Understanding the newly formed

conventions in telehealthcare: what can

the social sciences do for us?

Dr Yannis Pappas

Deputy Director, eHealth Unit

eHealth Unit - Imperial College London

Common investigative themes across eHealth

research and practice

• Optimisation of planning

• Enhancement of implementation

Different routes to reach to these objectives

Fact

• Financial viability

• Technological competence

• Managerial and organisational skills

Essential for the provision of successful telehealthcare initiatives.

What about human experience and skills?

A reasonable quote

As Whitten, Sypher and Patterson (2000) put it, ‘we know a

good deal about bandwidths and resolutions, but not enough

about the human dimensions that make practice possible’.

Healthcare as an “ecosystem”

A healthcare system is the result

of integration of at least four

interrelated factors:

Technical

Psychosocial

Medical

Organisational

Healthcare“ecosystem”

What can the social sciences do for us?

By looking at various aspects of human experience and

conduct, the social sciences help us understand some of the

dynamics that may determine the success or the failure of

eHealth initiatives.

„It‟s just a PC…‟

Patients’ verbal behaviour was subject to:

1. The movement of the doctors' hands and fingers.2. The relative intensity of keystrokes.3. Shifts in the doctors' gaze from the keyboard to the monitor.

(Greatbatch et al., 1995).

Types and outcomes of social science research

Surveys and Interviews

• Users’ perceptions and experiences

• User satisfaction

Participant involvement methods

• Ergonomic system development

• Human factors engineering

Observational studies and

analyses of interaction

• Analysis of workflow

• Process change

• Organisational dynamics

A case study in real-time telemedicine

(Pappas & Seale, 2009)

The setting

•The patient at his/her local primary care

accompanied by a GP and/or a nurse.

•The consultant at a hospital examining

the patient via real-time

videoconferencing.

•The consultant has electronically

received results from tests previously run

at the surgery.

Consultant

GP/Nurse Patient Companion

Hospital

Primary care

Real-time, video-mediated telemedicine

Integration or disruption?

Perceived benefits:

• Allows most of care to take place in the community

• Contributes to professional education at both ends

• Minimises missing appointments

Something to consider:

• Such implementation may require disruptive reorganisation of

care and infrastructure support

Research Objectives

• To perform a comparative analysis of communication between

participants in face-to-face and telemedicine consultations.

• To understand the newly formed communication conventions of

telemedicine consultations within their social and organisational

context.

The Method

Conversation analysis has been used to analyse:

• Interaction in classroom activities (Mehan, 1979; McHoul,

1978)

• News interviews (Greatbatch, 1985)

• Counselling sessions (Hutchby, 2001)

• Talk in medical settings (Heath, 1986; West, 1984; Maynard,

1989; ten Have, 1999; Silverman, 1987; 1997).

Physical examination in telemedicine

(Televascular, C, P, N)1 C: now if you could turn your legs outwards Mrs G. (2.1) and then 2 if you could go a little higher up (1.2) above the knees (0.5) 3 oka::y there are some varicose veins all the way up really on 4 the right[side] by the look of things5 N: [yeah]6 C: come down again (5.2) and there is a pigmentation in the gator 7 a:rea8 N: yes9 C: a little bit on both sides is that true H?11 (0.3)12 N: yes there is13 (0.7)14 C: ºyesº (1.5) okay (0.7) and at the moment the left leg looks 15 more swollen is that correct?16 N: yes it i:s17 C: alright Mrs G can I ask you to turn around and face away from 18 the camera?19 (5.0) 20 P: feet out?21 (1.2)22 C: yes that’s great (4.2) ºrightº (0.5) ºo:kayº (4.6) now there 23 are one or two varicose veins at the back but not an awful lot=24 N: =no:=25 C: my view at least (1.0) is that how you see it H?26 N: yea:h it’s not too: bad rea:lly27 C: okay if you could take a sit Mrs G to have a look at the lower leg

Consultant

Green: place the patient

Orange: place the camera

Blue: online commentary

Underlined: Explicit or implicit

requests for verification

Online commentary may be

perceived by the nurse as a

request for feedback

Nurse

Red: involved in physical

examination as a facilitator for

diagnosis. Physical proximity

to the patient is utilised to

verify or contest the

consultant’s observations

Management negotiation in telemedicine

(Telecardiology, C, GP)1 GP: I am just wondering if it is all alcohol damage 2 C: it- it's thickened it's definitely thickened and it is

3 asymmetrical 4 GP: so alcohol would do (.) generally would it 5 C: no alcohol make it thin and weak (.) and dilated it wouldn't

6 do this 7 GP: okay 8 C: all the other dimensions are normal 9 GP: okay 10 C: just a wall thickened 11 GP: okay 12 C: so:: I would suggest that you repeat that echo and re-assess 13 GP: alright 14 C: and then get a profusion scan 15 GP: okay

Realisations

Telemedicine is an unfamiliar terrain which requires constant

negotiation of communication skills and roles. Participant skills

in telemedicine are influenced by four characteristic traits of

telemedicine consultations:

a) the novelty of the institutional setting

b) the introduction of additional persons in the consultation

c) the inability of the consultant to physically examine the patient

and

d) the technological apparatus used

Conclusions

Telemedicine:

• Facilitates communication between primary and tertiary care.

• Takes place in an unfamiliar physical space and involves a degree of uncertainty in currying out various activities

• Enhances the role of the nurse in the consultation

• Produces conflicts of agendas and negotiation over the communicative floor between primary and tertiary care staff

• Contributes to GP and nurse education – any other professional in other modalities

• May exclude the patient from certain parts of the consultation because of extensive interprofessional talk

• Requires additional skills by consultants

Need for more social sciences research in eHealth

• Low cost

• Proven validity

• User involvement

Understanding the newly formed conventions in telehealthcare: what

can the social sciences do for us?

Dr Yannis Pappas

eHealth Unit – Imperial College London

y.pappas@imperial.ac.uk

Many thanks!