Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
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Using Videoconferencing in Practice:
NOSM Health Sciences Competency and
Curriculum Implementation Toolkit
Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
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Acknowledgements
This competency project was led by NOSM Health Sciences Unit with valuable input and
feedback from a number of individuals including:
Jackie Hummelbrunner, SLP, Lake of the Woods District Hospital, Kenora, ON
Kim Hooper, SLP,
Sioux Lookout Meno Ya Win Health Centre, Sioux Lookout, ONUniversity of Toronto SLP learners on placements in Northwestern Ontario
It has been recognized and acknowledged that this current document has an evidence based
perspective with a number of limitations such as:
1.
The literature review was conducted in July 2012 and ongoing reviews would be needed
to maintain a current evidence and knowledge base on the expanding videoconference
(VC) technology and its use in health service delivery and education and for
administrative purposes.
2.
This document also does not include an exhaustive list of practice activities; other
modes of training (e.g. online modules) and lived experiences that are needed to
translate theory to practice.
3.
The draft competencies are recognized as important to many Health Sciences preceptors
but confidence levels and uptake vary greatly depending on discipline and practice
setting as well as their videoconference (VC) access and organizational supports.
Additional curriculum resources and opportunities will likely be needed to assess and
integrate VC into the practice of this diverse group of preceptors and learners.
4.
The readiness surveys and tools were included to inform some NOSM Health Sciences
disciplines. These tools would require adaptation and pretesting with individual
disciplines to effectively assess VC readiness and uptake.
5.
Future documents and activities should be vetted through a consultation group to guide
and direct as well as strengthen this curriculum and maintain NOSM’s social
Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
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Table of Contents
1.
About this Implementation Toolkit………....4
2.
Toolkit Goals………...4
3.
Overview and Background……….…………5
a.
Literature Review-Executive Summary
b.
Key Informant Process and Results
4.
Competencies………..9
a.
Definitions and Assumptions
b.
Goal
c.
Minimum competencies
d.
Advanced competencies
5.
Resources………11
a.
Videoconference Readiness Tools and Surveys
b.
Training Opportunities and Resources
c.
Competency Checklist Tips for Preceptors
6.
Appendix A: Literature Review………..14
7.
Appendix B: VC Telepractice Competence Assessment Framework………..24
8.
Appendix C: VC readiness tools and surveys……….28
a.
TELBIL survey, Spain
b.
RCN Telehealth Readiness Survey
c.
NODIP VC Readiness Online Survey
Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
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About this Implementation Toolkit
The purpose of this toolkit is to continue efforts to articulate the clinical education/practica best
practices required to advance and integrate competencies into Health Sciences curriculum that relate to Health Informatics, specifically the use of videoconferencing (VC) in practice.
Some work has been initiated within Health Sciences, including a webcast series entitled Implementing Telepractice In Northern Ontario: Developing Telepractice Competence. This series was held from September 2012 to May 2013 and provided health professionals and administrators working in Northern Ontario and interested in exploring telepractice, the opportunity to develop competence in system choice, ethical and professional decision making, system use as well as discipline specific clinical application strategies. To view the archived webcasts, go to: http://www.nosm.ca/rssresources/. While this series supported a select group of practitioners, there is a need to approach this curriculum component more broadly to effectively integrate and assess VC telepractice competencies amongst diverse Health Sciences preceptors as well as learners. This includes assessing VC telepractice readiness within Health Sciences; identifying specific (structure, process and output) indicators and their utility and feasibility; and determining the measures of success to be used to monitor performance and evaluate competency development.
In summer 2012, consultation amongst a variety of Health Sciences Managers and Coordinators suggests the degree of readiness as well as the feasibility to integrate this competency into mandatory
curriculums that have been established by their accrediting bodies and partnering universities will be a challenge. Therefore this toolkit includes background information; VC readiness tools; minimum and advanced competencies; a draft competency checklist as well as generic training and support materials that can be adapted by Health Sciences preceptors to implement in a northern and rural context and also translate to student experiences and activities within clinical education. This toolkit can also be used by Program Managers in faculty development for preceptors and as a resource for learners.
Toolkit Goals
To increase the knowledge and understanding of the literature and research around telepractice amongst health professions.
To introduce videoconferencing (VC) as a potential telepractice strategy for NOSM Health Sciences preceptors and their learners.
To assist in planning and developing competency in VC telepractice for NOSM Health Sciences preceptors and their learners.
To assist in planning and delivering curriculum to support VC telepractice competency for NOSM Health Sciences preceptors and their learners.
Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
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Overview and Background Information
Literature Review-Executive Summary
A literature search using select key words (e.g., telehealth, videoconferencing, telemedicine utilization) was conducted in early July 2012 through Cochrane Database of Systematic Reviews, DARE (Database of Abstracts of Reviews of Effectiveness, MEDLINE and Google Scholar along with the retrieval other relevant articles and web sites from article reference citations. There were also inquiries and correspondences received from two Canadian telehealth experts, Dr. Marie-Pierre Gagnon of Laval University and Dr. Penny Jennett from the University of Calgary. Attempts to correspond with some Australian researchers (Dr. RJ Cohn and Dr. B Goodenough) were unsuccessful.
There is very little published literature on videoconferencing (VC) as a telemedicine technology that can be generalized to a wide range of health care practitioners, areas of practice and settings. There is also a lack of research on telepractice uptake and impact across a variety of health practitioners working in diverse settings. While there are numerous benefits cited on VC applications in health care (Walker and Whetton, 2002; Jennett et al, 2003; Hebert et al, 2004; Craig and Patterson, 2005; Gagnon et al, 2006; Jarvis-Selinger et al, 2008), there may also be key differences in attitudes and communication practices of health practitioners and so the design, implementation and evaluation of interventions to promote optimal uptake and utilization of VC use should be targeted by discipline and/or practice setting (Cohn and Goodenough, 2002; Gagnon et al, 2006). There is also the need to determine the need and receptiveness of VC use in educational and administrative purposes (Moehr et al, 2005).
The adoption of different modes of telepractice technologies requires identifying key individual, professional, organizational and systemic factors to design specific and tailored training and skill development strategies (Gagnon et al, 2009). Practitioners may be prepared to learn to use new technology if they perceive that the system is critical to their job performance or quality of service (Walker and Whetton, 2002). The degree of implementation success is associated with factors related to the degree of need for the service and local health service structure as well as ‘people’
factors-acceptance by clients, practitioners and operators (Hailey, 2001).
There are also a wide range of definitions and concepts, as well as proposed instruments to measure telepractice attitudes and perceptions, knowledge, skills as well as readiness, intent, habits and practices. Each tool has its strengths and limitations and should be adapted to the target audience and individualized; this process could include the use of readiness and knowledge assessment surveys or ideally with focus groups and/or key informant interviews (M-P. Gagnon and P. Jennet, personal communication, July 19, 2012). For those who are not familiar or slightly familiar with e-Health and telehealth, another approach is to first use community show cases to demonstrate and use those types of e-technologies with follow-up focus groups to determine perceptions and readiness (P. Jennet, personal communication). These recommended processes can be complex, as well as time and resource intensive. Therefore, a broader approach was taken to assess the VC telepractice competencies of
Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
6 Health Sciences clinical teachers and learners starting with the validation of an analytical framework to determine the degree of readiness and potential next steps. This key informant process will be described next.
See Appendix A for a more comprehensive literature review.
Key Informant Process and Results
In July 2012, a VC Telepractice Competence Assessment Framework (Appendix B) was drafted and circulated to three Health Sciences Program Managers (Dietetics, Physician Assistant, Rehabilitation Studies) as well as a Program Coordinator with expertise in VC telepractice. Each key informant was asked to review the draft framework and provide oral and/or written feedback on all components (definitions, focus areas, indicators, success measures, etc.) as well as provide any additional information to populate the framework. Also each informant was asked to determine and communicate the degree of readiness for their discipline area(s) and potential next steps in competency development. As well, informants were to review the draft competencies and provide feedback (orally and/or in writing) related to their discipline(s) as well as related to Health Sciences preceptors and learners. Four phone meetings and one face to face meeting as well as numerous email correspondences were conducted between July and October 2012 with the following results.
Education Commitment and Content
There was a consensus amongst the Program Managers that this curriculum topic is at a very early stage in NOSM as well as within Health Sciences. It was felt that NOSM has no standardized/structured curriculum on VC telepractice to support clinicians and/or learners and that it should first be a core competency for NOSM Managers and staff. There is also no NOSM staff person to support and train staff or clinicians since NOMEC but those support materials and resources may still be available. It was also not known if there is NOSM capacity to regularly train clinicians. A potential option to consider would be Administrative Assistant (AA) support but at what level and whether informally or formally. There would need to be an evaluation of the comfort level and teaching ability of these AAs.
There was also a question of the current NOSM partnerships to support this competency and a need to identify potential partners/sites such as Thunder Bay Regional Health Science Centre (TBRHSC), Points North FHT, and Sioux Lookout FHT. It was noted that no Northeast sites have been identified as potential partners but Espanola FHT seems to use OTN frequently. There was also a need to identify Health Sciences clinician ‘Champions’. While there is a list of some ‘experts’, there is not a process for gathering/maintaining a list of mentors.
There was a need to first determine VC telepractice readiness of all clinical teachers (structure indicator) and then validate and populate a competence assessment framework and draft appropriate
competencies. There was likely a need to have clinicians first embrace IT technology and increase their awareness (output indicator) which could include the integration of VC telepractice into the Preceptor
Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
7 101 Workshops (process indicator). In the meantime, this competency could be learner-driven which may drive NOSM curriculum and support but within Health Sciences there are diverse learners and all have discipline specific competencies that are a program priority and part of accreditation.
There are some process indicators currently in place e.g. lunch and learn series for clinicians, VC training for dietetic interns, but it is not consistent or a priority for some Health Science programs. OTN and Contact North have some generic resources such as VC etiquette, powerpoint slide guidelines and there are some best practices available for some disciplines (e.g. Speech language pathology/SLP) but there is a need for discipline and practice setting specific guidelines. This information should be gathered via Champions.
Clinician and Learner Performance
With the current NOSM education commitment and content, it is difficult to determine indicators, success measures and data sources. As noted above, an assessment of VC telepractice readiness of all clinical teachers is needed and currently this information amongst all the disciplines within Health Sciences is unknown. This information was gathered in February 2013 for the Registered Dietitians (RDs) within the Northern Ontario Dietetic Internship Program catchment areas of LHIN 12, 13, and 14 through an online survey. Similar data was gathered in March 2013 from the non-medical Health Sciences
preceptors but the response rate was disappointing (61 of 552, 11%) and approximately 40% of the sample were RDs and 30% were physiotherapists. Discipline specific surveys could be conducted with the Rehab Studies and Physician Assistant Programs to provide baseline measures of readiness. Draft Competencies
The proposed competencies in the July 2012 draft assessment framework were initially generated from the UME Health Informatics, version 2.0, 2010. Feedback suggested these were learning objectives, not competencies and very medically focused. Additional competencies were proposed and from a Manager perspective considered advanced versus entry level and very IT focused. The Managers felt that learners are still learning discipline specific knowledge and skills (which are mandated as accredited programs) and felt that we should increase clinician/learner awareness versus demonstrating operational skills. It was then suggested there is a need for some minimum competencies as well as more advanced competencies for clinicians and learners working regularly with VC in their clinical practice. Further discussions with a number of Rehab Studies Site Coordinators determined there was limited capacity for the advanced competencies and have emphasized starting with only ‘awareness’ competencies. These minimum competencies relate to discipline-specific college regulations and organizational guidelines around telepractice as well as the identification of services that might be appropriate for VC such as patient education / follow up / receiving education / discharge planning, professional development, and administration events (e.g. meetings). It was also felt that each learner should attend at least one VC session and write a reflection on this experience to explore the pros/cons, compare VC to face-to face, audio/visual efficiency, convenience, etc.
Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
8 Next Steps and Recommendations
It has been emphasized throughout the literature and from key informants that assessing VC readiness should be an initial first step. As noted above, readiness data has been gathered for the northern RD group and a small number of other non-medical Health Sciences preceptors. More research is needed. There have been draft minimum and advanced competencies that have been generated through this consultation as well as feedback on the level of preparedness to integrate these eight VC competencies. Based on the March 2013 needs assessment of the eight draft competencies, 35-60% and 44-70% respondents felt unprepared to integrate them as a practitioner and as a preceptor respectively. Yet most felt the two minimum competencies are needed by preceptors (75%) and learners (80%). Of the two minimum VC competencies, the competency with the least level of preparedness was around knowledge of effective VC delivery in clinical practice and/or continuing education including VC
etiquette, communication skills, powerpoint and speaker guidelines, hosting and moderating an event. An environmental scan for generic resources and tools to support these two minimum competencies has been conducted and included in this toolkit.
While barriers to VC professional development was not directly asked in the needs assessment; readiness and uptake will be influenced by current and future use and access. Currently only 20% of respondents use VC often/always and 19% never use or it is not available. The majority expect to use VC in the next five years but 20% were not sure. Most agree VC is relevant to their practice but only 60% have easy access. The top uses for VC are meetings, liaising with community resources, consulting specialists and training colleagues. Efforts are needed to encourage the use of VC across practice settings with OTN examples of use such as clinical rounds and patient education to increase practitioner exposure and relevance.
To date, the draft VC competency checklist has been piloted with select Health Sciences learners (SLP) and a Northwestern Ontario SLP with positive feedback. They have provided feedback on the feasibility of VC telepractice competency attainment, the usefulness of the resources as well as areas for
improvement. Additional input is needed from other Health Sciences disciplines and efforts are underway to encourage more participation. There is also a need to investigate the promotion and integration of these two minimum competencies into the Northern Studies Stream (NSS) curriculum and clinical educator evaluation. This would require the support and expertise of NSS and NOSM Health Sciences faculty.
A regular review and validation of the VC Competency Assessment Framework (Appendix B) is required to assess readiness as well as to monitor, evaluate and document this competency within the Health Sciences Unit. There needs to be success/progress indicators for education content and commitment e.g. promotion of self-directed learning activities, number of events, attendance, NSS curriculum content, event evaluations/feedback as well as indicators for preceptor competency/performance such completion of self-directed learning activities, attendance at events, increased competency. Measuring
Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
9 and monitoring competency would require development and/or access to valid and reliable tools. It is not known if such tools already exist via NOSM UME, NOSM Postgrad, others who have VC telepractice curriculum.
There are also opportunities to collaborate with other educational institutions (e.g. College Boreal) and agencies (CCAC Northeast) who have VC organizational supports and training materials as well as a common desire to increase the competence and use of VC telepractice amongst a number of allied health professionals serving northern Ontario. Efforts are needed to maintain and expand these potential collaborations.
The following sections of this toolkit will include the eight competencies and a variety of tools and links that can be used as a starting point for Health Sciences Program Managers and clinicians which can be adapted for specific disciplines and/or practice settings. There will be a need for ongoing revisions and updates to these resources including additional teaching strategies, curriculum, and best practices.
Competencies
Definitions and Assumptions
Telemedicineor telepractice refers to any medical service provided at a distance via electronic
communication (Gagnon et al, 2003) or delivery of health care and exchange of health care information over distances (Craig and Patterson, 2005). This can include diagnosis, treatment and prevention of disease, continuing education of health care providers and consumers and research and evaluation (Craig and Patterson, 2005). Rapid access to shared and remote medical expertise by means of telecommunications and information technologies, no matter where the patient or the relevant information is located (Craig and Patterson, 2005).
Telehealth is used to manage patient care remotely or in patients’ homes and includes care over the phone, using videoconferencing, and remote monitoring of signs and symptoms (Wallis, 2012).
Telehealth readiness is the degree to which communities, organizations and professionals are prepared to participate and succeed in telehealth (Gagnon et al, 2006). Readiness should be assessed prior to implementation and monitored to facilitate the transition of knowledge and awareness to skills in clinical practice (Gagnon, 2006).
There is little known about the telehealth readiness of all NOSM clinical teachers. Some work has been initiated within Health Sciences, including the webcast series Implementing Telepractice In Northern Ontario: Developing Telepractice Competence, from September 2012 to May 2013. There is also needs assessment data gathered from northern Ontario RDs (Feb 2013) and some non-medical preceptors in the Health Sciences Unit (March 2013).
Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
10 Little is known about NOSM Health Science learners and their telepractice competencies.There is also much diversity in clinical placement lengths and settings (rural/remote and urban, clinical, community, public health and food service administration) for these learners. There are also many differences in scopes of practice and regulatory bodies regarding telehealth/telepractice. Therefore there needs to be a very broad goal and some minimum competencies as well as competencies more appropriate for clinicians and learners working regularly with VC in their clinical practice.
Videoconference (VC) telepractice competency is the ability to share in real-time video and audio information between two or more people at different locations and may include clinical care and consultations, education for professionals and consumers, and transfer of data or information between health care organizations. (Source: Johnson et al. (2001). Interactive videoconferencing improved nutrition intervention in a rural population. JADA; 101 (2): 173-4)
Goal
To increase the knowledge and awareness of videoconferencing (VC) as a potential telepractice strategy amongst NOSM Health Sciences clinical teachers and learners.
Minimum Competencies for all clinicians and learners
1. Identify potential professional and ethical issues related to the use of Telepractice for your discipline. Be familiar with relevant legal and ethical principles and professional codes of conduct relating to security, confidentiality, consent and privacy of patient related data and information. Be knowledgeable of own regulated profession’s telepractice guidelines. 2. Knowledge of effective VC delivery in clinical practice and/or continuing education. This may
include VC etiquette/professional behaviour, communication skills, powerpoint and speaker guidelines, hosting and moderating an event.
Advanced Competencies for learners on placement with clinical teachers using VC regularly in practice
3. Identify appropriate physical (room choice and set up), audio (mic choice, placement and use) and visual (camera view, lighting, background considerations) set up required to successfully support intended clinical activity/educational session.
4. Identify components and VC options best suited for the intended service delivery (point-to-point, continuous presence, screen layout choices, computer interface options (data pushing), peripheral devices: ELMO (document camera), AMD camera, tele-stethoscope, video-otoscope, etc).
5. Knowledgeable of the booking, operating and troubleshooting requirements for various VC equipment components utilized in telepractice service delivery (e.g. document cameras, zoom/pan, camera adjust, etc).
Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
11 6. Awareness of the potential barriers, limitations, and complications as they relate to both human
and technological factors and how to compensate for these factors.
7. Identify and address the experiential (comfort and experience with technology), cultural, language and/or disability (hearing, vision, mobility) factors to be considered to ensure and maximize safe and efficient telepractice service delivery.
8. Implement quality control measures to ensure quality/accuracy/efficiency of service is delivered. (ie. Checks re: whether what you are doing by Telepractice is working…having the desired impact/outcome).
To facilitate learners attaining these competencies, a Competency Checklist (see Appendix D) has been designed for learner and clinical teacher use. This checklist can to be tailored to assist the learner and clinical teacher/preceptor to plan the placement activities and schedule. It is the responsibility of the learner to complete the checklist and submit to the NOSM-related Program Manager/Coordinator. The Program Manager/Coordinator will review checklist and collate for Health Sciences accreditation purposes. Some activities will not be applicable or available. Discussion, role-play, case study, and assignments can serve as an alternative to actual hands-on completion of the learning activities. There are also other resources that can be adapted for the individual Health Sciences program. These include VC readiness tools and surveys as well as training opportunities and materials.
Resources
VC readiness tools and surveys
There are some tools and surveys available electronically (links provided) or have been included
in Appendix C.
Focus group guide and questions (French only) from: Gagnon M, Godin G, Gagne C, et al. (2003). An adaptation of the theory of interpersonal behaviour to the study of telemedicine adoption by physicians. International journal of medical informatics, 71(2-3), 103-115.
http://www.theses.ulaval.ca/2003/21408/21408.html
TELBIL-What’s your opinion on home telemonitoring? (Source: M-P Gagnon, U of Montreal) (Appendix C1)
RNAO EHealth Knowledge Assessment Questionnaire (need to register)-15 item online questionnaire on various topics related to your use and interaction with eHealth in both your personal and work life. http://elearning.rnao.ca/mod/questionnaire/view.php?id=689
Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
12 RCN eHealth survey from: Wallis A. (2012). Survey explores nurses. Nursing management, 8
(10), 14-19. http://www.rcn.org.uk/__data/assets/pdf_file/0005/391109/004115.pdf (Appendix C2).
NODIP RD Preceptor Survey adapted from: Cohn R J, Goodenough B. (2002). Health
professionals’ attitudes to videoconferencing in paediatric health-care. Journal of telemedicine and telecare, 8(5), 274-282. (Appendix C3).
Training opportunities and resources
NOSM CEPD
September 2012 to May 2013: “Developing Telepractice Competence” , a "lunch & learn" series delivered live, videoconferenced to OTN sites throughout Ontario and webcast for epresence participants. Access to archived web casts are available at: http://www.nosm.ca/rssresources/. OTN
OTN telemedicine resource guide https://training.otn.ca/shared/portal/private/index.html
OTN e-Training centre https://training.otn.ca/index.asp
Training guides http://otn.ca/sites/default/files/otn_training_manual_-_clinical.pdf
Best Practices http://otn.ca/sites/default/files/best_practices_for_clinical_telemedicine_-_a_training_perspective.pdf
Hosting and moderating an event
https://training.otn.ca/d2l/lor/viewer/view.d2l?ou=6605&loId=2859
VC etiquette guidelines https://training.otn.ca/shared/portal/pdf/VCEtiquetteGuidelines.pdf
Moderating/chairing guidelines
https://training.otn.ca/d2l/lor/viewer/view.d2l?ou=6605&loId=2861
Resource library (ppt guidelines, speaker guidelines, etc.) http://otn.ca/en/members/resource-library
Contact North
College Boreal faculty training; programs offered through VC; curriculum, best practices
Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
13 College Boreal contact: Carmen Ferguson-Levac ([email protected])
Cambrian College edome http://www.contactnorth.ca/pockets-innovation/edome
VC training http://www.contactnorth.ca/training-opportunities/contact-north-learning-platforms-training-schedule
Training resources http://www.contactnorth.ca/training-opportunities/contact-north-videoconferencing-training-resources
Blended learning resources e.g. blogs, dropboxes, etc. http://www.contactnorth.ca/tips-tools/top-resources-blended-learning
RNAO Ehealth for Every Nurse Course and EHealth Toolkit (NOTE: this course does not include VC telepractice; there is a registration process required)
http://elearning.rnao.ca/mod/resource/view.php?id=224
NOSM Health Sciences Competency Checklist Tips
Competency 2, 2.2: List and describe 3 strategies you would use to maximize the effectiveness of your participation in an education session or professional meeting.
o For an educational session:
1. Camera View close up on all participants
2. Know how to use the remote to adjust volume and view
3. Know what to do if you are having connection difficulties (# to call) 4. Handouts/attendance and evaluation forms.
o Professional Meeting:
1. Camera view close up on your face to maximize the closeness of the connection/communication
2. Take steps to ensure audio and visual are effective for all participants
3. Strategies to ensure you are able to contribute to the discussion without cutting people off (how to signal you have something to say)
Competency 2, 2.3: List and describe 3 strategies you would use to maximize the effectiveness of an education session you would deliver via VC.
o If using power point: font size / slide content
o Knowing how to toggle back and forth from slide to speaker view o Strategies to engage the audience
Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
14 For more practical tips, preview the NOSM webinar (Facilitating Small Groups Using Telehealth:
Feedback from Participants)available at http://www.nosm.ca/rssresources/.
Appendix A: Literature Review
A literature search using select key words (e.g., telehealth, videoconferencing, telemedicine
utilization) was conducted in early July 2012 through Cochrane Database of Systematic Reviews,
DARE (Database of Abstracts of Reviews of Effectiveness, MEDLINE and Google Scholar along
with the retrieval other relevant articles and web sites from article reference citations. There
were also inquiries and correspondences received from two Canadian telehealth experts, Dr.
Marie-Pierre Gagnon of Laval University and Dr. Penny Jennett from the University of Calgary.
Attempts to correspond with some Australian researchers (Dr. RJ Cohn and Dr. B Goodenough)
have been unsuccessful to date.
There is very little published literature on videoconferencing (VC) as a telemedicine technology
that can be generalized to a wide range of health care practitioners, areas of practice and
settings. There are also a wide range of definitions and concepts such as:
Telemedicine refers to any medical service provided at a distance via electronic communication
(Gagnon et al, 2003) or the delivery of health care and exchange of health care information over
distances (Craig and Patterson, 2005). This can include diagnosis, treatment and prevention of
disease, continuing education of health care providers and consumers, and research and
evaluation (Craig and Patterson, 2005). It is also rapid access to shared and remote medical
expertise by means of telecommunications and information technologies, no matter where the
patient or the relevant information is located (Craig and Patterson, 2005).
Telehealth is used to manage patient care remotely or in patients’ homes and includes care over
the phone, using videoconference and remote monitoring of signs and symptoms (Wallis, 2012)
or the use of information and communications technology (ICT) to deliver health services,
expertise and information over distance, geographic, time, social and cultural barriers (Muttitt
et al, 2004). Telehealth also refers to public health services delivered at a distance to people
who are not necessarily unwell but who wish to remain well and independent (Craig and
Patterson, 2005).
Telecare is a way to monitor safety in the home of vulnerable client groups (Wallis, 2012) and
the provision of care at a distance (Craig and Patterson, 2005).
Telehealth readiness is the degree to which communities, organizations and professionals are
prepared to participate and succeed in telehealth (Gagnon et al, 2006).
Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
15
Information and communication technologies (ICTs) are technologies to help gather, store,
process and share information electronically (Gagnon et al, 2009). ICTs include electronic
medical records, medical journals and databases on the internet, videoconferencing for
provider/patient appointments, or systems on the internet to give feedback to providers so
they can improve the care they provide. ICTs also include informational websites,
e-consultations, online communities, online health decision support programs, tailored online
health education programs, online health care portals, virtual reality programs, home
automation, sensor technology, and robotics.
Digital interactive television systems (DITV) can facilitate communication of information to or
from an individual’s home with a health or social care application (Blackburn et al, 2011). Some
potential barriers include technology abandonment by people with physical, sensory or
cognitive impairments. There can also be infrastructure and costs associated with transmission
speeds in some communities. Input control and user interface should be suitable for the
intended users, particularly if targeted to the aging population, living independently at home.
There is a need to assess clinical and cost-effectiveness.
Internet-based Group Support Systems (GSS) cover a wide range of application functionalities
including systems supporting collaborative authoring, creative group processes, data gathering,
statistical evaluation, etc. Examples include white boards, application sharing, shared web
browsing, voice over Internet Protocol (IP) and video over IP (Moehr et al, 2005). There may
have some telehealth applications e.g., educational but likely insufficient to demonstrate
intricate processes such as insertion of central lines or to judge the dexterity, gait or the
emotional status of an individual. However, Skype is now being considered as an option since
the software is free and most patients have the necessary equipment (personal computers)
(Good et al, 2012). Skype uses encryption, cryptography, a digital certificate and authentication
to maintain security and prevent data theft. It has been used to accurately perform functional
assessments in outpatient follow-up visits for displaced clavicle fractures.
eHealth is promoting the health and wellbeing of individuals, families and communities, and
improving professional practice through the use of ICT (van Gemert-Pijnen, 2011; Wallis, 2012;).
It can be used to connect providers, patients and governments; to educate and inform health
care professionals, managers, and consumers; to stimulate innovation in care delivery and
health system management; and to improve the health care system (van Gemert-Pijnen, 2011).
Health informatics is about the practice and science of information, information processing, and
information systems in support of patient care (Ellaway, 2010).
eHealth (also known as Health
Informatics) is defined as ‘the knowledge, skills and tools which enable information to be
Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
16
collected, managed, used and shared to support the delivery of healthcare and to promote
health’ (RNAO, 2012). Nurse training and continuing education on the topic is available via a
toolkit and N e-Health online education program (RNAO, 2012); a number of undergraduate and
graduate courses (RNAO, 2012) and through the British Royal College of Nurses (RCN) Learning
Zone which has web-based resources e.g.; telehealth explained; eHealth Insider online news
and information service with updates on eHealth education and training opportunities (member
access only) (RCN, 2012).
Benefits and Limitations
Numerous benefits have been cited for telehealth/telemedicine use (Walker and Whetton,
2002; Jennett et al, 2003; Hebert et al, 2004; Craig and Patterson, 2005; Gagnon et al, 2006;
Jarvis-Selinger et al, 2008) including:
- better access, equity, quality and availability to specialized services as well as more complete
health care services in remote areas;
- increased access to health services, cost effectiveness (in mainly radiology and mental health),
enhanced educational opportunities, improved health outcomes, better quality of care, better
quality of life and enhanced social support;
- early intervention, reduced unnecessary use of health services, and help to manage symptoms
at home;
- improved continuity of care, increased availability of information, facilitating case
management;
- facilitating continuing medical education (CME), contacts with peers and access to a second
opinion, exchanges between professionals from various sites and specialties;
- supporting development of regional reference centres to provide a wide range of services to
remote populations; retention of local expertise; and cost savings e.g. avoid transfers, travel
costs for patients, families; and
- facilitating quality of service by treating patients both rapidly and appropriately with good
inter-rater reliability between remote and face to face settings; reducing patient transfers and
maintaining care within home community.
Some perceived limitations could be the replacement of onsite human resources; lower recruit
and retention to remote areas; and reduced CME outside the region that would allow
opportunities to socialize with colleagues (Gagnon et al, 2006). There is also need for more
indicators of the social-economic impacts e.g. health status, health outcomes, practice patterns,
patient management, health system resources as well as other organizational, social and ethical
implications and potential risks (Jennett, 2003). Most studies and reviews focus on general
Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
17
aspects of telemedicine (feasibility, outcomes, economics and satisfaction); economic viability
has not been adequately addressed (Bahaadinbeigy et al, 2010).
Various forms of telemedicine are feasible (including VC) with positive patient satisfaction but
there is not yet enough evidence to show the effects on health outcomes or costs (Currell et al,
2010). VC modes well to the demonstration of procedures and devices (e.g. communication
devices) as experimental learning sessions for teams and groups (Moehr et al, 2005). It has also
been used for in-person meetings and job interviews in British Columbia (BC) (Moehr et al,
2005). There is reported value in VC use by professionals, especially in education and training,
and psychosocial applications (Cohn and Goodenough, 2002). More recently, evidence indicates
that clinical outcomes are similar between in-person and VC-delivery modes and that patient
satisfaction is increasing (Steel et al, 2011). It should be noted that the majority of literature is
from the field of telepsychiatry and there is a gap concerning telerehabilitation for physical
conditions (Steel et al, 2011).
A BC evaluation did find that clinical applications of VC were more difficult but can be highly
beneficial when they involve patient management of chronic conditions with established teams
separated by distance, especially if scheduled regularly or well in advance and when case
management depends on visual information (Moehr et al, 2005). Educational applications are
highly appreciated by practitioners and patients, families, communities with likely unrealized
clinical effects. Key is the interactivity and demonstration potential of the educational sessions.
Administrative applications can lead to efficiencies that alleviate the financial burden of other
applications e.g. clinical and educational.
Despite a number of limitations, a meta-analysis found VC more efficacious than other
technologies (web-based interventions, data monitors only, video and data monitors, and
telephone only interventions) for three diseases-heart disease, diabetes and psychiatric
conditions with positive mild to moderate affects on clinical outcomes (DelliFraine and Dansky,
2008). VC may be useful for conditions that require close monitoring, clinical assessment and
early intervention to avoid hospitalization or emergency visits and has the potential to decrease
health care costs but cost effectiveness research is limited (DelliFraine and Dansky, 2008).
Overall e-health tools may facilitate self-management and empower patients and professional
skills in communication, education and health literacy, information about personal health
situations, self-care and support, decision-making and contact with fellow patients (Alpay et al,
2011). But technologies can’t help facilitate self-monitoring and self-management or improve
patient health outcomes when patients do not accept the technology (Or et al, 2009).
Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
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Knowledge, Attitudes and Uptake
Integrating VC use into practice requires reliable IT infrastructure, effective clinical
demonstrations, assessment of practitioners’ readiness, integration of IT into workflow, change
management practices, just-in-time IT support, policy synchronization, and quality assurance of
services (Jarvis-Selinger et al, 2008). Other key lessons include organizational readiness and
system adoption including protocols to ensure 24/7 preparedness; comprehensive change
management; and a user training plan to ensure comfort, competence and readiness to use
equipment. To be successful, there needs to be activity with large enough workloads to
maintain the skills and confidence levels of users.
The technological conditions to operate a clinical videoconferencing service include (Moehr et
al, 2005; Jarvis-Selinger et al, 2008):
- basic technological requirements (medium/high bandwidth for adequate audio and visual
clarity);
- need to monitor placement and room setup;
- technological compatibility between remote and central sites (interfacing computers and
appropriate application software); and
- ongoing technical support.
There may also be key differences in attitudes and communication practices of practitioners
and so design, implementation and evaluation of interventions to promote optimal uptake and
utilization of VC may need to be targeted by discipline and/or practice setting (Cohn and
Goodenough, 2002; Gagnon et al, 2006). Users may be prepared to learn to use a new
technology if they perceive that the system is critical to their job performance or quality of
service. Rural and remote site users seem more willing to participate in training and be more
tolerant of technical difficulties (Walker and Whetton, 2002). Practitioners must recognize that
different clinical and communication skills, and information giving approaches may significantly
alter the nature of the clinical encounter by VC and also the relationship between the
practitioner and patient (Currell et al, 2010).
The degree of success in uptake is associated with factors related to the degree of need for the
service and local health service structure as well as ‘people’ factors-acceptance by clients,
practitioners and operators (Hailey, 2001). Teleradiology has been well integrated and a
majority of teleconsultations are performed in mental health, pediatrics, dermatology,
cardiology and orthopediatics, often with interactive video (Craig and Patterson, 2005). Along
with ethical and medicolegal concerns, human and cultural factors include resistance to change,
linguistic differences and illiteracy (Craig and Patterson, 2005).
Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
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There is a need for increased knowledge in the design, implementation and evaluation of
interventions aimed at promoting the optimal integration of ICT in all groups of healthcare
professionals’ practice (Gagnon et al, 2009). Identifying the key individual, professional,
organizational, and systemic factors would help design more specific and tailored interventions.
Telehealth readiness should be first assessed with the target audience(s) and individualized; this
process could include the use of readiness and knowledge assessment surveys or ideally with
focus groups and/or key informant interviews (M-P. Gagnon and P. Jennett, personal
communication, July 19, 2012). A number of surveys have been designed for a variety of
practitioners including nursing (RNAO, 2012), physicians (Gagnon, 2003), and pediatric health
care providers (Cohn and Goodenough, 2002) using various theories e.g. Triandis Theory of
Interpersonal Behaviour (Gagnon, 2003) or models such as the technology acceptance model
(M-P. Gagnon, personal communication). Whatever tool is used needs to be adapted to the
specific topic and that will require interviews or focus groups in order to uncover the beliefs
regarding the use of videoconferencing in your target population (M-P. Gagnon, personal
communication).
Another approach to assessing telehealth readiness is the following strategies (P. Jennett,
personal communication):
1) For those who are not familiar or slightly familiar with e-Health and telehealth, first use
community show cases to demonstrate and use those types of e-technologies. Then follow
these show cases with focus groups to determine their perceptions and readiness of these
types of technologies and how they might assist them with their health or educational needs.
The "communities" help design the focus groups and some aspects of the focus groups.
2) For those who had used the technologies in their practices, use focus groups for small
identified groups, and then surveys for larger groups. The surveys need to be designed by
experts and users in the fields with pre and post-testing.
3) For special types of users- administrators/organizers, health users, and patients, use key
informant interviews which are designed based on the input of experts and key informants.
There needs to be a better fit between technological, human and contextual factors to improve
uptake and impact of e-Health technologies (Or et al, 2009; van Gemert-Pijnen et al, 2011).
Mixed methods of using both quantitative and qualitative designs should be used in order to
better measure uptake and impact of e-Health technologies (van Gemert-Pijnen et al, 2011).
The needs of patient end-users (physical, psychological, social) also must be adequately
addressed (Or et al, 2009).
Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
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There is some evidence that individual or group training or providing training materials may
improve the adoption/use of ICTs but it is not unknown if some of these strategies are effective
in general clinical performance or process outcomes (e.g. decision to prescribe a particular
drug/treatment), patient health outcomes, along with health professionals’ knowledge,
attitudes or satisfaction (Gagnon et al, 2009). Small effects with use of electronic databases and
digital libraries has been documented but not around videoconferencing. Yet telemedicine
attributes (feasibility, acceptability, cost, effectiveness, safety, sustainability) will vary from
application to application and publication requirements of tightly controlled systematic reviews
could limit clinical relevance and uptake into practice (Craig and Patterson, 2005). While many
studies are excluded in systematic reviews because of their non-experimental design, there is
likely a general lack of research in the area of healthcare education due to lack of funding or
little interest in this research field. More well designed trials are needed (Gagnon, 2009; van
Gemert-Pijnen et al, 2011).
Conclusions
There is very little published literature on VC as a telemedicine technology that can be
generalized to a wide range of health care practitioners, areas of practice and settings. There
are also a wide range of definitions and concepts and so a consensus is needed before designing
and implementing a process to measure VC telepractice competency of Health Science clinical
teachers and learners.
While there are numerous benefits cited on VC applications in health care, there may also be
key differences in attitudes and communication practices of health practitioners and so the
design, implementation and evaluation of interventions to promote optimal uptake and
utilization of VC use should be targeted by discipline and/or practice setting. Also the
receptiveness by patient users should be known. There is also the need to determine the need
and receptiveness of VC use in educational and administrative purposes.
Telehealth readiness should be first assessed with the target audience(s) and individualized; this
process can be complex, as well as time and resource intensive. Therefore, it has been proposed
that a broad approach be taken to assess the VC telepractice competencies of Health Science
clinical teachers and learners starting with the validation of an analytical framework to
determine the degree of readiness and potential next steps.
Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
21
References
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Blackburn S, Brownsell S, Hawley M S. (2011). A systematic review of digital interactive
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Cohn R J, Goodenough B. (2002). Health professionals’ attitudes to videoconferencing in
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Craig J, Patterson V. (2005). Introduction to the practice of telemedicine. Journal of
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Currell R, Urquhart C, Wainwright P, Lewis R. (2009). Telemedicine versus face to face patient
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Gagnon MP, Duplantie J, Fortin JP, Landry R. (2006). Implementing telehealth to support
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Gagnon M-P, Légaré F, Labrecque M, Frémont P, Pluye P, Gagnon J, Car J, Pagliari C, Desmartis
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Gagnon. (2011). Interventions for promoting information and communication technologies
adoption in healthcare professionals. Cochrane database of systematic reviews, (1).
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Hailey D. (2001). Some successes and limitations with telehealth in Canada. Journal of
telemedicine and telecare, 7 Suppl 2(2), 73-75.
Hebert MA, Jansen JJ, Brant R, et al. (2004). Successes and challenges in a field-based,
multi-method study of home telehealth. Journal of telemedicine and telecare, 10 Suppl 1, 41-44.
Jennet PA et al. J The socio-economic impact of telehealth: a systematic review. J Telemed
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van Gemert-Pijnen JE, Nijland N, van Limburg M, et al. (2011). A holistic framework to improve
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Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
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Appendix B: VC Telepractice Competence Assessment Framework
Videoconference Telepractice Competence Assessment Framework, June 2013
Videoconference (VC) telepractice competency:
is the ability to share in real-time video and audio information
between two or more people at different locations and may include clinical care and consultations, education for
professionals and consumers, and transfer of data or information between health care organizations. Source: Johnson et
al. (2001). Interactive videoconferencing improved nutrition intervention in a rural population. JADA; 101 (2): 173-4.
Domain:
Health Sciences Staff/Faculty and Learner Development
To ensure Health Sciences staff, faculty and learners have the requisite attitudes, knowledge and skills for delivering
telepractice/videoconference services relevant to their practice setting(s).
Focus Areas
Indicators-Structure
NOSM measures, data sources
NOSM measures, data sources
Indicators-Process
NOSM measures, data sources
Indicators-Output
Training
Commitment
Training plan for faculty
Training plan for
learners
UME Health Informatics
draft competencies?
Training linked to
quality improvement
efforts (as core
competency)
Provides basic/initial and
periodic telepractice
competence training for
staff/faculty
Telepractice series-8
weeks Sept 2012-May
2013
Provides basic/initial and
periodic telepractice
competence training for
learners
VC training during
orientation (NODIP,
Investment (monetary
and other) in
telepractice
competence training
All faculty complete
basic/initial and
periodic telepractice
competence training
All learners complete
basic/initial and
periodic telepractice
competence training
Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
25
Rehab Studies? PA?)
Incorporates telepractice
competence training into
overall staff/faculty
training activities
Incorporates telepractice
competence training into
overall learner training
activities
NODIP PD series via VC
Consultation provided on
telepractice competence,
upon request
Offers regular
opportunities for
staff/faculty to interact
with telepractice
community
Offers regular
opportunities for learners
to interact with the
telepractice community
Conducts regular
monitoring and periodic
evaluations of
telepractice competence
training efforts
Training Content
Telepractice
Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
26
addresses key
competence-related
knowledge, skills and
attitudes (as generally
applicable and as
related to practice
setting(s))
Telepractice
competence curricula
individualized to roles of
persons trained (e.g.
clinical, community,
front-line,
administrative, etc.)
needs of staff/faculty
IPE needs assessment
2010
HS Preceptor Needs
Assessment 2013
Assesses telepractice
competence training
needs of learners
Obtains telepractice
community input
regarding staff/faculty
training
Obtains telepractice
community input
regarding learner
training
Assesses the quality of
staff/ faculty training in
telepractice competence
Assesses the quality of
learner training in
telepractice competence
competence in
knowledge, skills,
attitudes and
behaviours (as
generally applicable
and as related to
practice settings(s))
Staff/Faculty
Performance
Telepractice
competence is part of
job description
System of incentives
(individual and team)
for telepractice
competence
Assesses staff/faculty
performance regarding
telepractice competence
Staff/faculty
performance evaluations
are conducted in a
telepractice competent
Staff/faculty
performance (including
self-efficacy) in the
application of
telepractice
competence
principles/practices
Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
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behaviours/activities
manner?
Learner Performance
Telepractice
competence is part of
learner expectations
System of incentives
(individual and team)
for telepractice
competence
behaviours/activities
Assesses learner
performance regarding
telepractice competence
Learner performance
evaluations are
conducted in a
telepractice competent
manner?
Learner performance
(including self-efficacy)
in the application of
telepractice
competence
principles/practices
Adapted from: The Lewin Group, Inc. (2002). Indicators of cultural competence in health care delivery organizations: An
organizational cultural competence assessment profile. Retrieved July 16, 2012 from:
Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
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Appendix C: VC readiness tools and surveys
Appendix C-C1-TELBIL Survey
¿What's your opinion on home
telemonitoring ?
Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
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PURPOSE OF THE QUESTIONNAIRE
To find out the opinion of health care professionals from Bilbao Primary Care Health Region on home telemonitoring.
The objective of this study is to find out your opinion on this new technology. Having had previous experience with home telemonitoring is not necessary to answer the questionnaire. The information will be analyzed confidentially.
Please, complete this questionnaire. Your opinion is important.
1. Sex: Male Female 2. Age: < 30 years 30-39 years 40-49 years 50-59 years > 60 years 3. 4. Medical specialty: General physician Nurse Paediatrician
Your health centre : ____________________________________________________
5. Number of years in clinical practice:_______________________________________
6. Highest degree obtained (you can choose more than one option): 3-year certificate
Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
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7. I often use computing tools in my work: Yes
No
8. I feel comfortable with information and communication technologies (e.g. e-mail, Internet, videoconference, on-line teaching, etc.):
Yes No
9. I have already used telemonitoring devices to monitor my patients: Yes
No
10. I am going to participate in the TELBIL study. Yes No
2
[W ha t's y ou r o pinio n on ho m e t ele m onit o ring? ]Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
31 Here are 26 statements related to various factors that may be involved in the acceptance of telemonitoring as a working tool. Please, indicate your level of agreement with each of the following statements using the scale provided below:
** Remember to select a single option for each statement.
-3 -2 -1 0 1 2 3
Totally Disagree Slightly Neither agree Slightly Agree
Totally
disagree disagree nor disagree agree
agree
-3 -2 -1 0 1 2 3
11. The use of the telemonitoring system (TMS) could help me to monitor my patients more rapidly
-3 -2 -1 0 1 2 3
12. I think that I could easily learn how to use the TMS
-3 -2 -1 0 1 2 3
13. I have the intention to use the TMS when it becomes available in my health centre
-3 -2 -1 0 1 2 3
14. The use of the TMS may imply major changes in my clinical practice
-3 -2 -1 0 1 2 3
15. The use of the TMS could improve the monitoring of my patients
-3 -2 -1 0 1 2 3
16. I think that it would be easy to perform the tasks necessary for the monitoring of my patients using the TMS
-3 -2 -1 0 1 2 3
17. Most of my patients will welcome the fact that I use the TMS
-3 -2 -1 0 1 2 3
18. I think that my health centre has the necessary infrastructure to support my use of the TMS
-3 -2 -1 0 1 2 3
19. Using the TMS could help me get the most out of my time to monitor my patients
-3 -2 -1 0 1 2 3
20. I believe that the monitoring carried out by TMS would be clear and easy to understand
-3 -2 -1 0 1 2 3
21. The use of the TMS is compatible with my work habits
Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
32 22. Most of my colleagues will welcome the fact that I use the TMS
-3 -2 -1 0 1 2 3
23. Using the TMS could improve my performance in patients care
-3 -2 -1 0 1 2 3
Totally Disagree Slightly
Neither agree Slightly Agree Totally
disagree disagree
nor disagree agree
agree
-3
-2
-1 0 1
2 3
24. I think that the TMS is a flexible technology to interact with
-3
-2 -1 0
1
2
3
25. I have the intention to use the TMS when necessary to provide health care to my patients
-3 -2 -1 0 1 2 3
26. Health managers would welcome the fact that I use the TMS
-3 -2
-1 0 1 2 3
27. Using the TMS could facilitate the care of my patients
-3 -2 -1 0 1 2 3
28. I think I would find it easy to acquire the necessary skills to use the TMS
-3 -2 -1 0
1 2 3
29. The use of the TMS could promote good clinical practice
-3 -2 -1 0 1 2 3
30. I would use the TMS if I receive appropriate training
-3 -2
-1 0
1 2 3
31. Other health professionals (specialist, nurses, GPs etc.) would welcome the fact that I use the TMS
-3 -2
-1 0 1 2 3
32. In general, the TMS could be useful to improve the care of my patients
-3
-2
-1 0 1 2 3
33. I have the intention to use the TMS routinely for the care of my patients
-3
-2
-1
0 1 2 3
34. The use of the TMS could interfere with the usual follow-up of my patients
-3
-2
-1
0 1 2 3
35. I think that the TMS will be easy to use
-3
-2
-1
0 1 2 3 [W ha t's y ou r o pinio n on ho m e t ele m onit o ring? ]
Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
33 36. I would use the TMS if I receive the necessary technical assistance
Do you have any comments?
____________________________________________________________________________ _________________________________________________-_________________________
Copyright © 2014 Health Sciences Unit, Northern Ontario School of Medicine
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