Use of store and forward technology for vascular nursing teleconsultation service

Accurate assessment is critical in planning appropriate therapeutic management of a patient with a vascular wound. However, several factors may inhibit wound assessment by trained professionals or subspecialists. Multiple co-morbidities and lack of transportation and finances contribute to problems with access to specialty clinics for both rural and urban patients with vascular disease. To assess the application of telemedicine in meeting the needs of rural patients with vascular disease, the vascular nurse clinician of a regional medical network was incorporated into a telemedicine research project that used a still-image transmission system known as the Picasso telephone, which allows a diagnostic quality image to be transmitted over a regular telephone line. Telephone consultation between sender and receiver occurs simultaneously at the time of image transmission. Because images can be collected and stored for future reference, this technology is commonly called "store and forward" technology. The application of advanced technology in a rural health care environment has the potential to reduce costs for both patient and managed care insurance plans, allow for expert consultation from distant centers, and promote collegiality and learning among professionals.     

Rural telepsychiatry

Telepsychiatry is the use of telecommunications technology to connect patients and health care providers, permitting effective diagnosis, education, treatment, consultation, transfer of medical data, research, and other health care activities. Telepsychiatry has been used as a partial solution to the problem of limited psychiatric services for clinics and hospitals in remote areas of areas underserved by psychiatrists and other mental health care specialists. In the United States, eastern Oregon's RodeoNet telepsychiatry program and the telemedicine program of the Kansas University Medical Center, which has a psychiatric component, are excellent models. Telepsychiatric applications can be cost-effective, but careful evaluation is needed.     

Planning criteria for multicentre, multilingual telemedicine conferences

The international telemedicine conference Chinese TeleMed 96 was held in November 1996. This three-way teleconference included delegates in London (where the international telemedicine conference TeleMed 96 was taking place) and medical staff from one Beijing hospital and one Hong Kong medical faculty. In total, over 1000 health-care personnel across eight time-zones participated. The event demonstrated that the quality of teleconferencing technology was suitable for medical teaching, for providing medical consultations to remote locations and for stimulating medical exchanges. In general, planning a telemedicine conference requires a longer lead time, a wider representation of expertise in the organizing committee and more financial resources than conventional conferences. It is recommended that the aim and format of a telemedicine conference be determined at least one year before the target date. Criteria for improving the preparation of such conferences have been identified and a set of guidelines for future conference organizers has been drawn up.     

"Brain attack": the rationale for treating stroke as a medical emergency

Stroke is the third leading cause of death in the United States, behind only heart disease and cancer. With an estimated three million survivors of stroke in the United States, the cost to society, both directly in health care and indirectly in lost income, is staggering. Despite recent advances in basic and clinical neurosciences, which have the potential to improve the treatment of acute stroke, the general approach to the acute stroke patient remains one of therapeutic nihilism. Most basic science studies show that to be effective, acute intervention to reperfuse ischemic tissue must take place within the first several hours, as is the case with ischemic myocardium. In addition, most neuroprotective agents must also be administered within a short time frame to be effective at salvaging at-risk tissue. Recent studies have suggested that the outcome after intracerebral and subarachnoid hemorrhage is improved with early intervention. However, most stroke patients fail to present to medical attention within this short "window of opportunity." The public's knowledge about stroke is woefully inadequate. However, clinicians who deal with stroke can use the dramatic changes in the treatment of acute myocardial infarction over the last 2 decades as a guide for shaping changes in the management of acute stroke. Comprehensive educational efforts aimed at clinicians and the public at large have dramatically reduced the time from symptom onset to presentation and treatment for acute myocardial infarction, enabling treatment methods such as thrombolysis to be effective. The Decade of the Brain offers a unique opportunity to all concerned with the treatment of the patient with acute stroke to engage in a concerted effort to bring patients with a "brain attack" to specialized neurological attention within the same timeframe that the "heart attack" patient is handled. Such an effort is justified because, although at the present time there are few therapeutic interventions of "proven" value in the treatment of acute stroke, there is more than sufficient suggestive evidence that a number of approaches may be beneficial within the first few hours after the onset of the stroke.     

Sperm morphology assessment: diagnostic potential and comparative analysis of strict or WHO criteria in a fertile and a subfertile population

In the National Institutes of Neurologic Disorders and Stroke (NINDS) recombinant tissue plasminogen activator (rt-PA) stroke trial, the primary adverse events monitored were intracranial hemorrhage (ICH), systemic bleeding, death and new stroke. Nurses caring for the study patients noted these adverse events and other complications. In addition to what is known about acute ischemic stroke (AIS), the NINDS trial provides further information for optimal care of this specific group of patients. The complications found in this trial require expert nursing care to monitor, prevent and intervene, making clinical decisions relevant to the patients needs. The critical decision-making process must be grounded in knowledge of acute stroke physiology and thrombolysis.     

Clinical cross-training: Compatibility of sport and family systems psychology.

Sport psychology offers unique opportunities for (a) expanding one's practice beyond areas regulated by managed care and (b) using one's knowledge of psychology to cultivate health, wellness, and positive aspects of life. This article describes how developing expertise in sport psychology may benefit a practitioner, with special attention to family systems psychologists evaluating their own suitability for working in the sport and exercise area. In addition to expanding one's practice, ways in which sport psychofogy expertise may enhance overall clinical skills are noted. The article concludes with a checklist to evaluate suitability for "cross-training" in sport psychology and recommendations for initiating the process. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The composition of individual molecular species of plasma phosphatidylcholine in human pregnancy

The role of medical informatics in telemedicine is dependent on using the power of the computerized database to not only feed patient specific information to the health care providers, but to use the epidemiological and statistical information in the data base to improve decision making and ultimately care. The computer is also a powerful tool to facilitate standardizing and monitoring of care and when applied in continuous quality improvement methodology it can enhance the improvement process well beyond what can be done by hand. The coupling of medical informatics with telemedicine allows sophisticated medical informatics systems to be applied in low population density and remote areas.     

Telehealth: A clinical application model for rural consultation.

This article describes how a child psychologist in a rural community provides the necessary comprehensive consultation and clinical services using a video telephone and the services of Kentucky Telecare. The authors present a clinical consultation model of health care for underserved populations where professional consultation with a team of professionals may benefit service providers in rural communities. The article examines an innovative model of telehealth care delivery through a university-based telehealth system to an underserved regional school system. A number of applications within a broad spectrum of services using telehealth technology are offered. Finally, shifts in administrative paradigms, clinical models, and information technology prevention services through telehealth are addressed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Tuberculosis in adolescents. A case commentary

The resurgence of tuberculosis (TB) in the United States has placed a substantial segment of the adolescent population at high risk, particularly those adolescents residing in metropolitan areas. Physicians providing health care to adolescents must be aware of the risk factors for TB and of the epidemiology of this insidious disease. Active alliances must be established among health-care professionals in the community to ensure effective screening, diagnosis, and treatment programs.     

Management of the hypertensive patient: a case report

Hypertension is a potentially life-threatening condition that can lead to heart failure, stroke, and kidney disease. Most patients with hypertension can be treated and controlled if they are diagnosed in a timely manner. This case report exemplifies how the dentist can play a key role in the detection of hypertension by simply taking vital signs on all patients. It is incumbent upon us as health-care professionals to understand the causes of hypertension, the therapeutic drugs used and associated side effects, and the potential for drug interactions. The dentist's ability to recognize and appropriately manage hypertension will greatly enhance the health and safety of our patients.     

The promise and performance of HMOs in improving outcomes in older adults

In summary, the promise of HMOs in caring for older adults far exceeds their performance to date. Until recently they had neither the motivation nor the knowledge to revamp their delivery systems to better needs of older, chronically ill patients. Market pressures and skyrocketing costs have provided the motivation. Physicians and researchers trained in epidemiology and health services research from programs such as that at UCLA are providing the knowledge. Based on the literature and experience described above, HMOs with the characteristics supportive of population-based care can put into place an approach to geriatric care likely to improve outcomes if they heed their patients and professionals rather than their accountants. These organizations will give highest priority to preserving function and will be guided by explicit clinical guidelines. Care will be rendered by organized primary care teams supported by systematic self-management approaches, standardized interventions for key risk factors, clinically useful computer systems, and available geriatric expertise. It will require a small revolution as old approaches, roles, and relationships will not go quietly. We are in the early phases of this revolution, and it's not too late to join us on the barricades.     

Replication of clinical innovations in multiple medical practices

BACKGROUND: Many clinical innovations had been successfully developed and piloted in individual medical practice units of Kaiser Permanente in North Carolina during 1995 and 1996. Difficulty in replicating these clinical innovations consistently throughout all 21 medical practice units led to development of the interdisciplinary Clinical Innovation Implementation Team, which was formed by using existing resources from various departments across the region. REPLICATION MODEL: Based on a model of transfer of best practices, the implementation team developed a process and tools (master schedule and activity matrix) to quickly replicate successful pilot projects throughout all medical practice units. The process involved the following steps: identifying a practice and delineating its characteristics and measures (source identification); identifying a team to receive the (new) practice; piloting the practice; and standardizing, including the incorporation of learnings. The model includes the following components for each innovation: sending and receiving teams, an innovation coordinator role, an innovation expert role, a location expert role, a master schedule, and a project activity matrix. Communication depended on a partnership among the location experts (local knowledge and credibility), the innovation coordinator (process expertise), and the innovation experts (content expertise). RESULTS: Results after 12 months of working with the 21 medical practice units include integration of diabetes care team services into the practices, training of more than 120 providers in the use of personal computers and an icon-based clinical information system, and integration of a planwide self-care program into the medical practices--all with measurable improved outcomes. CONCLUSION: The model for sequential replication and the implementation team structure and function should be successful in other organizational settings.     

Vulval lichen planus

The importance of easily available, high quality, and current biomedical literature within the clinical enterprise is now widely documented and accepted. Access to this information has been shown to have a direct bearing on diagnosis, choices of tests, choices of drugs, and length of hospital stay. However, many health professionals do not have adequate access to current health information, particularly those practicing in rural, isolated, or underserved hospitals. Thanks to a three-year telemedicine award from the National Library of Medicine, The University of Iowa (UI) has developed a high-speed, point-to-point telecommunications network to deliver clinical and educational applications to ten community-based Iowa hospitals. One of the services offered over the network allows health professionals from the site hospitals to access online health databases and order articles via an online document delivery service. Installation, training, and troubleshooting support are provided to the remote sites by UI project staff. To date, 1,339 health professionals from the ten networked hospitals have registered to use the Healthnet program. Despite the friendly interface on the computer workstations installed at the sites, training emerged as the key issue in maximizing health professional utilization of these programs.     

Preparing for the "silver age of dentistry"

Providing oral health care to older adults will be a challenging and rewarding part of dental practice in the years ahead. It will include understanding normal aging, appreciation of the pathophysiology of chronic diseases experienced by many elderly, and application of key principles of pharmacology in care of patients receiving medications for treatment of these diseases. It will involve an understanding of the interaction of systemic conditions with oral health status, adequate diagnosis of oral disease, and appropriate rational treatment planning with a strong emphasis on preventive dentistry. It will include care provided in nursing homes or during housecalls for the homebound. Dentist-geriatricians will be working with teams of healthcare professionals that include physicians, dentists, podiatrists, ophthalmologists, nurses, social workers, nutritionists, pharmacists, and occupational and physical therapists. Above all, the team will provide skilled compassionate care, which is always good business!     

Children, psychiatrists and the courts: understanding the ambivalence of the legal profession. Part 1--General principles

Psychiatrists and other mental health professionals are frequently involved as expert witnesses in court proceedings related to children and adolescents. Their testimony may be based on a therapeutic relationship, but frequently arises because of an assessment conducted specifically for the court process. This two part paper discusses some of the issues that arise when child psychiatrists are involved as expert witnesses in litigation, with specific focus on their role in child custody, sexual abuse and young offender cases. It also offers some practical advice for those who may be called as witnesses. There is controversy in the legal profession about the role of mental health professionals in the court process. While there is recognition of their expertise, there is also a concern about not wanting to have experts usurp the role of the courts. Legal professionals also question the "objectivity" of experts, and the reliability of their opinions. Frequently the opinions of psychiatrists about children and adolescents involved in litigation have inherently speculative and value based dimensions, and not "scientific". Participation in the court process by mental health experts is nevertheless a vitally important role, providing information, analysis and recommendations about what are often very difficult societal decisions. Part two of this paper starts on page 531.     

The clinical nurse specialist as expert practitioner in the obstetrical/gynecological setting

The role of the advanced practice nurse (APN) continues to evolve in specialty areas while healthcare systems seek solutions to issues of cost-containment, equity in access, and quality care. APNs have a significant role in facilitating the positive outcomes of clients utilized as measurable indicators in a managed care environment. The CNS as expert practitioner in the obstetrical/gynecological hospital setting integrates specialty knowledge and demonstrates specialty skills when working with childbearing and perimenopausal women and their families. Maintaining a holistic orientation to practice and keeping comprehensive documentation of activities facilitate achievement of quality outcomes for patients in this specialty field. Competencies essential to successful implementation of the expert practitioner role include: clinical expertise, effective communication skills, critical thinking and analytical skills, and a theoretical orientation to problem solving. The Roy Adaptation Model is an effective framework that can be used by the CNS in the obstetrical/gynecological hospital setting to promote, maintain, and restore health, as well as facilitate positive patient outcomes.     

Clinical psychology in general hospital settings: Issues in interprofessional relationships.

We suggest that the involvement of clinical psychologists in health care teams may not necessarily improve health care. The position of clinical psychology with regard to medical theory and practice is examined. Then issues arising from multidisciplinary teamwork, with particular emphasis on consultation–liaison work, are discussed. We conclude that professional power structures in hospital settings have a profound influence on clinical psychological practice and that these issues need to be explicitly addressed before health care can benefit from the expertise of clinical psychologists. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clinical risk management of the rapid-cycling bipolar patient

Important clinical-legal issues surround the management of patients with rapid-cycling bipolar disorder (RCBD). An increased risk of liability exposure may exist for improper diagnosis and treatment, lack of informed consent, inadequate assessment of the risk of violence toward self and others, and failure to monitor the patient. Practice guidelines may facilitate defensive practices by psychiatrists, which can increase the risk of liability. Clinical risk management combines professional expertise and knowledge of the patient with an understanding of the legal issues governing clinical practice to provide good care to patients and only secondarily to limit legal liability. A working understanding of the legal issues surrounding patient care in general and the RCBD patient in particular should provide more comfort and wider latitude in helping these difficult-to-treat patients.     

Recall by expert medical practitioners and novices as a record of processing attention.

Using recall of clinical protocols as a measure of expertise in medicine has yielded disappointingly small effects. Experiments using recall of clinical laboratory data are presented to provide an explanation. In one experiment, subjects either deliberately memorized or first diagnosed and then were incidentally asked for memory. With incidental instructions, experts recalled over twice as much data as did students, but with memorization instructions, student performance approximated that of experts. Experts also showed a large advantage over students in incidental recall of data that were not relevant to the problem solution. These results suggest that expert processing in this "discrete, independent inputs" domain requires effortful analysis with minimal reliance on default values, rather than relatively effortless pattern perception reported in highly visual areas of expertise. For this area, intentional memory is a misleading measure of expertise. However, incidental memory is a valuable measure of processing during diagnosis. (PsycINFO Database Record (c) 2010 APA, all rights reserved)