This document summarizes a review of 80 systematic reviews on the effectiveness of telemedicine. The reviews covered a range of telemedicine interventions and clinical areas. Some key findings from the reviews included:
- 21 reviews concluded that telemedicine is effective in improving outcomes.
- 18 reviews found evidence that telemedicine is promising but more research is still needed.
- Other reviews found evidence of telemedicine's effectiveness is limited and inconsistent.
- Economic analyses of telemedicine were often problematic and inconclusive.
- Some reviews highlighted benefits of telemedicine for patients, such as improved access to care.
This document describes two randomized controlled trial experiments being conducted by the Centre for Insurance and Risk Management (CIRM) in India to evaluate the impact of health microinsurance and related interventions.
The first examines an intervention by Calcutta Kids providing outpatient counseling services along with inpatient health insurance to increase renewal rates. The second examines an intervention by CARE Foundation providing outpatient counseling services to improve health outcomes. Both studies use RCT methodology to rigorously evaluate the impact of the interventions on key indicators like renewal rates, health expenditures, and client value. The results will help inform product design and policy to strengthen health microinsurance.
This study investigated the effects of 24 hours of partial sleep deprivation on temporal processing abilities in 20 young adults with normal hearing. Temporal ordering tasks and gap detection thresholds were measured before and after sleep deprivation using the Duration Pattern Test and Gaps-in-Noise test. Significant differences were found between baseline and post-sleep deprivation results for the Duration Pattern Test humming response and both measures of the Gaps-in-Noise test. However, no significant difference was seen for the Duration Pattern Test labeling response. The findings demonstrate that sleep deprivation impacts most temporal processing abilities associated with the prefrontal cortex, with the exception of more complex tasks.
Estimating the Cost of HIV Prevention Interventions with Demonstrated Effecti...CDC NPIN
This document summarizes a study estimating the costs of evidence-based behavioral HIV prevention interventions. The study developed a method to estimate total costs based on hours of labor required and fixed costs like training and facilities. It analyzed costs of two individual-level interventions (RESPECT and MIP) and two group-level interventions (WILLOW and SIHLE). Costs per participant ranged from $96 to $868 for individual interventions and $514 to $631 for group interventions. Costs depended on intensity and simplicity of the intervention.
This study evaluated the effectiveness of occupational therapy vocational rehabilitation (VR) delivered by a specialist traumatic brain injury (TBI) team compared to usual care for supporting return to work after TBI. 94 participants with minor to severe TBI were recruited within 4 weeks of discharge and received either specialist VR (n=40) or usual care (n=54). Specialist VR consisted of work preparation, assessment, and return to work planning delivered in participants' homes or workplaces. Results showed increased rates of return to and retention in work for the specialist VR group at all follow-up points up to 12 months post-injury, with the greatest differences seen in those with moderate-severe TBI. The study provides preliminary evidence
The document outlines Leo Guelman's PhD thesis on developing improved statistical and algorithmic methods for personalized treatment learning (PTL) models, with applications to insurance. It introduces PTL, which aims to select the optimal treatment for each individual based on their characteristics. The thesis contributes novel PTL methods like uplift random forests and causal conditional inference trees, and shows they outperform existing approaches in simulations. It also applies PTL to optimize insurance marketing strategies using experimental data from a large insurer.
This document discusses cognitive rehabilitation therapy (CRT). It began in the 1920s to help veterans with brain injuries relearn cognitive skills. CRT aims to restore lost cognitive functions or teach compensatory strategies. An interdisciplinary team may provide CRT to help those with conditions like stroke, dementia, TBI regain independence. Occupational therapists play a key role in CRT by helping clients relearn skills through functional activities to improve daily living. Strong evidence shows CRT's effectiveness, especially when provided through interdisciplinary collaboration.
Stakeholder perceptions of the efficacy of biodiversity offset policy in Aust...Megan Evans
This document summarizes a study on stakeholder perceptions of the efficacy of biodiversity offset policy in Australia. It conducted 31 interviews with stakeholders from industries, consulting, broking, government, legal and NGO groups involved in offset policy. Preliminary themes found that most stakeholders were primarily concerned with achieving good environmental outcomes from offsets. However, banks may see offset contracts as a financial risk and not approve mortgages on properties with offsets. Additionally, there is limited government resourcing and oversight capacity for offset policy.
The document provides an overview of a CRM system being proposed for One Direction, a luxury lingerie company in the Philippines. It discusses the company's background and management team, their goal of bringing high quality intimate fashion to the Philippine market, and why pursuing a CRM system would help them better understand customers, improve marketing strategies, and enhance customer communication and retention. The proposed CRM system would help manage sales, marketing, and customer relations through modules for contact management, complaints/feedback, marketing campaigns, and sales leads/transactions.
This document describes two randomized controlled trial experiments being conducted by the Centre for Insurance and Risk Management (CIRM) in India to evaluate the impact of health microinsurance and related interventions.
The first examines an intervention by Calcutta Kids providing outpatient counseling services along with inpatient health insurance to increase renewal rates. The second examines an intervention by CARE Foundation providing outpatient counseling services to improve health outcomes. Both studies use RCT methodology to rigorously evaluate the impact of the interventions on key indicators like renewal rates, health expenditures, and client value. The results will help inform product design and policy to strengthen health microinsurance.
This study investigated the effects of 24 hours of partial sleep deprivation on temporal processing abilities in 20 young adults with normal hearing. Temporal ordering tasks and gap detection thresholds were measured before and after sleep deprivation using the Duration Pattern Test and Gaps-in-Noise test. Significant differences were found between baseline and post-sleep deprivation results for the Duration Pattern Test humming response and both measures of the Gaps-in-Noise test. However, no significant difference was seen for the Duration Pattern Test labeling response. The findings demonstrate that sleep deprivation impacts most temporal processing abilities associated with the prefrontal cortex, with the exception of more complex tasks.
Estimating the Cost of HIV Prevention Interventions with Demonstrated Effecti...CDC NPIN
This document summarizes a study estimating the costs of evidence-based behavioral HIV prevention interventions. The study developed a method to estimate total costs based on hours of labor required and fixed costs like training and facilities. It analyzed costs of two individual-level interventions (RESPECT and MIP) and two group-level interventions (WILLOW and SIHLE). Costs per participant ranged from $96 to $868 for individual interventions and $514 to $631 for group interventions. Costs depended on intensity and simplicity of the intervention.
This study evaluated the effectiveness of occupational therapy vocational rehabilitation (VR) delivered by a specialist traumatic brain injury (TBI) team compared to usual care for supporting return to work after TBI. 94 participants with minor to severe TBI were recruited within 4 weeks of discharge and received either specialist VR (n=40) or usual care (n=54). Specialist VR consisted of work preparation, assessment, and return to work planning delivered in participants' homes or workplaces. Results showed increased rates of return to and retention in work for the specialist VR group at all follow-up points up to 12 months post-injury, with the greatest differences seen in those with moderate-severe TBI. The study provides preliminary evidence
The document outlines Leo Guelman's PhD thesis on developing improved statistical and algorithmic methods for personalized treatment learning (PTL) models, with applications to insurance. It introduces PTL, which aims to select the optimal treatment for each individual based on their characteristics. The thesis contributes novel PTL methods like uplift random forests and causal conditional inference trees, and shows they outperform existing approaches in simulations. It also applies PTL to optimize insurance marketing strategies using experimental data from a large insurer.
This document discusses cognitive rehabilitation therapy (CRT). It began in the 1920s to help veterans with brain injuries relearn cognitive skills. CRT aims to restore lost cognitive functions or teach compensatory strategies. An interdisciplinary team may provide CRT to help those with conditions like stroke, dementia, TBI regain independence. Occupational therapists play a key role in CRT by helping clients relearn skills through functional activities to improve daily living. Strong evidence shows CRT's effectiveness, especially when provided through interdisciplinary collaboration.
Stakeholder perceptions of the efficacy of biodiversity offset policy in Aust...Megan Evans
This document summarizes a study on stakeholder perceptions of the efficacy of biodiversity offset policy in Australia. It conducted 31 interviews with stakeholders from industries, consulting, broking, government, legal and NGO groups involved in offset policy. Preliminary themes found that most stakeholders were primarily concerned with achieving good environmental outcomes from offsets. However, banks may see offset contracts as a financial risk and not approve mortgages on properties with offsets. Additionally, there is limited government resourcing and oversight capacity for offset policy.
The document provides an overview of a CRM system being proposed for One Direction, a luxury lingerie company in the Philippines. It discusses the company's background and management team, their goal of bringing high quality intimate fashion to the Philippine market, and why pursuing a CRM system would help them better understand customers, improve marketing strategies, and enhance customer communication and retention. The proposed CRM system would help manage sales, marketing, and customer relations through modules for contact management, complaints/feedback, marketing campaigns, and sales leads/transactions.
This document systematically reviewed the literature on nonsurgical treatments for carpal tunnel syndrome (CTS). It found strong or moderate evidence for the effectiveness of oral steroids, steroid injections, ultrasound, electromagnetic field therapy, nocturnal splinting, and ergonomic keyboards in the short term. Moderate evidence was found for ultrasound in the midterm. No long-term results were reported except for oral steroids and steroid injections. Future studies should evaluate mid- and long-term effectiveness of nonsurgical CTS treatments.
This study examined 232 patients with symptoms of carpal tunnel syndrome and compared the results of clinical tests, nerve conduction tests, and ultrasound imaging. The study found that clinical tests like Phalen's, Tinel's, and carpal tunnel compression tests were more sensitive indicators of tenosynovitis (inflammation of the tendon sheath) than of carpal tunnel syndrome. Specifically, these clinical tests correctly identified tenosynovitis in 75-95% of cases but only correctly identified carpal tunnel syndrome in 30-47% of cases based on nerve conduction and ultrasound results. The study suggests these clinical tests may be better indicators for diagnosing and managing tenosynovitis rather than carpal tunnel syndrome.
Kaarkhana.com is an emerging software marketplace that connects thousands of buyers with talented resources. They create portfolios for artists and developers, manage their entries and exits from projects, and pay them for completed work. To achieve their mission of strengthening and developing a niche talent market, they provide a special exhibition platform where details are shared in forums and on their upcoming website.
Deforestation in Australia: drivers, trends and policy responsesMegan Evans
Deforestation has significantly reduced Australia's native vegetation since European settlement. This document summarizes the key drivers and trends of deforestation in Australia as well as policy responses over time. Major drivers include agricultural expansion incentivized by past government policies, while deforestation peaked in the 1980s before declining. National policy has aimed to achieve targets like no net loss of native vegetation but with limited success. Effective policy requires a mix of regulatory and economic instruments alongside long-term funding, enforcement, and reducing policy uncertainty.
This document discusses the importance of online marketing strategies for businesses. It explains that having a website alone is not enough, and that internet marketing is needed to generate traffic and leads. Various online marketing tactics are described such as search engine optimization, pay-per-click advertising, social media marketing, email marketing, mobile marketing, blogging, and online reputation management. The key message is that an integrated online marketing approach using multiple channels is important for businesses to effectively compete in today's digital environment.
Is no net loss possible? Evaluating policy instruments for reducing deforest...Megan Evans
This document discusses evaluating the impact of policy instruments on reducing deforestation in Australia. It summarizes a study that aims to: 1) Quantify forest loss across Australia from 1972-2011 using high resolution spatial data; 2) Develop a model of deforestation drivers at national/regional scales; and 3) Evaluate the impact of deforestation policies, accounting for macroeconomic and climatic factors. The challenges of evaluation are discussed, as well as approaches using spatially disaggregated data at the local government area level and a flexible "bent-cable" regression model to attempt to detect policy impacts, though the authors note detection remains difficult even with advanced methods.
This document provides a framework and guidelines for risk assessment in engineering projects. It discusses risk assessment as a process to support rational decision-making under uncertainty. The key points covered include:
1) Risk assessment involves modeling systems, hazards, and consequences, quantifying risks, and comparing alternatives to inform decision-makers.
2) It takes a holistic perspective considering the full lifecycle of projects and interactions between technical, human, and organizational factors.
3) The framework supports decision-making at multiple levels from strategic planning to operations. Consistent risk assessment of project portfolios allows for optimal resource allocation and risk management strategies.
2010 OCDE Achieving Efficiency Improvements in the Health Sector through the ...Madrid Network
The document discusses how information and communication technologies (ICTs) can help drive improvements in healthcare quality and efficiency by enabling better care coordination, safer care through access to patient information and clinical guidelines, and more efficient chronic disease management. However, implementing ICTs in healthcare has proven difficult, with significant costs, delays, and failures experienced across OECD countries. The report analyzes case studies from several countries to identify conditions under which ICTs are most likely to achieve efficiency and quality gains in healthcare.
The document discusses how information and communication technologies (ICTs) can help drive improvements in healthcare quality and efficiency by enabling better care coordination, safer care through access to patient information and clinical guidelines, and more efficient chronic disease management. However, implementing ICTs in healthcare has proven difficult, with significant costs, delays, and failures experienced across countries. The report analyzes case studies from several OECD countries to identify conditions under which ICTs are most likely to achieve efficiency and quality gains in healthcare.
2010 OCDE Achieving Efficiency Improvements in the Health Sector through the ...guest4c3ea7
The document discusses how information and communication technologies (ICTs) can help drive improvements in healthcare quality and efficiency by enabling better care coordination, safer care through access to patient information and clinical guidelines, and more efficient chronic disease management. However, implementing ICTs in healthcare has proven difficult, with significant costs, delays, and failures experienced across countries. The report analyzes case studies from several OECD countries to identify conditions under which ICTs are most likely to achieve efficiency and quality gains in healthcare.
E-Health - Enabler for Australia\'s Healthcare Reformbartlettc
This report discusses the place of E-Health initiatives in the Australian Health care system,
the need for IT in the reform agenda and the case for change.
HBS Management Challenge - Telemedicine for Prisons FinalSitul Shah
This document provides a summary of a management challenge report investigating the use of Cisco HealthPresence for telemedicine applications in UK prisons. It finds that the UK prison population has more than doubled since 1993, presenting challenges for healthcare provision. Cisco HealthPresence could enable remote consultations, expanding access to cost-effective healthcare while optimizing resources. Key benefits include improving access to healthcare, reducing travel costs, and increasing operational effectiveness through collaboration. The report concludes telemedicine could serve as a model for improving prisoner healthcare internationally while increasing efficiency.
This document discusses the benefits of partial discharge (PD) diagnosis for assessing the condition of high voltage gas-insulated switchgear (GIS). It begins by describing different technical methods for PD diagnosis, including UHF, acoustic, and conventional methods. It then addresses how the reliability of PD diagnosis results influences risk assessment and discusses approaches to determine an 'asset risk index'. Next, it analyzes the costs and benefits of investing in PD diagnosis systems through various scenarios and examples. It also provides case studies of PD diagnosis from several countries. In conclusion, reliable PD diagnosis can help optimize maintenance, prevent unexpected outages, and lower costs when used to inform decision making about GIS equipment condition and risk of failure.
Setting standards final_march06.pdf_25417421Ihab Osman
1. The document provides the views of members of the public and doctors on the standards of care and practice expected of doctors as set out in Good Medical Practice.
2. Participants generally agreed with the key duties in Good Medical Practice, but had differing views on concepts like "partnership" and expectations of doctors' probity.
3. Both groups recognized the importance of technical competence and communication skills, though the public was more skeptical about doctors reporting their own shortcomings while doctors focused on challenges like a lack of support for whistleblowers.
Understanding the Dynamics of Successful Health Systems Strengthening Interve...HFG Project
This document presents the results of a cross-case analysis of five case studies of successful health systems strengthening (HSS) interventions supported by USAID. The analysis aims to understand how the interventions were implemented and factors that facilitated or constrained their success. An implementation framework guided the analysis across four phases: pre-condition, pre-implementation, implementation, and maintenance/evolution. Key findings include the importance of engaging stakeholders, participatory planning, targeting multiple levels of the health system, and using monitoring and evaluation to support learning. The analysis concludes with recommendations for future HSS projects.
This article discusses a sociotechnical approach to evaluating the impact of information and communication technologies (ICT) on clinical care environments. A longitudinal, multimethod study was conducted involving pre-implementation and post-implementation assessments. Pre-implementation, interviews and focus groups were used to understand roles, workflows and communication. Post-implementation, the same methods examined how ICT altered these factors and impacted outcomes. Key findings showed ICT can increase efficiency and alter roles if aligned with clinical needs, but clashes with actual work can decrease uptake. The sociotechnical approach emphasizes understanding how the social and technical systems interact within a unique context.
MDT round protocol of yekatit 12 Hospital medical college.pdfAshenafiTigabu
This document outlines protocols for multidisciplinary team (MDT) rounds at Yekatit 12 Hospital Medical College. Key points include:
1. MDT rounds involve multiple care team members like doctors, nurses, pharmacists discussing patient care in real-time to coordinate care, establish goals, and plan discharge.
2. MDT rounds are done twice daily at the hospital to review all patients, evaluate new/critical cases, and ensure quality of care.
3. The rounds are led by senior consultants and include evaluating clinical status, nursing care, medication practices, and patient/family engagement.
4. Data from the rounds is documented and used for daily clinical audits to improve departmental
This document summarizes the findings of an international focus group on the regulation of examinations and qualifications. The focus group discussed several hypotheses: 1) the balance between technical excellence and political legitimacy in assessment systems, 2) the roles of different organizations in exams/qualifications, 3) centralization vs decentralization, 4) intervention when things go wrong, and 5) the future of globalization and technology in assessment. The focus group provided insight on these topics. Overall, the discussion supported the idea that public confidence benefits from a balance of centralization and decentralization in exams/qualifications systems.
This document examines the methodological issues involved in creating composite performance indicators. It discusses international examples of composite indicators in healthcare and other sectors. The key steps in developing a composite indicator are outlined, including choosing indicators and units to assess, transforming performance data, combining indicators, and adjusting for external factors. An empirical analysis uses UK hospital data to create a new composite index through simulations. The results demonstrate that technical choices around weights, thresholds and decision rules can significantly impact composite scores and hospital rankings. The document highlights the need to consider such methodological issues to minimize potentially misleading performance information from composite indicators.
This document provides an overview of operational research (OR) and its application in health management. It defines OR as the scientific study of operations to improve decision making. The document outlines the main features of OR, including taking a total systems approach and using tools from various disciplines. It discusses several quantitative techniques used in OR, such as linear programming, simulation, and inventory control. The document explains how these techniques can help optimize resource allocation and improve efficiency in health systems.
This document systematically reviewed the literature on nonsurgical treatments for carpal tunnel syndrome (CTS). It found strong or moderate evidence for the effectiveness of oral steroids, steroid injections, ultrasound, electromagnetic field therapy, nocturnal splinting, and ergonomic keyboards in the short term. Moderate evidence was found for ultrasound in the midterm. No long-term results were reported except for oral steroids and steroid injections. Future studies should evaluate mid- and long-term effectiveness of nonsurgical CTS treatments.
This study examined 232 patients with symptoms of carpal tunnel syndrome and compared the results of clinical tests, nerve conduction tests, and ultrasound imaging. The study found that clinical tests like Phalen's, Tinel's, and carpal tunnel compression tests were more sensitive indicators of tenosynovitis (inflammation of the tendon sheath) than of carpal tunnel syndrome. Specifically, these clinical tests correctly identified tenosynovitis in 75-95% of cases but only correctly identified carpal tunnel syndrome in 30-47% of cases based on nerve conduction and ultrasound results. The study suggests these clinical tests may be better indicators for diagnosing and managing tenosynovitis rather than carpal tunnel syndrome.
Kaarkhana.com is an emerging software marketplace that connects thousands of buyers with talented resources. They create portfolios for artists and developers, manage their entries and exits from projects, and pay them for completed work. To achieve their mission of strengthening and developing a niche talent market, they provide a special exhibition platform where details are shared in forums and on their upcoming website.
Deforestation in Australia: drivers, trends and policy responsesMegan Evans
Deforestation has significantly reduced Australia's native vegetation since European settlement. This document summarizes the key drivers and trends of deforestation in Australia as well as policy responses over time. Major drivers include agricultural expansion incentivized by past government policies, while deforestation peaked in the 1980s before declining. National policy has aimed to achieve targets like no net loss of native vegetation but with limited success. Effective policy requires a mix of regulatory and economic instruments alongside long-term funding, enforcement, and reducing policy uncertainty.
This document discusses the importance of online marketing strategies for businesses. It explains that having a website alone is not enough, and that internet marketing is needed to generate traffic and leads. Various online marketing tactics are described such as search engine optimization, pay-per-click advertising, social media marketing, email marketing, mobile marketing, blogging, and online reputation management. The key message is that an integrated online marketing approach using multiple channels is important for businesses to effectively compete in today's digital environment.
Is no net loss possible? Evaluating policy instruments for reducing deforest...Megan Evans
This document discusses evaluating the impact of policy instruments on reducing deforestation in Australia. It summarizes a study that aims to: 1) Quantify forest loss across Australia from 1972-2011 using high resolution spatial data; 2) Develop a model of deforestation drivers at national/regional scales; and 3) Evaluate the impact of deforestation policies, accounting for macroeconomic and climatic factors. The challenges of evaluation are discussed, as well as approaches using spatially disaggregated data at the local government area level and a flexible "bent-cable" regression model to attempt to detect policy impacts, though the authors note detection remains difficult even with advanced methods.
This document provides a framework and guidelines for risk assessment in engineering projects. It discusses risk assessment as a process to support rational decision-making under uncertainty. The key points covered include:
1) Risk assessment involves modeling systems, hazards, and consequences, quantifying risks, and comparing alternatives to inform decision-makers.
2) It takes a holistic perspective considering the full lifecycle of projects and interactions between technical, human, and organizational factors.
3) The framework supports decision-making at multiple levels from strategic planning to operations. Consistent risk assessment of project portfolios allows for optimal resource allocation and risk management strategies.
2010 OCDE Achieving Efficiency Improvements in the Health Sector through the ...Madrid Network
The document discusses how information and communication technologies (ICTs) can help drive improvements in healthcare quality and efficiency by enabling better care coordination, safer care through access to patient information and clinical guidelines, and more efficient chronic disease management. However, implementing ICTs in healthcare has proven difficult, with significant costs, delays, and failures experienced across OECD countries. The report analyzes case studies from several countries to identify conditions under which ICTs are most likely to achieve efficiency and quality gains in healthcare.
The document discusses how information and communication technologies (ICTs) can help drive improvements in healthcare quality and efficiency by enabling better care coordination, safer care through access to patient information and clinical guidelines, and more efficient chronic disease management. However, implementing ICTs in healthcare has proven difficult, with significant costs, delays, and failures experienced across countries. The report analyzes case studies from several OECD countries to identify conditions under which ICTs are most likely to achieve efficiency and quality gains in healthcare.
2010 OCDE Achieving Efficiency Improvements in the Health Sector through the ...guest4c3ea7
The document discusses how information and communication technologies (ICTs) can help drive improvements in healthcare quality and efficiency by enabling better care coordination, safer care through access to patient information and clinical guidelines, and more efficient chronic disease management. However, implementing ICTs in healthcare has proven difficult, with significant costs, delays, and failures experienced across countries. The report analyzes case studies from several OECD countries to identify conditions under which ICTs are most likely to achieve efficiency and quality gains in healthcare.
E-Health - Enabler for Australia\'s Healthcare Reformbartlettc
This report discusses the place of E-Health initiatives in the Australian Health care system,
the need for IT in the reform agenda and the case for change.
HBS Management Challenge - Telemedicine for Prisons FinalSitul Shah
This document provides a summary of a management challenge report investigating the use of Cisco HealthPresence for telemedicine applications in UK prisons. It finds that the UK prison population has more than doubled since 1993, presenting challenges for healthcare provision. Cisco HealthPresence could enable remote consultations, expanding access to cost-effective healthcare while optimizing resources. Key benefits include improving access to healthcare, reducing travel costs, and increasing operational effectiveness through collaboration. The report concludes telemedicine could serve as a model for improving prisoner healthcare internationally while increasing efficiency.
This document discusses the benefits of partial discharge (PD) diagnosis for assessing the condition of high voltage gas-insulated switchgear (GIS). It begins by describing different technical methods for PD diagnosis, including UHF, acoustic, and conventional methods. It then addresses how the reliability of PD diagnosis results influences risk assessment and discusses approaches to determine an 'asset risk index'. Next, it analyzes the costs and benefits of investing in PD diagnosis systems through various scenarios and examples. It also provides case studies of PD diagnosis from several countries. In conclusion, reliable PD diagnosis can help optimize maintenance, prevent unexpected outages, and lower costs when used to inform decision making about GIS equipment condition and risk of failure.
Setting standards final_march06.pdf_25417421Ihab Osman
1. The document provides the views of members of the public and doctors on the standards of care and practice expected of doctors as set out in Good Medical Practice.
2. Participants generally agreed with the key duties in Good Medical Practice, but had differing views on concepts like "partnership" and expectations of doctors' probity.
3. Both groups recognized the importance of technical competence and communication skills, though the public was more skeptical about doctors reporting their own shortcomings while doctors focused on challenges like a lack of support for whistleblowers.
Understanding the Dynamics of Successful Health Systems Strengthening Interve...HFG Project
This document presents the results of a cross-case analysis of five case studies of successful health systems strengthening (HSS) interventions supported by USAID. The analysis aims to understand how the interventions were implemented and factors that facilitated or constrained their success. An implementation framework guided the analysis across four phases: pre-condition, pre-implementation, implementation, and maintenance/evolution. Key findings include the importance of engaging stakeholders, participatory planning, targeting multiple levels of the health system, and using monitoring and evaluation to support learning. The analysis concludes with recommendations for future HSS projects.
This article discusses a sociotechnical approach to evaluating the impact of information and communication technologies (ICT) on clinical care environments. A longitudinal, multimethod study was conducted involving pre-implementation and post-implementation assessments. Pre-implementation, interviews and focus groups were used to understand roles, workflows and communication. Post-implementation, the same methods examined how ICT altered these factors and impacted outcomes. Key findings showed ICT can increase efficiency and alter roles if aligned with clinical needs, but clashes with actual work can decrease uptake. The sociotechnical approach emphasizes understanding how the social and technical systems interact within a unique context.
MDT round protocol of yekatit 12 Hospital medical college.pdfAshenafiTigabu
This document outlines protocols for multidisciplinary team (MDT) rounds at Yekatit 12 Hospital Medical College. Key points include:
1. MDT rounds involve multiple care team members like doctors, nurses, pharmacists discussing patient care in real-time to coordinate care, establish goals, and plan discharge.
2. MDT rounds are done twice daily at the hospital to review all patients, evaluate new/critical cases, and ensure quality of care.
3. The rounds are led by senior consultants and include evaluating clinical status, nursing care, medication practices, and patient/family engagement.
4. Data from the rounds is documented and used for daily clinical audits to improve departmental
This document summarizes the findings of an international focus group on the regulation of examinations and qualifications. The focus group discussed several hypotheses: 1) the balance between technical excellence and political legitimacy in assessment systems, 2) the roles of different organizations in exams/qualifications, 3) centralization vs decentralization, 4) intervention when things go wrong, and 5) the future of globalization and technology in assessment. The focus group provided insight on these topics. Overall, the discussion supported the idea that public confidence benefits from a balance of centralization and decentralization in exams/qualifications systems.
This document examines the methodological issues involved in creating composite performance indicators. It discusses international examples of composite indicators in healthcare and other sectors. The key steps in developing a composite indicator are outlined, including choosing indicators and units to assess, transforming performance data, combining indicators, and adjusting for external factors. An empirical analysis uses UK hospital data to create a new composite index through simulations. The results demonstrate that technical choices around weights, thresholds and decision rules can significantly impact composite scores and hospital rankings. The document highlights the need to consider such methodological issues to minimize potentially misleading performance information from composite indicators.
This document provides an overview of operational research (OR) and its application in health management. It defines OR as the scientific study of operations to improve decision making. The document outlines the main features of OR, including taking a total systems approach and using tools from various disciplines. It discusses several quantitative techniques used in OR, such as linear programming, simulation, and inventory control. The document explains how these techniques can help optimize resource allocation and improve efficiency in health systems.
MAST: a model for HTA-based assessment of telemedicine applicationsHTAi Bilbao 2012
This document describes MAST (Model for Assessment of Telemedicine), a multidisciplinary framework for assessing telemedicine applications. It was developed through a comprehensive process and aims to describe effectiveness and quality of care impacts of telemedicine. MAST consists of 3 stages: setting context, multidisciplinary assessment across clinical, economic, organizational and social domains, and assessing transferability. It is being empirically tested through large European projects and has supported over 25 trials. While time-consuming, MAST provides a standardized approach and ensures comparability. Feedback has been positive and several regions are adopting it, with revisions planned based on empirical results to establish MAST as a widely accepted methodology.
This document discusses medical audits, including definitions, components, stages, and types of audits. It provides information on the audit cycle and the roles and functions of an audit committee. Some key points include:
- Medical audits systematically analyze quality of care, procedures, resource use, and patient outcomes and quality of life.
- Audits can help provide reassurance that best quality services are being provided given available resources.
- The audit cycle involves setting standards, comparing practice to standards, implementing changes if needed, and closing the audit loop.
- An audit committee coordinates audits, ensures changes are made, and maintains confidentiality.
This document provides a literature review on factors influencing management acceptance of real options analysis in the mining sector. It defines real options analysis and discusses how it can be applied in mining through examples. Key themes explored include the benefits of real options over traditional discounted cash flow, numerical methods for evaluating real options, and frameworks for applying real options. The literature identifies potential factors such as skilled internal champions, executive support, training and education, and pilot projects. The review aims to develop research propositions to investigate the critical success factors for gaining management acceptance of real options analysis in mining.
Monitoring and evaluation toolkit - Conférence de la 2e édition du Cours international « Atelier Paludisme » - TUSEO Luciano - World Health Organization / Roll Back Malaria - maloms@iris.mg
Hospital management system project report.pdfKamal Acharya
The project Hospital Management system includes registration of patients, storing their details into the system, and also computerized billing in the pharmacy, and labs. The software has the facility to give a unique id for every patient and stores the details of every patient and the staff automatically. It includes a search facility to know the current status of each room. User can search availability of a doctor and the details of a patient using the id. The Hospital Management System can be entered using a username and password. It is accessible either by an administrator or receptionist. Only they can add data into the database. The data can be retrieved easily. The interface is very user-friendly. The data are well protected for personal use and makes the data processing very fast. Hospital Management System is powerful, flexible, and easy to use and is designed and developed to deliver real conceivable benefits to hospitals. Hospital Management System is designed for multispecialty hospitals, to cover a wide range of hospital administration and management processes. It is an integrated end-to-end Hospital Management System that provides relevant information across the hospital to support effective decision making for patient care, hospital administration and critical financial accounting, in a seamless flow. Hospital Management System is a software product suite designed to improve the quality and management of hospital management in the areas of clinical process analysis and activity-based costing. Hospital Management System enables you to develop your organization and improve its effectiveness and quality of work. Managing the key processes efficiently is critical to the success of the hospital helps you manage your processes.
Similar to Articulo: Systematic Review Telemedicine (20)
3. 738 i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 9 ( 2 0 1 0 ) 736–771
effectiveness of telemedicine with particular reference to 3.1.3. Comparisons
both outcomes and methodologies for evaluation. This paper Reviews of studies comparing telemedicine to standard care or
focuses mainly on the evidence about effectiveness, and to another type of care, as well as reviews of studies comparing
assesses the range of conclusions drawn by reviewers about different e-health solutions were included.
the effectiveness of telemedicine and the gaps in the evidence
base. A companion paper focuses on the methodological
issues and recommendations [13]. 3.1.4. Outcomes
Only reviews reporting relevant outcomes were included,
specified as health related outcomes (morbidity, mortality,
quality of life, patient’ satisfaction), process outcomes (qual-
2. Objectives
ity of care, professional practice, adherence to recommended
practice, professional satisfaction) and costs or resource use.
The objective of the work was to conduct a review of reviews Systematic reviews reporting emerging issues, such as an
on the impacts and costs of telemedicine services and con- unexpected finding or important new insights were also
sider qualitative and quantitative results, with the purpose included.
of synthesizing evidence to date on the effectiveness of
telemedicine. The key questions addressed were firstly, how
are telemedicine services defined and described in terms of 3.1.5. Languages
participants, interventions, comparisons and outcome mea- No articles were excluded based on language, although the
sures; secondly, what are the reported effects of telemedicine: main focus of the project was telemedicine in Europe.
thirdly which methodologies were used to produce knowl-
edge about telemedicine in studies included; fourthly, what
3.2. Exclusion criteria
are the strengths and weaknesses of these methodologies,
including HTA methodologies; and finally what are the knowl-
3.2.1. Design
edge gaps and what methodologies can be recommended for
Reviews considered not systematic, including commentaries
future research? The present paper addresses the first two of
and editorials, were excluded. Systematic reviews with major
these questions, and identifies assessments of the evidence
limitations (low quality reviews) according to a revised check-
base provided within the reviews and knowledge gaps in terms
list for systematic reviews from EPOC (Cochrane Effective
of outcomes.
Practice and Organisation of Care Group) were excluded.
If the same authors had produced several publications of
the same review, the most updated and/or the full report of
3. Methods the review was selected, and other versions excluded. Disser-
tations, symposium proceedings, and irretrievable documents
An initial search identified systematic reviews of telemedicine
were excluded.
published from 1998. A systematic review was defined as an
overview with an explicit question and a method section with
a clear description of the search strategy and the methods 3.2.2. Participants
used to produce the systematic review. The review should Studies with participants considered not relevant for the
also report and analyse empirical data. In addition, reviews review, for instance studies on use of ICT on people outside
which described or summarised methods used in assessing health care were excluded. Animal studies were excluded.
telemedicine were included. Because of the large number of
reviews retrieved, a decision was taken to include only reviews
published from 2005 and onwards in the final review. 3.2.3. Interventions considered not relevant for the review
Other exclusions were studies on interventions considered not
relevant for the review, such as studies on Internet and other
3.1. Inclusion criteria ICT media used for information seeking; quality of informa-
tion on the Internet; Internet based education of students and
3.1.1. Population/participants health professionals, including use of games; medical tech-
Systematic reviews on patients and consumers, health pro- nology in clinical practice in general, i.e. medical and surgical
fessionals and family caregivers, regardless of diagnoses or examinations and treatments based on computer technolo-
conditions, were included in the searches for systematic gies, except when used as remote diagnosis and treatment
reviews. (telehealth); ordinary use of electronic patient records; use of
telephone (including cell phones) only; e-health as only a very
limited part of an intervention; use of Internet for surveys and
3.1.2. Interventions research; online prescriptions; mass media interventions and
All e-health interventions, information and communication veterinary medicine.
technologies (ICT) for communication in health care, Internet
based interventions for diagnosis and treatments, and social
care if an important part of health care and in collaboration 3.2.4. Outcomes
with health care for patients with chronic conditions were Articles without relevant outcomes, i.e. not on the list of out-
considered relevant. comes specified above under inclusion criteria, were excluded.
4. i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 9 ( 2 0 1 0 ) 736–771 739
3.3. Information sources to which the systematic reviewers had assessed risk of bias in
individual studies.
Literature searches of the following databases: ACM Digital Systematic reviews with major limitations were excluded.
Library (ACM – The Association for Computing Machin- We assessed the methodological quality of studies in the
ery), British Nursing Index, Cochrane library (including field of telemedicine based on the review authors’ assess-
Cochrane database of systematic reviews (CDSR), Database ments of risk of bias in the primary studies they had
of reviews of effects (DARE), Health Technology Assess- included.
ment Database (HTA), CSA, Ovid Medline, Embase, Health
Services/Technology Assessment Text (HSTAT), Interna- 3.9. Summary measures and synthesis of results
tional Network of Agencies for Health Technology Assess-
ment (INAHTA), PsycInfo, Pubmed, Telemedicine Information The authors analysed the data collected by the members of
Exchange (TIE), Web of Science. the expert team. Due to the expected heterogeneity of stud-
The main search was performed in February 2009, and an ies, regarding participants, interventions, outcomes and study
updated search was performed in July 2009. designs, a quantitative summary measure of the results was
not planned. We did a qualitative and narrative summary
3.4. Search of the results of the systematic reviews. The results of the
literature review were presented and discussed in two work-
The search strategies are available on the website: (to be shops intending to validate results. In the first workshop
inserted). different user groups took part and in the second workshop
methodology experts participated. The analysis was inspired
3.5. Study selection by principles of realist review [14], considered appropriate for
complex interventions.
Based on the criteria for inclusion and exclusion, AGE and SF
independently screened the lists of titles/abstracts identified
4. Results
through searches for systematic reviews. Any discrepancies
were solved by discussion with the third member of the team,
We identified 1593 records through the searches and excluded
AB. The potentially relevant systematic reviews were retrieved
1419 following screening. We retrieved 174 potentially rel-
in full text.
evant articles in full text. We excluded 94 of these based
on the pre-specified inclusion and exclusion criteria. The
3.6. Data collection process
qualitative synthesis below relate to 73 of the 80 included
articles.
Data collection was carried out online using a data extrac-
The results of the 80 systematic reviews included are sum-
tion form. Each potentially relevant systematic review was
marised in seven tables in Appendix 1. Tables one through
assessed in full text by one member of an expert panel of
six list populations, interventions, outcomes, results and con-
reviewers. A revised check list from EPOC (Cochrane Effective
clusions for the reviews cited in this paper, according to the
Practice and Organisation of Care Group) was used to assess
headlines presented in the discussion below. Table 7 list the
the quality of the systematic reviews. The quality domains
seven included reviews not cited in this paper.
assessed according to this checklist were methods used to
identify, include and critically appraise the studies in the
review, methods used to analyse the findings and an overall 5. Telemedicine is effective
assessment of the quality of the review. The review team (AGE,
AB and SF) subsequently checked review reports for agreement Twenty reviews (Table 1) concluded that telemedicine works
regarding the inclusion and exclusion criteria. and has positive effects. These include therapeutic effects,
increased efficiencies in the health services, and technical
3.7. Data items usability.
Types of interventions that were found to be therapeuti-
Data on type of participants, interventions and outcomes cally effective include online psychological interventions [15];
included in the reviews were collected. Other data items were: programmes for chronic heart failure that include remote
geographical coverage of review, time frame of included stud- monitoring [16]; home telemonitoring of respiratory con-
ies, range of data collection methods used in studies included ditions [17]; web and computer-based smoking cessation
in the reviews, disciplines/areas covered and methodologi- programmes [18]; telehealth approaches to secondary preven-
cal traditions included in the review. The reviewers were also tion of coronary heart disease [19]; telepsychiatry [20]; virtual
asked to indicate emerging issues identified by the authors of reality exposure therapy (VRET) for anxiety disorders [21];
the reviews. robot-aided therapy of the proximal upper limb [22]; inter-
net and computer-based cognitive behavioural therapy for the
3.8. Quality of systematic reviews and risk of bias in treatment of anxiety [23,24]; home telehealth for diabetes,
individual studies heart disease and chronic obstructive pulmonary disease [25];
and internet based physical activity interventions [26]. A
The members of the expert team assessed the quality of the review comparing telepsychiatry and face-to-face work [27]
systematic reviews, including questions regarding the degree found no differences between the two, and suggested that
5. 740 i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 9 ( 2 0 1 0 ) 736–771
telepsychiatry will increase in use, particularly where it is are heterogeneous and interventions complex, making these
more practical. difficult to understand [49].
Interventions that are effective in reducing health service
use include vital signs monitoring at home with telephone
follow-up by nurses [28]; computerised asthma patient educa- 7. Evidence is limited and inconsistent
tion programs [29]; and home monitoring of diabetes patients
[30]. Twenty-two reviews (Table 3) however concluded that the evi-
Technical effectiveness and reliability are reported in dence for the effectiveness of telemedicine is still limited and
respect of remote interpretation of patient data [31]; smart inconsistent, across a wide range of fields.
home technologies [32]; and home monitoring of heart failure In terms of therapeutic effectiveness, there is some lim-
patients [33]. ited evidence regarding telemonitoring for heart failure [50];
One review concluded that home based ICT interventions despite reviewers suggesting that electronic transfer of self-
in general give comprehensive positive outcomes for chronic monitored results has been found to be feasible and acceptable
disease management, despite only identifying a small number in diabetes care, they find only weak evidence for improve-
of heterogeneous studies [34]. ments in HbA1c or other aspects of diabetes management [51];
others found only weak evidence of benefit relating to infor-
matics applications in asthma care [52]; and no evidence of
6. Telemedicine is promising improvement in clinical outcomes following teleconsultation
and video-conferences in diabetes care [53].
Nineteen reviews (Table 2) were less confident about the effec- Frequently, these reviewers call for further research,
tiveness of telemedicine, suggesting that it is promising, or has notably in the form of RCTs. Examples include calls relating
potential, but that more research is required before it is pos- to web-based alcohol cessation interventions [54]; and vir-
sible to draw firm conclusions. In some cases, in which the tual reality in stroke therapy, despite this being found [37] to
same conditions and interventions are discussed, these more be ‘potentially exciting and safe’. More work on telemonitor-
tentative conclusions must temper those of authors who find ing in heart failure is called for [55]; on e-therapy for mental
conclusive evidence. health problems [56]; on smart home technologies [57]; and
One review [35] for example found internet-delivered CBT on technological support for carers of people with demen-
to be a ‘promising’ and ‘complementary’ development, but did tia [58]. Others [28] underlined that lack of evidence does not
not provide the endorsements that others [23,24] did for CBT imply lack of effectiveness, and that in many cases interven-
for the more specific conditions of anxiety and depression. tions are simply ‘unproven’. Caution is also urged by reviewers
Similarly psychotherapy using remote communication tech- [59] who identified small numbers of heterogeneous studies
nologies was seen as promising [36], but still requiring more in relation to chronic disease management. One review [60]
evidence. found it impossible to draw any significant conclusions about
Areas in which review authors agreed that telemedicine the impact of interventions to promote ICT use by health care
shows therapeutic promise, but still requires further research, personnel.
include virtual reality in stroke rehabilitation [37,38]; improv- Several reviewers found that research has been somewhat
ing symptoms and behaviour associated with and knowledge narrowly focused and suggested further research which takes
about specific mental disorders and related conditions [39]; a broader perspective or a different one. They suggested that
diabetes [40,83]; weight loss intervention and possibly weight telemedicine researchers have not yet asked all the impor-
loss maintenance [41]; and alcohol abuse [88]. tant questions, or conducted research in appropriate ways.
Other authors found promise in terms of health service For example, in the cases of dermatology, wound care and
utilisation. One review [42] for example suggested that asyn- ophthalmology, it was argued that evaluation has explored
chronous telehealth developments could result in shorter ICT-based asynchronous services for efficacy, but outcomes
waiting times, fewer unnecessary referrals, high levels of or access issues have not been considered [61]. In a simi-
patient and provider satisfaction, and equivalent (or better) lar vein, although most of the studies of smart homes found
diagnostic accuracy. Another [43] found that home telehealth technical feasibility, there remain certain topics that require
has a positive impact on the use of many health services as further research, notably, ‘technical, ethical, legal, clinical,
well as glycaemic control of patients with diabetes. economical and organisational implications and challenges’
Positive patient experiences were highlighted as promising [32]. Others [44], whilst seeing significant potential for teleon-
in relation to home telemonitoring for respiratory conditions cology, especially in rural areas, suggested that local studies
[17]. There is potential for using Internet/web-based services may be needed to confirm this. A further contribution to the
for cancer patients in rural areas [44], and telemonitoring can debates about CBT (see above), found that whilst it appears to
empower patients with chronic conditions [45]. be effective for panic disorders, social phobia and depression,
Promising impacts on service delivery were identified its effects on obsessive–compulsive disorder and anxiety and
[46,47] in use of electronic decision support systems and depression combined remain insufficiently clear [62]. Causal
telemedicine consultations promise to support improved pathways in HbA1c decline in diabetes care remain unclear,
delivery of tPA in patients with stroke (a treatment which and this conclusion can be linked with the variations in pro-
requires to be administered within 3 h) [48]. Computer gramme designs [63]. Whilst smoking cessation programmes
reminders to professionals at the point of care show ‘small to appear to be effective across a range of studies, nevertheless
modest improvements’ in professional behaviour, but studies the mechanisms of action are not well understood [64].
6. i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 9 ( 2 0 1 0 ) 736–771 741
Telemedicine is a dynamic field, and new studies and One review found that health service users with ICT
new systematic reviews are rapidly being published. As used in support, education and virtual consultation feel
telemedicine extends into new clinical areas, it is unsurpris- more confident and empowered, with better knowledge and
ing that reviewers give renewed accounts of limited evidence. improved health outcomes, as well as experiencing better
Some examples of new areas from our review include little nurse-patient relationships [73]. The reviewers call for more
research on health promotion provided through the Internet research on the mechanisms for these changes. Generally
[65]; a Cochrane review that found no studies of smart homes there is evidence of high patient satisfaction ratings for telere-
that met their inclusion criteria [57]; a review of studies on habilitation, but reviewers argue that more process research,
spiritual care that found little systematic research in this area case studies and qualitative studies are needed to improve
[66]; and a review concluding that formative evaluation is our understanding of these outcomes [74]. Interactive health
needed for remote monitoring in hypertension [90]. communication applications (IHCAs) for people with chronic
disease appear to give benefit in terms of improved sup-
port, better knowledge and improved health outcomes, but
8. Economic analysis the authors asked for more larger studies to be conducted
[75].
An important emerging issue from our review is the lack of Others found no consistent results regarding user expe-
knowledge and understanding of the costs of telemedicine riences, though suggested that access can be improved [69].
(Table 4). Alongside development of technologies which aim to ben-
Several reviewers suggested that telemedicine seemed to efit patients and citizens as well as professionals, we need
be cost-effective, but few draw firm conclusions. One review research on the impacts of technologies for these groups [76].
found that 91% of the studies showed telehomecare to be cost- An example is that information websites relating to dementia
effective, in that it reduced use of hospitals, improved patient are geared more to carers than to people with dementia them-
compliance, satisfaction and quality of life [67]. This was the selves, and that the websites do not usually offer personalised
clearest conclusion, with others being much more cautious: information [77].
telemedicine was found to be cost-effective for chronic disease
management, but the authors cautioned that studies were few
and heterogeneous [34]. A comparison of the costs of telemon- 10. Asking new questions
itoring and usual care for heart failure patients found that
telemonitoring could reduce travel time and hospital admis- We have already noted the emergence of new topic areas in
sions, whilst noting that benefits are likely to be realised in the this dynamic and complex field. The focus on patient bene-
long term [68]. Others found home telehealth for chronic con- fits however indicates a more basic development, namely that
ditions to be cost saving, though underlining that studies were reviewers are starting to explore new questions beyond those
generally of low quality [25]. One review found remote inter- of clinical and cost-effectiveness. Our review produced two
pretation in medical encounters to be more expensive than its key examples (Table 6). Firstly, a review that identified gender
alternatives [31]. differences in computer-mediated communications relating
Other reviewers did not find good evidence about cost- to online support groups for people with cancer cautioned that
effectiveness; the cost-effectiveness of home telecare for studies are limited and heterogeneous [78]. Nevertheless, the
older people and people with chronic conditions is uncer- authors suggested that this issue needs to be considered by
tain [28]; there is a lack of consistent results regarding costs those designing interventions of this kind. This implies a con-
of synchronous telehealth in primary care [69]; there is lit- sideration that telemedicine is an ongoing intervention where
tle evidence for the economic viability of home respiratory users influence its development and hence that effectiveness
monitoring [17]; the cost-effectiveness of IT in diabetes care of outcome is a complex collaborative achievement. Secondly,
is undetermined [40]; one review was able to identify only one a review focusing on stroke thrombolysis service configura-
study of the costs of CBT, with significant weaknesses [70], tions, their potential impact and ways of recording data to
with another finding little evidence in the same area [62]. inform which configuration could be most suitable for a partic-
A particular limitation identified in terms of costs concerns ular situation, highlighted the need to consider a wider range
the wider social and organisational costs of telemedicine. One of service delivery issues [79]. Similarly, it was argued that in
review found that a societal perspective on costs has not yet post-stroke patients, the consideration of caregivers’ mental
been developed for home telehealth [71] and another high- health and high levels of patient satisfaction should be an
lighted the need to consider not only costs to health services integral element of studies [80].
of interventions, but also costs to service users and their social Furthermore, some of the papers included in the review
networks [72]. explored issues which can inform the future development
of telemedicine, that is, they provide formative assessments.
Examples include a review of 104 definitions of telemedicine
9. Is telemedicine good for patients? [81] which, in identifying four broad types of definitions,
suggested how stakeholder interests can alter perceptions
A second emerging issue concerns patient satisfaction with of priorities in telemedicine interventions, such that some
telemedicine, and indications that telemedicine may alter may focus on delivering healthcare over a distance and
the relationships between patients and health professionals others on the potential of technology per se; and work argu-
(Table 5). ing that clinical and technical guidelines can inform the
7. 742 i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 9 ( 2 0 1 0 ) 736–771
future development of telemedicine and facilitate evaluation
[20,82]. Summary points
“What was already known on this topic”
11. Reflections on the methodology of our • Evidence regarding the effectiveness of telemedicine
study is patchy and incomplete.
• The quality of much of the research conducted is poor.
Our study is a review of systematic reviews. There are some
inherent weaknesses in this approach. In general we have to “What this study added to our knowledge”
rely on the information in the included reviews. The quality
of the reviews may vary; the reviews may have done a poor • The evidence base is accumulating robust knowledge
job in specifying their inclusion and exclusion criteria, the about the effectiveness of telemedicine.
searches may not be comprehensive, the review authors may • As the field is rapidly evolving however, new knowl-
not have assessed or extracted data from the primary studies edge is constantly needed.
adequately, nor analysed and synthesised the findings across • Continuing areas of weakness but also of great interest
the studies properly. But even using high quality reviews, we include economic analyses, understandings of patient
necessarily lose information and details that we can only find perspectives, of effectiveness and outcomes as com-
if we go back to the primary studies. plex and ongoing collaborative achievements, and
Although we did a thorough job in developing the search formative assessments.
strategy and identified a vast amount of reviews on the effects
of telemedicine, we might have missed relevant systematic
reviews.
Some of the included reviews are probably outdated. Stud-
12. Conclusions
ies that are published after the search date in the reviews are
not included. Ideally we could have supplemented the review
Despite large number of studies and systematic reviews
with more recent primary studies not included in the reviews,
on the effects of telemedicine, high quality evidence to
but we did not have the resources to do this.
inform policy decisions on how best to use telemedicine
We did not check whether reviews included the same ref-
in health care is still lacking. Large studies with rigorous
erences. Several reviews have studied similar or overlapping
designs are needed to get better evidence on the effects of
topics, and have at least partially included the same studies.
telemedicine interventions on health, satisfaction with care
It may therefore be that evidence is counted twice, or that
and costs. As the field is rapidly evolving, different kinds
different interpretations of effectiveness are given by review
of knowledge are also in demand, e.g. a stronger focus on
authors. We have not analysed the degree to which there are
economic analyses of telemedicine, on patients’ perspec-
discrepancies in the analyses of similar studies, nor the rea-
tives and on the understanding of telemedicine as complex
sons for different interpretations of the same findings, for
development processes, and effectiveness and outcome as
instance did we not analyse the heterogeneity of the results
ongoing collaborative achievements. Hence formative assess-
among the reviews based on the quality of the reviews.
ments are also pointed out as an area of weakness and
The data collection and assessment of each included
interest.
review was accomplished by one external expert, while two
is considered to be optimal in order to reduce risk of bias. Acknowledgements
We did not train the data extractors, and we did not pilot
the data extraction form. The experts were not completely The study was funded by the EU under SMART 2008/0064
consistent in their judgments. This limitation was partly due and was conducted as part of the MethoTelemed project. We
to the resources and organisation of the project, in that two acknowledge the support of our MethoTelemed colleagues, the
workshops were held, intending to validate results. In addi- group of external review experts, the workshop participants,
tion, the review team made a quality check of the reviews by the project officers at the Norwegian centre for integrated care
comparing the reported data with information in the full text and telemedicine, and Ingrid Harboe at the Norwegian Knowl-
papers. Any unclear themes were discussed in the team to edge Centre for the Health Services, who did the literature
reach consensus. searches.
We have limited information regarding effect sizes and the
strength of evidence for the outcomes that we have studied.
We have however demonstrated that it is possible to make
Appendix 1.
such a large overview in quite a short time, involving both
methodology and content experts. We have used systematic In Tables 1–7, columns listing results and conclusions quote
methods in the literature searches and the assessment of the from the authors’ work. Where a review appears in more than
reviews, and we have excluded reviews of low methodological one table, this reflects the range of evidence produced. Full
quality. access to a searchable database of abstracts of items included
In combining rigorous and systematic methods with a in the review will be available on the MethoTelemed web-
pragmatic approach we have produced a relevant and rich site, which also includes guidance for evaluating telemedicine.
overview of the field. www.telemed.no/MethoTelemed.
8. Table 1 – Systematic reviews reporting that telemedicine is effective.
Reference Conditions Geographic Service/ Outcome Authors’ summary of results Authors’ conclusions
included area intervention
Barak et al. [15] Mental health Not stated Internet based Behavioural, Sixty-four studies included covering 94 Internet based intervention is as
psychotherapy Health, Percep- services. The overall mean weighted effect effective as face-to-face
tion/satisfaction, size was 0.53, similar to the average effect intervention.
Social size of traditional, face-to-face therapy.
Comparison between face-to-face and
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 9 ( 2 0 1 0 ) 736–771
Internet intervention across 14 studies
showed no differences in effectiveness.
Clark et al. [16] Cardio- All countries Remote Behavioural, Fourteen studies (RCTs) included. Four Programmes for chronic heart
vascular monitoring, Cost/economic, evaluated telemonitoring, nine structured failure that include remote
(CHF) telephone Health telephone support, and one both. Remote monitoring have a positive effect
support monitoring programmes reduced the rates of on clinical outcomes in
admission to hospital for chronic heart community dwelling patients with
failure by 21% and all cause mortality by 20%. chronic heart failure.
Three studies reported quality of life
improvements and four, reduced cost, one
found no gain in cost-effectiveness.
Jaana et al. [17] Respiratory USA, Europe, Remote Behavioural, Twenty-three studies included. Good levels of Home telemonitoring of
conditions Israel, Taiwan monitoring Cost/economic, data validity and reliability were reported. respiratory conditions results in
Feasibility/pilot, However, little quantitative evidence exists early identification of
Health, Percep- about the effect of remote monitoring on deteriorations in patient condition
tion/satisfaction patient medical condition and utilization of and symptom control. Positive
health services. Positive effects on patient patient attitude and receptiveness
behaviour were consistently reported. Only of this approach are promising.
two studies performed a detailed cost However, evidence on the
analysis. magnitude of clinical and
structural effects remains
preliminary, with variations in
study approaches and an absence
of robust study designs and formal
evaluations.
Myung et al. Smoking Worldwide Web and Behavioural Twenty-two studies included (RCTs). In a The meta-analysis of RCTs
[18] cessation computer-based random-effects meta-analysis of all 22 trials, indicates that there is sufficient
programmes the intervention had a significant effect on clinical evidence to support the
smoking cessation. Similar findings were use of Web- and computer-based
observed in nine trials using a Web-based smoking cessation programs for
intervention,(and in 13 trials using a adult smokers.
computer-based intervention Subgroup
analyses revealed similar findings for
different levels of methodological rigor,
stand-alone versus supplemental
interventions, type of abstinence rates
employed, and duration of follow-up period,
but not for adolescent populations.
743
9. 744
Table 1 (Continued)
Reference Conditions Geographic Service/ Outcome Authors’ summary of results Authors’ conclusions
included area intervention
Neubeck et al. Cardio- USA (3 Communication Behavioural, Health, Eleven studies included (RCTs). Telehealth interventions provide
[19] vascular studies), using ICT, psychosocial state, Telehealth interventions were associated effective risk factor reduction and
(CHD) Norway (1), patient- quality of life with non-significant lower all-cause secondary prevention. Provision of
Canada (3), professional mortality than controls. These telehealth models could help
Australia (3), interventions showed a significantly increase uptake of a formal
Germany (1) lower weighted mean difference at secondary prevention by those
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 9 ( 2 0 1 0 ) 736–771
medium long-term follow-up than who do not access cardiac
controls for total cholesterol, systolic rehabilitation and narrow the
blood pressure, and fewer smokers. current evidence-practice gap.
Significant favourable changes at
follow-up were also found in high-density
lipoprotein and low-density lipoprotein.
Pineau et al. Psychiatric Focus on Telepsychiatry Cost/economic, ‘About 60’ studies included. The authors The review concludes that
[20] conditions Canada and Ethical issues, Legal, argue that definition of clinical guidelines telepsychiatry should be
(adult and USA Organizational, and technological standards aimed at implemented in Québec and
paediatric) Technology related, standardising telepsychiatric practice will provides detailed clinical and
clinical guidelines promote its large scale implementation. technical guidelines for
and technical implementation. They add that
standards taking into account human and
organizational aspects plays a part
in ensuring the success of this
type of activity; that legal and
ethical aspects must also be
considered; and that a detailed
economic analysis should be
carried out prior to any large
investment in telepsychiatry.
Finally, implementation of
psychiatry should be subjected to
rigorous downstream assessment
in order to improve management
and performance.
Powers and Anxiety Not stated Virtual reality Behavioural, Percep- Thirteen studies included. VRET (Virtual Given the advantages and the
Emmelkamp (especially exposure tion/satisfaction, reality exposure therapy) is highly efficacy of VRET supported by this
[21] phobias) therapy Psychophysiology, effective in treating phobias and more so meta-analysis a broader
perceived control than inactive control conditions. VRET is application in clinical practice
over phobias slightly, but significantly more effective seems justified.
than exposure in vivo, the gold standard
in the field. Advantages of VRET: can be
conducted in the therapist’s office, rather
than in vivo situations, the possibility of
generating more gradual assignments
and of creating idiosyncratic exposure.
VRET is cost-effective.
10. Prange et al. Stroke USA Rehabilitation Health Eleven studies included. Robot-aided This systematic review indicates
[22] (robots) therapy of the proximal upper limb that robot-aided therapy of the
improves short and long-term motor proximal upper limb can improve
control of the paretic shoulder and elbow: short and long-term motor control
however, there is no consistent influence of the paretic shoulder and elbow.
on functional abilities. Robot-aided therapy appears to
improve motor control more than
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 9 ( 2 0 1 0 ) 736–771
conventional therapy.
Reger and Mental health Not stated Internet/computer- Behavioural, Health Ninteen studies included (RCTs). The results of this meta-analysis
Gahm [23] problems based Meta-analysis showed that ICT was provide preliminary support for
(anxiety) treatment superior to waitlist and placebo the use of Internet and
assignment across outcome measures computer-based CBT for the
The effects of ICT were equal to treatment of anxiety.
therapist-delivered treatment across
anxiety disorders. Conclusions were
limited by small sample sizes, the rare
use of placebo controls, and other
methodological problems. The number of
available studies limited the opportunity
to conduct analyses by diagnostic group.
Spek et al. [24] Mental health Global CBT via internet Health Twelve studies included (RCTs). Authors Despite study limitations, eCBT
(depression concluded that eCBT was effective, but seemed to be effective.
and anxiety) noted that there was only a small number
of studies and significant heterogeneity.
Tran et al. [25] Diabetes, heart Canada Home telehealth Cost/economic, Seventy-nine studies included. Of the Conclusions relate to the potential
failure, COPD focused, but Health, Percep- included studies, 26 pertained to for home telehealth in Canada
and other international tion/satisfaction diabetes, 35 to CHF, nine to COPD, and which is seen as positive. However,
chronic publications eight to mixed chronic diseases. The more research, such as multicentre
diseases included comparator “no care” was not identified RCTs, is warranted to accurately
in any of the included studies, so usual measure the clinical and economic
care was used as the comparator impact of home telehealth for
throughout the clinical review. Home chronic disease management to
telehealth appeared generally clinically support Canadian policy makers in
effective and no patient adverse effects making informed decisions.
were reported. Evidence on health service
utilization was more limited, but
promising The economic review
suggested cost-effectiveness, but the
quality of studies was low.
van den Berg et Internet based Not Physical activity Behavioural, Health Ten studies included. The analysis There is indicative evidence that
al. [26] physical mentioned focused on the methodological quality of internet based physical activity
activity other than the studies, which showed variation in interventions are more effective
interventions language study populations and interventions than a waiting list strategy.
limitations making generalization difficult.
745
11. 746
Table 1 (Continued)
Reference Conditions Geographic Service/ Outcome Authors’ summary of results Authors’ conclusions
included area intervention
Hyler et al. [27] Mental health France, Telepsychiatry Feasibility/pilot, Per- Fourteen studies included. Telepsychiatry Only a handful studies have
Australia, ception/satisfaction, was found to be similar to In person for attempted to compare
Canada, Quality of different studies using objective assessments. telepsychiatry with in-person
Japan, UK instruments used Bandwidth was a moderator. psychiatry (IP) directly, using
and US for consultations Heterogeneous effect sizes for different standardised assessment
moderators (bandwidth) High bandwidth instruments to permit meaningful
was slightly superior for assessments comparison. According to the
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 9 ( 2 0 1 0 ) 736–771
requiring detailed observation of patients. meta-analysis, there was no
difference in accuracy or
satisfaction between the two
modalities. Telepsychiatry is
expected to replace IP in certain
research and clinical situations.
Barlow et al. Elderly people, Worldwide Home telecare Behavioural, Health, Sixty-eight RCTs and 30 observational Having identified where there is
[28] chronic Organisational, studies with 80 or more participants evidence of effectiveness, and
diseases Safety included. Results show that the most where it is lacking, the authors
effective telecare interventions appear to conclude that insufficient
be automated vital signs monitoring (for evidence does not amount to lack
reducing health service use) and of effectiveness: more research is
telephone follow-up by nurses (for needed.
improving clinical indicators and
reducing health service use). Evidence on
cost-effectiveness is less clear, and on
safety and security alert systems
insufficient.
Bussey-Smith Asthma USA, Hawaii, Computer-based Behavioural, Nine studies included. One study each Although interactive CAPEPs may
and Rossen Sweden patient Cost/economic, showed reduced hospitalizations, acute improve patient asthma
[29] education Health, Percep- care visits, or rescue inhaler use. Two knowledge and symptoms, their
programmes tion/satisfaction, reported lung function improvements. effect on objective clinical
(CAPEPs) Social Four showed improved asthma outcomes is less consistent
knowledge, and five showed
improvements in symptoms.
Jaana et al.[30] Diabetes North Remote Behavioural, Health, Seventeen studies included. Most studies Positive effects are reported, but
America, monitoring Technology related, reported overall positive results in there is variation in patient
Europe and Structural Diabetes mellitus type 2, and found that characteristics (background,
Asia IT based interventions improved health ability, medical condition) sample
care utilisation, behaviour attitudes and selection and approach for
skills. treatment of control groups.
Azarmina and All All countries Remote Cost/economic, Nine studies included. Results showed The review suggests that remote
Wallace [31] interpretation in Feasibility/pilot, that time between encounters was interpretation is an acceptable and
medical Health, reduced, but evidence on consultation accurate alternative to traditional
encounters Organisational, Per- length was not consistent. Good client methods, despite the higher
ception/satisfaction, and doctor satisfaction was shown, but associated costs.
Safety those interpreting data preferred to do so
face to face. Costs of these interventions
are high, but efficiency gains are possible.
12. Demiris and Older people, Europe, USA, Smart home Behavioural, Health, Twenty-one projects included (drawing Most of the studies demonstrated
Hensel [32] people with Asia Safety, Social, on 114 publications). A table is presented the feasibility of the technological
disabilities Physiological and with their technologies, target audience, solution. Technical, ethical, legal,
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 7 9 ( 2 0 1 0 ) 736–771
functional technologies and different outcome. A clinical, economical and
lack of evidence on clinical outcomes is organisational implications and
identified. challenges need to be studied
in-depth for the field to grow
further.
Martinez et al. Heart failure All countries Remote Behavioural, Forty-two studies included. (1) Remote Evaluating the articles showed
[33] monitoring Cost/economic, monitoring for cardiac heart failure that home monitoring in patients
(home) Feasibility/pilot, appears to be technically effective for with heart failure is viable.
Health, Legal, following the patient remotely; (2) it
Organizational, Per- appears to be easy to use, and it is widely
ception/satisfaction, accepted by patients and health
Safety, Social, professionals; and (3) it appears to be
Technology related economically viable.
Gaikwad and Chronic Not stated Home based ICT Behavioural, Twenty-seven studies included. These Telecare, telehealth etc. have
Warren [34] disease interventions Cost/economic, systems can improve functional and positive clinical and cost outcomes
Health, Percep- cognitive patient outcomes in chronic – although studies are few in
tion/satisfaction disease and reduce costs. However, the number and heterogeneous. Better
research is not yet sufficiently robust. evidence-based outcome measures
are needed, especially regarding
costs and physician perspectives.
747