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A Wikicity for dentists and allied dental auxilliaries to discuss oral health care issues, solutions, and experiences.

= Telehealth = Using telecommunication and information technology to support access to health information for health professionals and the public, long-distance clinical healthcare services, public health, and health administration


 * Integrated electronic data
 * medical records, order entry, procedures, prescriptions, quality assurance, etc.
 * geo-encoding


 * Education & Training
 * Public
 * Professionals
 * Learning and daily practice inter-related
 * Dissemination of most efficient practices
 * Research
 * School
 * Continuing education


 * Public health surveillance/intervention
 * Awareness of healthcare issues and diseases
 * Geospatial and longitudinal health information
 * Population health assessment
 * Intervention planning & assessment of strategies


 * Patient-centered
 * Better access to expertise & multidisciplinary network of skills & competencies
 * Empowerment of consumer-driven choices in a competitive marketplace
 * Lifetime health planning
 * Personalized health care
 * Ubiquitous, on-demand support & consultative services
 * Interactive


 * Optimized management & care of patients
 * Consultation
 * Assessment
 * Intervention
 * Follow-up, rehabilitation, maintenance
 * Clinical decision support systems
 * Match regional planning policies with facilities and resources
 * Access of quality care to all
 * Coordinated and uninterrupted continuity of care
 * Attract patients
 * Reduce and manage costs


 * Multidisciplinary and collaborative network organization
 * Interactive involvement & regular partnership
 * Concerted decision-making
 * Complementary missions


 * Technologies
 * Internet
 * Point-to-point videoconferencing
 * E-mail
 * telephone
 * biosensor
 * virtual reality interactions

Home Telehealth
Home Health Care Health and social services provided to individuals in their homes or a home-like setting. Interactive Home Telehealth Two-way interactive audio and video between the patient and health care professional. Telemonitoring Collection and transmission of clinical data for the health provider to review and respond to. Self-Monitoring The patient periodically uses a device to measure their own health status.
 * Traditional home health agencies
 * Delivery of hospice services
 * Case management by hospitals and clinics to supervise chronically ill patients in their own homes
 * Assessment
 * Education
 * Data collection
 * Automated laboratory or other monitoring equipment
 * Manual data entry
 * Blood pressure
 * Glucose
 * Weight
 * Temperature

= Telemedicine = Using telecommunications and information technology to provide or support clinical care at a distance


 * Freedom from time & distance constraints
 * Improve health care in places where medical personnel are not readily available
 * Rural areas
 * Home
 * Improves access to health care
 * Reduces wasted time and expense in travelling
 * Diagnostic
 * Monitoring
 * portable, real-time
 * Therapeutic
 * Daily living assistive devices

= Teledentistry = Telemedicine approach applied to dentistry.
 * Often thought of as teleconsultation
 * Or even using the Internet to search for information to aid a patient's treatment
 * Or taking an online continuing education course

Teleconsultation
Teleconsultation is what many think of when telemedicine or teledentistry is discussed. Teleconsulting over telephone or Internet, calling an expert for advice.
 * 1) Dentist or physisian digitizes and transmits patient radiographs, photographs, diagrams, and drawings
 * 2) Originator fills out a standard consult form on the specialist's web site.
 * 3) Specialist returns a confidential consultation report to the originator
 * 4) Time-based fee paid to the expert
 * Benefits to local dentist
 * Practice builder for the local dentist
 * Opportunity enhance knowledge
 * Better serve patients, improve quality of care
 * Dentist may use Internet to seek direct patient contact
 * Direct consultation between the patient and the expert
 * "Cyberdentistry"
 * May not be in the best interest of the public
 * Need for Teledentistry
 * More than 200 oral diseases to differentiate and manage
 * Knowledge is rapidly changing
 * HIV/AIDS
 * Antibiotic-resistant infections
 * Oral cancer
 * 30,000 new cases per year
 * 9,000 deaths per year in the U.S. (more than ovarian or cervical cancer)
 * Chronic pain costs $100 billion per year
 * 20% to 25% of all chronic pain is orofacial in origin

= Related terms =
 * e-health
 * e-prevention
 * telecare
 * telemonitoring
 * telerehabilitation
 * telehomecare
 * teleconsultation
 * informatics
 * cybermedicine/cyberdentistry
 * tele____ (fill in the blank, i.e. dentistry, radiology, dermatology, etc.)

= Needs =
 * Aging Population
 * Growing
 * Consume higher proportion of healthcare services
 * Less support and less ability to be monitored because of isolation
 * Requires interdisciplinary approach
 * Normal aging process accelerated & exacerbated by multiple, complex chronic & acute diseases
 * Iatrogenesis is a major threat to wellbeing
 * Vulnerable state & Medical conditions
 * Increase of chronic illnesses
 * Limited ability to maintain homeostasis
 * Loss of physiologic reserve
 * Increased healthcare costs
 * Higher hospitalization rates
 * Longer lengths of stay
 * Increased home health care
 * Decreased access to health care providers
 * Financial
 * Mobility & transportation

= Obstacles =

Human Factors

 * User or technology driven
 * Acceptance and adoption
 * Rejection
 * Limited
 * Slow
 * Convenience & location
 * Coordination & Cooperation
 * Intraorganization & Interorganization
 * Stakeholders
 * Patients
 * Clinicians
 * Clinical support technicians & personnel
 * Engineering and computer specialists
 * Administrative support personnel
 * Managers
 * Researchers
 * Financial personnel
 * Policy-makers
 * Inadequate assesment of needs and preferences
 * End users cannot imagine use of unfamiliar technology
 * Patient, practitioner, organization, and healthcare system
 * Methods and tools for assessing and matching needs with technology
 * Professional culture & image
 * Patient trust
 * Self-conscious of video camera
 * Established culture and referral network/patters

Technology

 * Equipment reliability, convenience, integrity, quality
 * Extensive training, lengthy technical manuals, time constraints
 * Purchase decisons based on grants or finance requirements
 * Proprietary systems lacking flexibility
 * Vendor restrictions and requirements for large initial capital investments & maintenance contracts
 * Vendor power over small purchasers
 * Vendor marketing promises and clinicians' expectations unfulfilled
 * Constantly chaning product lines or sales representatives
 * Interoperability of systems and application software
 * Adaptaion of off-the-shelf hardware
 * Control and managment of data, systems, and networks
 * Cost of equipment and broadband networks
 * Referring or consulting site integration

Legal & Ethical

 * Liability
 * Doctor-patient relationship
 * Equipment deficiences
 * Confidentiality
 * Presence of technical and nontechnical personnel outside of treatment context
 * Electronic transfer of information
 * Multiple users, data entry mistakes, hackers
 * Jurisdiction, conflict of laws
 * Fee-splitting laws
 * Genuine identity of the participants
 * Protection of the patient’s identity
 * Patient’s Consent and personal information
 * Security of the Transmission network
 * Medicare conditions of participation

Regulatory & Institutional

 * Recognition of the network for long-term success
 * Quality
 * Availability of expertise


 * Instititionalization of mesh network
 * Different organizations
 * Varied disciplines and backgrounds


 * Appraisal difficulty
 * Cost/benefit/efficiency
 * Quality
 * Training value

Lack of Documented Benefit

 * Benefits and costs are unclear
 * Scarcity of formal, rigorous analyses of clinical applications
 * Cost-effectiveness
 * Cost-benefit ratio
 * Cost-offset and opportunity cost
 * Disease-adjusted life years
 * Conservative fear of "mistakes"
 * Lack of comparison groups for variety of technologies
 * Control group is usually routine medical care
 * Social-psychological outcome unknown
 * Limited understanding of relationship between consumer perceptions and desirability/utility of telehealth intervention and treatment outcome
 * Optimal fit (Gordon Paul, 1967)
 * Which interventions are most effective for what types of problems and for which consumer populations?
 * web or videoconference or speakerphone?

Lack of Funding & Reimbursement

 * Most telemedicine consultations are not covered by Medicare or third party payers
 * Interactive telecommunications (synchronous) system only, not asynchronous store and forward

Health Care System Restructuring

 * Centers of control over clinical practice changing
 * Managed care
 * Public and private purchasers of health care
 * Strategic alliances, joint ventures, and takeoveres
 * Practioners and administrators concerned with protecting patient base
 * Averse to further change and uncertainty
 * Potential shifting locus of patient care
 * Locally, regionally, nationally
 * Who will become telemedicine gatekeeper
 * New or reassigned roles and responsibilities in a networked environment
 * Legal or policy barriers to telemedicine

= Patient Attitudes = Patients' perceptions of health care whether before or after its delivery are critical to their satisfaction and the planning and delivery of these services to a population. The acceptance and diffusion of telehomecare is influenced by patients" understanding and attitudes. (Provider enthusiasm, knowledge of telemedicine, and actions are also important.)

Patient vision and motor control are also determinants of success

Stamm, 1998 reported that individuals with chronic illnesses are moderate in high satisfaction and comfort with the use of telehealth technologies.

Videoconferencing studies show that participants with chronic illnesses rate interactive videoconferencing for clinical interviews just as effective and comfortable as traditional face-to-face settings.

Rating specific aspects of telemedicine: Concerned about privacy and confidenciality

Disadvantages: lack of physical contact and reduced intimacy

Many do not see any immediate health benefits due to telemedicine

Telemedicine Perception Questionnaire) TMPQ instrument comprised of 17 items using a 5-point Likert scale (strongly agree, agree, disagree, strongly disagree, no opinion), ranges from 17 to 85. Higher scores reflect more positive perceptions.
 * 1) A nurse can get a good understanding of my medical problem over the television.
 * 2) Telehomecare can violate my privacy
 * 3) The use of the necessary equipment seems difficult to me
 * 4) I can be as satisfied talking to the nurse over the television as talking in person
 * 5) Telehomecare can improve my general health
 * 6) Telehomecare can save time for the nurses
 * 7) Telehomecare cannot save me any money
 * 8) Using telehomecare the nurse will be able to monitor my condition well
 * 9) I don't like that there is no physical contact during a telehomecare visit
 * 10) Telehomecare is a convenient form of healt care delivery for me
 * 11) Telehomecare saves me time
 * 12) Telehomecare will be a standard way of health care delivery in the future
 * 13) Telehomecare can be an addition to the regular care I receive
 * 14) Telehomecare can reduce costs for the health care agencies
 * 15) A nurse cannot examine me over the television as well as in person
 * 16) Telehomecare makes it easier for me to contact the nurse
 * 17) I cannot always trust the equipment to work

Experience with telehomecare leads to a statistically significant positive changes in patients' perceptions by 7.34% Negative changes in patients' perceptions Elderly homebound patients are able to cope with using telecommunications and monitoring equipment to participate in videoconferencing. With participation, patients become more familiar, confident, and less concerned with initial concerns of privacy.
 * A nurse can get a good understanding of my medical problem over the television
 * Equipment becomes less difficult to handle
 * Telehomecare can save time for the provider
 * Telehomecare does not save time for the patient
 * Contacting the nurse is more difficult (The system tested did not allow patients to contact the nurse. The nurses initiated the videoconference at prescheduled times.)

Most patients are satisfied with improved access to expertise of specialists, decreased travel, and reduced waiting times.

Some patients may refuse to participate over equipment concerns, but others with similar concerns but were willing to try are able to participate without problems.

Home Care Client Satisfaction Instrument (HCCSI) is 12 items rated on a 5-point Likert scale.
 * 1) Omitted, unrelated to telemedicine
 * 2) Attention to concerns
 * 3) Dependability of staff
 * 4) Respect shown by staff
 * 5) Knowledge of health problems
 * 6) Choices about care
 * 7) Feeling safe
 * 8) Know contact person
 * 9) Ability to meet needs
 * 10) Response to concerns
 * 11) Scheduling
 * 12) Consistency in staffing

Studies have shown no differences in quality between in-person visits and telehomecare. Potential for cost savings when substituted and greater benefits for longer duration care.

Potential to impact homecare delivery as an effective and efficient adjunct to traditional homecare.

= References =
 * 1) Field, Marilyn J. "Human factors and the acceptance of telemedicine" 1996.
 * 2) Ferrante, Frank E. "Issues, Problems, and Needs" State-of-the-Art Telemedicine/Telehealth Symposium. Ann Arbor, Michigan. August 23-25, 2001.
 * 3) Kopp, Stephen J. " Perspectives and Implications for Health Promotion/Disease Prevention, Epidemiological and Disease Surveillance" State-of-the-Art Telemedicine/Telehealth Symposium. Ann Arbor, Michigan. August 23-25, 2001.
 * 4) Lareng, Louis. "Telemedicine: Fortunes and Misfortunes" State-of-the-Art Telemedicine/Telehealth Symposium. Ann Arbor, Michigan. August 23-25, 2001.
 * 5) Ross, Linda S. "Legal Issues Afficting The Practice of Telemedicine" State-of-the-Art Telemedicine/Telehealth Symposium. Ann Arbor, Michigan. August 23-25, 2001.
 * 6) Tracy, Joseph. "A Guide to Getting Started in Telemedicine" University of Missouri-Schohol of Medicine, 2004.
 * 7) Glueckhauf, Robert L. & Ketterson, Timothy U. "Telehealth interventions for individuals with chronic illness: research review and implications for practice" Professional Psychology, Research and Practice, Dec 2004 v35 i6 p615(13).
 * 8) Demiris, George et al. "Change of Patients' Perceptions of TeleHomeCare" Telemedicine Journal and e-Health. Sep 2001, Vol. 7, No. 3:241-248.
 * 9) Finkelstien, Stanley M., et al. "Telehomecare:Quality, Perception, Satisfaction" Telemedicine Journal and e-Health. Jun 2004, Vol. 10, No. 2: 122-128.
 * 10) Clark, GT. "Teledentistry: what is it now, and what will it be tomorrow?" J Calif Dent Assoc. 2000 Feb;28(2):121-7.