Caterina Masino

Despite decades of international experience with the use of information and communication technologies in healthcare delivery, widespread telehealth adoption remains limited and progress slow. Escalating health system challenges related to access, cost and quality currently coincide with rapid advancement of affordable and reliable internet based communication technologies creating unprecedented opportunities and incentives for telehealth. In this paper, we will describe how Human Factors Engineering (HFE) and user-centric elements have been incorporated into the establishment of telehealth within a large academic medical center to increase acceptance and sustainability. Through examples and lessons learned we wish to increase awareness of HFE and its importance in the successful implementation, innovation and growth of telehealth programs.

Lack of response variability is problematic in surveys because of its detrimental effects on sensitivity and consequently reliability of the responses. In satisfaction surveys, this problem is caused by the ceiling effect resulting from high satisfaction ratings. A potential solution strategy is to manipulate the labels of the rating scale to create greater discrimination of responses on the high end of the response continuum. This study examined the effects of a positive-centered scale on the distribution and reliability of telemedicine satisfaction responses in a highly positive respondent population. In total, 216 telemedicine participants were randomly assigned to one of three experimental conditions as defined by the form of Likert scale: (1) 5-point Balanced Equal-Interval, (2) 5-point Positive-Packed, and (3) 5-point Positive-Centered Equal-Interval. Although the study findings were not statistically significant, partially because of sample size, the distribution and internal consistency reliability of responses occurred in the direction hypothesized. Loading the rating scale with more positive labels appears to be a useful strategy for reducing the ceiling effect and increases the discrimination ability of survey responses. The current research provides a survey design strategy to minimize ceiling effects. Although the findings provide some evidence suggesting the benefit of using rating scales loaded with positive labels, more research is needed to confirm this, as well as extend it to examine other types of rating scales and the interaction between rating scale formats and respondent characteristics.

Mobile phone-based remote patient monitoring systems have been proposed for heart failure management because they are relatively inexpensive and enable patients to be monitored anywhere. However, little is known about whether patients and their health care providers are willing and able to use this technology. The objective of our study was to assess the attitudes of heart failure patients and their health care providers from a heart function clinic in a large urban teaching hospital toward the use of mobile phone-based remote monitoring. A questionnaire regarding attitudes toward home monitoring and technology was administered to 100 heart failure patients (94/100 returned a completed questionnaire). Semi-structured interviews were also conducted with 20 heart failure patients and 16 clinicians to determine the perceived benefits and barriers to using mobile phone-based remote monitoring, as well as their willingness and ability to use the technology. The survey results indicated that the patients were very comfortable using mobile phones (mean rating 4.5, SD 0.6, on a five-point Likert scale), even more so than with using computers (mean 4.1, SD 1.1). The difference in comfort level between mobile phones and computers was statistically significant (P< .001). Patients were also confident in using mobile phones to view health information (mean 4.4, SD 0.9). Patients and clinicians were willing to use the system as long as several conditions were met, including providing a system that was easy to use with clear tangible benefits, maintaining good patient-provider communication, and not increasing clinical workload. Clinicians cited several barriers to implementation of such a system, including lack of remuneration for telephone interactions with patients and medicolegal implications. Patients and clinicians want to use mobile phone-based remote monitoring and believe that they would be able to use the technology. However, they have several reservations, such as potential increased clinical workload, medicolegal issues, and difficulty of use for some patients due to lack of visual acuity or manual dexterity.

Previous trials of heart failure telemonitoring systems have produced inconsistent findings, largely due to diverse interventions and study designs. The objectives of this study are (1) to provide in-depth insight into the effects of telemonitoring on self-care and clinical management, and (2) to determine the features that enable successful heart failure telemonitoring. Semi-structured interviews were conducted with 22 heart failure patients attending a heart function clinic who had used a mobile phone-based telemonitoring system for 6 months. The telemonitoring system required the patients to take daily weight and blood pressure readings, weekly single-lead ECGs, and to answer daily symptom questions on a mobile phone. Instructions were sent to the patient's mobile phone based on their physiological values. Alerts were also sent to a cardiologist's mobile phone, as required. All clinicians involved in the study were also interviewed post-trial (N = 5). The interviews were recorded, transcribed, and then analyzed using a conventional content analysis approach. The telemonitoring system improved patient self-care by instructing the patients in real-time how to appropriately modify their lifestyle behaviors. Patients felt more aware of their heart failure condition, less anxiety, and more empowered. Many were willing to partially fund the use of the system. The clinicians were able to manage their patients' heart failure conditions more effectively, because they had physiological data reported to them frequently to help in their decision-making (eg, for medication titration) and were alerted at the earliest sign of decompensation. Essential characteristics of the telemonitoring system that contributed to improved heart failure management included immediate self-care and clinical feedback (ie, teachable moments), how the system was easy and quick to use, and how the patients and clinicians perceived tangible benefits from telemonitoring. Some clinical concerns included ongoing costs of the telemonitoring system and increased clinical workload. A few patients did not want to be watched long-term while some were concerned they might become dependent on the system. The success of a telemonitoring system is highly dependent on its features and design. The essential system characteristics identified in this study should be considered when developing telemonitoring solutions.

Multidisciplinary heart function clinics aim to improve self-care through patient education and to provide clinical management. The objectives of the present study were to investigate the self-care and quality of life of patients attending a multidisciplinary heart function clinic and to explore the relationship between self-care and quality of life. One hundred outpatients attending a multidisciplinary heart function clinic were asked to complete a questionnaire. The questionnaire included the Self-care of Heart Failure Index (SCHFI) and the Minnesota Living With Heart Failure Questionnaire, which were used to assess self-care behavior and quality of life, respectively. Self-care practices and perceived barriers were also assessed through semistructured interviews with each patient. : The returned questionnaires (n = 94) were used to compute the following SCHFI maintenance, management, and confidence scores: 60.8 (SD, 19.3), 62.0 (SD, 20.7), and 55.9 (SD, 19.7), respectively. Higher SCHFI scores indicate better self-care. None of the self-care dimensions reached the self-care adequacy cut point of 70. The average score on the Minnesota Living With Heart Failure Questionnaire was 49.9 (SD, 25.4), indicating a moderate health-related quality of life. Lower ejection fraction, older age, and better quality of life were associated with better self-care. Determinants of better quality of life were older age, better functional capacity, higher self-care confidence, and fewer comorbidities. The patient interviews revealed that better quality of life is associated with higher self-care confidence and barriers to self-care caused anxiety to the patients. The self-care barriers were found to include lack of self-care education, financial constraints, lack of perceived benefit, and low self-efficacy. Patients attending a large multidisciplinary Canadian heart failure clinic do not perform adequate self-care as measured with the SCHFI and report only a moderate quality of life. Increasing self-care through education and tools that target self-care barriers are required and may help improve quality of life.

This study estimates the reduction in greenhouse gas (GHG) emissions resulting from 840 telemedicine consultations completed in a 6-month time period. Our model considers GHG emissions for both vehicle and videoconferencing unit energy use. Cost avoidance factors are also discussed. Travel distances in kilometers were calculated for each appointment using postal code data and Google Maps™ Web-based map calculator tools. Including return travel, an estimated 757,234 km were avoided, resulting in a GHG emissions savings of 185,159 kg (185 metric tons) of carbon dioxide equivalents in vehicle emissions. Approximately 360,444 g of other air pollutant emissions was also avoided. The GHG emissions produced by energy consumption for videoconference units were estimated to be 42 kg of carbon dioxide equivalents emitted for this sample. The overall GHG emissions associated with videoconferencing unit energy is minor when compared with those avoided from vehicle use. In addition to improved patient-centered care and cost savings, environmental benefits provide additional incentives for the adoption of telemedicine services.