Teleconsultation in geriatrics: Impact on professional practice

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Teleconsultation in geriatrics: Impact on professional practice Laurence Esterle a,∗ , Alexandre Mathieu-Fritz b a

Centre de recherche, médecine, sciences, santé, santé mentale et société (Cermes3), Inserm U988, UMR 8211 – CNRS, École des hautes études en sciences sociales, Université Paris Descartes, 7 rue Guy Môquet, 94801 Villejuif cedex, France b Laboratoire Techniques, Territoires et Sociétés (L.A.T.T.S.), UMR 8134 – CNRS, École nationale des Ponts et Chaussées, Université Paris-Est Marne-la-Vallée, Bâtiment “Bois de l’Étang”, rue Galilée, 77420 Champs-sur-Marne, France

a r t i c l e

i n f o

a b s t r a c t

Article history:

Teleconsultations in medicine are encouraged by authorities and decision-makers to

Received 10 July 2012

improve access to specialty services for isolated patients. For elderly patients in geriatric

Received in revised form

hospitals, they thus avoid trips to consult with specialists. However, teleconsultation can

26 April 2013

modify clinical practice and it may be abandoned for reasons not related to technical issues.

Accepted 29 April 2013

Qualitative research on the impact of teleconsultation on medical practice and organisation are thus crucial for an understanding of the changes it can generate.

Keywords:

Methods: We used qualitative methods to analyse the impact on professional work practices

Teleconsultation

and care organisation of an initially experimental and then permanent teleconsultation

The elderly

system using a video conference system set up between a geriatric hospital and a tertiary

Geriatrics

care hospital. Sixty-six teleconsultations (56 during the experimental phase and 10 when the

Specialists

system was in routine use) were observed and ten semi-structured interviews were carried

Clinical practice

out with the actors in the teleconsultations.

Professional work practices

Results: Our study shows that the uses of teleconsultation affected work practices of both

Care organisation

the consulted specialist and the geriatrician who participated in the consultation alongside the patient. The interactions of specialists with the patient were more difficult than in a face-to-face setting and delegation of the clinical examination of the patient depended on a specific form of cooperation and on trust in the person doing the examination. New kinds of relationships between health professionals contributed to sharing and transmission of knowledge between practitioners. While teleconsultations established alliances between geriatricians and specialists, they none-the-less called for a certain humility on the part of geriatricians. In order for these relationships to become routine and to facilitate interaction among participants, the project manager carried out important work during the experimental phase of the teleconsultations by organising these interactions. Finally, the teleconsultations went through several local reorganisations, especially within the geriatric hospital. These included changes in the geriatrician’s schedule and the added presence of an assistant knowledgeable in telemedicine. Conclusions: Specialists found the system used for teleconsultation between a geriatric hospital and a tertiary care hospital to be suitable for their consultations. The main advantage brought about by the teleconsultation system studied resulted from its collaborative nature, which created relationships between health professionals. This resulted in improved care for elderly patients. However, using the system required effort on the part of both the specialists and the geriatricians. Adapting to the system was facilitated by coordination work carried out by the project manager during the experimental phase that created a favourable

∗

Corresponding author. Tel.: +33 01 49 58 36 89. E-mail addresses: [email protected] (L. Esterle), [email protected] (A. Mathieu-Fritz). 1386-5056/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijmedinf.2013.04.006

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context for cooperation between actors, allowing diagnoses to be made at a distance. Finally, teleconsultations do not appear suitable for all specialties, by reason of the limits imposed on the delegation of tasks, or to all situations. They require setting up new forms of organisation that must be encouraged by decision-makers. © 2013 Elsevier Ireland Ltd. All rights reserved.

1.

Introduction

Teleconsultations enable health professionals to carry out patient consultation at a distance and to give access to secondary care or specialist services, for example. Teleconsultation appears convenient for patients unable to be moved around, either because they are in a closed institution (a geriatric hospital, a prison or psychiatric ward for example) [1–4] or because they live in areas difficult to reach [5–7]. Numerous experiments with teleconsultation have been carried out across the world [8], but many did not lead to its installation in spite of initial enthusiasm on the part of participants, who saw in it a way of dealing with problems in the organisation of care [7,9]. There are many reasons for these failures. The various techniques used (phone call, videophone, video conference, etc.) may constitute important limiting factors [10,11] and in this regard, video conferencing is increasingly used since it allows good-quality transmissions at an affordable cost [11–14]. However, along with technical difficulties, the impact on the organisation of care and professional practice is frequently mentioned as a possible factor jeopardising the establishment of telemedicine systems [10,15,16]. This is similar to what is known in general in the field of medical informatics as well as in Computer Supported Cooperative Work (CSCW) [17–22] which addresses the way information technology impacts cooperative works and practises. For this reason, recommendations have been made, both in scientific publications [23–26] as well as in manuals and guidelines [27–29] to evaluate cultural and organisational changes that may be brought about by telemedicine. In France, teleconsultation has long remained at a very experimental stage due to lack of a legal framework. But since 2009, it is not only authorised but even encouraged, in order to respond to problems linked to medical demography, to a lack of physicians in certain specialties and to the ageing of the population. Indeed, remote consultation appears particularly suitable for older patients who are difficult to transfer between institutions [2,4]. In France, as in other countries, a major problem concerns access to specialists by patients in geriatric hospitals. Usually, in order to gain access to a specialist consultation, patients must be transferred to another hospital, which frequently takes more than half a day (preparation for departure, delayed ambulances, waiting room time, etc.) for a consultation that takes less than 30 min. These trips are not only expensive, but also stressful and tiring for very elderly patients who often have cognitive impairments. Recently, a teleconsultation system called Telegeria HD1 was developed between a geriatric hospital and a specialist

1

For more information and presentation of Telegeria HD, see: http://www.telegeria.fr.

hospital, with the objective of facilitating patient access to specialists. The system is similar to the one used in videoconferencing and transmits pictures between two institutions in real time and on high definition screens. Following an experimental phase lasting nine months, the system was adopted for routine use, and more than 1500 teleconsultations had been carried out as of September 2012. In this article, we analyse the organisational impact of Telegeria HD, with the goal of understanding the processes of adaptation to clinical needs, clinical routines and the organisation of care that enabled the long-term adoption of this system for use with the elderly.

1.1. Background on the impact of teleconsultation on professional activities and the organisation of medical care 1.1.1. Teleconsultation: a medical act with group characteristics In many cases, an important change brought about by teleconsultation results from its collective nature [9,30]. This is true for Telegeria HD where the geriatrician and other health professionals (nurses, physical therapists) participate alongside the patient in the teleconsultation by the specialist. Thus, teleconsultation establishes relationships among health professionals who usually don’t work together in the presence of a patient. In this way, teleconsultation can change a traditional face-to-face act of consultation with the patient into an act necessitating collaboration, but also learning, with the videoconference system becoming a tool for interaction [30]. In general, the coordinated meeting of physicians promotes sharing of knowledge and expertise of a professional nature [10,30]. However, this new form of interaction brings together professionals who may be from different levels of the medical hierarchy, and this asymmetry of expertise may become a source of frustration or awkwardness [9,10].

1.1.2.

Limitations on clinical routines

Teleconsultation also has an impact on the way the physician establishes a diagnosis since he or she is unable to carry out a direct clinical examination of the patient. For the specialists, the use of the system requires a good deal of adjustment. First, they must adapt to communicating with patients in a setting different from face-to-face consultations [18,31,32]. Moreover, specialists who base their diagnosis mainly on signs discovered clinically through palpation or a thorough examination have difficulties during teleconsultation because they must delegate those tasks most important to their professional activity to a non-specialist physician or even to another health professional (physiotherapist, nurse) [33]. From previous analyses, it is apparent that teleconsultation is not always suitable for all specialties because of the limits imposed by the delegation of tasks [9,34].

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1.1.3.

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Multiple consequences for the organisation of care

The introduction of teleconsultations may require putting in place new forms of organisation so they can be used in a routine manner [11,35]. For example, in the hospital setting, teleconsultations duplicate the usual system for consultations, necessitating the creation of new appointment schedules [11]. They may increase workloads as well, and require internal reorganisation to handle them [34,35]. Finally, they may encourage the development of new management tools (personal information managers, PDAs, electronic health records) and contribute to the creation of new jobs such as coordinator in telemedicine or telemedicine assistant [11,13,36,37].

1.2.

Theoretical background

Drawing on a socio-technical systems approach [16,23,25,38,39], according to which technological innovations are accompanied by changes in professional practices, organisation and the division of labour, our initial hypothesis was that the use of a teleconsultation system would lead to adjustments enabling a diagnosis by a specialist to be made from a distance. Our analysis was also influenced by the work of Strauss et al. [40], who showed that patient care in the hospital is highly dependent on “articulation work” which “must be done to assure that the staff’s collective efforts add up to more than discrete and conflicting bits of accomplished work” (p. 151). For these authors, “if patients constitute ‘a source of potentially disruptive conditions’ [. . .], another source is medical technology, which harbours a host of conditions that can spawn contingencies affecting the articulation of the trajectory work” (p. 154). It was hypothesised that coordinating activity within the framework of teleconsultations involved articulation work not present in other tasks undertaken by the different protagonists. According to Cicourel [41], whereas the diagnosis is the job of the physician and relates back to his or her professional experience, it is also a collective and social decision. While all the care actors agree on the ultimate objectives of their participation, they do not have access to the same information concerning the illness and its pathology, nor do they share the same views concerning the means necessary for attaining these objectives. Our hypothesis was that articulation work is necessary so that participating actors develop routines during the experimental phase. As we will see, this articulation work is especially evident in processes related to the framing of interactions. These consist in bringing together a set of social and technical norms, values and representations concerning what it is important to do or not to do in the presence of others [42]. In other words, framing contributes to mutual comprehension between individuals present while it manages their participation in activities and their relationships with others [43].

1.3.

Our research

The global objectives of our research were to describe how teleconsultation is performed in clinical practice, in particular geriatrics, what measures and adaptations have been taken to make these teleconsultation sustainable over a longer

period of time and how teleconsultation is perceived and coconstructed by the various actors involved. First, we needed to grasp the role of the physician coordinating the teleconsultation project in order to understand how he managed to adapt the system to fit the practices of those using it, and to take note of the kinds of regulations and framing he was required to set up. The purpose of our research was also to describe new professional practices used by specialists within the context of teleconsultations. Thus, changes in the clinical routines of specialists responsible for diagnoses were given special attention in that many clinical acts (palpation in particular) cannot be carried out during teleconsultation. We sought to determine if new forms of cooperation had been put in place, under what conditions and how rigorously they were adhered to, and finally whether they had proved sufficiently adequate so that the specialist was able to make treatment decisions. We also examined whether the simultaneous presence of the actors led to new kinds of interactions and hierarchical relationships and to the acquisition of new knowledge and skills by the geriatricians. Finally, the system is likely to introduce new organisational constraints. Our research aimed to identify any impact on the organisation of care and examine how the use of this new resource was programmed. Therefore, our research questions were the following:

1. What kind of articulation work was done by the project coordinator? 2. What changes could be observed in the practice of specialists? 3. To what extent was the practice of geriatricians transformed by the installation of teleconsultations and how did they adapt to this? 4. How was the system integrated and coordinated with the functioning of services in the two hospitals concerned?

2.

System description

2.1.

The emergence of Telegeria HD

The experimental teleconsultation system, called Telegeria HD, was set up between the Vaugirard geriatric hospital (VH) and the Georges Pompidou European Hospital (GPEH), located several kilometres from the former. The introduction of teleconsultation between GPEH and VH was the initiative of a physician at GPEH, an expert in telemedicine, who had already developed a technically more modest pioneering system for remote consultations and played the role of project manager. His role consisted of the overall control of the technical and organisational system, including the practical details of implementation, in collaboration with industry stakeholders. The project manager easily convinced the VH physicians, in light of their significant needs for specialised consultations and the constraints inherent in transporting elderly and frail patients. On the other hand, he initially needed to use his professional networks at GPEH to mobilise specialists, with the latter in turn encouraging other colleagues to participate.

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The experimental phase was carried out between June 2009 and February 2010 during which time 333 teleconsultations in several specialties took place. More than 200 patients were involved, with a mean age of 85.7 years and an overrepresentation by women (83%). Two-thirds of patients had a cognitive impairment or severe dementia.

2.2.

Technological aspects

The Telegeria HD system uses the Cisco HealthPresence videoconferencing platform that transmits images in real time between two institutions to large high-definition screens using a secure high-speed network. Due to the system, pictures are rendered at 90% of original size. The effect obtained is not very perturbing since there is no distortion of the picture, but it initially contributes to reminding the actors they are indeed participating in an interaction mediated by a technological tool. However, the actors get used to these constraints because the technical quality of very high-speed communication allows satisfactory interactions to take place. There are no disruptions in the picture or sound, the level of synchronisation between the two is adequate and they are rendered instantly with no time-lag. This allows the actors involved to interact normally, that is without having to make a pause from time to time. According to participants, the level and quality of the sound is realistic and the picture quality satisfactory. Biomedical equipment is connected to the system, such as a dermatoscope, stethoscope, ultrasound, electrocardiograph, and otoscope. A teleconsultation room was installed in each hospital. The room at GPEH was composed essentially of a desk behind which the specialist sat facing the screen that was sending pictures from VH. A second smaller screen enabled viewing X-rays, the patient’s electronic medical record or pictures from a mobile camera. The consultation room at VH was compatible with norms for clinical examinations, including norms for hygiene used by the hospital. It had an open space allowing the patient to sit facing the screen while accompanied by the referring geriatrician and nurses and/or physiotherapists. An examination table allowed the patient to be placed in a prone or semi-sitting position for clinical examinations. Aside from biomedical equipment connected to the system, the room also included a hand-held mobile camera for showing close-up pictures.

2.3. The organisation of consultations prior to Telegeria HD The VH geriatric hospital delivers care to elderly patients for short or medium-term stays – for example, following an operation – or long-term care to chronically ill elderly patients. Aside from geriatricians, there are no other specialists at VH. When a patient’s condition required evaluation by a specialist, the referring geriatrician registered the patient for a specialty consultation at GPEH, with waiting times of up to several weeks. The day of the consultation, the patient was prepared in his or her unit and taken to GPEH by ambulance, accompanied by a letter written by the referring geriatrician explaining the medical reasons for the consultation and asking the specialist’s opinion. If the patient had signs of dementia or serious

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problems with time-space orientation, a nurse accompanied the patient. Upon arrival at GPEH, the patient was usually placed on a gurney or in a wheelchair in the specialist’s waiting room and awaited his or her turn. The specialist read the letter from the geriatrician and examined the patient. Following the consultation, he or she wrote a report on the consultation indicating the diagnosis made and including any prescriptions to be followed. Initially, there was no common system of electronic records between the two hospitals. The patient returned to VH at the end of the consultation, after having perhaps waited for the ambulance for the return trip.

2.4. The organisation of teleconsultation using Telegeria HD In the experimental stage, the request for a teleconsultation was made by the geriatrician and set up by the project manager at GPEH. A quarter of an hour before the teleconsultation, the patient was made ready in his or her room and then waited in a room used for that purpose before being moved into the teleconsultation room in the presence of VH staff. The patient could also be accompanied by a member of his or her family. Generally speaking, the same specialist saw several patients in turn. A debriefing between the specialist and the health professionals at VH could take place, either between two patient consultations or at the end of the teleconsultation session. During the first 300 teleconsultations, the project manager and a clinical research assistant respectively were present one at each end of the system to ensure its smooth operation. Following the experimental phase, the use of teleconsultations became routine and teleconsultations were set up by a telemedicine assistant trained for that activity.

2.5.

Ethics

Procedures for informed consent and anonymity of patients and health professionals were followed within the framework of French law. A charter for telemedicine was drawn up by the physician project manager in order to register the system within the legal framework envisaged by Article 32 of the law of August 13, 2004 on Health Insurance and by the National Council of the Order of Physicians in its report adopted in July 2009 concerning medical ethics and the practice of telemedicine. A written notice was routinely given to the patient to obtain his or her informed consent and an authorisation was signed by the patient or a family member. All technical measures were taken to ensure a high level of security in transmission of data between the two institutions and computer files were registered with the national data protection committee (CNIL).

3.

Research methodology

The analysis is qualitative and focuses on changes and adaptation in clinical practice and on the organisational consequences observed during teleconsultations between a geriatric hospital and a tertiary care university hospital. The methodology consisted of in situ observation of the first 56 teleconsultations during the experimental phase

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(without selection) and of 40 ‘technical sessions’. These technical sessions took place with the health professionals present, following the teleconsultations and at the request of the physician coordinator, but in the absence of the patient. They allow a discussion of the system, its advantages and limitations, as well as its impact on medical practice. In addition, video recording of the teleconsultations enabled the authors to examine them in detail and precisely analyse the technology in use. The observed teleconsultations concerned seven specialties: dermatology, orthopaedic surgery, neurology, geriatrics, vascular medicine, cardiology and haematology. Orthopaedics and dermatology constituted the majority of observed teleconsultations. A detailed report of observations was made on each teleconsultation by both authors. At the time of the teleconsultations observed by the authors, informal discussions were carried out with the project manager and some of the other health professionals (specialists, geriatricians, and paramedical personnel) involved in the experimental phase. The authors were also present at several meetings attended by health professionals and the project manager. These observations made it possible to study the early development of mechanisms for adapting to the system and the local arrangements made by those using it. Different documents were available to the authors: protocols, technical notices, exchanges of e-mail, etc. The study was supplemented in 2011 by observations of 10 now-routine teleconsultations and by semi-structured interviews with 10 health professionals at VH, selected on the basis of their participation in the experiment. These were comprised of six geriatricians involved in the experimentation (including one who was designated as the coordinator of teleconsultation at VH and another who was the director of the hospital), three physiotherapists who participated in the teleconsultations, and the nurse in charge of teleconsultation management. Only one geriatrician who participated in Telegeria HD refused to be interviewed. Interviews were carried out after all observations were completed and when the Telegeria HD system was being used in a routine manner. The script of open-ended questions was prepared by the authors but the interviews were interactive, with new questions emerging from the discussion. One or both authors were present at the interviews. The average duration of the interviews was 1 h, with a range from 30 to 120 min. The interviews were digitally recorded and fully transcribed. The transcripts served as the basis for an in-depth content analysis, first carried out separately, then jointly by the two authors of the article (who thus compared, then combined and reorganised the results of their analysis of the empirical data). Specifically, the identification of themes was done by reading the different transcripts several times in order to draw out the themes, which constituted nearly all practice categories.

4.

Results

4.1.

Articulation work by the project manager

Articulation work done by the physician who was project manager consisted of various ways of framing the interactions between actors located at one end or other of the system.

Three characteristic kinds of framing related directly to a continual effort to shape the interaction. The first kind was that of “technical” framing, or framing centred on the use of equipment. This took place during but also before or after the teleconsultations. It began with the setting up of the videoconferencing technical system to which was added biomedical equipment suited to the needs of the health professionals. Technical framing was also characterised by the arrangements of the two teleconsultation rooms, located respectively at GPEH and at VH. Each work space in the two rooms was organised as a mirror image of the other, giving the impression the two rooms were in line with each other, which added to the feeling of reality produced by the system’s pictures. The width of each room was the same and the walls were painted white. In effect, the configuration of the rooms reproduced that of a typical consultation office, with the specialist seated behind a desk and the patient placed facing him or her and usually seated in a wheelchair. In reality, specialist and patient were of course facing a screen. Technical framing continued during the actual teleconsultation and consisted in explaining the operation and use of the system and the different technological devices associated with it, such as handling of the mobile camera. Depending on the specialty of the GPEH physician, the physician project manager emphasised the possibility of using a device directly relevant to his or her area of activity (e.g., for the dermatologist, the dermatoscope or the mobile camera enabled close-up pictures of lesions). Early on, technical data sheets were made available to professionals to explain the starting up and functioning of the videoconferencing system, as well as the operation of the mobile camera. Another important factor in ensuring the fluidity of interactions was the proper positioning of actors facing the screen, especially at VH (at GPEH, the specialist was seated motionless in front of the screen, that is in the middle of the camera’s field of view). In the initial phases, the project manager intervened frequently during the teleconsultation to indicate where one should be positioned and how to move to be visible or to see the patient on the examination table. This technical framing appeared from time to time in the course of the teleconsultations, especially during the use of the various tools connected to the system, such as the hand-held camera, whose operation necessitated frequent advice to optimise its utilisation, to correctly adjust the picture and to find the best angle of view for participants at GPEH. Technical framing was especially useful to the specialist for facilitating the delegation of clinical tasks to practitioners located at the other end of the system. The second kind of framing was that of “social” framing, which contributed to defining the goal of the teleconsultation for the participants, and in general, to introduce the different actors present. During initial teleconsultations, the involvement of the physician project manager was necessary to structure the relationships between the actors present, in particular by asking the different participants to briefly introduce themselves (name, professional status, place of work, reason for being present). The need for an introduction, which initially was not apparent, was proved necessary for creating links between health professionals as well as for allowing patients to identify participants on the other

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side of the screen, including other people attending the teleconsultation. These introductions rapidly became routine for the professionals who regularly practiced teleconsultation. Finally, social framing also included “preparation” of the patient for the teleconsultation beforehand by the medical team at VH who provided information to the patient about the system and the sequence of events during the consultation, namely about the presence on the screen of the specialist working at GPEH. Clinical framing was the third type and consisted in attempting to use best practices for medical examinations, albeit in the context of what is henceforth a collective process. It endeavoured to coordinate sequentially the various tasks necessary for a teleconsultation. This began with a global presentation of the patient’s medical file by the referring geriatrician, which rapidly became a routine procedure. It continued with the implementation of diagnostic techniques, which might in part be delegated by the specialist to the care team at VH. It ended with a general statement by the specialist on the diagnosis and treatment, a phase concluded by the writing of a report. Norms concerning clinical framing were progressively established, often through trial and error and on the suggestion or initiative of one or another of the participants, more frequently by the specialist. Clinical framing also included following ethical codes that depended directly on norms in effect for telemedicine. As noted above, an informational note was systematically given to the patient to obtain informed consent and an authorisation request was signed by the patient or the patient’s family. In addition, beyond framing activities, articulation work done by the project manager consisted of various kinds of inter-organisational coordination. This dealt with the programming of future teleconsultations, people to contact (by e-mail or telephone), and the information needed for requesting a teleconsultation. These types of coordinating tasks led to modifications in the organisation of work since scheduling for teleconsultations had to be kept separate from that for traditional consultations by GPEH specialists and practitioners at VH had to follow new arrangements of their usual work schedules. At VH, they also led to organising the local preparation of the patient, checking on the availability of the teleconsultation room, and verifying that the system and its different tools were working properly. In the beginning, the project manager had to constantly repeat the same instructions and advice, so that the different participants could assimilate the new routines he wished to see put in place.

4.2. Changes for the specialists, transformations of clinical routines, and adjustments to criteria for teleconsultation Contrary to traditional consultation, which takes place face-to-face with the patient, the observed teleconsultations encompassed particular aspects to which the specialist had to adapt. First, the specialist was in an office (not his or her own), facing a screen showing the patient surrounded by health professionals from VH: the geriatrician in charge of the patient, usually the nurse who cared for the patient and, in the case of orthopaedic consultations, the physiotherapist.

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The teleconsultation thus took place within a collective framework where there were numerous interactions. As a result, relationships with the patient were considerably modified. During traditional face-to-face relationships, the physician (in this case, the specialist) takes the patient into his or her professional space and assumes the principal role. Within the collective framework of teleconsultations, the specialist had to maintain control by first greeting patients and, if they already knew them, asking how they were getting on (especially during follow-up for surgical procedures). If the specialist did not know the patients, or wished to know them better, the geriatrician at VH was able to supplement the initial patient history by reviewing the medical records. Knowledge of the patient was thus medically more accurate, even more so since the specialist could easily question the geriatrician to obtain further information. Most specialists agreed they found these professional exchanges useful – “it’s easier and more detailed than with letters” (an orthopaedist) – but to the detriment of a direct exchange with the patient, which some specialists still attempted to maintain. For example, one dermatologist communicated exclusively with the patient to ask medical questions and attempted to minimise the involvement of the care team. In spite of the technical performance of the system that produced very good rendering of sound and picture, interactions with the patient required a certain effort by the specialists on the other side of the screen. Observations showed that specialists tried to overcome the effect of distance due to the screen and the absence of physical contact with the patient by speaking louder, by modulating intonations, by accentuating their gestures. One specialist insisted upon the importance of touch as a reassuring act with elderly persons who often have auditory, visual or cognitive impairments, and indicated: “It’s tiring for me” [to replace touch by words]. Another mentioned, “Communication [with the elderly] is more difficult than in live contact”. Often, the geriatrician beside the elderly person played the role of intermediary, repeating a question from the specialist or making it more comprehensible or even answering in place of the patient. When the elderly person had cognitive impairments, the interaction usually took place between the specialist and the VH team, greatly diminishing the privileged dialogue between patient and physician. The greatest change in clinical routine was related to the impossibility for the specialist to do a direct physical examination of the patient. To make a remote diagnosis, the specialist had to delegate this task to one of the health professionals next to the patient. This delegation was based on a specific form of cooperation and depended on having confidence in the delegate. The delegated tasks varied according to the consulting specialties and involved interaction between persons from different levels of the medical and paramedical hierarchy. For example, in orthopaedic surgery, several kinds of palpation or manipulation may be necessary for making a diagnosis and deciding on what therapy to follow. This task may be delegated to the referring geriatrician but also to the physiotherapist. Thus, an orthopaedic surgeon might ask a physiotherapist to carry out rotating movements of the shoulder to test the mending of the joint after an operation. The

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dermatologist as well might ask the physician or the nurse to palpate a skin lesion to verify its nature. This delegation of tasks also affects the patient, which may pose other problems. First, the physical examination is not done by the consulting practitioner, which sometimes leads to reticence on the part of the patient. Concretely, problems may also arise when the patient needs to carry out a movement at the request of the specialist. For example, a surgeon who asked a patient to participate in a test involving extending the arm simulated and verbalised the gesture: “Raise your arm like this”. He departed from usual practice in a traditional face-toface relationship where the action would have consisted in physically accompanying the patient’s movements. In the opinion of specialists who had acquired experience after several teleconsultations, it is not possible to delegate all tasks and do everything at a distance. Moreover, when delegation is envisaged, it can only be done by making an extra effort within the framework of the interactions. Delegation of clinical tasks requires an effort in verbal expression on the part of specialists to describe the acts they want carried out, whereas these are very familiar to them in their daily clinical practice. Verbal expression also includes explaining the objectives of technical tests to be carried out: “In fact, what interests me is to know the degree of flexing it [the patient’s leg] can reach and if it has full extension”. Sometimes, the delegation of tasks could not be satisfactorily carried out but this failure did not always call into question the principle of teleconsultation. For example, orthopaedists were often able to give a diagnosis by using radiographs, which are a key element in this discipline. In addition, the specialist could also make use of further tests. Thus, a surgeon might suggest a scan to a patient for whom a diagnosis might have been possible by palpation, had the consultation taken place face-to-face. In the end, the limits of teleconsultation pointed out by the specialists depended on the medical specialty. The fact of preferring teleconsultation or a face-to-face relationship depended as well on the age of the patients and their functional status: “A 50 year-old patient, I want to see him. As for geriatrics, it’s suitable”. This orthopaedic surgeon also determined when teleconsultations were appropriate, by stating categorically the importance of this practice in geriatrics: “Any dependent person with a fracture of the neck of the femur can be seen in this way”. In this case, the advantages of teleconsultation took precedence over the inconvenience of an appointment at the GPEH by avoiding transporting the patient and by benefiting from the assistance of the professionals at VH. This orthopaedist also noted clearly that teleconsultation was important for postoperative follow-up of patients, but not for taking a decision to operate: “In geriatrics, it really sorts things out; it’s helpful . . . [It] avoids transporting these patients, which takes [them] 6 hours”. In dermatology, problems faced were usually related to the quality of the lighting on the lesion and the clarity of the picture (“to see the subtleties of colour”). When conditions were judged unsatisfactory, the dermatologist had to delegate some tasks of visualising, in addition to those of palpation in order to characterise the lesion. Here again, teleconsultation was seen as enabling a “sorting out” of patients that could be followed at a distance from those that had to be seen face-to-face: “I only

had to have four patients come see me out of around forty that I was able to see with telemedicine”, noted a dermatologist. According to the neurologists who participated in the experimental phase, the utilisation of teleconsultations did not appear suitable for an initial diagnosis among the elderly, who often present with complex problems. The neurological examination included exploratory acts that required intense interaction with the patient and for which each physician has his or her own procedures. Thus, a neurologist said: “For oculomotor examinations, we all have our own routines: for example, (. . .) to move about because the eyes are more attracted to a face than to a pen, (. . .) I don’t see myself telling my colleague opposite me, ‘do like that’. . .”. As in orthopaedic surgery, teleconsultation in neurology appeared suitable for dependent patients for a “cursory examination”, or for a first opinion “to sort things out” to avoid unneeded transportation of the patient or, on the contrary, it may lead to an appointment for a traditional consultation, but it was not suitable for doing in-depth neurological examinations.

4.3. Adaptation and cooperation of geriatricians – new relationships between health professionals Since the offer of teleconsultations filled a broadly expressed need at VH, no resistance was met in setting up the system and all geriatricians involved willingly participated in teleconsultations alongside their patients. All participants felt the technical system was very easy to use and that they rapidly became accustomed to it. One of the main advantages underlined by the physicians at VH was that teleconsultation allowed them to make contact with specialists they didn’t know at all: “One gets the impression of being in direct contact with [the specialist] . . . of actually being in the same room!”. The geriatricians were thus able to establish professional ties with certain specialists (including when the specialists were in a superior hierarchical position) and create social relationships that had not existed formerly. Thanks to teleconsultation, geriatricians and specialists could now communicate by other means, for example by telephone because they know each other. It’s in this sense that physicians at VH explained that telemedicine had “opened up” their hospital. However, these ties strongly depended on the specialists encountered, with some continuing to maintain a hierarchical distance during exchanges by videoconferencing. Teleconsultation took the place of communication through letters, judged frustrating by all the health professionals concerned. For example, it allowed greater details on the patient’s past history to be given verbally and for information exchange to be more efficient. “There’s dialogue”; “This is communication we couldn’t have had in a traditional consultation, with a short letter”. The geriatricians appreciated teleconsultation because they saw it as having many benefits for their patients. According to them, teleconsultation enabled better patient care in that access to specialists was easier and with no discomfort for the patient: “It saves time for the patient, it’s convenient” . . . “The consultations we had couldn’t have been done [without it]”. Thus, an appointment for a teleconsultation was normally given within several days of the request, whereas waiting periods for a hospital appointment can be one month, or even up to three

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for certain specialties such as dermatology. In an emergency, it was possible to have a teleconsultation the same day. Teleconsultation also allowed geriatricians to exchange ideas with the specialist with the view of making a diagnosis or prescribing a treatment: “We ask the specialist our questions and we have answers in real time”. The presence of the patient led to a “triangular” relationship (geriatrician – specialist – patient) that the geriatricians found “more humane”. According to them, it allowed a patient to hear the discussion with the specialist and to have things explained again after the teleconsultation, if need be. The presence of the geriatrician allowed specialists, who were often unfamiliar with very elderly persons, better case management that was more suited to the specificities of geriatrics, where care is conceived in a context that includes the patient’s pathologies and life project. However, teleconsultation affected the attitudes and practice of the geriatrician. During delegation of tasks, the geriatrician was confronted with problems elicited by the specialist’s requests. To begin with, task assignment raised the question of trust for the geriatrician: “We are essentially an extension of the specialist facing us”. For example, it may not be obvious how to perform a neurological examination for which the geriatrician has not had advanced training, or to recognise dermatological lesions. Being assigned tasks and presenting a case to a specialist, or even asking for a teleconsultation, required a certain humility since it exposed one’s own practice and knowledge to scrutiny. “When the specialist [a professor specialising in echocardiography] considers one’s request as unjustified, one has the impression of being reprimanded, like at school, which is not pleasant”. This embarrassment was also a reminder of the prevailing view of geriatrics, which is not considered a prestigious specialisation in France: “There is sometimes contempt for geriatricians”. However, over time, teleconsultation allowed the geriatrician to “soak up” the specialist’s skills. “Having the opinion of a dermatologist is very educational [. . .]”. Generally speaking, the geriatricians at VH agreed that the specialists made an effort to be educators. They recognised that, in the course of the teleconsultations, they acquired useful knowledge for their own practice and that the experience gained was liable to reduce their recourse to specialists in such areas as dermatology, care of pressure ulcers, internal medicine or endocrinology (the areas cited). The basic neurological examination done at VH was also supplemented by tests learned during teleconsultations. But for some specialties, orthopaedics in particular, the advice of specialists remained indispensable, not least because they were responsible for post-operative follow-up of their patients. Conversely, teleconsultation allowed geriatricians to increase awareness of difficulties and pitfalls in their specialty and make clear the limits they were sometimes obliged to impose, in terms of examinations and treatments, due to the physical and mental status, prospects and social environment of a patient. Teleconsultation thus provided geriatricians with an opportunity for communication, which facilitated dialogue and the taking of decisions with the specialist. As one of them noted, “With telemedicine, it’s also possible to discuss things we didn’t talk about before”, such as the patient’s social environment. This also contributed importantly to establishing trust between geriatricians and

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specialists, leading, in the words of one physician, to “a readjustment of each one’s role”. Overall, not only was a “downward” pedagogy evident from specialists at GPEH to geriatricians at VH, but there was also “upward” information from geriatricians to specialists concerning the difficulties and constraints of dealing with elderly patients in long-term care, something specialists don’t often see in their own units. However, in the end, each one stayed in their own role. In spite of these transformations, teleconsultation was not considered by the geriatricians as a multidisciplinary consultation: “It’s not a two-way consultation, we ask a specialist opinion from a specialist, [. . .], it’s not a multidisciplinary consultation, and it’s not a consultation meeting”. Teleconsultation produced exchanges where the geriatrician gave an opinion on a new treatment, for example. The geriatricians considered that “we have no trouble in convincing them [the specialists]” because relationships of trust had rapidly been established between the physicians at the two hospitals. The tone and attitude of the geriatricians towards the specialists remained respectful and no conflicts or heated discussions were observed nor reported during the interviews.

4.4.

Reorganisation to ensure routine practice

After several months, teleconsultation became “a habit”, a part of practice and irreplaceable: “Going back to the consultation with transportation, that would be the Middle Ages!” (the director of VH). However, for their long-term establishment, teleconsultations had to be integrated into the functioning of the two hospitals involved, especially at VH, and new organisations had to be created at the two sites. Henceforth, teleconsultation became a part of clinical practice, to be included in the time budgets of physicians and nursing staff. When geriatricians participated in teleconsultation with their patients, their presence required time that had not been envisioned in their already full work schedules. “It complicates things for us in our daily organization”. It was necessary to make plans for this time. For example, arrangements could be made to have a colleague see the referring physician’s hospital patients while the latter participated in a teleconsultation. The initial system was also reorganised and made more flexible as concerned the presence of the referring geriatrician. Some no longer systematically participated in a teleconsultation, especially during follow-up on orthopaedic treatment, where they might be replaced by the physiotherapist, which also required organisational readjustments. Geriatricians accompanied their patients more often for teleconsultations when their presence was useful for giving an opinion and describing symptoms or for discussing the case with the specialist. In other words, geriatricians carried out a triage according to the specialties, the characteristics of the patient, but also their own availability. In this respect, interviewed geriatricians mentioned the risk that teleconsultations might end up being done in a more traditional manner: “With the screens, we’ve gotten to something more humane, but vigilance is necessary so that it remains humane”. Following the experimental phase, which benefited from the presence of the project manager and his team, the VH hospital had to set up a more autonomous organisation devoted

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to this activity. A new teleconsultation room, longer than the previous one, was installed to improve patient comfort and professional activities. A nurse’s aid was trained by the project manager to become an assistant in telemedicine. She organised the teleconsultation sessions from a technical and practical standpoint, scheduled appointments with specialists at GPEH, ensured that patients were ready at the time of the teleconsultation, and accompanied them during the session. The designation of a referring physician in telemedicine also enabled the coordination of the medical activities related to telemedicine at VH and ensured coordination with GPEH. Similarly, a nurse became responsible for organising sessions of teleconsultation at GPEH and managing appointments for the specialists. While communication between geriatricians and specialists in both hospitals formerly took place solely through an exchange of letters, the electronic record system at GPEH was installed at VH to share information on patients and provide a place for recording reports on the teleconsultations. Finally, guidelines were drawn up by the project manager in collaboration with the specialists and geriatricians. These describe the practical details for making appointments and explaining requests for an opinion. They illustrate how to prepare patients, how to inform them and obtain their consent. They describe the technical tools to make ready, depending on the specialty consulted, the type of participants and finally the procedures to follow during the teleconsultation, including report-writing for inclusion in the electronic medical records. The guidelines thus organise the entire process by indicating the tasks, duties and responsibilities of each person.

5.

Discussion

Teleconsultation is a promising application of telemedicine as it makes it possible to offer speciality consultations that are not available to patients for various reasons (distance, lack of physicians, residence in an institution, etc.). Our initial hypothesis was that the technical quality of picture and sound transmission, now offered by numerous videoconferencing systems, would not be sufficient to ensure the sustainability of teleconsultations because their effects on professional practice and the organisation of care could constitute limiting factors. Our perspective differs from previous research recently published on a similar system of medical videoconferencing [11] in that it does not focus as much on the patient as on the practices of health professionals. The Telegeria HD system we observed has two key aspects. On the one hand, this system was installed for long-term use and made permanent after a few months of experimentation; on the other, it concerns geriatrics. Theoretically, teleconsultations can be useful for elderly hospitalised patients in specialised institutions by assisting in the organisation of care, and especially by avoiding the transportation of frail patients to obtain specialists’ opinions. However, geriatrics has specific aspects which may make the use of teleconsultation difficult. First, geriatricians do not enjoy high status in hospital hierarchies [44], which may pose a problem regarding their place in the context of what is essentially a collective consultation. This

may especially be the case for geriatricians in France who are considered more as general practitioners who deal with pathologies in the elderly than as specialists with high symbolic status. Second, patients may have signs of dementia or cognitive deficits that make interaction mediated by a screen particularly difficult for the specialist. Finally, patient care may be more “integrated” in geriatrics, taking into account factors related to decisions about care (multi-morbidity, the social environment, etc.) which were not taken into consideration during traditional consultations because of a lack of information. Our observations show that these specificities gave rise to adaptations by health professionals located on both sides of the screen. These changes were made possible by the nature of the experimentation, which was carried out on the basis of voluntary participation and directed by a physician project manager who listened carefully to participants’ suggestions, thus confirming the importance of the role played by project managers [11,27]. During this experimental period, there were also readjustments made concerning criteria for teleconsultation, depending on the specialties involved. Thus, in the view of health professionals, some specialties do not appear suitable for teleconsultations, particularly those that require direct clinical examination of the patient by the specialist to make a diagnosis [9]. In the end, Telegeria HD was indicated for specialties where, in addition to a clinical examination, the practitioner could rely on data transmitted digitally in making a diagnosis. The latter included radiographs for the orthopaedist, electrocardiograms or other examinations such as cardiac ultrasound for the cardiologist, pictures for the dermatologist. On the other hand, teleconsultations, such as those in psychiatry, requiring in-depth interactions with an elderly patient experiencing complex problems, were abandoned. Beyond constraints inherent in a clinical examination, we can also hypothesise that professional culture may also constitute a factor opposing the use of a teleconsultation system in the medical setting. In other words, habitual ways of doing things, or more precisely the ritualisation of daily professional practices as a means of increasing confidence in one’s effectiveness as a practitioner, may come into direct conflict with new practices resulting from use of the system [9,32,33]. Among possible factors of opposition should also be added the question of responsibility when caring for a patient one has not personally examined [45,46]. The number of specialists who accepted to take part in the experiment or were interested in it remained limited. One of the shortcomings of our study was not to have explored the reasons behind the reticence of those physicians who did not accept to participate. Finally, even though the health professionals were in agreement that patients were satisfied with the teleconsultation system, which, among other things, relieved them of a difficult transfer to a tertiary care hospital, questions remain on the true acceptability of the system by the patients [13,47,48] and the possibility that ethical issues may develop [46,49,50]. To definitively establish the success of the system, a qualitative evaluation needs to be carried out on the effects of teleconsultations on patients, especially elderly patients with visual, auditory or cognitive impairments who may feel frustrated by

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the absence of direct contact with the specialist during the teleconsultation. Ultimately, the important question for the future is whether teleconsultation will remain a context for privileged exchanges between specialists and geriatricians if geriatricians scarcely have the time to participate in it, or whether, for various reasons their motivation declines. Monitoring over the long term will clarify whether or not remote consultation will evolve in a more traditional and less collaborative direction.

6.

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Summary points What was already known on the topic: • In some isolated cases, it has been shown that teleconsultations may present difficulties linked to changes in medical practice, but not because of the technology used. • These changes may limit the long-term use of teleconsultations. • Qualitative research needs to be done on the social and organisational impact of telemedicine.

Conclusions What this study added to our knowledge:

Telegeria HD which enables specialist consultations between a geriatric hospital and a tertiary care university hospital proved to be a genuine innovation, allowing elderly patients, often with cognitive impairments, access to several medical specialties. The system has technical features allowing very high speed transmission of high quality sound and pictures. However, its use by health professionals required that, during the experimental phase, the project manager ensure articulation work that consisted in carrying out technical, social and clinical framing to shape the interaction of the different actors. The articulation work done by the project manager also consisted of coordination which in turn gave organisational and practical coherence to patient care. The use of teleconsultation required actors to adapt their clinical and organisational practices. Specialists had to learn to delegate routine clinical acts to geriatricians located beside the patients, thus necessitating new forms of cooperation and trust. This delegation imposed limits on the use of teleconsultation for elderly persons, both in terms of medical specialities and in terms of specific clinical situations. Generally speaking, even for specialists whose clinical practice was suitable for teleconsultations, the physicians agreed these should be limited to follow-up of a patient they already knew or for carrying out preliminary examinations to determine the need for a traditional consultation. Geriatricians who participated in teleconsultations at their patient’s side also had to make adaptations, and to show a certain amount of humility. They agreed, however, that teleconsultation made communication with specialists easier and provided them with new medical and clinical knowledge. Yet these teleconsultations had other important effects not tied to the technical system properly speaking but rather to its use, necessitating new organisational schemes, primarily in the geriatric hospital. These included the reorganisation of geriatricians’ schedules, the installation of a teleconsultation room, the setting up of a system of electronic medical records, etc. Above all, daily use of teleconsultation required the presence of a telemedicine assistant capable of maintaining a care relationship with patients while being proficient at operating the teleconsultation station and participating in various kinds of professional cooperation with specialist physicians. These changes should be acknowledged and encouraged by decision-makers to enable telemedicine systems to become permanent. In the end, the Telegeria HD system enabled the opening up of the geriatrics hospital by “letting in” the specialists from the

• The qualitative research methods used are appropriate for studying the impact of teleconsultations for elderly people on clinical routines and for assessing their limitations, which are dependent on the specialty and the patient situation. • The system studied brought about a reconfiguration of group work, the actual social relationships between health professionals, and it opened up the geriatric hospital to the outside. • The project manager performed articulation work that produced various types of framing (technical, social and clinical) and coordination, which in turn gave organisational and practical coherence to the care of patients. • The long-term establishment of the system required organisational adaptations.

tertiary hospital, providing a new way of looking at the work carried out by health professionals among elderly patients.

Role of funding source This research was financially supported by the Institut Francilien Recherche, Innovation et Société (IFRIS). IFRIS simply contributed financially to this study, without intervening in any way in the conduct of the project, in the study design, in the analysis and interpretation of data and in the writing of the manuscript. The manuscript was not submitted to IFRIS for publication.

Author contributions Both authors contributed towards the conception and design of the study, the observations of teleconsultations and the interviews, and the analysis and interpretation of data. They contributed in drafting the article and revising it. They both approved the final version.

Conflict of interest None of the authors have any conflicts of interest that could bias this work, its results and their interpretation.

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Acknowledgements We would particularly like to thank the project manager for the Telegeria HD experiment, Dr. Pierre Espinoza, for having given us full access to the experiment and for having allowed us to carry out our research under the best possible conditions. We also want to thank the physicians and health professionals at the Vaugirard hospital and the Georges Pompidou European Hospital for their unreserved welcome. This research benefited from the invaluable help of Pierre Chalmeton. Finally, we acknowledge the nice translation work from Jon Cook. In addition, we want to thank the anonymous reviewers for their very valuable comments on the earlier version of the article.

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