One of the important issues, tackled during the recent ITIS-ITAB Conference in Amsterdam, constituted the evaluation of telemedical services. Dr. Gudrun Zahlmann from the German national research centre for Health and Environment (GSF Medis), highlighted the current approach in this area and presented to the audience an illustrative case study of a teleconsultation network in ophthalmology. The implementation of a telemedical application requires a continuous evaluation strategy which is divided into four phases. The clinical trial method used for assessment of therapeutic effectiveness as well as diagnostic accuracy forms an excellent starting point for telemedical evaluation. Gradually, the focus has to shift from the system's technological capabilities to its medical performance and cost-effectiveness.
The problem which rises in the evaluation of telemedical services is that there exists only a small number of test sites in geographically narrow regions. Also the number of cases is very limited while project life times are relatively short. Standards have insufficiently been established if any of them exist at all. The technological progress is extremely fast, whereas new users are emerging all the time. In addition, there has to be a preliminary training phase before proper evaluation even can start. Basically, two approaches are found in the literature on evaluation. The first one is concentrated on a tight scheme of verification of the technical parameters, validation and evaluation. The second one, which particularly interests us, has four different phases to start with a technical pilot study.
In this stage, the quality and performance of both the system's hardware and software are checked out. Phase two consists of a feasibility study performed in co-operation with the users and the telecommunication networks. For the project, it means the first step out of the laboratory. Phase 3 deals with the effects of the telemedical service. A controlled trial is being organized in order to compare the system's effectiveness with the standard health care norms. In addition, the outcome quality has to be verified by a representative sample of user institutions. The standard technical equipment is also submitted to a detailed examination. In phase 4, analysis is performed on the data which originate from phase 3 or from a separate model to measure the cost/benefit relationship. Here, the number of participating institutions has not so much importance.
Telemedical applications within the ophthalmology project, launched by GSF Medis, include patient-related services, like the distributed electronic patient record, as well as knowledge-based information systems. Teleconsultations with videoconferencing over ISDN-lines are equally used, despite the limited image quality. The user group is formed by seven private ophthalmologists. In phase 1 of the project's evaluation, a verification of the system's technical components has been undertaken. At present, a detailed feasibility study is being performed on the technical and related aspects of the ophthalmology service. The participating specialists have received questionnaires to express their opinion on the usability, acceptability, and general assessment of the tele-ophthalmology system.
As such, the developers learned that the system's integration into the work area has been somewhat difficult. The ophthalmologists have had to make an effort to become acquainted with its use in daily practice. All in all, the importance of telemedicine for ophthalmology has been put in evidence by an inquiry among different patient groups. The first group consisted of the patients who received advice for treatment planning or surgery through the teleconsultation service. Patients in this group were asked to share their opinion after synchronous teleconsultation and after surgery. The second group constituted a so-called control group which received medical advice via a traditional visit to the medical expert.
The teleconsultation patients acknowledged their general satisfaction with the service which allowed them to save one physician's encounter. Quite remarkable for the first group was that the patients felt much safer using the tele-ophthalmology service. This might be due to the fact that co-operation and communication between physicians was very much improved with the teleconsultation. Further analysis will be carried out in phase 3 and 4 of the evaluation process. For more news on the GSF teleconsultation network in ophthalmology, please consult the OPHTEL home page.