Introduction

This chapter describes the purpose and approach of the three laboratory studies that we conducted during the development of the broadband telehealth system for remote outpatient consultations. These three studies are then described separately in the following chapters (Chapters 6, 7 and 8).

Purpose

These laboratory studies were conducted to resolve design and functionality issues that arose in the early stages of developing our telehealth system. The three specific issues all related to the way that generic elements of our telehealth system would support interactions between the participants, access to the physical spaces of the rooms in the telehealth suite and interaction with data about the patient. Each issue was addressed with a purpose-designed laboratory study.

1. Fixed video and audio between the surgeon’s and patient’s rooms. We

needed to establish whether the video and audio links between the two rooms provided sufficient coverage of the rooms and awareness of what the

participants would be doing during a typical outpatient consultation. The first study was designed to exercise the room coverage and situational awareness that wanted to achieve.

2. User-interface design for tablet-based remote guidance. We planned to use

the electronic pen and tablet displays to let the surgeon guide the assistant to conduct an examination of the patient, using pointing and drawing over displays of live video of the patient. The second study explored three different user- interface designs for tasks that mimicked the actions that we expected the assistant to perform during the examination.

3. Support for collaborative behaviour between surgeon and assistant. We

expected the process of examining the patient to be a collaboration between surgeon and assistant, rather than the expert-novice guidance scenarios that had been used in previously published work on remote guidance. The third study repeated the tasks of the user-interface design study, but in a collaborative manner rather than a directed manner.

These issues all related to the way the participants in the eventual telehealth scenario would use these aspects of the telehealth system. This is the reason that we carried out laboratory studies with human participants rather than just conducting technical testing with hardware and software test harnesses.

Approach

The approach we took in conducting these laboratory studies was characterised by five features:

• The studies were intended to answer specific questions about our telehealth system and its planned trial at the hospital.

• The tasks used in the studies were abstractions of activities that we had seen during our early field observations of outpatient clinics at Royal Children’s and

Royal Hobart Hospitals. These abstractions addressed the generic use of the telehealth system’s components and had no clinical content.

• The settings in which the studies were carried out approximated in size and use of physical space the counterpart settings that were observed in actual outpatient consultations.

• The studies were evaluated in terms of the ways that the system components under investigation supported the participants to perform actions that

corresponded to the actions which we expected the clinicians and patients to perform in the actual hospital trial. This is in contrast to the performance-based comparative studies that have been published in areas such as remote guidance.

• The study participants were generic adult volunteers with no specific clinical training.

Motivation

Two aspects that were directly related to our broad application domain – tertiary-level telehealth – motivated us to conduct these laboratory experiments in the manner described here.

• Ensuring a workable telehealth system for the very first patient in the

hospital trial. We had observed that there was a high level of personal and professional pressure on the patients, families and staff at this tertiary level of healthcare. The patients present with potentially very serious health situations, and they and their families are both emotionally and physically exhausted by their day at the hospital. The clinicians have a high case-load, driven by a demanding schedule during their outpatient clinics, with little room to deal with extraneous problems or to repeat consultations. For these reasons it was

important that the basic communication pathways of our telehealth system work in practice at the very beginning of the trial.

• Minimising the demand we placed on the hospital clinicians during our

system development. Access to the hospital clinicians’ time was scarce, and we reserved our demands on their time for application-level evaluation of our progress work. We therefore designed our laboratory studies to be accessible to non-clinically-trained participants so that we could conduct them in our own laboratory without making additional demands on the hospital staff.

Abstract tasks

The tasks that the participants performed during these studies were abstractions of the activities that we had observed the surgeons and patients perform during normal outpatient consultations. These tasks involved access to and management of the large spaces in the two rooms (the patient’s room and the surgeon’s room) that formed the nodes of our telehealth system and collaborative performance of three-dimensional tasks in smaller spaces within one of the rooms. We had observed the way the surgeons and the patients and families made use of the space in the consulting rooms at the hospital – sitting together to discuss issues, using the whole of the room to allow for examining the young patient and using specific examination procedures in a more bounded space within the room and we designed the study tasks to match what we had observed.

The intention of the tasks was that they be performed using the resources provided by the three fixed video/audio links between the two rooms, the steerable pole-mounted camera above the designated examination space in the patient’s room, the pen and tablet tools for pointing and drawing over live video and, finally, the laser drawing system in the patient’s room that was controlled by a pen and tablet interface in the surgeon’s room. Figure 5.1 shows the relationships between the abstracted tasks and their associated real-world conclusions.

The tasks that we devised were in a sense free of external meaning and so there was no way for prior knowledge or learning on the part of a participant to skew the outcomes of the study. This is in contrast to many remote guidance studies, such as those of Kirk and colleagues (Kirk, Crabtree et al. 2005), where the task involved teaching someone to assemble components such as Lego and where prior experience with this toy could dramatically change a person’s ability to perform the task. We drew inspiration for this approach from some of the early media spaces work, such as the “room drawing” and “furniture placement” tasks of Gaver and his colleagues (Gaver, Sellen et al. 1993) where the tasks were dependent only on the placement and contents of the rooms and where completing the tasks required collaboration between the two participants – one in each room.

Figure 5.1: Schematic for component evaluation in the laboratory

Laboratory Hospital

Construct

component Abstract the clinical setting

Abstract the clinical task

Abstract the evaluation criteria

Draw conclusions from the laboratory experiment Conduct experiment with generic participants

Generic participants

For participants in these laboratory studies we invited adults with normal or corrected- to-normal vision, with no other special requirements. We recruited from our local region – colleagues at CSIRO, staff and students on the Australian National University campus, friends or acquaintances from within the Canberra community. This approach to recruiting matched the generic nature of the tasks to be performed in the laboratory studies.

We particularly avoided limiting our recruiting to medical practitioners for these studies even though the ultimate purpose of the studies was to guide the development of our telehealth system. There were two main reasons behind this approach. Firstly, the features of the telehealth system that we were testing were themselves generic in nature and we had designed the studies so as to not have any explicit “health” content.

Secondly, the health professionals who would be using the telehealth system were a scarce and heavily committed resource which would be wasted evaluating our system at its generic level. Not only were they scarce, but they were also located 600 kilometres away in Melbourne and therefore they were in practice not available.

This issue highlights the levels at which it is appropriate for the highly skilled and heavily committed clinicians in the tertiary health sector to be involved in review or evaluation activities. For example, one reviewer of our paper on the third of these case studies (Stevenson, Li et al. 2008) commented favourably on the paper then noted that the next step would be to repeat this study using medically trained people as the participants. My response is that this would not be an appropriate use of such a scarce resource in this field of tertiary health care. A more appropriate approach would be to match the evaluation situation to the skills and scarcity of the participants, with abundant generic participants to evaluate generic or content-free features and scarce clinicians to evaluate the clinical application of the system.