اکتشاف کیفیت استفاده پزشکی از راه دور

“Simply saying that more use will yield more benefits without considering the nature of this use (and context) is clearly insufficient” [W.H. DeLone, E.R. McLean, The DeLone and McLean model of information system success: a ten-year update, Journal of Management Information Systems 19 (4) (2003) 9–30, p. 16]. Our research specifies the use quality construct in the context of a mission critical system deployment—namely, the use of medical video conferencing for patient exams. The product of this field study is a socio-technical framework for use quality in telemedicine service encounters. We also propose generalized categories (which may extend across domains) for identified attributes, provide a comparative overview of patient and provider perspectives, and discuss the effects of and remedies for selected attribute deficiencies.

Quality is never an accident; it is always the result of intelligent effort.”—John Ruskin In medical informatics, the manner in which a technological intervention is used can have a significant impact on the health and well being of patients who depend on it. If we are to effectively manage technology-based medical information systems, we must understand and manage their use, especially as it applies to encounters between health care providers and patients.3 A critical and increasingly important application of medical informatics is the use of video conferencing for patient exams (see Fig. 1). In this context, video conferencing is frequently used to support a knowledge discovery process (concerning the medical condition of the patient), as well as decision-making in the form of diagnosis and recommended protocols. There is widespread interest in utilizing medical video conferencing technology as an economical method to provide expert medical service to patients in remote and awkward locations, and to address misdistributions of health care resources (i.e., facilities and medical expertise) outside major urban centers [14] and [35]. There is also a growing recognition that telemedicine can facilitate the timeliness of medical care by providing access to a wider range of appropriate medical providers during the ‘golden window’ of treatment opportunity [13]. Full-size image (57 K) Fig. 1. Medical video conferencing layout [30]. Figure options Advocates of telemedicine believe that telemedicine encounters (e.g., medical video conferencing) should be recognized as a “timely technology to facilitate health decision-making and clinical service support.” These encounters address patients' needs for communication and caring, as well as physicians' concerns for high quality clinical care, while having a positive financial impact on containing medical costs (especially after policy and reimbursement constraints are addressed by governing bodies) [27]. In broad terms, the quality of this kind of technology-based service encounter may be described as the expected level of performance and information provided by the organization, technology, employee and, to some degree, customer (as indirect user of the technology) to support the interaction and transaction success [31]. To pronounce a medical video conferencing encounter a success, decisions regarding suitable care and patient satisfaction must be supported by the effective use of the socio-technical system. Since this form of telemedicine promises to bridge geographic distances in the provision of medical expertise, it is of great concern that mixed results have been reported in terms of utilization rates, even when external issues such as reimbursement issues and policy constraints are not major impediments (e.g., [31] and [50]). These mixed results suggest that telemedicine-related research should not merely recognize constraints imposed by organizational and legislative policy, but should also look deeper into the telemedicine system as an integrated socio-technical process and product in order to assure its successful utilization. As stated by Jennett et al., “Telehealth systems can have impact at three levels: the health system level, the program level, and the patient encounter level. Each level requires different types of evaluation models” [26] (p. 364). Telemedicine researchers recognize that there is a paucity of explanatory research that predicts and facilitates the success of telemedicine encounters [45]. In our study of telemedicine encounters, we attempt to address this research gap by introducing the term use quality to address the effectiveness of the actual encounter usage. In the case of medical video conferencing, use quality spotlights the attributes of the socio-technical decision-making process of utilizing telemedicine for patient diagnosis and assessment. The exploration of use quality focuses on work practices and methods of organizing work. Though such studies are needed as a basis for the formation of “post-bureaucratic” organizational theory, few such studies exist in the modern organizational literature. Barley and Kunda [6] call for the study of new forms of work in emerging, situated contexts to facilitate understanding of changing work patterns. Research by Jennett et al. provides recognition that telemedicine may alter the nature of work in health care [27]. However, the information systems (IS) literature lacks strong models of use quality to serve as guides for providers and researchers. The literature has not qualified use in most studies, though the IS community has known for a long time that unused systems are unsuccessful systems [34]. However, the corollary that system use produces success is not necessarily true, though many IS models and studies portray use as a proxy for, or an implied indicator of, system success [55]. The telemedicine literature has also adopted use as a proxy for success (e.g., [38] and [56]). Though some researchers assert that continued use is a better indicator of success than simply use, they do not elaborate on the attributes of quality that recur in specific episodes of use that promote successful patterns and continuance of use [7]. Even the industrial and data management literatures, in which strong research efforts exist in the realm of total quality management, lack focused studies about quality in the usage stage, though considerable research exists concerning quality in the design and production stages. “The literature on improving the quality of use is vague, and specific procedures and guidelines for improving the quality of use are non-existent” [3] (p. 8). In the telemedicine domain, use quality encompasses technology, medical procedures, decision-making and human interactions in a holistic, integrated view of the system. Medical video conferencing provides an intriguing context for exploring use quality as perceived by people in different roles in the telemedicine encounter (direct/indirect users and health care providers/consumers) via different aspects of system use (technology/human interactions). Of all the uses of medical video conferencing (e.g., education, peer consultation, patient exams), video conferencing for direct medical care, given its immediate impact on patient care, requires the highest use quality standard. There exist no definitive references to use quality attributes based on a thorough search of IS and software engineering literatures. The telemedicine literature does address some instances of use quality-related concepts. For example, the need for training and integration into other modes of care is recognized from an organizational level, though not specified and directly addressed through the encounter experience [26] and [27]. Other examples reference use in telemedicine adoption and diffusion without qualification regarding the process or standard of use (e.g., [24], [57] and [60]). An interesting project in Canada by the National Telehealth Outcome Indicator Project (NTOIP) [47] has identified four indicators that are related to use quality: (1) quality of the telehealth encounter (ease of use and communication of critical health care information), (2) integration of telehealth with traditional health care, (3) the quality of the technology used and (4) user satisfaction. New to the literature is the NTOIP's recognition that the actual telemedicine user may participate in different roles (e.g., patient, provider) and have different understandings of the use process [32]. Overall, however, there is currently no high level guidance provided by medical standards, such as JACHO guidelines, that would lead to a clear, generalized understanding of the attributes of use quality in the telemedicine encounter context. Telemedicine researchers indicate that guidelines and standards are needed at a number of levels (e.g., technological, procedural, service) for telemedicine consultation for the health sector to fully embrace and diffuse telemedicine care options [26]. By citing literature references and comments made by participants in our study, we aim to provide insights into quality specifications, the effects of attribute deficiencies, and the means of addressing quality issues. In essence, we attempt to define the factors of intelligent effort (i.e., use quality) as users and technologies interact within the telemedicine system. We take a bottom-up approach from which theories within various domains may be extended or synthesized as insight deepens. We contribute to this synthesis by proposing generalized categories for specific attributes that may extend across research domains, a general assessment of constructs, and a comparative overview of patients and provider perspectives. We keep our research at the level of patient encounters and do not directly expose policy, legislative or social influences that act at the organizational level.