CHI 97 Electronic Publications: Technical Notes
Telemedical Consultation: Task Characteristics
Leon Watts
and
Andrew Monk
Department of
Psychology
University of York
York YO1 5DD UK
+44 1904 433186
law4 |
am1@york.ac.uk
ABSTRACT
Three telemedical projects were studied that used ISDN video to link
primary care medical centres to hospitals. Specifically, a doctor
or nurse practitioner with the patient was able to consult a
remote specialist about treatment or diagnosis. Five task
characteristics for this particular form of telemedical
consultation are identified. These characteristics make clear the
need for high quality multi-party sound communication and
multiple-view slow-scan video but suggest that full motion video
may not be necessary to support this kind of work. Some issues in
analysing technologically-mediated collaborative work are briefly
discussed.
Keywords
Videoconferencing, telemedicine, task analysis.
© Copyright ACM 1997
INTRODUCTION
Telemedicine, broadly defined, is the delivery of some medical
service at a distance, via communications technology. However, it
is increasingly associated with sophisticated, image-based
technologies to bring medics together for the benefit of a
patient. Supporting a live, or 'synchronous', consultation with a
medical expert many miles distant has been seen as a potential
solution for remote populations under served by medical resources
in comparison with their urban counterparts. Unfortunately,
making the idea a reality has proven somewhat problematic.
As costs of equipment have fallen, and with increasing autonomy in
primary care centres in the UK, video links have been installed
to support medical consultation for primary care practitioners in
a number of locations. At least seven separate schemes are
currently in operation in the UK, supporting care ranging from
dermatology through to psychiatric counselling. Although high
profile, seven is a conspicuously small number. The rarity of
synchronous telemedical technologies contrasts with the rapid
expansion of essentially 'asynchronous' technologies, such as
teleradiology [5]. Historically, the situation is the same:
several large-scale studies of synchronous teleconferenced
consultation have been carried out over the years yet little in
the way of benefit has been identified[1, 2, 4].
Telemedical research has tended to focus either on technological
possibilities or evaluative criteria such as diagnostic accuracy
and time required per patient seen. Few studies have taken a
close look at the nature of the work involved. This paper
addresses this omission by looking at the characteristics of the
tasks carried out when a local doctor or nurse practitioner
consults with a remote specialist, in the presence of the
patient.
METHOD
Three sites visited
Three different telemedical,
video-linked facilities in the United Kingdom were visited. One
was between a remote community hospital and the accident and
emergency (A&E) department of a major regional hospital; the
second was between two nurse-practitioner-run urban clinics and
the A&E department of a (different) major regional hospital, and
the last was a roving unit, setting up links between several
urban general practices and participating consultants at two
local hospitals. All sites involved consultation between the
medic with responsibility for a patient, a remote medical expert
and the patients themselves.
Research Data
A total of seventeen interviews were conducted with a range of
associated professionals across all sites. These included nurses
and nurse practitioners, doctors, managers, and consultants. Each
interview was structured by an interview schedule designed to
encourage interviewees to elaborate on their dealings with the
telemedical facility, and the people with whom they interacted
around the facility. A report was generated for each site and
copies circulated to those who had been interviewed. Comments
were encouraged and used to refine our understanding of the
practices at each site. In addition, five video recorded
teleconsultations were obtained and examined for instances of
communication difficulty and opportunity, informing the model of
communication in telemedical consultation drawn from the
interview data.
Communications Usage Diagrams
A model of remote assistance in telemedicine was produced using a
graphical notation. The model was intended to bring together
three sets of considerations for analysing collaborative
activity: the activities of participating agents, the
interactions between agents and the communication channels
available to them. The notation is intended as a companion to the
kind of analysis supported by, for example, Hierarchical Task
Analysis or Work Objective Decomposition [3], to take into
account synchrony and availability for interaction in
collaborative activity.
TASK CHARACTERISTICS AND IMPLICATIONS
Five important task characteristics (TCs) for telemedical
collaboration were identified through the analysis referred to
above. These are associated with design implications.
TC1: Most of medical consultation is about talking
Although it is common to describe contact with a doctor as "being
seen", most of a medic's work involves finding out how some
problem has come about and how it feels by question and answer.
TC2: Consultation often involves several parties
There were always three primary parties in these scenarios, the
patient and the local and remote medics. Commonly other people
would be around and have a legitimate interest. For example,
patients, especially children, often attend with relatives, and
assistants may well be on hand to help the local primary medic to
perform requested manoeuvres.
TC3: Speech is designed for specific recipients
The remote specialist needs to assess the competence of the local
medic in order to provide effective advice. The building of
working relationships means that the specific capabilities of
individuals become known, and that the specific history of
interactions between them can be drawn upon to guide future
interactions.
Design implications: High quality multi-party sound is needed so that
all parties can overhear and contribute effectively (TC1 and
TC2). The remote consultant needs several views: a view of a
doctor's face will serve as a useful reminder of previous
consultations (TC3). A view of the patient's face will serve to
assess whether they have understood what is required of them
(TC3). A wide angle view of the whole treatment room is needed to
assess who is present (TC2 and TC3). These views are all in
addition to a view of the patient's problem. This implication
might seem to be technologically difficult, given bandwidth
limitations. However, there is no obvious requirement for all to
be full motion video. The images could be slow scan and
transmitted down a narrow bandwidth link in turn.
TC4: Pictures as shared resources
When discussing, for example, a dermatological problem it is
important that the remote and local medics have the same view of
the patient's skin problem.
Design implication: As an extension of the established "WYSIWIS"
principle, image support must be fully reciprocal. Unless images
are equivalent, "warts'n'all", it is very difficult to
co-ordinate on their content. If the specialist has a poor image
of a patient's problem, then the local medic needs to be able to
see just how poor that is. If the consultant wants to point at
some feature then the local medic should be able to see that
gesture.
TC5: Patient confidence is important for all concerned
Patients, at least in the UK, are frequently concerned about getting
proper recognition for their problems. Having confidence that
they have been dealt with appropriately is their priority.
Design implication: Patient attitudes towards their telemedical
consultations were invariably reported as very positive and in
particular that the video component of the facility was
responsible. The patient seems to benefit greatly from a feeling
of having a senior medic having taken a direct and personal
interest in their problem. A video image of the consultant seems
to give patients confidence. Again, this need not be full motion
video.
DISCUSSION
It would seem that synchronous 'telemedicine' has come to be
identified with the visual component of communications
technology. However, the audio component is of far greater
importance in the first instance and should benefit
correspondingly from investment in its support. There are
benefits to be had by ensuring that all parties concerned are
able to at least hear the exchanges between those in primary
contact.
This is not to say that a synchronous video link is without value.
When a video image is provided, it may be used as a shared
resource in its own right and can be capitalised upon by the
group. In other words, having a picture of some injury is not the
same as one person seeing the injury 'in the flesh' and a remote
person seeing some degraded image of it. Sharing an image
facilitates discussion of the thing the image is of.
Consideration of the work described here brought to light some
challenging analytic problems Reasoning about collaborative work
for the purpose of designing support systems requires treatment
of concepts such as "awareness", "shared activity" and "joint
resources" together with an understanding of synchronisation and
sequence of activity.
ACKNOWLEDGMENTS
This work was supported by the ESRC Cognitive Engineering Programme.
We would like to thank the following organisations: BT
Laboratories, Advanced Media Group; Royal Free Hospital, Virtual
Outreach project; the South Westminster and Parson's Green Minor
Treatment Centres of the Riverside NHS Trust, together with
Belfast Royal Infirmary; and the Peterhead Community Hospital
with Aberdeen Royal Infirmary.
REFERENCES
1. Dunn, E.V., Conrath, D.W., Bloor, W.G. and Tranquada, B. An
evaluation of four telemedicine systems for primary care. Health
Services Research, 1 (1977), 19 - 29.
2. McLaren, P. and Ball, C.J. Telemedicine - lessons remain
unheeded. British Medical Journal, 310 (1995), 1390-1391.
3. Monk, A.F. Lightweight techniques to encourage innovative user
interface design. In L. Wood and R. Zeno (Eds).Bridging the gap:
transforming user requirements into user interface design. CRC
Press. (In press).
4. Moore, G.T., Willemain, T.R., Bonanno, A.B., Clark, W.D.,
Martin, A.R. and Mogielnicki, R.P. Comparison of television and
telephone for remote medical consultation. The New England
Journal of Medicine, 13, (1975) 729 - 32.
5. Sund, T. and Rinde, E. Telemedicine - still waiting for users.
Lancet, 346 (1995), 24.
CHI 97 Electronic Publications: Technical Notes
