International Journal of Medical Informatics (2005) xxx, xxx—xxx

A comparison of communication models of traditional and video-mediated health care delivery George Demiris a,∗, Santosh Vijaykumar b a

Department of Health Management and Informatics, University of Missouri-Columbia, 324 Clark Hall, Columbia, MO 65211, USA b School of Journalism, University of Missouri-Columbia, USA Received 10 January 2005; accepted 22 March 2005 KEYWORDS Communication; Telemedicine; Dermatology; Interpersonal relations

Summary Background: While there may be benefits that accrue to the use of telemedicine technology in patient care, such as decreased costs and improved access, it has yet to be determined how telemedicine impacts patients’ ability to express themselves and accordingly, how it impacts health care providers’ communication of instructions or expressions of empathy. Aim: The aim of this study was to examine the effect of telemedicine technology on communication by comparing the style and content of communication between actual (i.e., face to face) and virtual (i.e., non-face to face, telemedical) dermatology visits. The hypothesis was that there is no difference in the content and style of communication between actual and virtual visits in dermatology. Methods: Face-to-face and video-mediated dermatology sessions were observed and also audiotaped, timed and transcribed. A content analysis was performed. Results: Average duration of a face-to-face session was 11 min (S.D. 0.08) and of a telemedical session 9 min (S.D. 0.002). Small talk occurred in 20% of all face-toface and 29.6% of all telemedical visits. Clinical assessment occurred in all sessions. Patient education occurred in 90% of face-to-face and 78% of telemedical visits. Other themes were also identified (e.g., discussion of treatment, promotion of compliance, psychosocial issues). In 14.8% of telemedical sessions technical issues were raised. Findings indicate that communication patterns in the two modes of care delivery are comparable. © 2005 Elsevier Ireland Ltd. All rights reserved.

1. Introduction * Corresponding author.

E-mail address: [email protected] (G. Demiris).

Telemedicine is a general term that refers to a wide range of technologies and applications. In a broad

1386-5056/$ — see front matter © 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijmedinf.2005.03.018 IJB-2108;

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2 sense it is defined as the use of medical information ‘‘exchanged from one site to another via electronic communications for the health and education of the patient or health care provider and the purpose of improving patient care [1].’’ A survey by the US Healthcare Information and Systems Society (HIMSS) found that the majority of the responding health care executives currently use or plan on using telemedicine [2]. The three characteristics of health care delivery that telemedicine has the potential to impact, are cost of, access to and quality of care. Telemedicine’s impact on cost of care has been studied in several settings [3—5]. Access to care has been addressed by designing telemedicine applications for rural and urban underserved populations. However, telemedicine’s impact on quality of care remains unexplored to some extent. Although some argue that telemedicine will alter the pattern of doctor—patient communication [6—8], this claim has not been investigated and there is no consensus as to whether telemedicine enhances or damages the therapeutic relationship or the traditional practice of medicine [9]. This lack of information on the relational aspects of telemedicine needs to be addressed given the fact that the interaction between patient and provider in traditional care settings have been found to have great impact on both immediate and long-term medical outcomes [10,11]. One might argue that technology alters the interaction between provider and patient and decreases quality of care due to the lack of personal contact. Face-to-face interactions are considered ‘‘more spontaneous, free-flowing and fasterpaced than videoconference interactions [12].’’ Therefore, one might expect that the range of issues addressed during a virtual visit differ from those of an actual visit. A typical teleconsultation usually involves at least three people and thus, is based on a ‘‘hybridization’’ of face-toface and mediated communication. Finally, the use of technology could possibly result in limited patient participation. The lack of patient participation is potentially significant because patients tend to value the opportunity to express their concerns, questions and opinions when seeking care [13,14]. Communication between patient and provider affects patient satisfaction, symptom burden, number of referrals [10], and medical outcomes [11]. While there may be benefits that accrue to the use of telemedicine technology in patient care, such as decreased costs [5,15] and improved access, it has yet to be deter-

G. Demiris, S. Vijaykumar mined whether telemedicine enhances or inhibits patient’s communication of their discomfort, symptoms and emotional state, and accordingly, whether it encourages or inhibits doctor’s communication of instructions or expressions of empathy [9]. The literature in the health care field lacks studies of direct comparison of face-to-face and videomediated communication. Often, generalizations concerning the quality of video-mediated communication are limited due to variation in technology performance, based on hardware, software and state of the art at the time of the study. However, several studies have focused on videomediated communication in areas outside of health care. Heath and Luff [16] found that non-verbal signals tend to be often missed in video-mediated communication and this may effect verbal communication as well. Storck and Sproull [17] studied video-mediated communication, and found that ‘‘the impressions people form of remote others are different from and less positive than the impressions they form of face to face others’’. Sellen [18] studied how groups discuss and reach consensus via quality video/audio systems, and face-to-face communication and found no process differences between the video/audio systems and speech only communication. The video/audio systems showed reduced ability of listeners to spontaneously take the conversational floor, as measured by number of interruptions. Similar findings were reported by O’Conaill et al. [19] and Whittaker and O’Conaill [20], who also found that participants used more formal turn-taking techniques during videoconferencing sessions than were observed in face-to-face interaction. For the context of health care delivery, the content and style of communication have to be studied and compared if one wants to assess the overall impact of telemedicine on quality of care. The overall objective of this study is to investigate if and how the use of telemedicine technology impacts the process of care with a focus on dermatology, and specifically communication during patient encounters which can affect the quality of care, patient safety, the provider—patient relationship and future utilization. Thus, in this study we aimed to examine the effect of telemedicine technology on communication by comparing the style and content of communication between actual (i.e., face to face) and virtual (i.e., non-face to face, telemedical) dermatology visits. The content and style of communication are defined by the themes of the interaction and the time spent addressing each theme.

Comparing traditional and telehealth communication

2. Methods The study setting was the Missouri Telehealth Network, one of the country’s most established telehealth programs. The Missouri Telehealth Network operates a videoconferencing suite over telephone lines, the Internet, an Integrated Services Digital Network, Primary Rate Interface (ISDN PRI) and T1 lines, enabling video encounters between the University of Missouri Health Sciences Center in Columbia and rural sites throughout the state of Missouri. Currently, over 15 specialties utilize telemedicine at MU Health Care, dermatology being one of the most active clinics. Up to date there have been over 1400 dermatology patients who participated in ‘‘teledermatology’’ (or ‘‘virtual’’) visits; currently a one-half day teledermatology clinic is being conducted weekly with an average of 12—15 patients. Face-to-face dermatology (actual) visits and telemedical consultations (virtual visits) were taperecorded if the patient gave consent to and permission of this recording and following requirements were met: (1) patient spoke English and (2) patient was mentally capable of meaningful verbal communication (as assessed during the initial conversation with the research assistant). All subjects who met these requirements and attended either the dermatology clinic or a satellite office of the Missouri Telehealth Network for a scheduled visit in the time between July 2003 and October 2003 were recruited for the study. All subjects agreed to participate. Due to the length of the study the sample may be labeled as representative of the patient population of both the traditional dermatology and the teledermatology clinics. The audio recordings of both ‘‘actual’’ and virtual visits were transcribed. The transcriptions were coded by two coders in order to measure reliability in coding decisions. In addition, during the visits an observer recorded observations, provided notes to support the content analysis and timed the interactions. The ‘‘utterance’’ (e.g., a simple sentence, an independent clause, nonrestrictive dependent clause, multiple predicate) served as the unit of analysis for coding. The coding procedure referred to a content analysis of the verbal communication between patients and providers. A content analysis can be either theory driven, prior data driven or following a hybrid approach combining the two other ones [21]. The latter was the approach for this study. The protocol used for the content analysis was based on a previously developed and tested protocol used for the study of virtual visits in home care [22]. The design of this protocol was inspired by the

3 Davis Observation Code [23] (DOC). The DOC is a 20item direct observation scale for physician—patient interactions that has been tested extensively for reliability and validity. The protocol for the observation of virtual visits [22] includes the following themes: • General informal talk (small talk-including session initiation and closure greeting, discussion about weather, current events) • Assessment of patient’s clinical status (e.g., collection of clinical data such as temperature, blood pressure, pain, other symptoms, nutrition, amount of exercise, etc.) • Addressing technical issues (e.g., asking to adjust camera or volume) • Addressing psychosocial issues (discussing patient’s personal problems or concerns, matters unrelated to the patient’s medical condition such as discussion about the spouse, family members, friends, etc.) • Patient education (e.g., providing in-depth information about a specific medical condition) • Promoting compliance; this category includes the following themes: ◦ Reminders (e.g., ‘‘Do not forget to take your medication twice a day!’’) ◦ Identifying barriers to compliance (e.g., ‘‘Why do you have trouble taking your medication?’’) ◦ Positive reinforcement (e.g., ‘‘You have done so great so far, keep up the good work.’’) ◦ Negative reinforcement (e.g., ‘‘If you keep forgetting to change the dressing of the wound, you will eventually have to come to the clinic for a while.’’) ◦ Addressing administrative issues ◦ Scheduling or confirming upcoming actual/ virtual visit ◦ Scheduling or confirming a visit to the doctor • Ensuring accessibility (reminders for numbers to call and persons to contact in case of a question or an emergency) In order for the two coders to analyze and code the transcripts, the coders were trained to use the coding protocol. For each of the protocol items, five elements were provided: a label, a definition of the theme, indicators on how to flag the theme, description of qualifications or exclusions and examples. For example, for the General informal talk/ Smalltalk category, the label was ‘‘Smalltalk’’, the definition was ‘‘utterances unrelated to the health status and condition of the patient, including matters unrelated to the reason of the visit, such as weather, upcoming events, news, greetings, etc.’’ and the coders were provided with specific examples that constitute

4

G. Demiris, S. Vijaykumar

Smalltalk (e.g., ‘‘It looks like we will be getting rain this weekend.’’) and examples that do not (e.g., ‘‘are you coping well with your wound?’’).

3. Results A total of 40 face-to-face and 54 telemedicine visits were observed and audiotaped. The transcripts were then analysed. The inter-rater reliability for the coding of utterances was high. Cohen’s kappa for agreement between the two coders was 0.89. An additional theme that was not included in the original protocol was identified, namely that of discussing the treatment. Originally, this theme was meant to be coded as part of patient education; however, it became clear that it was a separate theme of communication and thus, was added in the observation protocol. The average duration of a face-to-face visits was 11 min (S.D. 0.8) and that of telemedicine visits 9 min (S.D. 0.02). Small talk occurred in 20% of all face-to-face and 29.6% of all telemedical visits. Clinical assessment occurred in all sessions. Patient education occurred in 90% of face-to-face and 78% of telemedical visits. The category of addressing technical issues is obviously not applicable to actual visits. Addressing accessibility was not a theme that Table 1

Themes of communication for both actual and virtual visits

Duration (min) General informal talk/Smalltalk Clinical assessment Education Discussion of treatment Promoting compliance Psychosocial issues Administrative issues Technical issues

Table 2

occurred in any of the actual and virtual visits. Table 1 displays the categories of communication and the number of visits that included each of these categories. Virtual visits were shorter (M = 9 min, S.D. 0.02) than actual visits (M = 11 min, S.D. 0.08), t(92) = −184, p < 0.001. The shortest virtual visit was 8.5 min and the longest 9.1 min. The shortest actual visit was 6 min and the longest 16 min. Table 2 displays the average time spent addressing each of the communication themes. It is noteworthy that the standard deviations for the duration of segments within virtual visits are low; this is due to the fact that telemedicine or virtual visits are scheduled for 10 min intervals and health care providers follow a routine procedure when they communicate with numerous patients scheduled to be seen via videoconferencing in 1 day. The amount of time spent on clinical assessment was correlated to the time spent discussing the treatment both for the actual visits (r = 0.83) and for the actual visits (r = 0.64). Furthermore, we conducted a one-way MANOVA design to test the hypothesis that both actual and virtual visits have the same means for all dependent variables (codes of interaction); i.e., equal distribution of time spent on each theme for both the actual and the virtual visit. Normal distribution of the duration of the communication themes

Face-to-face visits (N = 40)

Telemedicine visits (N = 54)

p-Value

11 (S.D. 0.8) 8 (20%) 40 (100%) 36 (90%) 38 (95%) 7 (17.5%) 5 (12.5%) 25 (62.5%) N/A

9 (S.D. 0.02) 16 (29.6%) 54 (100%) 42 (77.7%) 50 (93%) 10 (18.51%) 3 (5.5%) 37 (68.5%) 8 (14. 81%)

0.362 <0.05 0.143 0.112 0.221 0.314 0.562 0.402

Duration of communication themes

Duration (min) Smalltalk Clinical assessment Education Discussion of treatment Promoting compliance Psychosocial issues Administrative issues Technical issues

Face-to-face mean duration in minutes (S.D.)

Telemedicine visits mean duration in minutes (S.D.)

11 (0.8) 2 (1.3) 4.5 (2) 2.5 (2.7) 2.1 (1.6) 0.7 (0.02) 1 (0.07) 0.2 (0.01) —

9 (0.02) 2.1 (0.1) 3.5 (0.03) 2.1 (0.9) 2.7 (1.3) 0.3 (0.01) 0.4 (0.7) 0.3 (0.001) 0.7 (0.001)

Comparing traditional and telehealth communication was assumed due to the low skewness and kurtosis coefficients of the datasets. First, we applied the Box’s test that demonstrated homogeneity of the variance—covariance matrices, as the test was not significant at an alpha level of 0.001 (Box’s M = 19.260, F = 3.182, Sig. 0.007). The univariate tests of homogeneity of variance for each of the dependent measures indicate that homogeneity of variances has not been violated for either virtual or actual visits. When applying the Levene’s Test of Equality of Error Variances which tests the null hypothesis that the error variance of the dependent variable is equal across the two modes of care delivery (actual and virtual visits), we found that we can assume equal variances (F = 0.078, Sig. 0.673). MANOVA results showed no significant difference in duration of each of the communication themes between actual and virtual visits except for Smalltalk (see Table 1). Based on these findings, there is a statistically significant difference in time spent on Smalltalk between virtual and actual visits.

4. Conclusion The major finding of this study is that the virtual visits that were examined included most of the important patterns of interaction that one would expect in an actual visit. The observations of the technical quality of video-mediated consultations demonstrate that the majority of virtual visits can take place without technology interfering or equipment failing. Obviously, assessing the patient’s medical status is one of the major purposes of a dermatology visit and was the dominant component in the observed actual and virtual visits. Patient education, defined as a key factor in dermatology, played a major role. Psychosocial issues were emphasised in the virtual visits. An important component of the patient—provider communication takes place when patients or even providers disclose details about their family life, cultural background and ‘‘other revelations about the self and personal identity [24].’’ According to Parrott et al. [24] experienced care providers frequently focus on the patient’s description about personal matters and use it as a framework to determine what the patient knows, how to communicate at the patient’s level and ways of expressing empathy. Such conversations can reveal far more than that however, as care providers learn to listen for and invite patients’ revelations about how their culture or environment influence their health behavior. By displaying empathy and engaging patients in discussing matters of

5 importance to them, a care provider can lower patient anxiety, increase compliance and achieve higher levels of patient satisfaction. It is, therefore, encouraging that the telemedicine visits, at least within the sample of this study, did not miss this important component of communication. This study lays the groundwork for an extensive analysis of video-mediated communication in health care. The validity of qualitative inquiry has more to do with the information-richness of the cases selected than with sample size [25]; thus, there are no clear guidelines for calculating an appropriate sample size for content analysis studies. Our sample consisting of 43 actual and 50 virtual visits provided us with a large and diverse sample of dermatology visits. However, within this pilot study we did not record information about the patient’s age or diagnosis, factors that can impact the style and content of the interaction with the health care provider. After completion of this analysis, we aim to introduce the second phase of our study where we will be investigating patient demographics characteristics and diagnosis, and determine whether these impact or are related to the type of communication in actual and virtual visits. Furthermore, for the second phase we aim to expand beyond dermatology and cover other clinical areas. A further point of consideration is that the duration of virtual visits had a low standard deviation as these visits are scheduled by the Missouri Telehealth Network for 10 min intervals and the providers are aware of the time limitation as they are scheduled to see several patients via the videoconferencing network. Since there are no specific guidelines for the duration of telemedicine visits and whether these should be scheduled for the same intervals as actual visits, an in-depth analysis of the process of care delivery via videoconferencing can provide further insight. Our preliminary findings indicate that the themes of communication in actual and virtual dermatology visits are comparable.

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