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A Field Trial of 2 Telemedicine Camera Systems in a Family Practice
William J. Crump, MD;
Ravi Kumar, MD;
Glenn Orsak, MD;
Thom Pfeil, MD
Arch Fam Med. 1998;7:174-176.
ABSTRACT
Previous reports of telemedicine consultations have demonstrated that the technology is effective but inefficient. Little attention has been directed to the use of telemedicine in a primary care practice, especially the use of the medical peripheral devices. We used a functioning primary care practice as a telemedicine test bed, providing unselected patients in the study group. The goal was to study the performance of a new generation of a compact set of medical peripheral devices specifically designed for telemedicine examinations. In a 3-week field trial, 2 second-generation camera systems were used by physician faculty and residents in family practice to examine the skin, ears, and pharynx of 34 patients, ranging in age from 10 months to 78 years. Evaluations by the clinicians and patients were obtained. The average duration of an examination using these systems was 2 minutes. Patients' response was uniformly positive. A "pistol grip" video otoscope obtained an acceptable image, unless canal debris obscured the view. The system that provided pneumatic otoscopy was preferred, with some modifications necessary to obtain an airtight seal. The preferred skin camera was one that provided an image of a size that clinicians were most accustomed to viewing, although stability of this handheld camera was a problem. This camera also worked well to visualize the pharynx, especially in children with symptoms of pharyngitis. Color was deemed important in all 3 anatomical areas, and using auto-white balance and excluding fluorescent lights were preferred. Thus, the second-generation telemedicine peripheral devices were effective for use in a group of unselected primary care patients. These camera systems can be used by nursing personnel and require a minimum of time per examination.
INTRODUCTION
As the cost of computer compression methods and digital communication lines has decreased and their availability in most suburban and rural areas has increased, there has been a recent renewed interest in telemedicine.1-2 The success of telemedicine consultations is largely determined by cost and user acceptance, including hardware and communications aspects. For a truly interactive video consultation, an image often must be obtained from a patient using a medical device. The perceived efficiency and user acceptance of these systems will depend heavily on the design of the medical peripheral devices. The assumption of the series of projects reported from this telemedicine test bed is that careful attention to the practicalities of medical peripheral use in a typical primary care practice will result in equipment design that makes the telemedicine consultation more efficient.3-4 The purpose of this project was to study the performance of a new generation of a compact set of medical peripheral devices specifically designed for telemedicine examination of the skin, ears, and pharynx. In addition, the participants were asked to predict the performance of these systems in a telemedicine arrangement in which a nurse is with the patient at 1 end and the family physician, acting as a consultant, is at the other end.
METHODS
The 2 systems tested were the newest telemedicine products available from AMD (American Medical Development, Lowell, Mass) (Figure 1) and JedMed (Jedmed Instrument Company, St Louis, Mo) (Figure 2). The clinical assessment portion of the project included a 10-day trial of the AMD system followed by a 5-day trial of the JedMed system, with 1 day of overlap when both sets of equipment were available. The telemedicine examinations occurred in a 3.7x4.3-m (12x14-ft) procedure room that had been converted to a telemedicine examination room, providing up to a full T1 digital connection (equivalent to 24 regular telephone lines) to the medical center 32 km away.3-5 The room was equipped with a 53-cm (21-in) video monitor with a general-view camera and a built-in microphone mounted above the monitor (Figure 3). The office where this study was done comprises a 371.6-m2 (4000–sq ft) clinical facility that includes 12 examination rooms and 2 procedure rooms, both of which have telemedicine capability. The physicians in this practice see patients of all ages, including those receiving prenatal care, at a volume of about 20 patients per physician per day. About 70% of the patients are in managed care, and the practice includes a demonstration Medicaid project with a physician–case manager model and several Medicare managed care plans.
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Figure 1. The AMD (American Medical Development, Lowell, Mass) equipment.
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Figure 2. The JedMed (Jedmed Instrument Company, St Louis, Mo) equipment.
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Figure 3. The telemedicine test bed examination room.
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Appropriate patients were recruited from among the patients seen each day, with no special attempts made to schedule individual patients for telemedicine. After the physician completing the usual visit explained the project, the patient was taken to the telemedicine procedure room, signed the informed consent form, and was examined using the telemedicine equipment. At the conclusion of the examination, the patient completed a form evaluating the comfort with the examination, protection of confidentiality and privacy, and satisfaction with the equipment and requesting any general comments or suggestions regarding the new equipment. The physician performing the examination then completed an evaluation form that asked him or her to compare the image obtained with each medical peripheral system with that seen with his or her eyes or the usual instruments. The form comprised a 9-item questionnaire, each question having a 4 or 5-point Likert scale, that addressed the working diagnosis and level of certainty, comfort with the examination, an estimation of the level of skill required for equipment use, the adequacy of information obtained, and suggestions for design modifications for increased effectiveness. The project director (W.J.C.) reviewed each videotaped encounter to assess the validity of the clinician's evaluation and to clarify the responses.
RESULTS
Thirty-four patients were examined during the 3-week field trial. They ranged in age from 10 months to 78 years, with 12 (35%) patients being younger than 18 years and 20 (59%) of the participants being female. The average duration of the examination was about 2 minutes, with a skin examination averaging about 1 minute and ear or pharynx examination averaging about 3 minutes. Table 1 lists the working diagnoses recorded by the examining physicians. Overall, in 29 (85%) of the 34 examinations, the clinicians recorded that they were fairly certain or very certain of the diagnosis. In all 34 patients, the clinicians reported that they were very or moderately comfortable carrying out the examination. In 28 of the examinations, the clinicians suggested that a nursing assistant or aide could be adequately trained to complete the examination without a physician on site. In 6 cases, a licensed vocational nurse or more highly trained professional (registered nurse, physician assistant, or physician) was suggested to ensure appreciation of the necessary anatomical landmarks and to present a complete image to the remote consultant. Patients were uniformly positive about the examination.
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Table 1. Conditions Evaluated During the Field Trial
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Table 2 shows a comparison of the 2 camera and peripheral systems used. The AMD system used a contact skin camera that provided complete stability and resolution but a greatly magnified image. In addition, 3-dimensional skin lesions (warts, pedunculated nevi, skin tags) had to be flattened for viewing, and lesions on curved surfaces (skin fungus on nails or digits) could not be well visualized. The JedMed system provided a free-handheld focal length camera that produced an image of the size most clinicians are accustomed to, but stability was sometimes a problem. The video otoscopes were effective if the canal was free of debris.
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Table 2. Evaluation of Telemedicine Equipment
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COMMENT
The trial accomplished the goal of assessing this new equipment in a "real-world" environment, providing useful information for those designing the next generation of equipment and those considering purchasing currently available telemedical equipment. Earlier trials had shown large differences in ease-of-use scores among staff with differing experience.3-4 The similarity found in this trial supports the simplicity of design of the current generation of equipment. Further supporting the effective design of the equipment is the short examination times and the minimal difference in examination times among clinicians. The examination portion of previous trials with the first-generation equipment averaged 5 to 8 minutes for skin and ear examinations.3-4
Within the constraints of the trial, the following recommendations can be made:
• A smaller, lighter otoscope simulating a pistol grip provides an acceptable image for diagnosing ear abnormalities. The capability for pneumatic otoscopy is important, and careful attention to speculum design that facilitates an airtight seal is indicated.
• A skin camera that functions at a focal length of 31 to 36 cm (12-14 in) provides an image that is most like what clinicians are accustomed to seeing, and it also provides an acceptable view of the pharynx. Although a contact camera eliminates movement, the magnification provided makes diagnosis less certain, and an adequate image of 3-dimensional lesions cannot be obtained. Stability of the camera is important, and placing the free-handheld camera on a jointed adjustable arm that can be attached to the examination table or ceiling mounted would be preferable.
• True color is important in skin, ear, and pharyngeal examinations. The design should include auto-white balance mechanisms that are normally on, requiring the clinician to disable them only if preferred. When using a device such as a free-handheld camera that does not exclude ambient light, it is important to turn off any fluorescent lights and best to use only the balanced light source provided with the equipment.
CONCLUSION
The current generation of telemedicine equipment for skin, ear, and pharynx examinations was effective for use in an unselected group of patients from a primary care practice. A substantial improvement over previously available equipment, these camera systems can be used by nursing personnel and require a minimum of time per examination. Further studies will address the cost-effectiveness and consultant acceptability of the new systems in the test bed.
AUTHOR INFORMATION
Accepted for publication February 5, 1997.
We thank both AMD and JedMed for making their new equipment available for study in the test bed. Oliver Black, Ruth Salas, and Bebe Dwiggins provided technical support, and Jackie Orozco did the videotaping.
Reprints: William J. Crump, MD, Department of Family Medicine, University of Texas Medical Branch, 400 Harborside Dr, 301 University Blvd, Galveston, TX 77555-1123.
From the Department of Family Medicine, University of Texas Medical Branch, Galveston. Dr Kumar is now with Lakewood Clinic, Staples Minn; Dr Orsak, Friendswood Family Physicians, Friendswood, Tex; and Dr Pfeil, Family HealthCare Centers, Galveston.
REFERENCES
1. Perednia DA, Allen A. Telemedicine technology and clinical applications. JAMA. 1995;273:483-488.
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2. Crump WJ, Pfeil T. A telemedicine primer: an introduction to the technology and an overview of the literature. Arch Fam Med. 1995;4:796-803.
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3. Crump WJ, Driscoll B. An application of telemedicine technology for otorhinolaryngology diagnosis. Laryngol J. 1996;106:595-598.
4. Crump WJ, Levy BJ, Billica RD. A field trial of the NASA telemedicine instrument pack in a family practice telemedicine testbed. Aviat Space Environ Med. 1996;67:1080-1085.
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5. Crump WJ, Tessen RJ, Montero AJ. The department without walls: acceptability, cost, and utilization of interactive video technology. Arch Fam Med. 1997;6:273-278.
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