Bounded trial in the application setting

These results show the importance of conducting such a trial and evaluation in an actual application setting. The trial was designed to have items that were in scope and to exclude or manage separately items that were out of scope. As described previously, features that were in scope included:

• There would be both a telehealth phase and an immediately following face-to- face phase to each consultation.

• The patients were selected on the basis that they already had a scheduled

outpatient appointment for timeslot of the clinic and they fitted the target profile for the design of the telehealth system – post-operative with indications of normal clinical progress or pre-operative with indications that the intended surgery would be straightforward.

• The surgeon and clinic assistant(s) for any particular clinic already had an existing working relationship and the assistants were familiar with the type of surgery involved in the cases.

Features that were out of scope included:

• Actual or simulated matching of patient/surgeon schedules across two hospitals

• Coordination of patient clinical records across two hospitals

• Coordination of paperwork for clinical referrals (for example arranging X-rays or photography for subsequent appointments)

Telehealth phase

For all of the patients the surgeons followed their normal pattern of consultation from initial greetings through to agreed outcomes. This is consistent with the surgeons’ approach to the training sessions that we conducted prior to the trial. During those sessions they focused on how they would conduct their clinics using this system and they left the sessions having addressed the major components of talking with the patient/family, examining the patient and accessing radiological data. We saw the patients and family engaging with the telehealth phase in the same manner that we observed during our preliminary field observations at the two hospitals. We saw them able to report on progress, observe and comment on the examination of their child, ask probing questions and agree on a treatment plan.

Face-to-face phase

The face-to-face phase was part of the scope of the trial, included to ensure the quality of care for the patients given that the ability of telehealth phase to adequately support the consultations was not known prior to the trial. We saw from their actions that the surgeons were largely satisfied with the telehealth phase and so they appropriated the face-to-face phase for a mixture of extended closure of the consultation and selective confirmation of points that they had observed in the telehealth phase.

Screening of patients for the trial

From the video recordings we saw that all of the consultations followed the standard pattern during the telehealth phase, and reached an agreed outcome. This indicates that there was a good match between the clinicians’ understanding of the design criteria for this stage of the telehealth system and the actual implementation, and that the pilot study was able to proceed without putting the patients and families to the inconvenience of repeating the whole consultation in face-to-face mode.

Relationship between surgeon and assistant

The existing relationships between surgeon and assistant, supported by the prior training session, allowed the trial to begin smoothly without needing to build that relationship in the presence of the patients. Further, we saw that the close match between the skills of the assistants and the particular cases they were managing meant that the instructions from the surgeon and the interactions between surgeon and assistant were conducted at a very high clinical level. Even then, the experience of the surgeon was seen at the times where he needed to caution or provide detailed instructions to the assistant. This created some discussion about how this bounded trial might be extended to a hospital- to-hospital trial and raised the need to pay attention to both the relationship between surgeon and assistant and to refining the skills of the assistant.

Out of scope features

Apart from patient selection the out-of-scope features largely dealt with issues external to the core of the consultation, such as appointment scheduling and follow-up

paperwork. We saw that the clinicians and patients/family were happy to step out of the telehealth role to complete paperwork for subsequent referrals and they generally used the face-to-face phase for these tasks.

Two important issues regarding scope and patient clinical data were resolved early in the trial. Shared access to radiology data (X-rays and CT scans) was crucial to the success of the consultations and prior to the trial we were expecting difficulties

coordinating surgeon’s and patient’s access to this data via the two hospital computers (one in each room). The clinicians found, however, that the minor degradation of X-ray image caused by our hardware implementation of screen capture was not an impediment and they used our tablet display system to share the display from the hospital computer located with the surgeon. This gave them simultaneous shared access to and interactive annotation over the X-ray images and they used this feature extensively. The clinicians experimented with access to the patient’s paper-based clinical records and they

developed a new procedure whereby the surgeon briefed the assistant over the telehealth link prior to the patient entering the room.