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Asynchronous Web-Based Patient-Centered Home Telemedicine System Christopher Lau, R. Sean Churchill, Janice Kim, Frederick A. Matsen, III, and Yongmin Kim*, Fellow, IEEE
Abstract—A web-based system for asynchronous multimedia messaging between shoulder replacement surgery patients at home and their surgeons was developed and tested. A web browser plug-in simplifies the process of capturing video and transferring it to a web site for novice computer users. The design of the video capture plug-in can be reused to acquire and securely transfer any type of data over the web. For example, readings from home biosensor instruments (e.g., glucometers and spirometers) that can be connected to a personal computer can be transferred to a home telemedicine web site. Both patients and doctors can access this web site to monitor health status longitudinally. Six patients, whose familiarity with computers ranged from no experience to expert users, used the system. All of the subjects were able to use the system to check treatment reminders and to send at least one message with video to their surgeons. The surgeons monitored the system regularly and always responded to messages within 24 h during the six-month trial period. Index Terms—Home monitoring, Internet, physical therapy, rehabilitation, shoulder replacement arthroplasty, telecare, telemedicine, world wide web.
I. INTRODUCTION
T
RADITIONAL telemedicine systems have been based upon using point-to-point real-time videoconferencing connections between locations to replace in-person visits [1]. Due to the cost and complexity of the equipment, telemedicine contacts were mostly used for consultations between special telemedicine centers in hospitals and clinics in the past. More recently, however, providers have begun to experiment with telemedicine contacts between healthcare providers and patients at home to monitor conditions such as chronic diseases. The approaches to home monitoring range from low-cost and easy to use touch-tone telephone systems to more expensive systems that mimic the real-time videoconferencing approach in traditional telemedicine and web-based systems that allow access to patient data from anywhere an Internet connection is available. The telephone has proven to be an effective means of monitoring congestive heart failure patients at home where patients enter their blood pressure, weight, pulse, and symptoms into an
Manuscript received December 19, 2001; revised January 17, 2002. Asterisk indicates corresponding author. C. Lau and J. Kim are with the Department of Bioengineering, University of Washington, Seattle, WA 98195-2500 USA. R. S. Churchill and F. A. Matsen, III are with the Department of Orthopedics and Sports Medicine, Box 356500, University of Washington, Seattle, WA 98195-6500 USA. *Y. Kim is with the Department of Bioengineering, University of Washington, Seattle, WA 98195-2500 USA (e-mail:
[email protected]). Digital Object Identifier 10.1109/TBME.2002.805456
automated answering system [2]. The advantages of this system are the telephone is a simple device that patients already know how to use, and telephones are inexpensive and nearly ubiquitous. One disadvantage is difficulty in expanding the system to accommodate data that cannot be easily entered by hand, or at least eliminating the manual data entry step as a source of error and inconvenience. To address this need, some manufacturers of videoconferencing systems designed for home telemedicine provide interfaces to various instruments, such as glucometers, blood pressure meters, pulse oximeters, stethoscopes, and scales [3]. The measured data are sent to providers using the data channel in the H.32x videoconferencing standards. Videoconferencing using these units over plain old telephone service (POTS) and higher speed lines has been shown to be useful in some cases [4]. Although synchronous videoconferencing with patients at home has been effective, asynchronous messaging could be more convenient for routine monitoring and nonurgent questions. In teleradiology, the store-and-forward model has been noted to be more practical than videoconferencing because it eliminates the need to schedule the telemedicine contact [5]. This type of asynchronous telemedicine has also been extended to home monitoring over the Internet. The system in [6] collects blood glucose levels in a PC application separate from the web browser and transmits the data to the central storage server using TCP/IP over the Internet. However, the uncommon and nonstandard server to server protocol (STSP), which is an extension to HTTP, is used. The system in [7] provides a web interface to patients. However, data collection is in an external application and the data are transferred using a separate FTP server. The use of STSP and FTP was reasonable at the time these systems were initially developed, but there are now a number of methods to securely transfer data over secure HTTP (HTTPS) that are portable between web server platforms. The Java applet in [8] uses one of these methods in sending its glucose measurements across the Internet. Furthermore, it reads a device serial number from the glucometer to use for authentication in combination with a user name and password. Although the home monitoring systems discussed above use a completely asynchronous approach, there is a hybrid approach where videoconferences are available, but data between conferences are also collected over the web [9]. Along with the development of home telemedicine systems for monitoring physiology, web sites have been developed for storing medical records that are targeted toward patients [10]. These systems are different from web interfaces to medical records systems at hospitals. In the hospital systems, only care providers can view and add information to records. In the
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Fig. 1. SF-36 functional self-assessment.
patient-targeted systems, patients can access their records. For example, at a pediatrics site, parents can review their child’s prescribed medications, review allergies, and add a recent photo of the child [11]. These types of systems are also targeted toward people who travel so that their medical history is easily available if they need medical care in another city. Some commercial consumer medical records systems also provide secure messaging with providers through their web site. Using a web-based system [12] for messaging addresses some of the security problems with using e-mail to contact providers [13], [14]. Although encryption and digital signature capabilities can be found in many modern e-mail clients and external programs can also be used to encrypt and sign messages, these features are not routinely used. When accessing a secure web site, the connection is automatically encrypted. Although encryption secures the contents of a connection against eavesdropping and tampering, consumer medical records sites currently use the bare minimum required for authentication, a user name and password combination. As smart cards and biometric devices become more well-developed and widely distributed, these more robust methods of authentication could be incorporated by more medical resources on the web that store individually identifiable patient information. We have developed a system that bridges home monitoring via the web with patient-accessible medical records and secure
asynchronous messaging. The primary design goal of our system was to streamline the process of adding data to patients’ medical records from various instruments that can be used in the home. The task of acquiring data from an instrument, such as a video camera, and adding it to their medical record should not require the user to open multiple applications and transfer data between them. We present a system where all instrument interfaces are embedded in web pages, and the interface is as easy to use as other common consumer web applications. Messaging between patients and providers is allowed, but the interactions are structured to provide more information than a simple e-mail and to reduce the workload of physicians in managing the messages. II. METHODS A web-based messaging system, called E-Medicine, was developed that allows patients to easily send multimedia information, such as video and audio, to their physicians. Patients are also monitored through multiple-choice self-assessment questionnaires, such as the SF-36 [15], implemented as web forms. To streamline the user interface and eliminate the multiple steps involved in acquiring video, saving it to a file, compressing the file, and entering the path to the file in a web form, we have developed a browser plug-in that performs these tasks. The plug-in
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Fig. 2. Patients’ home page.
posts videos using the same message format that web browsers use when posting binary data, so no proprietary server software is required to accept the posted files. All connections are made using HTTP over the secure sockets layer (SSL) so that all data are encrypted when traveling over the Internet. This is an advantage over systems that use a separate FTP server to accept files. Although the files transferred using FTP can be encrypted, login information is always transmitted in clear text. The secure HTTPS-based file transfer code we developed can be reused in the future to implement plug-ins that acquire and transmit data from various biosensors, such as blood glucose, blood chemistry, heart rate, motion and acceleration sensors, etc. A. Functional Overview The target application of our initial E-Medicine system is monitoring the recovery of shoulder replacement surgery patients. Surgeons would like to monitor their patients’ progress through video status updates of how they are progressing in their assigned physical therapy exercises. Videos are necessary to help identify problems that may be developing and to assess whether they are progressing normally. Through the system, physicians can change assigned exercises and link patients to digital video on the web site demonstrating how to properly perform the exercises. The system also reminds patients about
the medications they should be taking. Patients are asked to periodically fill out SF-36 and simple shoulder test (SST) [16] self-assessments. Doctors can view the scores from these surveys graphically over time. The information flow for the system proceeds as follows. Patients are authenticated during log-in by entering a user ID and password. If they have not completed an SF-36 health status survey in the past week, they will be given this choice before proceeding further (Fig. 1). The SF-36 is a general health questionnaire used commonly in the medical field, which gives a general indication of physical and mental health and can be used to track patients’ progress through the recovery process. After the survey, patients proceed to their main page (Fig. 2). The most recent message from their surgeon is displayed at the top of the page, and a reminder of prescribed medications and physical therapy exercises are shown below it. A concise description of each exercise is displayed on the page, and patients can choose to watch a video demonstration of the exercise as well (shown in the popup window in Fig. 2). Using the menu along the left-hand side of their main page, patients can review previous status reports and service requests filed, they can file a new status report, or they can send a message with video to their physician. If they choose to file a status report, they will be asked to complete a simple shoulder test form, which contains questions used to gauge their shoulder function.
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Fig. 3. Patients’ video recording interface.
After the survey, they are asked to record videos of themselves performing each of their physical therapy exercises (Fig. 3). The exercise descriptions and video demonstrations are repeated in the same format as shown in the treatment reminder section of the patients’ main page of Fig. 2. The left-hand side of Fig. 3 shows the video capture browser plug-in, and an exercise video demonstration is shown on the right-hand side in the popup window. Users initiate video capture by pressing a button in the plug-in. The plug-in then goes into a preview mode so that users can adjust the camera position and focus. Users then press another button to start the actual video capture. They are given 10 s to get into position before video recording starts. In Fig. 3, the number 27 in the capture plug-in is the number of seconds of video capture time remaining. The capture time is restricted to 30 s since it would not take longer than 30 s to show any of the exercises that could be assigned in this study, and we did not want patients to send unnecessarily lengthy videos. After recording the videos, patients press the Send button in the plug-in to initiate the compression and file upload process. When orthopedists log in, they see a list of service requests from their patients. After choosing a request to view, the page shown in Fig. 4 is presented to them. The SF-36 composite scores of interest to orthopedic surgeons (bodily pain and role physical) are graphed over time along with the SST scores at
the top of Fig. 4. Partially shown in Fig. 4 above the graphs are the more detailed views of the SF-36 composite scores and SST responses for the three most recent SST surveys and two most recent SF-36 surveys. In the case of a question, the text of the question would appear above the survey information. Since the sample report in Fig. 4 is a status report, there are links to the exercise videos sent from the patient at the bottom of the figure. The popup video window will appear when a link is clicked. After reviewing the service request, physicians then type in a response to the service request being viewed and optionally change the medication and exercises assigned to the patient. At the patients’ next log-in, they will see physicians’ responses to their requests (top of Fig. 2) along with updated exercises and medications. The Message Archive link at the bottom of the response allows patients to review old status reports and questions along with any videos submitted to track their progress. B. Implementation The system is a typical three-tier web application using Internet Information Server (IIS) and Microsoft SQL Server 7.0 running on Windows 2000 Advanced Server and Windows 98 with Internet Explorer 5.5 or Netscape Navigator 4.7 on the client side. Connections are restricted to the HTTPS port, and the web server is set to only accept 128-bit SSL connections. The text of the web pages is generated using the Active Server
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Fig. 4. Physicians’ status report review page.
Pages (ASP) filter included with IIS. The graphs of the SF-36 and SST results are generated using an IIS extension that produces JPEG streams using the Intel JPEG Library. Although the GIF or PNG format would be ideal, a free library for encoding GIF was not readily available when we were implementing the system, and support for PNG on the browsers our clinicians sometimes used was weak. An application runs on the server once a day to send e-mail reminders to doctors if they have unanswered messages on the E-Medicine system and patients who want status report reminders. The Active Desktop feature of Internet Explorer was used on patients’ machines so that a simple login screen is displayed after the computer is booted. By clicking a login button on the Active Desktop, patients can establish a dial-up connection to the Internet and connect to the E-Medicine web site in one step after turning on the computer. Video and audio, which cannot be entered using HTML forms, is collected using a web browser plug-in. Although browsers can post a binary file to a web server, users must manually select the file to post either from a graphical interface or by typing in the file path on a web form. An example form that will upload a file and its corresponding HTML code is shown in Figs. 6 and 7. In E-Medicine, the patients’ web browsers have a plug-in installed that can capture video directly from the browser window, compress it, and transfer it to the server without the need for patients to have knowledge of the
presence of video files. The plug-in was implemented using the Microsoft DirectShow API to control a video camera set to capture video at 160 120 resolution and 15 frames/s. The video is compressed to 128 kbits/s using the H.263 codec included with QuickTime 4.0 and higher. QuickTime was chosen as the video format because the most common computers used by our clinicians are Macintoshes, and the QuickTime software has both Macintosh and Windows implementations. The characteristics of the video we are acquiring are consistent with the conditions needed for optimal coding with the H.263 codec at 128 kbits/s—the camera is stationary, and there is no fast motion in the videos. The encoded videos are sent to the web server using the HTTP POST request format specified in Internet RFC 1867 [17] for file posting from an HTML form. Alternatively, the web site developer can ask the plug-in to post the files using the HTTP PUT method. In both methods, the secure HTTP connection is established using the WinInet library included with all desktop versions of Microsoft Windows since the Windows 95 with Internet Explorer product. A base library was created for data acquisition browser plug-ins to share. To develop a plug-in to acquire data from a glucometer, for example, the developer would need to code the hardware interface and the user interface. Once the data are acquired from the instrument, our E-Medicine Plug-in Services module could be called to upload the data to a web server.
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Fig. 5. System usage. TABLE I PRIOR COMPUTER EXPERIENCE
Fig. 6.
File upload form.
C. Field Testing The E-Medicine system was tested with patients recovering from shoulder operations at the University of Washington Medical Center (UWMC). Patients were trained to use the system in their hospital rooms on the second day after their operation and issued a user ID and password to log on to the system. When they were discharged, they were loaned a video camera and laptop computer (Intel Celeron 500 MHz with 64 MB RAM) with all the necessary software installed. The computers were configured with Microsoft Windows 98 Second Edition, Microsoft Internet Explorer 5.5, ViCAM camera drivers, QuickTime 4, and Indeo 5 software in addition to our own software consisting of a web browser plug-in for video capture and upload and a component object model (COM) object for shutting down the laptop from a web page. Patients were asked to try to file two status reports including videos each week for six weeks. Usage of each feature of the application was tracked using application level logs. Subjects’ responses to a questionnaire were also collected after six weeks. This study period was chosen because shoulder replacement surgery patients at UWMC normally return after six weeks for a follow-up examination. Usually, patients have met their target for shoulder range-of-motion by this time, so it was a convenient time for them to return the computer equipment. III. RESULTS Over the study period of six months, a total of six patients used the system at home. Four patients were male, two were female, and the average age was 59. Table I shows the prior com-
puter experience of these subjects, with frequent e-mail usage defined as daily. Those who used e-mail frequently were designated as experienced computer users, and those who either never used a computer or used e-mail occasionally were designated as novice users. Using these designations, three of the six subjects were experienced computer users and three were , , novice users. We will refer to the experienced users as and the novice users as , , and . Note that paand was recovering from a complex humeral reconstruction tient for a chronic humeral infection, while all of the other subjects were recovering from a total shoulder arthroplasty. Whereas the E-Medicine system was used largely to monitor range-of-mo’s use of the system was tion for the arthroplasty patients, primarily for monitoring his incision for signs of recurrent infection in the first few weeks before moving on to range-of-motion monitoring. A. Observations During the training sessions, patients’ usage of the system was observed. Two of the three patients with little computer and , had difficulty with the user interface. experience, , who had never Manipulating the mouse was difficult for used a computer before. The use of separate popup windows for the videos and scrollbars on pages with lengthy content were and . Since the videos were stored loproblematic for cally on the patients’ laptops to eliminate the download time, they could not be displayed in the same window as the downloaded web content without generating security warnings from the browser. All of the experienced computer users and one of , had no problems with the user interthe three novice users, commented face during the training sessions. Furthermore,
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File upload form HTML code. TABLE II LOGIN SUMMARY
that he found the system very easy to use after his six weeks with the system were over. B. Usage Logs Over a period of 155 days, there were 104 logins by the surgeons and the patients in the study (Table II). Out of 56 patient logins, 27 of these sessions were used to send messages. The remaining 29 logins were used to review information on the web site, such as old messages and current treatment plans. Of the nine questions submitted, four included a video. Fig. 5 shows the logins graphically with distinct user logins plotted against time. There may appear to be fewer than 104 dots on the graph due to users sometimes logging in multiple times on a single day. The period between patient logins ranged from a few days to a , , and used the system most heavily. week. Patients The surgeons’ logins were typically in response to questions from users, since they were alerted by e-mail once a day if there were unanswered questions and/or status reports. Other logins were needed to set up treatment instructions and an initial message (e.g., the login on January 18, 2001, several days before the first patient login). The surgeons also logged into the system at other times for activities such as demonstrations, training, and troubleshooting. In particular, there were no patients using the system when one of the surgeons logged in on March 30 and April 16. Most video recording and uploading sessions took between two and 30 min, with the average session length of 17 min. The wide range is due to the number of videos the surgeons asked patients to upload increasing from two videos to five toward the end of each patient’s involvement in the study. The capture plug-in was programmed to limit videos to 30 s, but patients could stop the recording before the 30 s had elapsed to reduce the file size. When sending in questions, patients were prompted to categorize their question as relating to one or more of the following categories: incision, comfort, range-of-motion, strength, stability, smoothness, activity, new event, and other. After se-
TABLE III PATIENT CONCERN AREAS
lecting the categories, patients were presented with a text box for each area of concern selected, and in these text boxes the patients asked their question or stated their problem. The category “other” was automatically selected if an area of concern was not chosen. Of the questions submitted by the study subjects, only three of the possible nine categories were selected: comfort, range-of-motion, and other. The distribution of these three categories as areas of concern is shown in Table III. The other was the most highly selected choice, range-of-motion was chosen once, and comfort was between the two extremes with four selections. “Comfort” and “other” were selected as a pair three times, accounting for the difference between the 12 area of concern categorizations and nine questions. Although only three areas of concern were used, patients appropriately categorized all of their questions. For example, if a concern was categorized as comfort, then the patient asked a question that was related to their shoulder comfort. C. Patient Satisfaction and Comments Table IV shows the results of a user satisfaction survey for five did not respond to the survey. Responses of the six subjects; to survey questions are in numerical form ranging from one to five with one corresponding to strongly disagreeing with the statement and five corresponding to strongly agreeing. Patients and left questions blank for features they did not use. wrote in that he was not comfortable operating the laptop, but his friend helped him out and found the system very easy also wrote in a similar comment that the system was to use. difficult to operate at first because she was not very familiar with computers, but her daughter assisted her in using the system the first few times. IV. DISCUSSION Surgery is a major intervention in the health of the patient. The response of a patient to a surgery is highly individualized, especially over the first several months. During that period of time, relatively minor adjustments in medication and exercise may have major effects on the benefit the patient would receive from the procedure. Also during that time, individuals will have questions regarding the meaning of sensations they experience (“Is it expected that … ?”) or activities they would like to
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TABLE IV USER SATISFACTION (5 = STRONGLY AGREE, 4 = AGREE, 3 = NEUTRAL, 2 = DISAGREE, 1 = STRONGLY DISAGREE)
carry out (“Would it be alright for me to … ?”). This important fine-tuning of the postoperative experience for the individual patient would ideally be accomplished by no-threshold communication between the patient and surgeon. However, distance, cost and scheduling are currently major barriers to optimal communication. Current practice is that the patient is given a standard protocol to follow. If there are questions or concerns, the patient needs to schedule either a phone call or, more often, a visit to the surgeon’s office. Because of the cost ineffectiveness of postoperative visits, they take place infrequently—often to the detriment of optimal care. When patients live at a distance from their surgeon’s office, they often get their postoperative care from a local physician who was not involved with and is not knowledgeable about the details of the surgical procedure. Thus, the traditional one- and six-week postoperative checks never take place in many cases and are replaced with the invitation, “let me know if you have problems.” Because patients usually do not like to “bother” their surgeon, questions go unanswered, problems go unaddressed and the opportunity for an optimal result is compromised. Even when in-office or telephone communication takes place, the content of the communication is not recorded in a convenient way and is not reaccessible. As a result, the patient may return home unsure of the answers to their questions. Thus, much of the value of the communication is lost. E-Medicine seeks to eliminate the threshold that distances the patient from the surgeon. It seeks to allow text and video interaction ad libitum and at the convenience of both parties. It also allows other electronic resources to be referenced easily.
For example, the patient may have encountered an article of apparent relevance about which she or he desires the surgeon’s opinion, or the surgeon may wish to refer the patient to pre-prepared web-based resources of relevance. The communications are recorded in a secure location where they can be accessed whenever needed. E-Medicine is not without its difficulties, however. The first challenge is that it may be removing one set of barriers only to substitute another. Patients or surgeons may not have access to or enjoy using web-based systems. They may be troubled by the need to boot up a computer and connect to the Internet as opposed to calling up the surgeon using the telephone. They may prefer infrequent face-to-face contact rather than on-demand web encounters. Patients and surgeons may lack the sophistication to use the systems. Finally, a move to E-Medicine carries the risk that access to healthcare may be better for individuals that are better educated or financially better off. In the present work, we begin to examine some of these issues. As seen in both Table II and Fig. 5, the surgeons involved in this study used the E-Medicine system regularly while there were patients enrolled. Nearly half of the total logins were by physicians, and during the times of patient participation in the study, the time intervals between physician logins ranged from one day to several days. Furthermore, physician responses to patients’ questions and status reports were prompt and were always within 24 h with the average of 10 h. Such a regular pattern of usage suggests that the E-Medicine system may be similarly well received by other physicians. Physician cooperation
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and acceptance of the system is an integral part of the success of E-Medicine and will be important for future applications of E-Medicine and its possible deployment for widespread use. The surgeon in our study identified certain specific benefits of E-Medicine. First of all is the assurance that these patients had unimpaired access to him. This assurance is important, even if the access is not used. Having the E-Medicine system in place for these patients took away the anxiety of, “I wonder how Ms. X is doing after that extensive procedure I did on her shoulder.” The video records of the range-of-motion provided a unique and useful way of tracking progress. They also provided motivation for the patients to do their exercises in that the video report called for a higher level of accountability. While we did not collect specific data to support the observation, the perception is that patient behavior was modified by this accountability. Since patients interacted with the surgeon at least once a week, there was more pressure to do their exercises so that they could demonstrate progress to the surgeon. In the case where the wound was being followed, there can be no question that the quality and convenience of care was enhanced by the use of E-Medicine. Without E-Medicine, frequent physician visits would have been required, but even weekly visits would not have provided the same level of follow-up. In that many of our patients are from distances prohibitively far from our medical center, we would have, without E-Medicine, had to relegate the responsibility for the postoperative care to local physicians unfamiliar with the procedures we do here. Patient acceptance is just as important to the success of E-Medicine as clinician acceptance. Patients need to feel comfortable using the system to communicate with clinicians, and the system needs to be easy enough to use for patients with limited computer experience. Patient use of the system was mixed, but success with the system was not necessarily associated with previous computer experience. Fifty-four percent of the total logins were by the patients, and the majority of these logins were by three of the six subjects. Two of the three heaviest users , who had difficulties were novice computer users, including with the user interface during the training session. Even two , who of the three relatively infrequent users, including also had difficulty during the training session, still logged into E-Medicine on a fairly regular basis throughout their course of participation in the study. Such use by novice computer users demonstrates that even those with limited computer experience can use E-Medicine to communicate with their physicians. The user satisfaction survey was another indication of patient acceptance. From the survey results, it appears that users were somewhere between neutral and satisfied with the E-Medicine was the system. Of the five survey respondents, patient least enthusiastic about the system, but even she agreed with the statement, “Being able to ask my physician questions via my E-Medicine account was helpful.” Therefore, though all patients may not have necessarily received the system with enthusiasm, all patients found some aspects of the system useful if not the system as a whole. All six subjects were able to use the system successfully, as every patient was able to submit at least one set of videos for his/her status reports. During the 56 patient logins, 27 total messages were sent, of which 18 were status reports, and nine were
questions. Four of these service requests included a video. Patient , however, submitted three of these four questions, as he was instructed to use the service request form to send in videos of his incision. Consequently, only one arthroplasty patient sent in a question with a video. During the design phase for the E-Medicine system, we felt that allowing patients to send videos with their questions was a salient feature, as patients may have difficulty explaining a shoulder problem to their physician in words. The low patient use of this feature was therefore unexpected. All of the patients sent in status reports with video, so we know they were able to record and send videos. Although patients were capable of sending in videos, it may have been too much of a burden to include one when all that was needed was a quick text-only message. Another possibility is all the patients were doing very well after the surgery. There may have been no need to ask an extensive question that required a video to demonstrate a concern. Given the weekly range-of-motion videos patients submitted, they may also have felt that the weekly video was adequate and a follow-up question did not require sending in another video. Although the patients in this study did not use the question-with-video capability extensively, it may still be beneficial for other patient populations. For example, foot lesions are a potential complication for diabetics due to peripheral neuropathy. An E-Medicine system could be used to encourage monitoring of the feet in this population and for answering questions. Of the nine questions that were submitted, most areas of concern were categorized as relating to either “comfort” or “other.” Patients were able to appropriately categorize all of their own questions. Due to the high number of “other” categorizations, the categories will need to be redesigned. However, the need for narrower categorizations will need to be balanced with the need to present a list of manageable size to patients. To answer the question of whether this categorization reduces the doctors’ workload will require a larger study with more physicians, patients, and question interactions. For two of the novice users, the Windows and web browser user interfaces were too daunting. Even though the patients’ web interface had very few hyperlinks and screens compared to a typical Internet portal site, these patients had difficulty using the system. If this type of system will be deployed to novice computer users in the future, using a custom client front-end instead of using a web browser may be necessary for some patients. Although there has been great progress in making dynamic HTML more capable of producing advanced user interfaces in the past few years, some details of the Internet and the native operating system user interfaces still cannot be hidden from novice users. For example, browser security settings prevented us from making a user interface for viewing local video files using a single window. Users had to learn how to manage multiple windows to use our system. However, the cost of developing and maintaining the system would increase if native code instead of dynamic HTML clients were used. The freedom to explore information on the Internet, such as patient education material, would also be diminished with a custom client application. One solution would be to provide a simple custom client with limited functionality to train patients while still being useful for collecting data and maintaining contact with the pa-
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tient. As the patients become more proficient with using a computer, they could be gradually introduced to the feature-rich web interface, or they could keep using the simplified client if it provides all the features they need. While commercial synchronous telemedicine system vendors have taken the approach of simplifying the user interface to the device, a web-based system, even though it is a little bit more difficult to use, can complement other web applications and information resources in healthcare. For instance, consider the shoulder exercise demonstration videos used in our system. These videos could be linked to more detailed information about the purpose of the exercises, and the anatomy and biomechanics of the shoulder for interested patients. Every part of the medical record available to the patient could have these links to explain the meaning of each piece of information. If the appointment scheduling, billing, and insurance claims processes were also available on the web in addition to these condition-specific information sources, patients would have a convenient way of managing many aspects of their healthcare online. V. CONCLUSION The goal of this E-Medicine system was to demonstrate that an asynchronous web-based telemedicine system could be successfully implemented with low-cost components that are available off the shelf. Results indicate that the system was well received by physicians and that all patients used the system successfully and found some aspects of the system useful. Even novice computer users were able to operate the system, although the web browser user interface may be too complex for some. A larger trial with a patient population that has a greater need for telemedicine support is needed to comprehensively test the clinical impact of E-Medicine systems. According to a recent report from the Institute of Medicine [18], even medicine’s best people are struggling to keep up with medical advances and to communicate with each other and with patients. The report faults the current healthcare system for lagging behind in adopting computer technology and states that not only should care be available when patients need it, but that patients should also have increased control over their treatments and medical records. The home telemedicine system we have developed recognizes this need and takes the opportunity to enhance the role of the patient in the fundamental shift occurring in medicine toward patient-centered healthcare. ACKNOWLEDGMENT The authors would like to thank H. Chang, M. Wilson, and J. Gattinella for their contributions in designing, implementing, testing, and evaluating E-Medicine.
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[4] J. Peifer, A. Hopper, and B. Sudduth, “A patient-centric approach to telemedicine database development,” in Proc. Medicine Meets Virtual Reality 6, 1998, pp. 67–73. [5] R. Welz, Y. Ligier, and O. Ratib, “Design of a cooperative teleradiology system,” Telemed. J., vol. 1, pp. 195–201, 1995. [6] R. Bellazi, S. Montani, A. Riva, and M. Stefanelli, “Web-based telemedicine systems for home-care: Technical issues and experiences,” Comput. Methods Programs Biomed., vol. 64, pp. 175–187, 2001. [7] F. Magrabi, N. H. Lovell, and B. G. Celler, “A web-based approach for electrocardiogram monitoring in the home,” Int. J. Med. Informatics, vol. 54, pp. 145–153, 1999. [8] D. J. Nigrin and I. S. Kohane, “Glucoweb: A case study of secure, remote biomonitoring and communication,” in Proc. AMIA Symp., 2000, pp. 610–614. [9] S. M. Finkelstein, S. M. Speedie, G. Demiris, M. Hoff, and J. M. Lundgren. Successful aging: Older adults and technology applications encouraging self directed care in the older population—what can we expect with the help of technology tools. presented at Amer. Telemedicine Assoc. Annu. Meet., Ft. Lauderdale, FL, 2001. [Online]. Available: Telemedicine library at http://www.atmeda.org. [10] J. H. Schneider and D. Kofos. Consumer Internet medical records: Benefits for pediatrics, problems and proposed standards. presented at Amer. Telemedicine Assoc. Annu. Meet., Ft. Lauderdale, FL, 2001. [Online]. Available: Telemedicine library at http://www.atmeda.org. [11] B. W. Rosenthal, C. P. Friedman, and S. Bagnato. Special vision: Patients private web sites for children with special health care needs. presented at Amer. Telemedicine Assoc. Annu. Meet., Ft. Lauderdale, FL, 2001. [Online]. Available: Telemedicine library at http://www.atmeda.org. [12] T. Kiuchi, K. Ohe, and S. Kaihara, “Using a WWW-based mail user agent for secure electronic mail service for health care users,” Methods Informat. Med., vol. 37, pp. 247–253, 1998. [13] K. D. Mandl, I. S. Kohane, and A. M. Brandt, “Electronic patient–physician communication: Problems and promise,” Ann. Internal Med., vol. 128, pp. 495–500, 1998. [14] B. Kane and D. Z. Sands, “Guidelines for the clinical use of electronic mail with patients,” J. Amer. Med. Informatics Assoc., vol. 5, pp. 104–111, 1998. [15] J. E. Ware and C. D. Sherbourne, “The MOS 36-item short form health survey, I: Conceptual framework and item selection,” Med. Care, vol. 30, pp. 473–483, 1992. [16] F. A. Matsen, III, D. W. Ziegler, and S. E. DeBartolo, “Patient self-assessment of health status and function in glenohumeral degenerative joint disease,” J. Shoulder Elbow Surgery, vol. 4, pp. 345–351, 1995. [17] E. Nebel and L. Masinter. (1995, Nov.) RFC 1867: Form-based file upload in HTML. Xerox Corporation. [Online]. Available: http://www.ietf.org/rfc. [18] Committee on Quality of Health Care in America, Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: Nat. Acad. Sci., 2001.
Christopher Lau received the B.S. degree in biological science from Carnegie Mellon University, Pittsburgh, PA, in 1997. He is currently working toward the Ph.D. degree in bioengineering at the University of Washington, Seattle. His research interests include the use of Internet technologies in telemedicine.
REFERENCES [1] C. Lau, J. E. Cabral, Jr., D. R. Haynor, and Y. Kim, “Telemedicine,” in Handbook of Medical Imaging, Y. Kim and S. Horri, Eds. Bellingham, WA: SPIE, 2000, vol. 3, pp. 305–331. [2] P. A. Heidenreich, C. M. Ruggerio, and B. M. Massie, “Effect of a home monitoring system on hospitalization and resource use for patients with heart failure,” Amer. Heart J., pp. 633–640, 1999. [3] B. Johnston, L. Wheeler, J. Wheeler, J. Deuser, and K. H. Sousa, “Outcomes of the Kaiser Permanente tele-home health research project,” Archives Fam. Med., vol. 9, pp. 40–45, 2000.
R. Sean Churchill received the B.S. degree in chemical engineering from Colorado State University, Fort Collins, in 1988 and the M.D. degree from the University of Michigan, Ann Arbor, in 1995. In 1995, he completed an Orthopedic Surgery Residency program at The Cleveland Clinic Foundation, Cleveland, OH, in 2000 and a Shoulder and Elbow Fellowship at the University of Washington, Seattle, WA, 2001. He is currently employed as a shoulder and elbow specialist for Advanced Healthcare, S.C., Milwaukee, WI.
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Janice Kim received the B.S. degree with honors in biochemistry and the B.S.E. degree with distinction in bioengineering from the University of Washington, Seattle, in 2001. She is currently working toward the M.D. degree at the University of Washington.
Frederick A. Matsen, III received the B.A. degree in chemistry from the University of Texas, Austin, in 1964 and the M.D. degree from Baylor University College of Medicine, Houston, TX, in 1968. Currently, he is a Professor and the Chair of orthopaedics and sports medicine at the University of Washington, Seattle. His research interests include improving the outcomes for patients having shoulder and elbow reconstructive surgery.
Yongmin Kim (S’79–M’82–SM’87–F’96) received the B.S. degree in electronics engineering from Seoul National University, Seoul, Korea and the M.S. and Ph.D. degrees in electrical engineering from the University of Wisconsin, Madison. Currently, he is Professor and Chair of bioengineering, Professor of electrical engineering, and Adjunct Professor of radiology, and computer science and engineering at the University of Washington, Seattle. He has more than 350 publications. His group has 69 patents, and 21 commercial licenses have been signed. His research interests are in distributed diagnosis and home healthcare, algorithms and systems for multimedia, image processing, medical imaging, high-performance programmable processor architecture, and modeling and simulation. Dr. Kim received the Early Career Achievement Award from the IEEE Engineering in Medicine and Biology Society in 1988. He is a member of the Editorial Board of the Proceedings of the IEEE, IEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING, and IEEE TRANSACTIONS ON INFORMATION TECHNOLOGY IN BIOMEDICINE.
