordination, and distribution of health information. The authors present overviews of these areas and discuss ongoing work efforts of experts in each. (+info)
Telehealth: reaching out to newly injured spinal cord patients.
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OBJECTIVES: The authors present preliminary results on health-related outcomes of a randomized trial of telehealth interventions designed to reduce the incidence of secondary conditions among people with mobility impairment resulting from spinal cord injury (SCI). METHODS: Patients with spinal cord injuries were recruited during their initial stay at a rehabilitation facility in Atlanta. They received a video-based intervention for nine weeks, a telephone-based intervention for nine weeks, or standard follow-up care. Participants are followed for at least one year, to monitor days of hospitalization, depressive symptoms, and health-related quality of life. RESULTS: Health-related quality of life was measured using the Quality of Well-Being (QWB) scale. QWB scores (n = 111) did not differ significantly between the three intervention groups at the end of the intervention period. At year one post discharge, however, scores for those completing one year of enrollment (n = 47) were significantly higher for the intervention groups compared to standard care. Mean annual hospital days were 3.00 for the video group, 5.22 for the telephone group, and 7.95 for the standard care group. CONCLUSIONS: Preliminary evidence suggests that in-home telephone or video-based interventions do improve health-related outcomes for newly injured SCI patients. Telehealth interventions may be cost-saving if program costs are more than offset by a reduction in rehospitalization costs, but differential advantages of video-based interventions versus telephone alone warrant further examination. (+info)
Transcontinental robot-assisted remote telesurgery: feasibility and potential applications.
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OBJECTIVE: To show the feasibility of performing surgery across transoceanic distances by using dedicated asynchronous transfer mode (ATM) telecommunication technology. SUMMARY BACKGROUND DATA: Technical limitations and the issue of time delay for transmission of digitized information across existing telecommunication lines had been a source of concern about the feasibility of performing a complete surgical procedure from remote distances. METHODS: To verify the feasibility and safety in humans, the authors attempted remote robot-assisted laparoscopic cholecystectomy on a 68-year-old woman with a history of abdominal pain and cholelithiasis. Surgeons were in New York and the patient in Strasbourg. Connections between the sites were done with a high-speed terrestrial network (ATM service). RESULTS: The operation was carried out successfully in 54 minutes without difficulty or complications. Despite a round-trip distance of more than 14,000 km, the mean time lag for transmission during the procedure was 155 ms. The surgeons perceived the procedure as safe and the overall system as perfectly reliable. The postoperative course was uneventful and the patient returned to normal activities within 2 weeks after surgery. CONCLUSIONS: Remote robot-assisted surgery appears feasible and safe. Teletransmission of active surgical manipulations has the potential to ensure availability of surgical expertise in remote locations for difficult or rare operations, and to improve surgical training worldwide. (+info)
Trade in health services.
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In light of the increasing globalization of the health sector, this article examines ways in which health services can be traded, using the mode-wise characterization of trade defined in the General Agreement on Trade in Services. The trade modes include cross- border delivery of health services via physical and electronic means, and cross-border movement of consumers, professionals, and capital. An examination of the positive and negative implications of trade in health services for equity, efficiency, quality, and access to health care indicates that health services trade has brought mixed benefits and that there is a clear role for policy measures to mitigate the adverse consequences and facilitate the gains. Some policy measures and priority areas for action are outlined, including steps to address the "brain drain"; increasing investment in the health sector and prioritizing this investment better; and promoting linkages between private and public health care services to ensure equity. Data collection, measures, and studies on health services trade all need to be improved, to assess better the magnitude and potential implications of this trade. In this context, the potential costs and benefits of trade in health services are shaped by the underlying structural conditions and existing regulatory, policy, and infrastructure in the health sector. Thus, appropriate policies and safeguard measures are required to take advantage of globalization in health services. (+info)
Desiderata for personal electronic communication in clinical systems.
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Electronic communication among clinicians and patients is becoming an essential part of medical practice. Evaluation and selection of these electronic systems, called personal clinical electronic communication (PCEC) systems, can be a difficult task in institutions that have no prior experience with such systems. It is particularly difficult in the clinical context. To directly address this point, the authors consulted a group of potential users affiliated with a nationally recognized telemedicine project, to determine important characteristics of a hypothetical PCEC system. They compiled a list of these characteristics and produced a desiderata, or list of desired features, for PCEC systems. Two conventional e-mail implementations and three Web-based PCEC systems were evaluated with respect to the features. The Web-based systems all scored higher than conventional e-mail. It is the hope of the authors that this paper will initiate further discussions about the features of PCEC systems and how to evaluate them. (+info)
Systematic review of cost effectiveness studies of telemedicine interventions.
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OBJECTIVES: To systematically review cost benefit studies of telemedicine. DESIGN: Systematic review of English language, peer reviewed journal articles. DATA SOURCES: Searches of Medline, Embase, ISI citation indexes, and database of Telemedicine Information Exchange. STUDIES SELECTED: 55 of 612 identified articles that presented actual cost benefit data. MAIN OUTCOME MEASURES: Scientific quality of reports assessed by use of an established instrument for adjudicating on the quality of economic analyses. RESULTS: 557 articles without cost data categorised by topic. 55 articles with data initially categorised by cost variables employed in the study and conclusions. Only 24/55 (44%) studies met quality criteria justifying inclusion in a quality review. 20/24 (83%) restricted to simple cost comparisons. No study used cost utility analysis, the conventional means of establishing the "value for money" that a therapeutic intervention represents. Only 7/24 (29%) studies attempted to explore the level of utilisation that would be needed for telemedicine services to compare favourably with traditionally organised health care. None addressed this question in sufficient detail to adequately answer it. 15/24 (62.5%) of articles reviewed here provided no details of sensitivity analysis, a method all economic analyses should incorporate. CONCLUSION: There is no good evidence that telemedicine is a cost effective means of delivering health care. (+info)