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We examined 62 telehealth websites using four assessment criteria: design, literacy, information and telehealth content. The websites came from the member list of the American Telemedicine Association and the Office for the Advancement of Telehealth and partner sites, and were included if they were currently active and at least three clicks deep. Approximately 130 variables were examined for each website by two independent researchers. The websites reviewed contained most of the design variables (mean 74%, SD 6), but fewer of those relating to literacy (mean 26%, SD 6), website information (mean 35%, SD 16) and telehealth content (mean 37%, SD 18). Only 29% of websites encouraged users to ask about telehealth, and 19% contained information on overcoming telehealth barriers. Nonetheless, 84% promoted awareness of telehealth. All evaluation assessments were significantly correlated with each other except for literacy and information. The present study identified various matters that should be addressed when developing telehealth websites. Although much of this represents simple common sense in website design, our evaluation demonstrates that there is still much room for improvement.

We investigated why hospice nurses were slow to adopt videophones to care for their patients. We used the unified theory of acceptance and use of technology (UTAUT) model and the organizational readiness for change (ORC) assessment via interviews and focus groups with hospice staff. Twenty-five hospice employees participated. Eighteen (72%) were in clinical positions and seven were in non-clinical positions (28%). Thirty-nine percent of respondents reported no videophone training, despite the fact that every employee had received training. Only four staff members actually used a videophone with patients. The respondents overwhelmingly stated that they had the organizational resources necessary to use the videophone and that it was easy to operate. Despite initial enthusiasm, leaders in the hospice agency did not endorse the videophones for work, nor offer incentives for using the videophones or providing them to patients. It is important to note that videophone technology is not meant to replace face-to-face visits, but to supplement them and to provide an additional tool for the nurses.

In Michigan, the use of telemedicine for dialysis patients began in three centres in 2005. A total of 747 clinical consultations was conducted in the following 22 months. Telephone surveys were conducted with 34 patients and four providers. The patients and providers all had positive perceptions of the telemedicine system and the care that was delivered. Most of the clinical measures of the patients met or exceeded the recommendations made by Renal Network 11. In addition to the clinical work, the telemedicine equipment was used for educational events. Twenty-six professional educational events were provided with a total audience of 105 individuals, and 35 administrative meetings were provided with 286 staff members in attendance. The study showed that patients and providers could participate in educational events that might not be available locally. Despite the success of dialysis telemedicine, the Marquette General Health System discontinued its use in 2007 when the Center for Medicare and Medicaid Services re-affirmed that dialysis centres were not approved sites for telemedicine.

We evaluated the use of home telehealth for patients with chronic obstructive pulmonary disease (COPD) and/or congestive heart failure (CHF). Patients diagnosed with COPD and/or CHF who were prescribed home health-care services were randomly assigned to an experimental group where they received home health care through a combination of traditional face-to-face and telemedicine visits (n = 83), and a control group where only conventional home care was employed (n = 78). Data were collected via the Short Form 36 (SF-36), Outcome and Assessment Information Set (OASIS) and patient charts. In the experimental group, patient perceptions of the home telecare services were collected via telephone interviews. Overall, the addition of telehealth to COPD/CHF patient care was not a significant predictor of health and wellbeing, either positively or negatively. Although those receiving telehealth had worse ratings on the SF-36 general health subscale after the intervention, this measure was only significant when controlling for a number of key variables in the model. In regard to patient perceptions of home telecare, patients were satisfied with the technology and the way that care was delivered via this modality.

We conducted a systematic review of 15 relevant databases for articles about telemedicine. After eliminating articles that did not meet the inclusion criteria, 1615 remained for analysis. Three raters coded the articles to assess various theoretical and methodological variables. Only 5% (n = 85) of the telemedicine articles made mention of any theory or paradigmatic approach. Studies commonly reported the objectives (96%) but rarely stated a research question or hypothesis (11%). Randomized selection of the subjects was reported in 11% of patient studies and 4% of studies where providers were the subject. There was a wide range in the number of subjects employed, although the majority of studies were based on sample sizes of less than 100. Only 26% of the studies reported a time frame. Until the telemedicine field adheres to agreed standards of reporting methodological details it will be difficult to draw firm conclusions from review studies.

We used qualitative interviews to examine the perceptions of direct providers of telemedicine services, primary care providers (PCPs) and hospital administrators about opportunities and barriers to the implementation of telemedicine services in a network of Veterans Health Administration hospitals. A total of 37 interviews were conducted (response rate of 28%) with 17 direct telemedicine providers, nine PCPs and 11 administrators. The overall inter-coder reliability across all themes was high (Scott's pi = 0.94). Direct telemedicine providers generally agreed that telemedicine improved rapport with patients, and respondents in all three groups generally agreed that telemedicine improves access, productivity, and the quality and coordination of care. Respondents mentioned several benefits to home telemedicine, including the ability to better manage chronic diseases, provide frequent clinician contact, facilitate quick responses to patient needs and provide care in patient's homes. Most respondents anticipated future growth in telemedicine services. Barriers to telemedicine implementation included technical challenges, the need for more education and training for patients and staff, preferences for in-person care, the need for programme improvement and the need for additional staff time to provide telemedicine services.

Policy-makers and researchers lament the absence of telehealth registries to enhance knowledge regarding outcomes and efficacy of telehealth interventions. A number of different organizations operate registries, but there do not appear to be any true telehealth registries. One reason is that federal requirements through such policies as the Health Insurance Portability and Accountability Act (HIPAA) have led to heightened fear of inadvertently releasing confidential or unauthorized information. Also, it would be more efficient if patient data were captured electronically at the local level, ideally through electronic medical records (EMRs), and then transferred electronically to registries. However, the diffusion of EMRs at the local level is in its infancy. As a result, it is unlikely that we will see a comprehensive telehealth data repository within the next decade.

Over the last few years, telepsychiatry services in Michigan have been developed by LifeWays, a Medicaid-managed behavioural health-care organization. The project had four phases, involving the introduction of telepsychiatry services between a rural and an urban clinic, to a crisis intervention centre, to a youth detention centre and to patients' homes. The role of organizational issues in the success of the programme was examined through patient interviews, provider interviews, patient and provider pre- and post-project focus groups, and service documents. Utilization data were obtained from activity logs and patient charts. During the study, 297 clients received 578 teleconsultations. Almost 97% of the telepsychiatry visits were scheduled. Telemedicine usage varied between the four project phases. The reasons for its variation in use included provider roles, existing organizational strategic goals and resources, the inherent organizational culture and quirks, and leadership and managerial factors. The major difficulties stemmed from the providers and the organization itself. There is tremendous potential for telepsychiatry and the ways in which organizational variables can be managed to influence the success of telepsychiatry programmes deserve further study.

We studied two rural telemedicine projects in the state of Michigan: one that enjoyed success and steady growth in activity, and one that experienced frustration and a lack of clinical utilization. Multiple data collection strategies were employed during study periods, which lasted approximately one year. Both projects enjoyed a grassroots approach and had dedicated project coordinators. However, the more successful project benefited from resources and expertise not available to the less successful project. In addition, the more successful project possessed a more formalized organizational structure for the telemedicine application. A comparison of the two projects leads to a simple conclusion. Telemedicine programmes are positioned within larger health organizations and do not operate in a vacuum. It is crucial that the organization in which it is intended to launch telemedicine is examined carefully first. Each organization operates within a larger environment, which is often constrained by fiscal, geographical and personnel factors. All these will affect the introduction of telemedicine.

Telemedicine programmes are often complex undertakings that result in combinations of success and failure. Michigan State University and LifeWays received a grant for a four-phase telepsychiatry research project in 2000. We employed multiple data-collection techniques, including patient and provider surveys, in-depth interviews, observation, patient chart analyses, and organizational archival data analyses. Of the four phases in the project, two proved to be successful, one failed in its initial goal but succeeded with a redefined goal, and one failed completely. Issues that affected success or failure included human resource conflicts, organizational structure, inter-organizational relationships and allocated resources.

Two large hospice organizations in Kansas and Michigan began a telehospice project with the goal of improving care at the end of life using telemedicine. Hospice nurses provided services using video directly to the homes of hospice patients. The telemedicine equipment operated over ordinary telephone lines. Nursing services included symptom assessment and psychospiritual evaluations. Patients lived in both urban and rural settings. Studies were designed to evaluate utilization patterns, access to care, patient/carer acceptance, medical outcomes and cost. During the first year of the project, telehospice care was initiated at five rural sites (two in Michigan and three in Kansas) and three urban sites (two in Michigan and one in Kansas). There was greater telehospice activity in Michigan than in Kansas, with 118 and 44 patients served, respectively. The urban site in Kansas withdrew from the study after participating for only nine months. In an effort to understand the difference in utilization patterns and reasons for withdrawing from the project, in-depth interviews of key study participants, including hospice administrators, nurses and research personnel, were conducted. Human factors appear to be important in the adoption of novel telemedicine applications.

A telemedicine network has operated in the Upper Peninsula (UP) region of Michigan since 1995. The Marquette General Health System (MGHS) is the tertiary hospital that provides telemedicine services to 14 surrounding rural health facilities and another seven clinics. In order to assess the state of telemedicine in the UP region and its potential for development, three main factors were assessed: organizational development, telemedicine activity and perceptions of the key players. Data were collected through interviews with five MGHS telemedicine staff, 10 physicians (five from the MGHS and five from surrounding rural areas), 13 of the 14 chief executive officers (CEOs) of the remote telemedicine sites and a survey of 21 telemedicine site coordinators. This information was analysed in order to outline job roles and responsibilities; to document the process of doing telemedicine; and to understand current policies and procedures. Telemedicine activity from 1995 to 1999 was analysed in terms of the purpose of the session. In 1999, a total of 515 telemedicine sessions were conducted, 323 being non-educational and 192 being educational. Most CEOs of the rural hospitals were interested in furthering their use of clinical telemedicine applications. The data also indicated a great need for education, particularly of the rural physicians. The overall view of those surveyed about MGHS's telemedicine programme was positive. Respondents were quick to compliment the staff whenever possible. New telemedicine staff have been employed, which will allow responsibilities to be reassigned in such a way as to create a more efficient system.

We attempted a meta-analysis of telemedicine research studies of the costs associated with telemedicine. First, we performed a search of six well known databases with a variety of relevant keywords. After discarding non-English publications, books and duplicate publications resulting from the same study, we were left with 551 articles for analysis. Our second step was to separate the articles into two groups: those with and those without quantitative cost data. Only 38 articles contained any type of real data. Because many of these 38 studies proved to be inadequately designed or conducted, we were unable to perform a traditional meta-analysis. Furthermore, there were a number of disturbing features common to these studies, including the omission of the number of consultations or patients, almost non-existent longitudinal data collection and lack of uniformity in cost analyses. We conclude that it is premature for any statements to be made, either positive or negative, regarding the cost-effectiveness of telemedicine in general.

Local and county jails rarely offer telepsychiatry services to their inmates. We have established a telepsychiatry pilot project between the Kansas University Medical Center and the Lyon County Jail in Emporia, Kansas. A total of 264 telepsychiatry consultations were conducted with jail inmates. Of these, 70 were initial evaluations and 194 were follow-up visits; only one inmate refused to be seen. Approximately one-third of all inmates were seen for psychiatric consultation within one week of their incarceration and 68% were seen within one month of incarceration. Among lessons learned during the first year of service were: the monthly demand for consultations was five times greater than projected; moderately to severely ill inmates with a broad range of psychiatric illness can be seen and treated effectively using videoconferencing; and the technology was accepted by the jail personnel and the inmates alike and integrated into the jail's routine in terms of the delivery of psychiatric care.

In 1997, a telemedicine project began in Kansas which brought health-care directly into elementary schools using interactive video-links. The project initially involved four schools, but was expanded to cover 10 schools, including two middle and one high school. We examined the organizational issues related to telemedicine links to schools. Specific attention was paid to the perceptions of the nurses, teachers and key administrators. The research involved analysing archive data and interviewing participants in the project from the schools and the medical centre. The results showed the difficulties in delivering health-care, especially by telemedicine, to under-served urban children. However, the data also revealed that these can be overcome. Once they had experienced it at first hand, almost all concerned began to see telemedicine as an effective and important asset to the delivery of health-care.

We studied patients' perceptions of telemedicine (interactive video) as a means of delivering specialist oncology/haematology care. Semistructured telephone interviews were performed with 22 patients attending a tele-oncology/haematology clinic in Kansas. Interviews were audio-taped and thematic content analysis of the transcripts was done. The response rate was 96%. All participants expressed satisfaction with their tele-consultations. For 50% of respondents, satisfaction with the tele-oncology/haematology clinic was qualified by two factors: participants also saw the specialist in person on occasions and the clinic was perceived as providing mainly a 'monitoring' function. In addition, 9 of the 22 patients expressed concern about the role of the nurse as a proxy for the doctor in performing certain parts of the physical examination. Overall, participants valued improved access to specialist services but had clear views as to the limitations of such a service. As the use of telecommunications technology grows, patient perspectives merit greater attention.

In the USA, children in low-income, medically understaffed areas have difficulty accessing health care. A pilot telemedicine service was established in Kansas, linking four elementary schools with a local hospital at 128 kbit/s. PC-based videoconferencing systems, a stethoscope, an otoscope and fax machine were installed for each school's nurse. During the first three months of operation, 187 consultations were conducted by a hospital physician over the video-link. Ear, nose and throat problems were the most common reason for referral (29%), followed by dermatological problems (20%) and mandatory school physicals (20%). Prescriptions were issued in 67% of cases. Eighteen per cent of children required referrals for specialist care. The pilot service successfully enabled medically disadvantaged children to receive health care and prompted four additional schools to join the project.

We have studied nurse reactions to a prototype home health telemedicine system. The system used interactive video through the local cable television network. Six nurses were directly involved with telecare video-visits. There were 54 patients. The average age of the patients was 76 years (range 21-101). Thirty-six (67%) patients were female and 18 (33%) were male. The patients had an average of 4.6 different diagnoses (range 1-16). They were also on a very wide range of medications (mean 9.9, range 2-23). Nurses overwhelmingly felt the system was effective for what this particular project was trying to accomplish. They were enthusiastic about the prospects of practising nursing by telemedicine, even though they had reservations about aspects of the particular system being used. Their main complaints were about limitations of the software and limitations of the telecommunication system that linked them to the patients.

Pilot studies have suggested that telemedicine is a satisfactory means of delivering nursing services into the home. A home telecare programme in Kansas provided nursing services to homes in four towns in Kansas. The present study examined patients' and nurses' perceptions of a variety of issues related to home telecare. Data-collection methods included in-depth interviews, observation and analyses of archival data from patient records. Patients suffered an average of 4.6 concurrent illnesses. On the whole, patients perceived the system as a valuable resource that offered great potential, although many saw no immediate health benefits for themselves. Nurses were enthusiastic about the prospect of practising in this way, although they did have strong opinions about what types of nurses, patients and illnesses were suited to telemedicine.

Elderly individuals involved in a home telenursing project were studied. The project nurses provided home health services from 'telenursing cockpits' located in three separate sites in Kansas. A cable television-based interactive video system was used to transmit video pictures at 30 frames/s, with 288 horizontal lines of resolution. During phase 1 of the study, interview data were collected from 22 subjects (4 men, 18 women). During phase 2, the original participants were contacted but only 9 (1 man, 8 women) were still receiving home health services. Contrary to expectations, the technology was not an important issue for the participants. They did not express any particular worry or excitement about it. Nor did they describe difficulties in adapting to its use. Use of telemedicine technology did not appear to have any negative effects on communication. The results suggests that further thought needs to be given to defining clearly the purpose and goals of telemedicine projects.

We investigated the perceived quality of teleradiology services offered at a rural hospital in comparison with radiology provided by three other methods: 'circuit riding', an on-site radiologist, and a hybrid arrangement. The research design was a case study, with interviews of administrators, technologists and physicians at the rural hospital, followed by a structured survey of all staff physicians. Responses were analysed both qualitatively and quantitatively. Both interviews and the survey indicated that teleradiology was perceived to be as accurate as on-site film interpretation. All other aspects of the service--efficiency, reports, communications and the overall contribution to patient care--were judged to be poorer than on-site radiology. We conclude that the provision of acceptable teleradiology requires considerable attention to all aspects of the radiology service, with attention to differences in institutional culture and mission, and to communication.

The purpose of our study was to investigate knowledge of, attitudes to, and use of interactive telemedicine for specialist consultation among rural practitioners Kansas. We interviewed 28 rural primary-care practitioners at seven remote health-care facilities in six locations. Content analyses of the interviews showed universal but superficial knowledge of telemedicine, appreciation of the value of the technology, but relatively low usage of the telemedicine service available (32% of subjects). Physicians did not appear to be afraid of change. Telemedicine usage was not related to the professional characteristics of the physicians. Our findings suggest that further growth in the use of telemedicine will depend on efforts directed towards physicians which are aimed at creating a more user-friendly environment and at accommodating the referral practices of potential users.