Chapter 4: Supporting Seamless Delivery of Telehealth Solutions

Telemedicine has a fairly long and rich history when one considers its roots both in the context of medicine and communication. ¹ Recent evidence clearly supports the use of telemedicine in a wide variety of clinical specialties in terms of feasibility, satisfaction, cost effectiveness, and clinical outcomes. ^2–7 The success of telemedicine is evidenced by the recent rapidity with which it has become a commercial enterprise that provides services “on demand” to patients outside of the traditional health care enterprise. ^8–10 The American Telemedicine Association (ATA) actually has an accreditation program that “recognizes organizations providing online, real-time patient health services that comply with operational, clinical and consumer-related standards. The program promotes patient safety, transparency of operations and adherence to all relevant laws and regulations.” ¹¹

Clearly telemedicine is here to stay, but it does and will take many forms just as traditional health care always has. Many factors contribute to the success of individual programs, of which many are discussed in the other chapters in this book, especially as they relate to individual clinical specialties. Common to the success of all enterprises, from academic to commercial endeavors, is the degree to which telemedicine becomes integrated into the existing system in order to effectively and efficiently deliver telehealth solutions. Again, many factors affect the successful integration of new delivery modes into established systems, but this chapter deals with two: leveraging common points between new and existing technologies and health care environments, and optimizing the environment within which telemedicine is practiced from a human factors perspective. To address the first point, we provide an overview of perhaps the most successful telemedicine application: teleradiology. Afterward we provide a review of some of the more common human factors issues that should be considered during the planning, implementation, and operation of telemedicine services.

Teleradiology is unique among telemedicine applications in that it grew out of the evolution of the specialty itself. Radiology by its nature is probably the most technology-dependent clinical specialty in existence and thus had an advantage over nearly all other specialties by having technology, technical support, practice procedures and knowledge, and research programs in place even before the “tele” option arose. Yet even with this infrastructure, radiology faced (and still faces) challenges when it came to convincing users that it was at least as good as traditional film-based radiology in terms of quality, diagnostic accuracy, cost, and utility.

Teleradiology has its origins in the development of digital radiography. For over 80 years patient care depended on film-based radiology, but these images had to be physically transported throughout a hospital, between hospitals, and between cities. This was very labor intensive and often involved radiologists doing “windshield” duty, driving from small town to small town to interpret batches of cases that had been acquired over the previous week or even month, delaying interpretation and thus treatment. Film-based radiology was also subject to lost or misplaced images. ^12,13

In the 1970s, the idea of an electronic-based imaging system replacing all X-ray film took root. Research with video-based and other digital detector systems primarily being conducted at the University of Arizona and the University of Wisconsin ^14,15 led to the first digital subtraction angiogram being successfully performed and reported in 1977 followed by other digital imaging applications. ^16–18 All of these early efforts led to digital radiology as we know it today and made direct transmission of digitally acquired images possible for teleradiology. ¹⁹

From an integration point of view, it is very difficult to distinguish teleradiology from radiology today, as from the perspective of the radiologist, the majority of the workflow is very much the same. Before digital radiography, images were acquired and viewed on pieces of film that were put on a lightbox for viewing and interpretation. Digital imaging changed this dramatically. Although printed to film in the early days, it soon became obvious that digital images are most effectively displayed on digital/electronic computer monitors. This led to increased interacting between image and viewer as radiologists could now use window/level techniques to adjust the contrast of images, use zoom/pan (instead of a magnifying glass and hot light) to view fine image details at high resolution, and use image processing and image analysis tools to extract more information from the images and render more accurate decisions. Once digital images were introduced, computer-aided detection and diagnosis tools were rapidly developed and are becoming commonplace in many radiology applications such as breast and lung screening. ²⁰

In this transition from film to the digital world, however, issues arose that affected integration and acceptance of the new technologies—very much in the same ways that new technologies for other telemedical applications face integration challenges. In the transition, film images were the gold standard against which digital was judged due to its higher resolution and rendition of fine details required for interpretation (in fact, film is still technically better than digital in this respect). Complicating the transition to digital display was the fact that electronic displays in the 1980s and early to mid-1990s were basically inadequate in terms of resolution and contrast. As a result of the mismatch between high-quality, high-resolution digital images and low-quality, low-resolution displays, significant developments in medical-grade display technology were started in the late 1980s and actually continue to today as new display technologies are developed.

The first displays used for digital radiographs were cathode ray tubes (CRTs), ^21–23 and issues such as luminance and even the type of phosphor in the display faceplate were variable and less than ideal. Today liquid crystal displays (LCDs) and variants (organic light-emitting diodes, or OLEDs) are the norm in most radiology reading rooms. ^24,25 As with telemedicine in general, the quality of images is the deciding factor on whether users (radiologists) are satisfied with the information presented to them clinically. ^26,27

Some of the key display parameters that have guided the development of these displays are directly related to the perceptual requirements of the radiologists and the digital nature of the images, and the complex nature of the anatomic structures and lesions in those images. ²⁸ All of these factors are also important in telemedicine displays, including luminance (or brightness) and contrast, ^29,30 viewing angle, ^31,32 calibration methods, ^33,34 and, more recently, the use of color and commercial off-the-shelf displays instead of more expensive medical-grade monochrome and color displays. ^35–37 It is important to note that much of this foundational research on display optimization has been incorporated into the major practice guidelines for the practice of digital radiology and teleradiology. ^38–40 Today even laptops, iPads, and smart phones are being considered for use, especially in teleradiology for viewing images ^41–44 and capturing images. ^45–47 Many of the recommendations in these guidelines are directly applicable to telemedicine applications and should be referenced as feasible when designing a telemedicine work area.

Another key aspect of integration that helped advance teleradiology was the development and use of the DICOM (Digital Imaging and Communications in Medicine) standard. ^48,49 In fact, the DICOM standard is used today in many telemedicine applications as a tool for formatting, transmitting, and archiving visible light and other images (eg, ophthalmology, pathology, dermatology). The development of technical standards to optimize interoperability across platforms and institutions was fundamental to teleradiology, and the lessons learned in radiology are readily transferable to telemedicine in general.

Through joint efforts of the American College of Radiology (ACR) and the National Electrical Manufacturers Association (NEMA), DICOM was developed in 1993. DICOM is an internationally accepted standard for medical images and metadata (now extending beyond radiology to visible light and other images used in telemedicine) with respect to handling, storing, printing, and transmitting image and other medical record information. It includes standards for file format and network communications. For example, the communication protocol uses Transmission Control Protocol/Internet Protocol (TCP/IP) for system communications enabling system interoperability or the exchange of image and patient data in a standard format so that images acquired on a device from one vendor can be viewed on any workstation.

The display used in teleradiology is obviously critical for efficient and accurate diagnoses, and the same is true in any telemedicine application. Two DICOM standards are important when considering displays: the Grayscale Presentation State Standard (GSPS) and the Grayscale Standard Display Function (GSDF). These are not only important for teleradiology but also for any other tele-application in which radiographic images would be viewed—for example, telestroke, teleorthopedics, telesurgery, and telecardiology, to name a few. GSPS is a data object associated with an image specifying how it should be presented on any DICOM-compliant viewer. It includes features such as customized look-up tables (LUTs), text overlay, and zoom/pan. The GSDF addresses the issue of having multiple displays from multiple vendors, each with different luminance ranges, white points, and minimum and maximum luminance settings. Standardization was required because the same image would look very different depending on the display it was viewed on. The GSDF maximizes the perceptibility of information and promotes consistency of presentation across different displays. As a calibration tool, it is based on the concept of perceptual linearity across grayscale values, so changes in image pixel values across a grayscale range are perceived as having similar contrast.

A similar display standard does not exist for telemedicine or for color medical images in general, whether for telemedicine or standard clinical uses. This has been the topic of a number of papers, with a recent consensus report ⁵⁰ being the most relevant to telemedicine. It is noted in this consensus report that areas that would benefit the most from consistency and standardization of color would be digital microscopy, telemedicine, medical photography (eg, ophthalmic, dental photography), and display calibration. It provides overviews of some of the most critical color applications (including telemedicine) and then notes that a variety of important organizations are addressing this issue, including DICOM, American Association of Physicists in Medicine (AAPM), International Color Consortium (ICC), International Commission on Illumination (CIE), International Engineering Consortium (IEC), Video Electronics Standards Association (VESA), International Committee for Display Metrology (ICDM), and the American College of Radiology (ACR). It does provide reference to some methods available for calibrating color displays.

At the heart of any radiology or teleradiology enterprise is its Picture Archiving and Communications System, or PACS. A PACS is usually composed of various digital acquisition imaging systems (eg, computed radiography/digital radiography [CR/DR], magnetic resonance imaging [MRI], computed tomography [CT]), a secure network for transmitting images from those devices to workstations (onsite or offsite as with teleradiology), archives (onsite, offsite, or cloud based) to store and retrieve images and related data, and viewing terminals (eg, workstations, mobile devices). Increasingly, PACS systems that were traditionally limited to radiology departments and their images are becoming enterprise-wide transmission and archiving systems that many departments use not only for routine images but also for those used in telemedicine practices. ⁵¹ Images from devices such as digital cameras, endoscopes, digital slit cameras (ophthalmology), digital otoscopes, and many other devices are being stored in and retrieved from PACS systems (often using a DICOM wrapper).

As with telemedicine in general, the main drivers for teleradiology were the need for after-hours (∼5:00 P.M. to 8:00 A.M., weekends and holidays) coverage for urgent and emergent radiologic studies ^19,52 and the need for subspecialist or expert reads. Even in its more advanced stage of acceptance and integration, however, there is still considerable debate in the radiology community regarding its use, regulation, and commoditization, ^53–63 with many of the same concerns being raised in many other clinical specialties using telemedicine. It is clear and evidence supports its role, and with appropriate care ⁶³ and consideration, one can select an appropriate teleradiology or any other telemedicine provider.

On the regulatory side, telemedicine may someday soon follow the path of teleradiology in some aspects. For example, how well teleradiology has been integrated into general radiology practice is demonstrated by the ACR Teleradiology Guidelines and its history. The ACR Standard for Teleradiology was first issued in 1994 and was revised in 1996, 1998, and 2002. In 2007 the ACR sunset it, as everyday digital practice could not be differentiated from teleradiology. Recently released white papers on teleradiology practice from the ACR and the European Society of Radiology summarize the pros and cons of teleradiology and comment on best practices. ^64–66 With respect to licensing, the ACR position is that physicians who interpret images originating from another state must be licensed and credentialed at the site of origin of the images and in the state they are doing the interpretation. ^67,68 Telemedicine has a number of practice guidelines as well (many from the ATA), and some of them have been updated over the years much like the ACR guidelines—and in many cases deal with similar issues: quality, process and procedures, legal and regulatory, safety, and privacy and security. It will be interesting to track these guidelines to see when and if they, too, sunset at some point in time!

The key thing to remember in any telemedicine enterprise is that although technology is integral to telemedicine, telemedicine is not about the technology, but rather about the people. Integration of technology obviously has its own challenges (in general a good Information Technology [IT] department can solve practically anything), but many would say it is the integration of people into the telemedicine environment that is the main challenge. In many cases, taking care of some rather basic and often commonsense variables makes this integration easier, as the users then do not have to worry about all the “peripheral” aspects and can concentrate on the consultation. For example, one early consideration is the patients likely to be seen and what types of consultations will take place. A clinic for geriatric patients needs to account for their vision, hearing, and mobility challenges in the room design; pediatric rooms need to include toys or books to entertain the kids while they are waiting for consultations to start; and telesurgery clinics needs to position cameras and other equipment around the existing surgical equipment and tools. Even radiology room design was important in the transition from film to digital. With film, the film alternators or lightboxes used to face each other (with radiologists looking at the images and their backs toward each other). This was replicated with the move to digital and teleradiology, but it was quickly realized that it would not work because the monitors facing each other across the rooms produced reflections and glare that interfered with image quality and the interpretation process! Rooms had to be redesigned to address this, often using walls and other room separators to isolate workstations from each other (also isolating radiologists to some extent from each other).

Where the consult room is located is important. ⁶⁹ In the early days (and now) there were stories about how janitor closets and other spare (but inappropriate) rooms were converted into telemedicine rooms simply because they were there and unused (and often remained unused for telemedicine, as they were inconvenient to get to or simply too small or poorly designed for effective use). A room near the outpatient check-in area of a hospital or clinic will likely have a wide variety of cases referred to telemedicine simply by proximity and familiarity. If it is situated in a pediatric wing, it will attract pediatric cases but likely not adult cases. One easy solution is to have a dedicated telemedicine room with portable equipment that is easy to deploy and move to where the patient is located. This is quite easy with teledermatology (especially store-forward) as the key piece of equipment is a digital camera and dedicated task lighting. Transporting a cardiology patient to the telemedicine clinic may be less feasible, but portable electrocardiogram (ECG) devices can be taken to the patient. Synchronous real-time (RT) services are increasingly portable using tablets, smart phones, and roaming robots. These portable devices are very useful with elderly and disabled patients.

It is useful to plan the layout of a room in advance of using it for telemedicine. Measure it and draw a floor plan, including locations of features such as doors and windows, HVAC (heating, ventilation, air conditioning) vents, electricity and plumbing fixtures, telecommunications lines, lighting fixtures, and so on. It often helps to act out clinical scenarios so equipment and furniture needs and locations are anticipated and space accounted for. Telerehabilitation consults, for example, may need to evaluate patient gait and ability to navigate between locations by having them walk from one end of a room to the other, so the room has to be long enough and free of obstacles to avoid tripping or falling; have enough room to accommodate walkers and other assistive devices; and the videoteleconferencing (VTC) equipment has to be situated properly and flexible enough to move the camera as the patient walks.

The arrangement of telemedicine equipment (eg, carts, cameras, docking stations, peripherals) should be considered. Rooms (even revamped closets!) should not be too crowded with lots of wires hanging loose or running along the floor without being taped down or secured. Provider and patients, especially those with mobility or stability issues and using a cane, walker, or wheelchair, should not have to worry about tripping over things, bumping into equipment, and injuring themselves.

In radiology, standard ergonomic concerns with workstations such as monitor height, monitor distance, mouse placement, and task lighting have been of concern since going digital, ²⁵ and many of the human factors and ergonomic considerations addressed for teleradiology transfer directly to telemedicine. The ambient environment needs to be considered. In some areas (both rural and urban), dirt or dust blowing in from the outside can ruin equipment and cause problems for patients and clinicians (eg, telepulmonology clinics where patients already have respiratory problems). Using dust filters for the air system helps. Controlling temperature is important as telemedicine rooms have lots of electronic equipment that can generate extra heat. Even short amounts of time in a small hot room can exacerbate symptoms of ill and stressed patients. Fans and dehumidifiers can help with these conditions (or heaters in large or cold rooms).

Lighting is very critical, and lots of options are available. There are obviously differences for teleradiology and other specialties, but again teleradiology serves as a model. For example, all of the technical practice guidelines ^38–40 for digital practice include statements about ambient lighting (should be 25 to 45 lux in most cases) as it affects the quality of the images displayed on the workstation monitors and thus diagnostic performance. The same types of considerations hold for telemedicine. When there are no patients (eg, reviewing store-forward images or charts), standard office lighting for computer environments can be used, but brighter lights may be needed when a patient is present.

A single lighting system may not suffice. The lighting should be adjusted as appropriate during exams or when images are being acquired. Some key points to consider include:

• Artificial “natural” light is preferred

• A range of 3200 to 4000 K is recommended as it is a warm, white light

• Avoid colored lighting (eg, yellow)

• Fluorescent is preferred

  • Usually 3500 K low-end “home” use, but commercially can get white light 5000 K

  • Dedicated fixtures (indirect wash fluorescent fixtures) are available specifically for videoconferencing and are available in cool white to reduce ambient heating

• When acquiring digital photos, the room should be well lit (150 foot-candles) using light white light, fluorescent daylight, or full-spectrum bulbs instead of incandescent bulbs

• For RT, the best lighting is 300 to 500 lux and angled away from the participants to avoid shadows

  • Place and aim fixtures to achieve vertical illumination on subject 35 to 40 degrees above horizontal

• Avoid traditional downlighting, as it creates facial shadows

• If only one light source is used, place it as close as possible in the same direction as the camera, but in back of the camera

• Multiple frontal light sources are recommended as this improves the “3-D” effect

• Backlighting helps the body stand out from the background

• Use desk lamps as task lighting and fill lighting to compensate for poor lighting conditions

• Avoid reflecting/glare surfaces in the field of view

  • Avoid white doctor's coats as they create reflections

The background is important as well:

• The recommended wall color is light blue, but only one or two walls

  • The color temperature (physical measurement in degrees Kelvin comparable to hue) should not affect the appearance of the skin

  • Use flat latex blue paint rather than gloss or semigloss to avoid glare and reflections

• Avoid clutter and distracting details or objects in the background

Display (monitor) options vary considerably, but some factors to consider include:

• Large monitor screens (≥50 inches) are useful in the clinic setting, but smaller monitors also work well

• HD (high-definition) cameras and displays are readily available at a reasonable cost

• Traditional desktop displays and mobile devices are very useful for reviewing store-and-forward (SF) data

• If viewing radiographic images, adequate spatial and contrast resolution is required

  • It is not necessary to use a medical-grade radiology display, but it should be properly calibrated for reading radiographic images (DICOM GSDF)

• Calibrate color displays as feasible

  • Standards regarding what type of calibration should be performed do not exist, but there are some easy methods to at least standardize the appearance of color images ⁵⁰

• When using multiple displays, it is important to angle them optimally to avoid strain on the neck, back, and shoulders (Figure 4-1)

• Audio and cameras are critical factors as well, whether separate or integrated systems

• Speaker and microphone capabilities and placement need to accommodate all types of users

  • Some patients, like the elderly, are soft spoken or have trouble projecting, so microphones should be placed close to them

  • With mobile devices, move the device close to the speaker (if the same device serves as the camera, this can be a problem)

  • Speakers may need to be placed closer or the volume turned up to compensate for hearing loss/difficulties

• Cameras with as high a quality as possible should be secured on a stable platform to avoid wobbling and shaking

  • Tablets and phones may need stands to stabilize them

• Cameras should be placed at eye level with the face clearly visible to the other person

Workstations are abundant in traditional practice, as well as telemedicine, by virtue of increased use of electronic health records and simply everyday computer use. Care should be taken, however, because concerns arise as use increases. Radiology in particular has seen an increase in computer-related injuries and concerns about increased stress and fatigue (Figure 4-2) the more digital it has become ^70–71 . There has also been an increase in the awareness of fatigue in the digital environment and its impact on diagnostic accuracy and efficiency. ^72–76

For example, it can take longer to find abnormalities like fractures in X-ray images the later in the day a radiologist reads them (Figure 4-3). Adhering to guidelines for good ergonomic computer use can help. ⁷⁷ Using the 20-20-20 rule can help as well: every 20 minutes of working at a computer display, look 20 feet away for 20 seconds. Getting up every now and then helps as well, given recent concerns about sedentary behavior due to computer use in medicine. ⁷⁸

Telemedicine is fundamentally just a tool to improve the delivery of health care services, but it still requires attention to a number of details if it is going to be integrated efficiently and effectively into an existing or even a new telehealth practice. Teleradiology serves as a model of some of the issues and challenges that can arise when making the transition from traditional to technology-based modes of delivery. Adherence to guidelines regarding technology optimization, environment design, human factors, and ergonomics can readily facilitate the transition and reduce resistance and stress, making the experience beneficial and pleasant for patients and providers alike.