By the time the clinicians had conducted three or four outpatient clinics they were able to use the interpersonal components of the consultation with confidence and knew exactly which camera systems to use for examining their patients. In particular, the orthopaedic surgeons who had requested the “walking view” camera made extensive use of it. After his first two clinics one surgeon commented:
Surgeon: I was, I was really worried on Friday when we saw what we had and I think you guys have just been brilliant bringing that camera in, ‘cause you saw with each one we were able to get far more information just by getting them to walk and even stand and even do part of the clinical examination without having to go to the handheld camera. Only once did we have to get the handheld camera in up and close and again that was just because we wanted to look at his foot.
The surgeon who predicted that 3D video would be very useful confirmed that prediction in his clinic and used the 3D video facility extensively to examine all his patients.
The registrar who had seen the parallel between presenting a case to a panel of consultants and presenting a physical examination of a patient to a set of cameras observed that he had learned to anticipate what his surgeon would want to see and how that surgeon would want to see it. He attributed the smooth functioning of the third clinic in large part to this learned collaboration between himself and the surgeon. Some of the surgeons reported changes in the way they were conducting their clinics. All of them embraced using the pen and tablet displays as a tool for communicating with the patient and family about the patient’s condition and future treatment. One saw the issue of the hands-off involvement with the patient in a new light, writing up his patient notes in detail while the assistant conducted the actual examination and reducing the elapsed time for the consultation.
10.4 Discussion
In this chapter I make the distinction between the training provided to the clinicians so that they could understand and use the telehealth system and the process change
identified by the clinicians during the training sessions that prepared them to use the telehealth system.
The training that the research team provided covered the mechanics of using the
telehealth system – use of the room space, fixed camera/screen subsystems, examination cameras and the interactive pen and tablet display subsystem. The system and its
components had been designed for the purpose of outpatient surgical consultations, and had been tested in our laboratory for interface and collaborative usability, so we were pleased that the clinicians very quickly understood the system and the mechanics of using it. They demonstrated this understanding by their actions – brief conversations over the video subsystems, looking at objects with the examination cameras, annotating X-Rays with the pen and tablet subsystem – and confirmed their understanding in conversation with the researchers. They also understood the range of options offered by the system and chose to concentrate on those that were relevant to themselves.
I note here that we were not training the clinicians in their clinical tasks. We were offering the training in using the telehealth system based on our generalised knowledge of the clinical problem gained from our observations and clinical input. The clinicians were using the knowledge of their own clinical context to give this training concrete meaning.
The issue of process change surfaced very quickly during the training sessions and the clinicians saw it as an issue of high importance. Even though the system had been designed to reduce the difference between a tele-consultation and a face-to-face consultation by, for example, supporting simultaneous interactive access to image and video data for all participants, the physical nature of the consultations and the depth of personal interactions meant that there would necessarily be changes to process. Each of the clinicians, and the five surgeons in particular, spent their time during the training sessions focusing on how they were going to conduct their outpatient clinics during the trial. The patterns that emerged over the six training sessions can be grouped into three categories: dealing with real-time collaboration between surgeon and clinic assistant, making changes to their clinical practice to accommodate the telehealth setting and identifying changes that they required of the telehealth system for it to accommodate to their practice.
The important point is that these issues of process change were raised by the clinicians and addressed by the clinicians individually by reference to their actual clinical practice. In particular, each surgeon had a specific personal approach to his practice that the researchers would not have been able to anticipate. What the surgeons did, however, was to involve the researchers in their (the surgeons’) investigations about using the telehealth system. They frequently broke the flow of the training plan to practise using a particular component with their own or simulated patient data, role-playing or
rehearsing what they would do with actual patients. From this they were able to identify the process changes that would be required of them in order to conduct their clinics as part of the telehealth pilot trial.
We saw in this study that there were three broad areas of change that the clinicians identified and dealt with during the training sessions. In the broader picture we might use these three areas as a way of managing this change.
• Firstly, we can expect that there will be an assistant located with the patient and we can expect the clinician and assistant to establish how they will work
together. Even if they have an existing working relationship, it is likely that they will have to modify how they work together in a telehealth mode.
• Secondly, we can expect that there will be changes to the process of conducting their clinical practice and even changes to the practice itself to adapt to a telehealth mode.
• Thirdly, we can expect changes to be required of the telehealth system to meet the needs of particular clinicians. We saw that each of the five senior surgeons had a different way of matching his surgical practice with the telehealth system. In this study we had a large multifunctional system to match the complex needs of the healthcare situation. We might expect such a large complex system to be made available to a range of senior clinicians, not all of whom would have been involved in the requirements gathering process. We should therefore be
prepared to adapt the telehealth system as new requirements arise.
We have been looking at the next generation of telehealth system, functioning in a tertiary healthcare environment and used by experts in their clinical fields. We have seen that the time allocated for training these experts can also have a role in letting those experts confront and deal with the process changes involved in making the transition from face-to-face to telehealth clinical practice. We also saw, in our case study, that it was the experts (our surgeons) who drove the exploration of this process change, each in their own way. This study can, therefore, act as a highlight for researchers and developers in this field, inviting them to focus attention on both the training and process change aspects as they introduce their system to its prospective users.
10.5 Conclusion
This case study deals with the observations of twelve clinicians during their training sessions with a research prototype of a broadband telehealth system. The clinicians quickly understood the resources of the telehealth system and they focused their attention on the process changes required for them to use the system in their own clinical practice. In particular, there were three areas of concern:
• How the clinicians would collaborate with their remotely located clinical partner in using the telehealth system;
• How the clinicians would adapt their practice to match the practicalities and resources of the telehealth system; and
• How the clinicians would adapt the telehealth system at points where it did not meet their needs.
In this study we saw the clinicians using the telehealth system for the first time. They were able to understand the spatial arrangements in each of the rooms and to use this information to make decisions about how they would conduct their clinics. They were readily able to use the pen and tablet interface for pointing and drawing gestures both relating to the physical space in the patient’s room and relating to the information space of displayed video and still images. They were also able to use these pointing and drawing gestures to work together to decide how best to employ the technology in their clinics. These observations, supported by direct dialogue between the clinicians,
indicate that the design conclusions reached from the three laboratory studies were valid when the clinicians came to use the telehealth system.
The results from this study highlight the distinction between training provided to the clinicians and the process changes identified by those clinicians as they prepared to use the telehealth system. This distinction and the three areas of process change observed during the case study can form a basis for other researchers and developers working on broadband telehealth systems in a complex hospital environment.
A summary of the major results of this thesis is given in Section 1.6, pages 8-9, and this case study supports result R2: The surgeons, who were in charge of these outpatient consultations, spent most of the allocated training time mapping their own particular way of conducting the outpatient consultations onto the resources of the telehealth system. This involved establishing how they would work with their clinic assistant, how they would need to adapt their practice to use the telehealth system and, in some cases, identifying changes that they would require of the system before they could use it.
This phase was not limited to the training sessions. Some patients presented with conditions which required ways of using the telehealth system that had not been resolved during the training sessions, thereby extending the adaption phase into the early weeks of the trial.