From Telehealth to E-Health: Internet and ... - Semantic Scholar

CYBERPSYCHOLOGY & BEHAVIOR Volume 3, Number 6, 2000 Mary Ann Liebert, Inc.

From Telehealth to E-Health: Internet and Distributed Virtual Reality in Health Care GIUSEPPE RIVA, Ph.D.

ABSTRACT Since the development of methods of electronic communication, clinicians have been using information and communication technologies for the exchange of health-related information. However, the emergence of new shared media, such as the Internet and virtual reality are changing the ways in which people relate, communicate, and live. E-health, the integration of telehealth technologies with the Internet, is the next logical step of this process. To date, some e-health applications have improved the quality of health care, and later they will lead to substantial cost savings. However, e-health is not simply a technology but a complex technological and relational process. In this sense, clinicians and health care providers that want to successfully exploit e-health need to pay significant attention to technology, ergonomics, human factors and organizational changes in the structure of the relevant health service. The goal of the article is to analyze the processes by which e-health applications can contribute to the delivery of state-of-the-art health services. Particular attention is given to shared hypermedia and distributed virtual reality worlds.

INTRODUCTION

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“medicine at distance” where “medicine” includes not only medical activities involving ill patients but also public health activities involving well people.1 In other words, telehealth is process and not a technology, including many different health care activities carried out at distance. Since the development of methods of electronic communication clinicians have been using information and communication technologies for the exchange of health-related information: Telegrapy—signalling by wires— in the forms of telephony, radio, and television have been used for distance medicine since ELEHEALT H MEANS

mid-19th century.2 However, rapid and farreaching technological advances are changing the ways in which people relate, communicate, and live. Technologies that were hardly used a few years ago, such as the Internet, e-mail, video teleconferencing, and shared virtual reality (VR) are becoming familiar methods for modern communication. Health care is one of the areas that could be most dramatically reshaped by these new technologies. Distributed communication media could become a significant enabler of consumer health initiatives. In fact, these technologies provide an increasingly accessible communications channel for a growing segment of the population. Moreover, in comparison to tradi-

Applied Technology for Neuro-Psychology Laboratory, Istituto Auxologico Italiano, Milan, Italy.

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tional communication technologies, shared media offer greater interactivity and better tailoring of information to individual needs. E-health, the integration of and telehealth technologies with the Internet and shared VR is the next logical step. Although e-health is a branch of telehealth, it is differentiated in several important ways. As noted by Allen,3 telehealth to date has been largely non-Internet-based and has been characterized by pointto-point (e.g., T1) and dial-up (e.g., telephone, ISDN) information exchange. E-health, on the other hand, is more accessible due to its increasingly affordable ability to communicate through a common set of standards and across operating systems. According to Wootton,2 there are basically two reasons why telehealth is used: “either because there is no alternative, or because it is in some sense better than traditional medicine” (p. 12). In this sense telehealth has been used very successfully for optimising health services delivery to people who are isolated due to social and physical boundaries and limitations.4,5 Nevertheless, the benefits of telehealth, due to the variety of its applications and their uneven development, are not self-evident.6,7 In a recent study, Currel et al.8 assessed all the randomised trials available in scientific literature to verify the effects of telemedicine as an alternative to face-to-face patient care. Although none of the studies showed any detrimental effects from the interventions, neither did they show unequivocal benefits. The findings did not constitute evidence of the safety of telemedicine. However, the emergence of e-health is supporting the cost-effectiveness of certain applications 9 such as radiology, prisoner health care, psychiatry, and home health care. Its key advantage is the possibility of different, shared media and different health care tools in a simple-to-use and easily accessible interface. A recent Australian study showed that the costeffectiveness of both telehealth and telemedicine improves considerably when they are part of an integrated use of telecommunications and information technology.10 The conclusion of the author is that it is unwise to promote telehealth in isolation from other uses of technologies in health care. To date, some e-health applications have im-

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proved the quality of health care, and later they will probably lead to substantial cost savings.11 However, e-health is not simply a technology but a complex technological and relational process.12 In this sense, clinicians and health care providers who want to successfully exploit e-health need a significant attention to technology, ergonomics, human factors, and organizational changes in the structure of the relevant health service.13 The goal of the paper is to analyze the processes by which e-health applications can contribute to the delivery of state-of-the-art health services. Particular attention is given to shared hypermedia and distributed VR worlds.

E-HEALTH: PROCESSES AND OPPORTUNITIES Shared media, such as Internet and distributed VR offer different paths for augmenting the health care services in clinical and nonclinical settings. In particular it is possible to identify three areas in which e-health can offer a competitive advantage over traditional processes: clinical care, health education, and public health activities. These three areas will be discussed and the potential of shared media will be investigated in this article. E-health in clinical care The first area in which e-health can offer a competitive advantage is medical consultation and diagnosis. Remote video consultation, for example, could give consumers greater access to skilled health professionals regardless of geographic proximity. The efficacy of the use of remote consultation in e-health is confirmed by different research. For instance, Craig et al.14 recently compared the outcome of neurological patients admitted to two small hospitals. In one hospital, all patients with neurological symptoms were seen by a neurologist at a distance using an interactive video-link transmitting at 384 kbit/sec; in the other, patients with neurological problems were managed as per usual practices. No appreciable differences were noted between the two hospitals in the final outcome.

FROM TELEHEALTH TO E-HEALTH

Lange et al.15 developed an Internet based ehealth system for treatment of post-traumatic stress disorder. The treatment comprised 10 writing sessions (45 min each) over 5 weeks. Reduction in post-traumatic stress symptoms compared favourably to changes in control and experimental groups in trials of similar but face-to-face treatment. Elford and colleagues16 used a PC-based videoconferencing system transmitting at 336 kbit/sec to conduct child psychiatry assessments. An independent evaluator concluded that in 96% of the assessments the diagnosis and treatment recommendations made via the videoconferencing system were the same as those made in face-to-face meetings. No significant difference was found in the patients’ or parents’ satisfaction responses after the two types of assessment even if most parents (91%) indicated that they would prefer to use the videoconferencing system than to travel a long distance to see a psychiatrist in person. Also, the cost-effectiveness of remote video consultation is supported by experimental data. In Finland, Mielonen et al.17 assessed the costs of psychiatric inpatient care-planning consultations to remote areas using videoconferencing instead of the conventional face-toface consultations at a hospital. At a workload of 20 patients per year, the cost of the videoconferences was FM2,510 per patient; the cost of the conventional alternative was FM4,750 per patient. At 50 care consultations per year, a remote municipality would save approximately FM117,000. Even if, for the most part, remote consultation programs rely on dedicated networks (not the Internet) to provide connectivity between remote clinics and a centralized consulting facility, e-mail is emerging as a low-cost alternative to facilitate electronic communications between patients and care providers.12 In particular, the use of e-mail in e-health offers the following advantages: the ability to offer routine transactions and patient education; increased efficiency; the self-documenting nature of this medium; cost-effectiveness; and serving as a clinical extender.18 Given the successful results obtained using a less immersive medium, some researchers are thinking that the use of immersive VR in e-

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health could further strengthen the assessment and rehabilitation process,19–20 resulting from its ability to immerse the patient in a life-like situation that she/he is forced to face. As noted by Miller & Rollnick,21 people are “more persuaded by what they hear themselves say than by what other people tell them” (p. 58). Future applications of remote VR in e-health are expected to appear during the next year for the treatment of phobias and eating disorders.22,23 A second important section of e-health for clinical care is medical imaging. In fact, the use of the Internet to transfer medical images to expert interpreters could accelerate and improve the diagnostic processes as well as reduce costs.24 For instance, Braun et al.25 recently verified the efficacy of teledermatoscopy under routine conditions in private practice. In particular they found that diagnostic accuracy of the teledermatoscopy approach was superior to that of the conventional approach for malignant melanocytic lesions. Usually, data visualization is performed slice by slice or by using volume rendering on costly graphics workstations.23 However, the recent development of Internet technologies, the dramatic improvements of rendering capabilities on PCs and the diffusion of the VR Modelling Language (VRML) make three-dimensional (3D) visualization based upon client-server architecture possible.26 Moreover, state-of-the-art VR and high speed networks have made it possible to create an environment for clinicians geographically distributed to share immersively massive medical volumetric databases in real time. One of the most successful systems in this area is the one developed by the VRMedLab at the University of Illinois at Chicago. This research group has developed a tele-immersion program that allows clinicians to interact with the same volumetric models, point, converse, and see each other through an ATM network.27 Participants are depicted by virtual representations (avatars) that have their head and hand tracked so that they can convey natural gestures such as nodding and pointing. Moreover, the system allows the users to fly through space using a joystick and to interact with objects in the space using a tracked wand. Participants can pick, delete, or move any of the objects and

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speak to each other using a virtual intercom system. A more advanced research project was developed at NASA in the “Virtual Collaborative Clinic” project at Ames Research Center. It used the high bandwidth Abilene network (9,920 Gbps) for multicasting in real-time complex images (1,200,000 polygons) generated on a central graphic server at NASA.28 To allow interaction with remote sites, the project used a combination of client-side (local) low resolution rendering (20,000 polygons) during object manipulations and multicast image distribution for single frame (static) image display. To achieve these outstanding results, the project used a 39Mbps bandwidth through satellite communication. Another typical use of visualization applications is the planning of surgical and neuro-surgical procedures.29,30 The planning of these procedures usually relies on the studies of series of two-dimensional MR (Magnetic Resonance) and/or CT (Computer Tomography) images that have to be mentally integrated by surgeons into a 3D concept. This mental transformation is difficult because complex anatomy is represented in different scanning modalities on separate image series that are usually found in different sites/departments. An e-health VRbased system is capable of incorporating different scanning modalities coming from different sites providing an interactive 3D view. Within the Virtual Collaborative Clinic project, NASA researchers developed Cyberscalpel, a VR-based telemedicine surgical system for planning and practice.28 To plan the operation of a patient with cancer of the jaw, the upper and lower jaws were reconstructed using Cyberscalpel starting from a CT scan. The scan was reduced to 20,000 polygons, and the final model used to prove how fibular bone could be sectioned to mimic and replace the jaw pieces. The display of the Cyberscalpel was multicast to the participant Virtual Clinic clients during this procedure. E-health in health education Even if computer-assisted instruction programs for medical education were developed more than 30 years ago, their limits—lack of

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portability, update and local availability— would have drastically reduced the potential impact of this approach.31 However, the appearance of Internet-based information and communication technologies is changing how training is being conducted in many medical schools.32 As noted by Federico,33 “We are in the midst of a paradigm shift in education and training from classroom centric to network centric” (p. 653). The key to this shift is the emergence of “hypermedia,” which can be described as “on-line setting where networks of multimedia nodes connected by links are used to present information and manage retrieval” (p. 662).33 The Internet is a well-known hypermedia environment that users can access by using interactive browsers, such as Microsoft’s Internet Explorer or Netscape’s Navigator. If the information is textual in the first place, we talk of a hypertext, and if there are certain visual, musical, animation elements, or the like included, we talk of a hypermedia.34 Hypertexts and hypermedia are structured around the idea of offering a learning environment that mimics human thinking—that is, an environment that allows the user to make associations between “concepts” rather than move sequentially from one to the next, as in an alphabetical list. Using hypermedia, students are no longer forced to follow linear lesson sequences but can choose “what to view, when to view, for how long to view and how many times to view” (p. 104).35 Consequently, on-line students, can dynamically adapt the educational experience to their own momentary needs by directly interacting with hypermedia.36 However, some researchers are skeptical about the educational relevance of hypermedia environments. As noted by Large,35 “Linking information may be a necessary condition for learning, but it is not sufficient. Links can be made in many ways, including totally arbitrary ones with little semblance to how people associate ideas” (p. 98). Moreover, enabling learner control assumes that students have sufficient knowledge to select and make optimal links. Unfortunately this is not always true, especially for novices who also have to face the cognitive load required to keep track of their naviga-

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tional paths or for experienced users who have to face a badly structured hypermedia. For instance, Gotwald et al.37 recently assessed 30 websites for radiological education. Even if many of them contained large numbers of interesting radiological images of good quality, the structure and organization of the sites were their weakest features, reducing their educational potential. To overcome these problems, a new form of hypermedia is now emerging: shared hypermedia (SH). SHs are new Internet tools attaching computer-mediated-communication to Web browsing (see Table 1 for a list of available SHs). In SHs, different users, who are simultaneously browsing the same website, can communicate with each other and share files or web addresses. Using a simple interface, usually resembling a little remote control, SHs users can get a constantly updated list of all the other online users who are visiting the same website. Usually, a SH lets the user conduct group and private chats, exchange information or files, and share the same web pages. On any website, SH users can see a list of other users and talk with them on group and private levels. SHs further enhances the user experience by consolidating different form of CMC (e-mail, IRC, etc.) into one fully integrated interface. Many SHs also have a search engine that can be used to find a user with a specific age and/or similar interests. In this way, it is really easy to set up a group with a common interest, such as cardiology or eating disorders, or get online to practice a foreign language with a native speaker of that language. The most advanced SHs (i.e. Cahoots and Firetalk) have an option called the web tour that is very interesting for its possible use in teaching. During a web tour, a leader can guide the

TABLE 1.

browsing of a small group of users (usually up to 20), who are forced to follow him, interacting with them in real time. By assembling people with similar interests and surfing habits, this new Internet platform transforms Web browsing into a social activity. In this sense, SHs can be the starting point of communitycentered environments that can improve the experience of learning. A second emerging area in e-health applications for health education is remote visualization of massive volumes of information and databases. Through remote 3D visualization, students can understand important physiological principles or basic anatomy. For instance, Internet-based VR can be used to explore the organs by “flying” around, behind, or even inside them. In this sense, VR-based e-health can be used both as didactic and experiential tool, allowing a deeper understanding of the interrelationship of anatomical structure that cannot be achieved by any other means, including cadaveric dissection. The number of developed applications in this area is very large. For instance, Westwood and colleagues38 reported more than 10 different educational and visualization applications. A typical example is Anatomic VisualizeR, a VRenhanced multimedia application used in medical school anatomy and high school biology classes.39 A more advanced attempt in using a VR-based telemedicine system for surgical simulations comes from the Manchester Visualization Center.40 Using VRML and JAVA to render the 3D models, the authors created simulations of ventricular catheterisation accessible through the Internet. Early in their training, trainees in neurosurgery need to gain an appreciation of the ventricular system and how to cannulate it in an emergency. The flow of cerebrospinal fluid can be obstructed in the

SHARED HYPERMEDIA TOOLS

Tool

Developer

Cahoots Firetalk Gooey ICQSurf Instant Rendezvous Odigo

Cahoots Multitude Hypernix ICQ Multimate NovaWiz

Website http://www.cahoots.com http://www.firetalk.com http://www.gooey.com http://www.icq.com/icqsurf http://www.multimate.net http://www.odigo.com

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ventricles by several pathological processes leading to hydrocephalus. The pressure within the ventricles can rise, leading to loss of consciousness. The ventricular system can be cannulated in the operating theatre, fluid can be drained, and a potentially lethal rise in pressure can be relieved. In the virtual environment the user can move the virtual cannula to the entry point on the 3D patient. The cannula is then placed with the correct orientation. Finally, it is inserted through the virtual patient and into the ventricular system. The authors are also exploring the possibility of allowing multi-user collaboration. Using Deep Matrix software41 as a base platform, researchers have extended the simulators to allow a single instance of one simulator to be accessed by several users over the Internet. Any change in the VRML word produced by one user is propagated to all the other participant web browsers. This enables the teacher to explain to a remote audience how a procedure should be performed. A similar approach—VRML plus JAVA—is used by the Department of Neurosurgery in the Leeds General Infirmary (United Kingdom) to train surgeons in the treatment of trigeminal neuralgia. Specifically, the teletraining system simulates the insertion of a needle in the percutaneous rhizothomy.42 The collision detection between the instrument and patient is critical to this simulation. Hence, the virtual environment provides a pair of linked views: one from the eye of the surgeon and one from the viewpoint of the needle. The different parts of the procedure—marking anatomical landmarks, orienting the needle, and inserting it— are all simulated by the application. The simulator is freely available on a public access website (http://synaptic.mvc.mcc.ac.uk/home. html). The opportunity for international collaboration in medical conferences is another potential application now being explored43 in this area. Interaction and participation using shared VR might alleviate some of the stiltedness of current videoconferencing capabilities. However, even if many of these applications could be developed, their actual use in this area is still limited by both technology-related factors (such as lack of high visual fidelity or price/perfor-

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mance issues) and design-related factors (such as poor interface and sensory overload). E-health in public health activities Public health activities are one of the areas that could be most dramatically reshaped by the Internet. Public health activities include all the health care activities aimed at giving consumers a more pronounced role in their own health and health care. In detail, public health activities range from home-based monitoring of health status to the development of tools for self-assessment of health risks and management of chronic diseases.24 One public health area that has exploded over the past few years includes consumer-oriented Internet sites. In fact, many providers of health information have identified the Internet as an effective medium for reaching large numbers of health consumers. These sites are usually dedicated to the promotion of various healthy lifestyles, the diagnosis and management of diseases, and interventions to prevent the onset of disease. The formats range from mailing lists to interactive websites, chat sessions, or compilations of online resources. However, given the huge volume of health information available on the Internet, a key issue for the diffusion of e-health is the creation of tools and guidelines to help consumers find information of interest and evaluate its quality.44 For example, a simple Web search for “cannabis” can return more than 130,000 Web pages, 44 and some 61,000 websites contain information on breast cancer.24 To search through this incredible amount of data, consumers need effective searching and filtering tools and a way to judge the quality, authoritativeness, and provenance of the information. In a recent study, Kim et al.45 analyzed the published criteria for specifically evaluating health-related information on the Internet. The most frequently cited criteria were those dealing with content, design and aesthetics of site; disclosure of authors, sponsors, or developers; currency of information (includes frequency of update, freshness, maintenance of site); authority of source, ease of use; and accessibility and availability. The results suggest that, even if there is a general agreement on some crite-


ria, the identification and assessment of a clear, simple set of consensus criteria is still required, which the general public can understand and use. Another key area of public health activities that is affected by e-health is the access to health records.46 Historically, care providers have maintained voluminous records of patient encounters within their organizations, documenting dates and times of consultations, diagnoses, lab results, prescriptions, and more. Electronic medical records are the e-health evolution of traditional paper-based health records. These systems have evolved from simple databases to true medical records systems with variable levels of functionality. Early systems provided simple anamnestic data. Modern systems now even provide laboratory results, copies of the radiology images and therapeutic orders. Electronic medical records were initially used for allowing medical specialists to share patient records and to communicate with each other on the Internet,47 and, in the last years, a number of new websites have begun to allow consumers to store their own health records online. The potential benefits of these sites are many. As noted by Shortliffe,24 Using them, consumers can create comprehensive, longitudinal records that capture information about the care received from different organizations over an extended period of time. Consumers can use these records to help monitor and evaluate their health status, and they can grant access, if they wish, to different providers for purposes of care. (p. 53).

Some sites also provide some sort of emergency feature that enables care providers to gain access to a patient’s records in an emergency situation; something that is much more difficult to do if the records are not stored online. CONCLUSIONS The emergence of e-health could have a strong effect on health care. As we have seen, the key characteristic of e-health is the use of shared media. Using the Internet, therapists

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can present, from a remote site, a wide variety of stimuli and measure and monitor a wide variety of responses made by the user. However, at this stage, there are different short-comings to the potential of this approach. The main problem is non-technical and is related to the personal and organizational changes needed to introduce e-health in healthcare organizations.48 Although the introduction of shared media has been successful and become accepted practice in many areas of industry, traditional methods have tended to prevail in health-care. Telehealth and e-health have been adopted by enthusiasts who recognize the potential benefits of a these new media. However, the more widespread introduction of e-health requires considerable organizational change in the way health care is delivered.49 This requires an alteration of established factors such as consultations and referral patterns, ways of payment, specialist support for primary healthcare, co-operation between primary and secondary healthcare, defining geographical catchment areas, and the “ownership” of the patients.50 A further problem is the technology of ehealth. Actual technology (hardware, software, and transmission) is expensive and far from perfect. 51 Insufficient image quality, low framing rate, flickering, and delays makes working in front of a video terminal unattractive and in particular very tiring. An important effect of this is, among others, an increased tendency to produce errors. Fortunately the quality of technology in this area is increasing while costs are falling down. Prices are declining by approximately 25% every year.52 Simple, telephone-based videoconferencing systems are now available for under $500, whereas high quality, board-based ISDN systems can cost less than $1,000. New transmission technologies, including Digital Subscriber Line (xDSL) and cable modem, promise to provide order-of-magnitude increases in dependable bandwith for a small increment of price. Widespread access to the Internet is also required for the success of e-health applications. Many applications currently demand only moderate bandwidth and latency, meaning that standard modem access to the Internet, at 28.8 to 56 kbit/s may suffice.

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A recent research evaluated a low-bandwidth, e-health system in eight community hospitals connected to a central hospital via the Internet. PCs were used with videoconferencing software and modem connections to the telephone network. Even if the average live video frame rate was 1 frame/sec (at the best image quality), with an average latency of 3 seconds, the results suggested that Internetbased videoconferencing is acceptable for certain telemedicine applications.53 Successful results with a limited bandwith have also been obtained by an e-health teleconsultation application developed in Croatia: a 33 kbit/s link was established between a team of specialists in the general hospital, Sveti Dub (Zagreb), and a general practitioner’s clinic in Selca (on the island of Brac) using $700 computer system.54 Another relevant issue is that of ensuring equitable access to health resources by different demographic groups. There are already considerable differences in access to health care in the world. Ensuring that differential access to the Internet along demographic lines does not exacerbate this imbalance could become an increasingly important issue, especially if the provision of health care moves online.24 Security and legal protection are two more key issues for the diffusion of e-health.55,56 In fact this approach involves three fundamental types of relationships57 in which a duty is owed by one party to another: the the the the the

relationship between the clinician and patient; relationship between clinicians; and relationship between the provider of telemedicine system and the user.

The situation may be complicated by the involvement of multiple clinicians and/or the providers of the telemedicine systems (call centers, telecommunications network, etc). As noted by Stanberry,57 if “a patient is harmed during a teleconsultation, (the healthcare centre) could choose to name a number of these organisations or individuals as defendants to a legal action for negligence if it is unclear what went wrong or where responsibilities are” (p. 24). Moreover e-health can hide severe privacy

and security risks because patient data and hospital data stored on a secure Intranet can be manipulated by connecting it to the Web. This is even more true for e-mail consulting. Most email exchanges between patient and provider involve discussions of personal health information, which must be suitably protected from breaches of confidentiality and, to a lesser extent, alteration.58 However, the establishing of a firewall and the introduction of health professional cards can drastically reduce the risk of unauthorized access to the hospital server. For secure e-mail, pretty good privacy can be easily used as a standard protocol.55 In general, planning all activities exactly as well as introducing an advanced form of data protection are important requisites for the reduction of security risks on the Internet.59 To spread the diffusion of e-health, further research is needed. More evaluation is required of clinical outcomes, organizational effects, benefits to health-care providers and users, and quality assurance. It is also very important that professionals in this field share information about their experiences and examine the results of evaluations so that the suitable development work can be accelerated.

ACKNOWLEDGMENTS The present work was supported by the Commission of the European Communities (CEC), specifically by the IST programme through the VREPAR 2 (HC 1055) and VEPSY UPDATED (IST-2000-25323) research projects. REFERENCES 1. Wootton, R. (Ed.). (1999). European telemedicine, 1998/99. London: Kensington Publications Ltd. 2. Wootton, R. (1999). Telemedicine: An introduction. In: Wootton R. (Ed.). European telemedicine, 1998/1999 (pp. 10–12). London, Kensington Publications Ltd. 3. Allen, A. (1999). When the ship comes in. Telemedicine Today, 7, 7. 4. O’Sullivan, U.M., and Somers, J. (1999). Southern Health Board—Advanced telematic/telemedicine in healthcare services in the south west of Ireland. Studies in Health Technologies and Informatics, 64, 230–240.

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FROM TELEHEALTH TO E-HEALTH 5. Fletcher, R. (1999). Telehealth rescues isolated patients. Health Management Technologies, 20, 52–53. 6. Lehoux, P., Battista, R.N., and Lance, J.M. (2000). Telehealth: Passing fad or lasting benefits? Can J Public Health, 91, 277–280. 7. Mair, F.S., Haycox, A., May, C., and Williams, T. (2000). A review of telemedicine cost-effectiveness studies. Journal of Telemedicine and Telecare, 6, S38–S40. 8. Currell, R., Urquhart, C., Wainwright, P., Lewis, R. (2000). Telemedicine versus face to face patient care: Effects on professional practice and health care outcomes. Cochrane Database Syst Rev, 2. 9. Charles, B.L. (2000). Telemedicine can lower costs and improve access. Healthcare Financial Management, 54, 66–69. 10. Mitchell, J. (2000). Increasing the cost-effectiveness of telemedicine by embracing e-health. J Telemed Telecare, 6, S16–S19. 11. Coile, R.C., Jr. (2000). The digital transformation of health care. Physician Executive, 26, 8–15. 12. Jerome, L.W., DeLeon, P.H., James, L.C., Folen, R., Earles, J., and Gedney, J.J. (2000). The coming of age of telecommunications in psychological research and practice. American Psychologist, 55, 407–421. 13. Riva, G., Gamberini, L. (2000). Virtual reality as telemedicine tool: Technology, ergonomics and actual applications. Technology and Health Care, 8, 113–127. 14. Craig, J., Chua, R., Russell, C., Patterson, V., and Wootton, R. (2000). The cost-effectiveness of teleneurology consultations for patients admitted to hospitals without neurologists on site. 1: A retrospective comparison of the case-mix and management at two rural hospitals. Journal of Telemedicine and Telecare, 6, S46–S49. 15. Lange, A., van de Ven, J.P., Schrieken, B.A., Bredeweg, B., and Emmelkamp, P.M. (2000). Internet-mediated, protocol-driven treatment of psychological dysfunction. Journal of Telemedicine and Telecare, 6, 15–21. 16. Elford, R., White, H., Bowering, R., Ghandi, A., Maddiggan, B., St John, K., House, M., Harnett, J., West, R., and Battcock, A. (2000). A randomized, controlled trial of child psychiatric assessments conducted using videoconferencing. Journal of Telemedicine and Telecare, 6, 73–82. 17. Mielonen, M.L., Ohinmaa, A., Moring, J., Isohanni, M. (2000). Psychiatric inpatient care planning via telemedicine. Journal of Telemedicine and Telecare, 6, 152–157. 18. Taylor, K. (2000). The clinical e-mail explosion. Physician Exec, 26, 40–45. 19. Glantz, K., Durlach, N.I., Barnett, R.C., and Aviles, W.A. (1997). Virtual reality (VR) and psychotherapy: Opportunities and challenges. Presence, Teleoperators, and Virtual Environments, 6, 87–105. 20. Riva, G., Bacchetta, M., Baruffi, M., Rinaldi, S., and Molinari, E. (1998). Experiential cognitive therapy: A VR based approach for the assessment and treatment of eating disorders. In: Riva, G., Wiederhold, B., and Molinari, E. (Eds.). Virtual environments in clinical psy-

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25.

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34. 35.

36.

chology and neuroscience: Methods and techniques in advanced patient-therapist interaction (pp. 120–135). Amsterdam, IOS Press. Miller, W.R., and Rollnick, S. (1992). Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press. Riva, G., Wiederhold, B., and Molinari, E. (Eds.). (1998). Virtual environments in clinical psychology and neuroscience: Methods and techniques in advanced patient–therapist interaction. Amsterdam: IOS Press. Riva, G., and Gamberini, L. (2000). Virtual reality in telemedicine. Telemedicine Journal, 6, 325–338. Shortliffe, E.H. (Ed.). (2000). Networking health: Prescriptions for the Internet. Washington, DC: National Academy Press. Braun, R.P., Meier, M., Pelloni, F., Ramelet, A.A., Schilling, M., Tapernoux, B., Thurlimann, W., Saurat, J.H., Krischer, J. (2000). Teledermatoscopy in Switzerland: A preliminary evaluation. J Am Acad Dermatol, 42, 770–775. Kling-Petersen, T., Pascher, R., and Rydmark, M. (1999). Virtual reality on the Web: The potentials of different methodologies and visualisation techniques for scientific research and education. Studies in Health Technology and Informatics, 62, 181–186. Ai, Z., Rasmussen, M., and Silverstein, J.C. (2000). Radiological tele-immersion for next generation networks. Studies in Health Technology and Informatics, 70, 4–9. Ross, M.D., Twombly, I.A., Bruyns, C., Cheng, R., and Senger, S. (2000). Telecommunications for health care over distance: The virtual collaborative clinic. Studies in Health Technology and Informatics, 70, 286–291. Abbasi, H.R., Weigel, R., Sommer, C., Schmiedek, P., Kiessling, M. (1999). Telepathology in neurosurgery. Studies in Health Technology and Informatics, 62, 1–7. Bergman, W.C., Tse, V., Schulz, R.A., Geil, G.E., Shatsky, S.A., and Bao, L. (1999). An improved stereotactic technique for cyst cannulation. Studies in Health Technology and Informatics, 62, 45–48. Haag, M., Maylein, L., Leven, F.J., Tönshoff, B., Haux, R. (1999). Web-based training: A new paradigm in computer-assisted instruction in medicine. International Journal of Medical Informatics, 53, 79–90. Cox, C.G., White, D., Brinson, H., Ramey, D. (2000). Distance learning: Health education for ninth-grade students. Journal of Telemedicine and Telecare, 6, S8–S10. Federico, P.A. (1999). Hypermedia environments and adaptive instructions. Computers in Human Behavior, 15, 653–692. Encarta: World English Dictionary. (1999). Seattle, WA: Microsoft Press. Large, A. (1996). Hypertext instructional programs and learner control: A research review. Education for Information, 95–106. Barab, S., Bowdish, B., and Lawless, K. (1997). Hypermedia navigation: Profiles of hypermedia users. Educational Technology Research and Development, 45, 23–41.

998 37. Gotwald, T.F., Daniaux, M., Stoeger, A., Knapp, R., zur Nedden, D. (2000). The value of the World Wide Web for tele-education in radiology. Journal of Telemedicine and Telecare, 6, 27–30. 38. Westwood, J.D., Hoffman, H.M., Robb, R.A., and Stredney, D. (Eds.). (1999). Medicine meets virtual reality: The convergence of physical and informational technology. Amsterdam: IOS Press. 39. Hoffman, H., and Murray, M.A. (1999). Anatomic VisualizeR: Realizing the vision of a VR-based learning environment. In: Westwood, J.D., Hoffman, H.M., Robb, R.A., Stredney, D. (Eds.). Medicine meets virtual reality: The convergence of physical and informational technology. (pp. 134–139). Amsterdam, IOS Press. 40. John, N.W., and Phillips, N. (2000). Surgical simulators using the WWW. Studies in Health Technology and Informatics, 70, 146–152. 41. Reitmayr, G., Carroll, S., and Reitemeyer, A. (1999). Deep matrix—An open technology based virtual environment system. The Visual Computer Journal, 15, 395–412. 42. Li, Y., Brodlie, K., and Phillips, N. (2000). Web-based VR training simulator for percutaneous rhizotomy. Studies in Health Technology and Informatics, 70, 175–181. 43. Brennan, J.P., and Brennan, J.A. (1995). Clinical applications of a high-performance computing system for visualizing and monitoring human labor and birth. Studies in Health Technology and Informatics, 18, 48–52. 44. Gamberini, L., and Riva, G. (2000). Net Ergonomics: Information retrieval in health care domains. Studies in Health Technology and Informatics, 70, 83–85. 45. Kim, P., Eng, T.R., Deering, M.J., and Maxfield, A. (1999). Published criteria for evaluating health related websites: Review. British Medical Journal, 318, 647–649. 46. Paperny, D.M. (2000). Computers and information technology: Implications for the 21st century. Adolescent Medicine, 11, 183–202. 47. Sung, M.Y., Kim, M.S., Kim, E.J., Yoo, J.H., and Sung, M.W. (2000). CoMed: A real-time collaborative medicine system [In Process Citation]. International Journal of Medical Informatics, 57, 117–126. 48. Cardno, E.J. (2000). Managing the “fit” of information and communication technology in community health: A framework for decision making. Journal of Telemedicine and Telecare, 6, S6–S8. 49. Birch, K., Rigby, M., Roberts, R. (2000). Putting the “tele” into health-care effectively. Journal of Telemedicine and Telecare, 6, S113–S115. 50. Olsson, S., and Calltrop, J. (1999). Telemedicine: A tool

RIVA

51.

52.

53.

54.

55.

56.

57.

58.

59.

for organisational and structural change in healthcare. In: Wootton, R. (Ed.). European telemedicine, 1998/1999 (p. 26). London: Kensington Publications Ltd. Lou, S.L., Lin, H.D., Lin, K.P., and Hoogstrate, D. (2000). Automatic breast region extraction from digital mammograms for PACS and telemammography applications. Comput Med Imaging, 24, 205–220. Allen, A. Telemedicine: A global perspective. In: Wootton, R. (Ed). European telemedicine, 1998/1999 (pp. 13–15). London: Kensington Publications Ltd. Lemaire, E.D., Boudrias, Y., and Greene, G. (2000). Technical evaluation of a low-bandwidth, Internetbased system for teleconsultations. Journal of Telemedicine and Telecare, 6, 163–167. Ostojic, V., Stipic-Markovic, A., Tudman, Z., Zivkovic, N., Cvoriscec, B., Trajbar, T., Donnelly, C.L., Grgic, M., Matek, P., Lusic, M., and Iskra, M. (2000). A feasibility study of realtime telemedicine in Croatia using Internet videoconferencing. Journal of Telemedicine and Telecare, 6, 172–176. DeVille, K., and Fitzpatrick, J. (2000). Ready or not, here it comes: The legal, ethical, and clinical implications of E-mail communications. Semin Pediatr Surg, 9, 24–34. Hirsch, W.R. (2000). Policing the electronic frontier: An introduction to E-health legal issues. J Cardiovasc Manag, 11, 9–11. Stanberry, B. (1999). Legal and ethical issued in European telemedicine. In: Wootton R. (Ed.). European telemedicine, 1998/1999 (pp. 20–25). London, Kensington Publications Ltd. Sogner, P., Goidinger, K., Reiter, D., Stoeger, A., and zur Nedden, D. (2000). Security aspects of teleradiology between the university centre and outlying hospitals in Tyrol. Journal of Telemedicine and Telecare, 6, S160–S161. Seibel, R.M., Kocher, K., Landsberg, P. (2000). Security aspects on the Internet. Radiologe, 40, 394–399.

Address reprint requests to: Giuseppe Riva, Ph.D. Istituto Auxologico Italiano Applied Technology for Neuro-Psychology Laboratory Casella Postale 1 28900 Verbania, Italy E-mail: [email protected]