- Email: [email protected]
Is there a future for telemedicine?
COMMENTARY
services deemed necessary. An alternative model with some evidence of low recidivism rates is that of the peer court, wherein adolescents function as attorney, jury, and sometimes judge. Peers hold one another accountable by enforcing restorative justice, wherein sentences are based on a model of reparations instead of on a punitive approach. Such reparative acts may include writing letters of apology to victims and engaging in community service. Offenders are also referred to educational, vocational, and/or mentalhealth services, and their attendance is monitored by the court.8 Perhaps such community-based alternatives may prevent the emergence of the new disorders suggested in Kroll’s study, and may start to target the root causes of entry into the juvenile justice system. Other critical recommendations to address the issue of justice and mental health for juveniles, as suggested by Kroll and colleagues, are the development of screening for mental disorders, the provision of mental-health services, and the linkage of secure care to families and to community agencies. For such recommendations to be implemented, mental-health professionals must continue to research the long-neglected juvenile-justice population and must use the results as a basis for standards for secure-care facilities and for community-based alternatives. Carol Kessler Albert Einstein College of Medicine, Bronx-Lebanon Child and Adolescent Psychiatric Institute, New York, NY 10457, USA (e-mail: [email protected]) 1
2
3
4
5
6
7 8
Arroyo W, Buzogany W, Hansen G, et al. AACAP task force on juvenile justice reforms: recommendations for juvenile justice reform. Washington, DC: AACAP, 2001. Coalition for Juvenile Justice. Ain’t no place anybody would want to be: conditions of confinement for youth. Washington DC: Coalition for Juvenile Justice, 1999. Leone P, Meisel S. Improving education services for students in detention and confinement facilities. Children’s Legal Rights J 1007; 17: 1–12. Hansen G. Meeting the educational needs of incarcerated youth. In: AACAP task force on juvenile justice reforms: recommendations for juvenile justice reform. Washington, DC: AACAP, 2001. Cooper CS, Bartlett S. Juvenile and family drug courts: profile of program characteristics and implementation issues. Office of Juvenile Justice Programs Drug Court Clearinghouse and Technical Assistance Project at American University, 1998: http://www.ojp.usdoj.gov/dcpo/ familydrug (accessed April 24, 2002). Borduin CM, Henggeler SW, Blaske DM, Stein RJ. Multisystemic treatment of adolescent sexual offenders. J Offender Ther Comparative Criminol 1990; 34: 105–14. Kamraott B. Wraparound Milwaukee: aiding youth with mental health needs. Juvenile Justice J 2000; 7: 1–6. Kessler C. Youth force in the South Bronx. Newsletter of American Academy of Child and Adolescent Psychiatry, July/August, 2000. Washington, DC: AACAP, 2000.
Is there a future for telemedicine? See page 1961 As early as 1906 the inventor of the electrocardiograph, Wilhelm Einthoven, started experiments with remote consultations via the telephone network.1 The 1950s and 1960s saw individual experiments in medical telecommunication. Often it was enthusiasts with a medical background who saw the possibilities as the technology gradually developed. These experiments were mainly about technology. The first telemedicine system in which there was a regular interaction between physicians and patients was installed in Boston in 1967. A radiologist who worked at the Massachusetts General Hospital (MGH) set up a diagnostic “shop” in the medical station of Logan airport. Physicians passing through were invited to bring radiographs and patients’ THE LANCET • Vol 359 • June 8, 2002 • www.thelancet.com
data to a room on the passenger concourse. The radiographs were illuminated by an ordinary light-box, scanned by a black-and-white television camera, and the images were transferred to a videomonitor in the MGH’s radiology department. The physician could discuss the case with MGH radiologists via a telephone. The equipment used was poorly adapted to the services to be practised, and the costs were so high that they limited the use of the findings. In the 1990s there were many experiments with remote consultations based on videoconferencing where medical equipment or specialised cameras were used to give the second-care specialist the same visual inspection of the patient as the referring doctor. Videofilming was used, for example, in dermatology,3 radiology, pathology, gynaecology,4 and cardiology.5 After the initial trials, some institutions began to use the findings in practice, although the results of other trials were not put into practice.7 Teleradiology has become a regular service in many areas and included routinely when image manipulation in radiology departments became digitised. Videoconferencing in medical specialties that require advanced diagnostic tools is not as widespread as in ordinary services. The development of telemedicine assumes advantages for the individual patient in the interaction between primary and secondary care. In addition, general practitioners can gain educationally and hospital followup appointments may be reduced in number, because the general practitioner can handle more advanced medical problems. Economic savings for the health service are a driving force. Evidence to date is that the patient seems satisfied and the general practitioner gains competence, but the extent to which telemedicine results in reduced hospital follow-up appointments and economic savings8 remains unclear. A systematic review8 found that the best evidence for the effectiveness of telemedicine was in some of the studies on teleradiology (especially neurosurgical applications), telemental health, transmission of echocardiographic images, teledermatology, and home telecare (medical examination and therapy where patients are located at home, communicating with health-care personnel via videoconferencing). Telemedicine follows on from the development of endoscopy. Endoscopy has increased diagnostic accuracy and many specialist decisions rely on this technique. Otorhinolaryngoscopy is much used diagnostically in ear, nose, and throat medicine. Teleconsultation without otorhinolaryngoscopy will end up as a discussion about differential diagnosis based on symptoms and a follow-up appointment must be offered. If necessary medical equipment is not available or the general practitioner cannot handle it properly, then a remote consultation cannot be done. Telemedicine relies on adequate examination methods. Patients’ satisfaction is emphasised in many trials9 and is a valuable feature, but this factor must not exceed the quality of the medical diagnosis. In today’s Lancet, Paul Wallace and colleagues report a randomised trial of joint teleconsultations for patients referred by their general practitioner for a specialist opinion compared with routine referral for a hospital appointment. The investigators randomised a large number of patients (1000 per group) and conclude that virtual-outreach consultation resulted in a reduction in the number of tests ordered and higher satisfaction among the patients, but a greater number of offers for standard outpatient appointments in the telemedicine 1957
For personal use. Only reproduce with permission from The Lancet Publishing Group.
COMMENTARY
group. This difference probably depends on incomplete examination in the telemedicine group but the foundation for follow-up appointments in the two groups is hardly comparable. Follow-up rates in the study were increased, especially in ear, nose, and throat medicine and in orthopaedics. This difference is probably because general practitioners do not use peripheral devices such as fibreoptics or other instrumentation in their consultations and the receiving specialists do not get sufficient visual information from the consultation. If the clinical examination is incomplete, telemedicine cannot give diagnostic adequacy and would be useless. In 1995, another report10 predicted that use of the term telemedicine would disappear when the technique became successful. In teleradiology this prediction has come true to some extent. Radiological images can be read at a location separate from the image’s source, such as the radiologist’s home or at another hospital, and the term teleradiology is no longer used to describe this routine. With today’s available technology, a few specialties seem to have no future in telemedicine. Diagnosis in microbiology, which partly depends on smell, is an example. Clinical examinations mainly based on palpation, as in examination of the prostate gland and in gynaecology, may also be hard to do via telemedicine. Several factors need to be considered for successful specialist teleconsultation. Medical personnel with the requisite skills and equipment must be present at the outreach clinic. The remote examinations have to be reliably documented. The group of patients referred for virtual outreach must be selected appropriately. Williams and colleagues9 concluded that patients’ satisfaction with a telemedicine service is complicated by the patients’ subjective health status. Providers of telehealthcare need to recognise that a patient with a poor quality of life may want and benefit from face-toface interaction with expert clinicians. In addition the general practitioner’s skills in examination techniques and access to instrumentation have an influence on which patients may be selected for virtual outreach, depending on their medical symptoms. There must be good logistical support for arranging and doing the consultations, and resources to sustain the system. And someone must be willing to pay for the extra costs for communication equipment, high-speed telecommunication lines, and the extra time spent by the general practitioner and specialist. These extra costs may be offset by reduced costs of transporting patients or reduced sickness pay, but such costs are usually accounted for in budgets separate from those for telemedicine. The future of telemedicine depends on wide regular use in the medical areas where telemedicine has been a success and shown to be cost effective—eg, radiology and dermatology. The digitising of medical equipment in, for example, radiotherapy11 makes it a good candidate for success in telemedicine. Technical and organisational innovation in specialties where telemedicine has been useful may be a driving force for other telemedicine applications. *Eivind Rinde, Lise Balteskard *Telenor Research, N9001 Tromso, Norway; and Department of Oncology, University Hospital of Northern Norway, Tromsø (e-mail: [email protected]) 1 2
Einthoven W. Het telecardiologram. Ned Tijdschr Geenesk 1906; 50: 1517-47. Bashur RL, Lovett J. Assessment of telemedicine: results of the initial experience. Aviat Space Environ Med 1977; 177: 65–70.
1958
3
Josendal O, Fosse G, Andersen KA, Stenvold SE, Falk ES. Distance diagnosis of skin disease. Tidsskr Nor Laegeforen 1991; 111: 20–22. 4 Ferris DG, Macfee MS, Miller JA, Litaker M, Crawley D, Watson D. The efficacy of telecolposcopy compared with traditional colposcopy. Obstet Gynecol 2002; 99: 248–54. 5 Sable CA, Cummings SD; Pearson GD, et al. Impact of telemedicine on the practice of pediatric cardiology in community hospitals. Pediatrics 2002; 109: E3. 6 Moseng D. Teledermatology-experiences from Northern Norway. Tidsskr Nor Laegeforen 2000; 120: 1893–95. 7 Oakley A, Rademaker M, Duffill M. Teledermatology in the Waikato region of New Zealand. J Telemed Telecare 2001; 7 (suppl 2): 59–61. 8 Hailay D, Roine R, Ohinmaa A. Systematic review of evidence for the benefits of telemedicine. J Telemed Telecare 2002; 8 (suppl 1): 1–7. 9 Williams TL, Esmail A, May CR, et al. Patient satisfaction with teledermatology is related to perceived quality of life. Br J Dermatol 2001; 145: 911–17. 10 Sund T, Rinde E. Telemedicine: still waiting for users. Lancet 1995; 346 (suppl): s24. 11 Olsen DR, Bruland S, Davis BJ, Telemedicine in radiotherapy treatment planning: requirements and applications. Radiother Oncol 2000; 54: 255–59.
Coagulation signals for intact blood vessels Coagulation is generally thought of as the process leading to the formation of the haemostatic plug in a wound. However, it should also be viewed as the start of the subsequent healing process because the fibrin that is formed acts as scaffolding for invading cells, and also because activated coagulation factors can directly activate cellular receptors and thus stimulate tissue cells. Furthermore, recent work has suggested that coagulation factors may have a role in the maintenance of embryonic blood vessels. Tissue repair has many properties in common with tissue development, not least because the healing process requires neovascularisation and invasion of tissue cells into the area of the wound. Studies of murine development have shown that the lack of some coagulation factors or a deficiency of the thrombin receptor PAR-1 seriously impairs embryonic development and survival because of bleeding.1–3 The loss of blood is not due to incomplete clot formation because fibrinogen-deficient animals develop normally. What seems to be needed for maintenance of vascular integrity is direct action of certain coagulation factors on vascular cells. The importance of direct action of thrombin on vascular cells is underscored by Courtney Griffin and colleagues,4 who showed that mice deficient in the thrombin receptor PAR-1 could be prevented from bleeding to death by the specific expression of this receptor in endothelial cells. Deficiency of PAR-1 in mice halves embryonic survival because of haemorrhage and cardiovascular failure.2,3 The protein PAR-1 is a member of the protease-activated receptors (PARs), of which four members are presently known.5 Three of these PARs, including PAR-1, are activated by thrombin. Thrombin receptors play an important role in platelet activation and the formation of a haemostatic plug. They are also present on endothelial cells and on other tissue cells, such as fibroblasts (in wound repair) and on smooth-muscle cells (in atherosclerotic lesions). The bleeding in PAR-1-deficient animals suggests a general defect either in the formation of a haemostatic plug or in the integrity of the vascular tree. Abnormal platelet function could be excluded, because, unlike human platelets, murine platelets do not have PAR-1. In mice this function is taken over by other PARs. Furthermore, mice lacking platelets develop normally, whereas PAR-1-deficient embryos were bleeding at day 9·5 THE LANCET • Vol 359 • June 8, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
services deemed necessary. An alternative model with some evidence of low recidivism rates is that of the peer court, wherein adolescents function as attorney, jury, and sometimes judge. Peers hold one another accountable by enforcing restorative justice, wherein sentences are based on a model of reparations instead of on a punitive approach. Such reparative acts may include writing letters of apology to victims and engaging in community service. Offenders are also referred to educational, vocational, and/or mentalhealth services, and their attendance is monitored by the court.8 Perhaps such community-based alternatives may prevent the emergence of the new disorders suggested in Kroll’s study, and may start to target the root causes of entry into the juvenile justice system. Other critical recommendations to address the issue of justice and mental health for juveniles, as suggested by Kroll and colleagues, are the development of screening for mental disorders, the provision of mental-health services, and the linkage of secure care to families and to community agencies. For such recommendations to be implemented, mental-health professionals must continue to research the long-neglected juvenile-justice population and must use the results as a basis for standards for secure-care facilities and for community-based alternatives. Carol Kessler Albert Einstein College of Medicine, Bronx-Lebanon Child and Adolescent Psychiatric Institute, New York, NY 10457, USA (e-mail: [email protected]) 1
2
3
4
5
6
7 8
Arroyo W, Buzogany W, Hansen G, et al. AACAP task force on juvenile justice reforms: recommendations for juvenile justice reform. Washington, DC: AACAP, 2001. Coalition for Juvenile Justice. Ain’t no place anybody would want to be: conditions of confinement for youth. Washington DC: Coalition for Juvenile Justice, 1999. Leone P, Meisel S. Improving education services for students in detention and confinement facilities. Children’s Legal Rights J 1007; 17: 1–12. Hansen G. Meeting the educational needs of incarcerated youth. In: AACAP task force on juvenile justice reforms: recommendations for juvenile justice reform. Washington, DC: AACAP, 2001. Cooper CS, Bartlett S. Juvenile and family drug courts: profile of program characteristics and implementation issues. Office of Juvenile Justice Programs Drug Court Clearinghouse and Technical Assistance Project at American University, 1998: http://www.ojp.usdoj.gov/dcpo/ familydrug (accessed April 24, 2002). Borduin CM, Henggeler SW, Blaske DM, Stein RJ. Multisystemic treatment of adolescent sexual offenders. J Offender Ther Comparative Criminol 1990; 34: 105–14. Kamraott B. Wraparound Milwaukee: aiding youth with mental health needs. Juvenile Justice J 2000; 7: 1–6. Kessler C. Youth force in the South Bronx. Newsletter of American Academy of Child and Adolescent Psychiatry, July/August, 2000. Washington, DC: AACAP, 2000.
Is there a future for telemedicine? See page 1961 As early as 1906 the inventor of the electrocardiograph, Wilhelm Einthoven, started experiments with remote consultations via the telephone network.1 The 1950s and 1960s saw individual experiments in medical telecommunication. Often it was enthusiasts with a medical background who saw the possibilities as the technology gradually developed. These experiments were mainly about technology. The first telemedicine system in which there was a regular interaction between physicians and patients was installed in Boston in 1967. A radiologist who worked at the Massachusetts General Hospital (MGH) set up a diagnostic “shop” in the medical station of Logan airport. Physicians passing through were invited to bring radiographs and patients’ THE LANCET • Vol 359 • June 8, 2002 • www.thelancet.com
data to a room on the passenger concourse. The radiographs were illuminated by an ordinary light-box, scanned by a black-and-white television camera, and the images were transferred to a videomonitor in the MGH’s radiology department. The physician could discuss the case with MGH radiologists via a telephone. The equipment used was poorly adapted to the services to be practised, and the costs were so high that they limited the use of the findings. In the 1990s there were many experiments with remote consultations based on videoconferencing where medical equipment or specialised cameras were used to give the second-care specialist the same visual inspection of the patient as the referring doctor. Videofilming was used, for example, in dermatology,3 radiology, pathology, gynaecology,4 and cardiology.5 After the initial trials, some institutions began to use the findings in practice, although the results of other trials were not put into practice.7 Teleradiology has become a regular service in many areas and included routinely when image manipulation in radiology departments became digitised. Videoconferencing in medical specialties that require advanced diagnostic tools is not as widespread as in ordinary services. The development of telemedicine assumes advantages for the individual patient in the interaction between primary and secondary care. In addition, general practitioners can gain educationally and hospital followup appointments may be reduced in number, because the general practitioner can handle more advanced medical problems. Economic savings for the health service are a driving force. Evidence to date is that the patient seems satisfied and the general practitioner gains competence, but the extent to which telemedicine results in reduced hospital follow-up appointments and economic savings8 remains unclear. A systematic review8 found that the best evidence for the effectiveness of telemedicine was in some of the studies on teleradiology (especially neurosurgical applications), telemental health, transmission of echocardiographic images, teledermatology, and home telecare (medical examination and therapy where patients are located at home, communicating with health-care personnel via videoconferencing). Telemedicine follows on from the development of endoscopy. Endoscopy has increased diagnostic accuracy and many specialist decisions rely on this technique. Otorhinolaryngoscopy is much used diagnostically in ear, nose, and throat medicine. Teleconsultation without otorhinolaryngoscopy will end up as a discussion about differential diagnosis based on symptoms and a follow-up appointment must be offered. If necessary medical equipment is not available or the general practitioner cannot handle it properly, then a remote consultation cannot be done. Telemedicine relies on adequate examination methods. Patients’ satisfaction is emphasised in many trials9 and is a valuable feature, but this factor must not exceed the quality of the medical diagnosis. In today’s Lancet, Paul Wallace and colleagues report a randomised trial of joint teleconsultations for patients referred by their general practitioner for a specialist opinion compared with routine referral for a hospital appointment. The investigators randomised a large number of patients (1000 per group) and conclude that virtual-outreach consultation resulted in a reduction in the number of tests ordered and higher satisfaction among the patients, but a greater number of offers for standard outpatient appointments in the telemedicine 1957
For personal use. Only reproduce with permission from The Lancet Publishing Group.
COMMENTARY
group. This difference probably depends on incomplete examination in the telemedicine group but the foundation for follow-up appointments in the two groups is hardly comparable. Follow-up rates in the study were increased, especially in ear, nose, and throat medicine and in orthopaedics. This difference is probably because general practitioners do not use peripheral devices such as fibreoptics or other instrumentation in their consultations and the receiving specialists do not get sufficient visual information from the consultation. If the clinical examination is incomplete, telemedicine cannot give diagnostic adequacy and would be useless. In 1995, another report10 predicted that use of the term telemedicine would disappear when the technique became successful. In teleradiology this prediction has come true to some extent. Radiological images can be read at a location separate from the image’s source, such as the radiologist’s home or at another hospital, and the term teleradiology is no longer used to describe this routine. With today’s available technology, a few specialties seem to have no future in telemedicine. Diagnosis in microbiology, which partly depends on smell, is an example. Clinical examinations mainly based on palpation, as in examination of the prostate gland and in gynaecology, may also be hard to do via telemedicine. Several factors need to be considered for successful specialist teleconsultation. Medical personnel with the requisite skills and equipment must be present at the outreach clinic. The remote examinations have to be reliably documented. The group of patients referred for virtual outreach must be selected appropriately. Williams and colleagues9 concluded that patients’ satisfaction with a telemedicine service is complicated by the patients’ subjective health status. Providers of telehealthcare need to recognise that a patient with a poor quality of life may want and benefit from face-toface interaction with expert clinicians. In addition the general practitioner’s skills in examination techniques and access to instrumentation have an influence on which patients may be selected for virtual outreach, depending on their medical symptoms. There must be good logistical support for arranging and doing the consultations, and resources to sustain the system. And someone must be willing to pay for the extra costs for communication equipment, high-speed telecommunication lines, and the extra time spent by the general practitioner and specialist. These extra costs may be offset by reduced costs of transporting patients or reduced sickness pay, but such costs are usually accounted for in budgets separate from those for telemedicine. The future of telemedicine depends on wide regular use in the medical areas where telemedicine has been a success and shown to be cost effective—eg, radiology and dermatology. The digitising of medical equipment in, for example, radiotherapy11 makes it a good candidate for success in telemedicine. Technical and organisational innovation in specialties where telemedicine has been useful may be a driving force for other telemedicine applications. *Eivind Rinde, Lise Balteskard *Telenor Research, N9001 Tromso, Norway; and Department of Oncology, University Hospital of Northern Norway, Tromsø (e-mail: [email protected]) 1 2
Einthoven W. Het telecardiologram. Ned Tijdschr Geenesk 1906; 50: 1517-47. Bashur RL, Lovett J. Assessment of telemedicine: results of the initial experience. Aviat Space Environ Med 1977; 177: 65–70.
1958
3
Josendal O, Fosse G, Andersen KA, Stenvold SE, Falk ES. Distance diagnosis of skin disease. Tidsskr Nor Laegeforen 1991; 111: 20–22. 4 Ferris DG, Macfee MS, Miller JA, Litaker M, Crawley D, Watson D. The efficacy of telecolposcopy compared with traditional colposcopy. Obstet Gynecol 2002; 99: 248–54. 5 Sable CA, Cummings SD; Pearson GD, et al. Impact of telemedicine on the practice of pediatric cardiology in community hospitals. Pediatrics 2002; 109: E3. 6 Moseng D. Teledermatology-experiences from Northern Norway. Tidsskr Nor Laegeforen 2000; 120: 1893–95. 7 Oakley A, Rademaker M, Duffill M. Teledermatology in the Waikato region of New Zealand. J Telemed Telecare 2001; 7 (suppl 2): 59–61. 8 Hailay D, Roine R, Ohinmaa A. Systematic review of evidence for the benefits of telemedicine. J Telemed Telecare 2002; 8 (suppl 1): 1–7. 9 Williams TL, Esmail A, May CR, et al. Patient satisfaction with teledermatology is related to perceived quality of life. Br J Dermatol 2001; 145: 911–17. 10 Sund T, Rinde E. Telemedicine: still waiting for users. Lancet 1995; 346 (suppl): s24. 11 Olsen DR, Bruland S, Davis BJ, Telemedicine in radiotherapy treatment planning: requirements and applications. Radiother Oncol 2000; 54: 255–59.
Coagulation signals for intact blood vessels Coagulation is generally thought of as the process leading to the formation of the haemostatic plug in a wound. However, it should also be viewed as the start of the subsequent healing process because the fibrin that is formed acts as scaffolding for invading cells, and also because activated coagulation factors can directly activate cellular receptors and thus stimulate tissue cells. Furthermore, recent work has suggested that coagulation factors may have a role in the maintenance of embryonic blood vessels. Tissue repair has many properties in common with tissue development, not least because the healing process requires neovascularisation and invasion of tissue cells into the area of the wound. Studies of murine development have shown that the lack of some coagulation factors or a deficiency of the thrombin receptor PAR-1 seriously impairs embryonic development and survival because of bleeding.1–3 The loss of blood is not due to incomplete clot formation because fibrinogen-deficient animals develop normally. What seems to be needed for maintenance of vascular integrity is direct action of certain coagulation factors on vascular cells. The importance of direct action of thrombin on vascular cells is underscored by Courtney Griffin and colleagues,4 who showed that mice deficient in the thrombin receptor PAR-1 could be prevented from bleeding to death by the specific expression of this receptor in endothelial cells. Deficiency of PAR-1 in mice halves embryonic survival because of haemorrhage and cardiovascular failure.2,3 The protein PAR-1 is a member of the protease-activated receptors (PARs), of which four members are presently known.5 Three of these PARs, including PAR-1, are activated by thrombin. Thrombin receptors play an important role in platelet activation and the formation of a haemostatic plug. They are also present on endothelial cells and on other tissue cells, such as fibroblasts (in wound repair) and on smooth-muscle cells (in atherosclerotic lesions). The bleeding in PAR-1-deficient animals suggests a general defect either in the formation of a haemostatic plug or in the integrity of the vascular tree. Abnormal platelet function could be excluded, because, unlike human platelets, murine platelets do not have PAR-1. In mice this function is taken over by other PARs. Furthermore, mice lacking platelets develop normally, whereas PAR-1-deficient embryos were bleeding at day 9·5 THE LANCET • Vol 359 • June 8, 2002 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.