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Telemedicine and doctor-patient communication: an analytical survey of the literature |
Miller E A |
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Authors' objectives To review the literature about the effect of telemedicine on doctor-patient communication.
Searching MEDLINE and HealthSTAR were searched using combinations of the following keywords: 'telemedicine', 'doctor-patient relations', 'communication', 'satisfaction', 'acceptance', 'surveys', 'qualitative methods' and 'remote consultation'. The bibliographies of all retrieved articles were examined for further references.
Study selection Study designs of evaluations included in the reviewThe author specified that essays, editorials and other non-peer-reviewed pieces, as well as duplicate publications, were excluded. No further inclusion or exclusion criteria relating to study design were defined.
Six of the included studies were surveys of attitudes towards telemedicine, whilst a further 21 were post-encounter surveys of participants in a medical consultation. Eight of the post-encounter surveys reported using a comparison group: 2 randomly allocated patients to a video or in-person control condition, 1 randomly distributed providers across various telemedicine configurations, 2 compared patients receiving video and face-to face consultations without randomisation, 2 compared video and in-person assessments made by the same participants, and the remaining study used both of the last two methods. The remaining 11 included studies were qualitative analyses of medical encounters. Five of these reported using a comparison group but no randomisation was described, instead they used several quasi-experimental alternatives: 2 studies compared the same participants in a variety of consultation modes, 1 compared video patients with face-to-face controls, 1 compared video patients with conventional cases reported elsewhere in the literature, and 1 recorded practitioners' insights from both their video and in-person experiences.
Specific interventions included in the reviewThe author states that all peer-reviewed articles about the nature and content of doctor-patient communication via telemedicine were eligible for inclusion. Articles did not have to focus exclusively on communication.
The review included: surveys of provider and community attitudes, in which participants had a variety of exposures to telemedicine; post-encounter surveys of participants in a medical consultation; and qualitative analysis of medical encounters, compared for on-site and off-site consultations. No details of the telemedicine used were reported.
Participants included in the reviewThe author did not specify any participant inclusion or exclusion criteria, and no details of the participants in included studies were reported.
Outcomes assessed in the reviewThe author stated that acceptable studies had to include some findings relevant to the study of communication during interactive video communications. However, no specific outcome measures were defined. Included studies largely measured participant attitudes and opinions using structured survey or interview techniques. Methods of analysing consultation behaviour were case-note review, verbal content analysis, video analysis of non-verbal behaviour, observation and self-report.
How were decisions on the relevance of primary studies made?The author does not state how the papers were selected for the review, or how many of the reviewers performed the selection.
Assessment of study quality The author does not state that they assessed validity.
Data extraction The author does not state how data were extracted for the review, or how many of the reviewers performed the data extraction. Data were extracted from the included studies for the categories of study location, telemedicine experience or type of consultation, study methods and the numbers of participants, and communication and other findings.
The authors stated that they grouped communication findings into 23 categories. In addition to general communicative efficacy, specific categories related to patient and provider question asking, understanding, explanation and comfort, patient-provider relations and rapport development, embarrassment, anxiety and miscellaneous affect, audio and video quality, non-verbal behaviour, touch, viewing self on screen, multiple providers, patient involvement, privacy and encounter length. After coding each study's findings according to these categories, a positive or negative rating was assigned to each individual result, based on the following predetermined criteria.
1. For results reported using sample percentages, more than 50% had to rate a particular aspect favourably in order for the finding to receive a positive rating.
2. For results reported using mean scores on survey questionnaire items, the average participant had to rate a given item higher than the mid-point on the scale used in order for the finding to receive a positive rating.
3. For results reported using comparisons between telemedicine and other modes of service delivery, the performance of telemedicine had to equal or exceed that recorded for conventional encounters in order for the finding to receive a positive rating.
4. For results reported using qualitative research techniques, investigators had to come to unambiguously favourable conclusions regarding the particular aspect of doctor-patient communication assessed, in order for the finding to receive a positive rating.
Methods of synthesis How were the studies combined?A narrative synthesis was undertaken. The methods used in the primary studies were described according to the category: surveys of provider and community attitudes, post-encounter surveys of participants in medical consultation, and qualitative analyses of medical encounters. The findings of the primary studies were assigned positive or negative ratings, and were briefly summarised in tabular form and in the final paragraph of the results section.
How were differences between studies investigated?The author does not state a method for assessing any differences between the studies.
Results of the review Forty-one articles met the authors' criteria for inclusion. This was reduced to 38 studies following the exclusion of articles describing the same study.
Six studies were surveys of provider and community attitudes to telemedicine; 5 of these had a total of 603 respondents (461 from one study). Response rates, where indicated, varied from 29 to 80%.
Twenty-one studies were post-encounter surveys of participants in medical consultations. The total participant numbers in this category were unclear as some studies described the number of participants whilst others refer to the number of consultations; in addition family as well as individual consultations were included.
Eleven studies were qualitative analyses of medical encounters, including participant and non-participant observation, in-depth interviews, case reports, archived resources and content analysis. The total number of participants was unclear, for reasons similar to those described for the post-encounter surveys.
From the 38 studies included in the review, 213 findings were abstracted; 7 findings each from surveys of provider and community attitudes, 106 from post-encounter surveys of patients, 18 from consultants, 11 from local providers, and 64 from qualitative analyses of medical encounter behaviour. Overall, there were more than three times as many positive results as negative results. For all but two of the categories, the number of findings rated positive exceeded those rated negative. The categories with at least eight more positive than negative results were: general communicative efficacy, patient and provider comfort, patient-provider relations, anxiety or nervousness, miscellaneous effect, audio quality and video quality. The only areas for which the number of positive findings did not exceed the number of negative findings were non-verbal behaviour and lack of touch. While the majority of findings abstracted from post-encounter surveys of patients (93%), consultants (72%) and local providers (100%) were rated positively, there were comparatively fewer for qualitative (58%) and attitude (43%) study findings.
Authors' conclusions The present review strongly favours doctor-patient communication via telemedicine: almost 80% of the abstracted findings were rated positive, with all but two of the 23 communication categories reporting more positive than negative results,. However, further research is necessary if the nature and content of the communication process are to be fully understood. This will help us better understand the interpersonal dynamics associated with telemedicine and its effects on health care outcomes, and will also allow us to develop and implement technological improvements and adjustments to facilitate communication between providers and patients. It will also represent a first step towards formulating behavioural norms to aid telemedicine transactions, while furthering the development of educational and other strategies to reduce any trepidation associated with this comparatively new medium. Understanding the relationship between telemedicine and doctor-patient communication will also shed light on the distribution of decision-making power between consultation participants, as well as any effect telemedicine may have on patient trust and privacy, and the exposure of doctors to claims of malpractice. Together, these insights should provide payers and policy-makers with solid evidence about the ability of telemedicine to promote high-quality care that maximises value for money.
CRD commentary The review question was vague and poorly defined. Consultation approaches considered to constitute telemedicine were not specified and there were almost no predefined inclusion or exclusion criteria.
The literature search was limited, covering only two bibliographic databases. The references of retrieved articles were examined, but it seems unlikely that all relevant studies were retrieved. There was no attempt to identify unpublished studies.
There was no attempt to assess the validity of primary studies included in the review. Bias in some form is likely to be present since the majority of the included studies had design types which are ranked low in the hierarchy of evidence, and the nature of the intervention makes blinding impossible. The authors discussed, to a limited extent, the possibility that participants' ratings may be skewed in favour of telemedicine, but even so the possibilities of bias in the primary studies remained largely unacknowledged.
The details of individual primary studies included in the review were vague, and were scattered between the tables and the text. Detailed descriptions of individual study findings were provided, but there was very little detail of either their participants or the methods that they used. This lack of detail renders the author's conclusions about the positive impact of telemedicine on doctor-patient communication difficult to apply in practice. Further, it is stated that a significant proportion of the included studies (approximately 40%) involved psychiatric patients, thus raising doubts about the extent to which findings can be generalised to the broader population of patients.
The majority of the results section of this review was devoted to a description of the numbers and types of primary studies identified. The summary of findings, in terms of numbers of positive and negative, is concise and relatively clear. However, it appears to be based entirely upon the author's subjective interpretation (no supporting evidence is cited for the technique used) of the results of the primary studies, and as such should be treated with caution.
Implications of the review for practice and research Practice: The author did not state any implications for practice.
Research: The author states that future research on doctor-patient communication should be expanded from psychiatry to other specialities, with the caveat that analysing data by speciality has the effect of spreading results across a large number of categories and may, therefore, make it difficult to accumulate evidence. It is therefore suggested that focusing on processes of care, such as primary, emergency and tertiary care, rather than on individual specialities may represent a more useful approach (see Other Publications of Related Interest no.1).
The potential for bias in participants' ratings means that post-encounter surveys of the participants in a medical consultation need to be supplemented with qualitative investigations of actual behaviour in the medical encounter, in order to obtain a better understanding of the effects of telemedicine on the doctor-patient relationship. Since there have been few such studies, more research is required.
Future research should employ instruments similar to the interaction analysis systems used to study conventional doctor-patient communication. It would be inappropriate, however, to adopt such systems wholesale without first developing instruments specific to the telemedicine experience.
To ensure the appropriate use of interaction analysis to study doctor-patient communication via telemedicine, a research strategy grounded in three types of analysis should be used, referred to as involving, respectively, developmental/descriptive, sub-experimental/etiological and interventional (randomised controlled trials) studies (see Other Publications of Related Interest no.2)
Bibliographic details Miller E A. Telemedicine and doctor-patient communication: an analytical survey of the literature. Journal of Telemedicine and Telecare 2001; 7(1): 1-17 Other publications of related interest 1. Grigsby J, Sclenker RE, Kaehny MM, Shaughnessy PW, Sandberg EJ. Analytic framework for evaluation of telemedicine. Telemedicine J 1995;1:31-9. 2. Inui TS, Carter WB. Design issues in research on doctor-patient communication. In: Stewart M, Roter D, editors. Communicating with patients. Newbury Park (CA): Sage; 1989. p. 197-210.
Indexing Status Subject indexing assigned by NLM MeSH Attitude to Health; Communication; Confidentiality; Humans; Patient Satisfaction; Physician-Patient Relations; Telemedicine AccessionNumber 12001000674 Date bibliographic record published 28/02/2002 Date abstract record published 28/02/2002 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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