1.1 Objectives of this Study
Over the past twenty years, there have been various demonstrations of advanced telemedi-cine service introductions. However, many projects have been of short duration. Consider-ing telepathology applications, which this study is focused on, health care providers are reluctant in introducing telepathology services and the utilization rates of existing systems and services are often poor. There seems to be a lot of resistance at health care decision makers and pathologists do not rarely appear to be skeptical about telepathology.
Several research studies in the past have attempted to collect data on various aspects of telepathology systems, such as diagnostic accuracy analysis [see appendix VI and VII].
However, unfortunately there are no publications that have summarized the elements of success or failure of telepathology projects so far.
It is similar with other telemedicine projects [Puskin, 1995/(2), p. 129; Moore, 1995].
Many articles have been published, but mostly with a specific view of the author. To give some important pioneers and researchers who investigated telemedicine developments on a broader scale, Douglas A. Perednia MD (Portland, Oregon), Ace Allen, MD (Kansas City, Kansas), or Jim Grigsby (University of Colorado) often mentioned their opinion in the lit-erature. Yet, most of their publications are also focused on several aspects but do not regard the full spectrum of difficulties. It seems that systematic evaluations of telemedicine systems and its impact on health care delivery systems are still an exception.
The aim of my study was to collect data about telepathology systems in a standardized manner in order to gather and quantify larger volumes of multi-faceted information in a systematic way. Therefore the key success factors of telepathology projects and service utilization have been examined. Doing so, areas which are often mentioned as problemati-cal in the literature are thoroughly regarded. Differences related to the type of system em-ployed (static / dynamic) are emphasized. Additionally, a fundamental matter of concern was to trace the meaning of different critical success factors. Opinion polls were executed, where users and non-users of telepathology were asked to rate various criteria with regard to the influence of telepathology’s success or failure. Summarizing these criteria into groups of factors resulted in a simplified way of comparison and additionally showed a characteristically relationship within the factors. Furthermore significant factor differences related to the users' characteristics were carried out statistically by variance and correlation analysis.
1.2 Delimitation of the Research Study
In this study, telepathology is seen as the usage of information technology for direct inter-action between individuals at geographical separated locations by involving an specialized expert on one side - in our case a telepathologist - and mostly a non-expert on the other side. Data and images of the patient and of his medical condition have to be transferred by using networks. That means that telephone, FAX and E-mail can be involved but the main focus is on the data interaction for especially exchanging video images, but also textual, numerical or graphical medical pathological data via networks. Special attention was
Objectives, Design, and Methods of the Study Page: 5
drawn to the execution of tele-diagnostics (primary diagnosis) and tele-consultations (sec-ond opinion), yet also tele-education, tele-discussion and other valuable areas concerning telepathology were included. I will not considered virtual reality systems, computer simu-lations (except for robotic microscopes), or investigations in comprehensive intelligent database system developments for tele-imaging.
The study was designed to consider the opinion of pathologists from all over the world, since telepathology systems have the advantage that they enable an international communi-cation in telepathology and because this enables to work out country related differences.
Yet due to the limitation of research money and time, the opinion pool of pathologists, who do not use telepathology was geographically restricted to Germany. The request of tele-pathology users was executed internationally. Most data was collected by using ques-tionnaires. Since the amount of effort for participants had to be kept in an acceptable scale, areas of interest could not be regarded too detailed (still the questionnaires had five and seven pages – see appendix V). To still illuminate the broad meaning of various aspects of telepathology’s success, experiences reported in the literature had been integrated and discussed. Doing so, there occurred the additional problem that factors, which depend on the special characteristics of a country (e.g. legal restrictions) could only be roughly con-sidered by illuminating the main fields of difficulty. These factors should be further investigated in additional research studies.
Several articles of the literature were retrieved ‘fulltext’ from information databases. That is why the exact page number was not available. The same it is with sources retrieved from web-pages and Internet files. Comments of these sources are just give with author and year of publication. The rest of the quotations also includes the exact page number of the quota-tion.
Using pronouns in the text (mostly referring to a pathologist), only the pronoun ‘he’ is used instead of she/he. Feminists may excuse this behavior.
1.3 Study Design and Methods
The objective of this study was to gather comprehensive data about the critical key success factors and pitfalls of telepathology systems. For this the method of literature analysis, standardized questionnaires and interviews were employed.
The study started with an intensive literature analysis in information databases. First of all general literature about projects in telemedicine had been selected and considered carefully in order to investigate factors of success and failures. One study which delivered interesting inputs for this study was the ‘ANARAD’-study (see chapter: 4.2.5.3) executed in Germany in 1996. Two-hundred radiologists were requested about their opinion related for example to their interest in different teleradiology services, their actually available communication infrastructures, or the obstacles of teleradiology services [Bolte, 1998, pp. 123 ff.;
http://www.rzuser.uni-heidelberg.de/~n17/anarad.html]. Another study which also pro-vided several vital aspects for this study was executed by Williams and Moore [Moore, 1995; Williams, 1995].
Specific literature about telepathology project had been investigated as well. Names like Weinstein, Nordrum, Dunn, Callas, Dusserre, Beltrami, Adachi just to mention some of the
Objectives, Design, and Methods of the Study Page: 6
pioneers in telepathology, reported about their experiences and problems they had to face when introducing telepathology systems. Further, to gain concrete and very detailed infor-mation about telepathology, one project was examined within a direct field study. Professor Oberholzer, telepathologist at the University Hospital of Basel (CH), was interviewed (nar-rative interviews in 1998) about his experience with his robotic-dynamic telepathology sys-tem. Mr. Oberholzer is using a hybrid telepathology application for frozen section
examinations with a small hospital in Samedan, three-hundred kilometers apart from Basel (project description see: 4.2.7).
Field Study in Basel, Switzerland
Finally hypotheses about the most critical factors of success had been set up and all the collected information was put down to a guided interview manual [Schnell, 1995, pp. 238 ff.]. The advantage of standardized interviews in comparison to the questionnaire is that the specifications of a telepathology project can be collected more detailed and answers are more differentiated. This way decision processes for telepathology projects set-ups, the political background, organizational or human peculiarities, etc. will be gathered, too. The structure makes it possible that all areas of interests are entirely regarded. Since case stud-ies demand a lot of time and money (travel fares, hotel), only the project in Basel was directly investigated. The other planned direct project investigations in Tromsoe (Norway), Udine (Italy), Vermont (USA), Tucson (USA) and Milwaukee (USA) were examined by questionnaire and e-mail contact.
The developed manual was used in May 1999 as the basis for the field study at the Univer-sity Hospital of Basel. There detailed data about the telepathology approach of Professor Oberholzer was systematically collected2. Further two system developers were requested by telephone about their impressions regarding the factors of success of their system (Prof.
Schwarzmann, system HISTKOM, Stuttgart/Germany; Mr. Hilgers, system DISCUS, Königswinter/Germany). Their comments were added to the results (chapter: 18.3).
Development of Standardized Questionnaires
The final questionnaires were developed based on the previous findings [Schnell, 1995, pp.
333 ff.; Friedrichs, 1990, pp. 209 ff.]. One was developed for non-users of telepathology systems (pathologists at hospitals and private offices in Germany) to discover their attitude towards telepathology developments, and another one was addressed to the users of
telepathology applications (direct clients and consultants, that means that computer staff or system suppliers were not requested). The first one was in German, since only German pathologists were requested, the second one was in English (questionnaires see appen-dix V). Both questionnaires are in most parts identically. This way data became compara-ble. Yet, the questionnaire of users contained additional questions about their telepathology equipment, about the examined cases, diagnostic accuracy results, etc.
The method of standardized questionnaire had been chosen, because it enables the re-quested individuals to pick criteria out of a list, to rate various factors on a scale from zero to four, or to add comments about their attitude to a certain point. In addition, the method of standardized mail survey allowed to reach a huge amount of individuals without
2 Here I want to thank Mr. Brauchli,, the assistant of Professor Oberholzer, for the time he has spend at this field study.
Objectives, Design, and Methods of the Study Page: 7
spending a lot of money and time. The standardization and scale measures allow to do quantitative evaluation studies between the two groups. However questionnaires have sev-eral disadvantages. First of all, for not overtaxing the requested individual, the amount of questions is limited. Second, in comparison to narrative interviews, the content of the questions has to be kept simple. Multiple choice method was mostly used instead of open answers.
Questionnaires to Non-Users (Pathologists)
Since the number of pathologists, who do not use telepathology systems, was to high to request all of them, the study was geographical confined to pathologists in Germany. The addresses of these pathologists were selected by spot-checks form a list of the German Association of Pathologists. Five pathologists took part on a pre-test. Besides the request to fill out the questionnaire, these pathologists were asked about comprehensibility of ques-tions, and about their opinion of missing criteria. Since one of these test persons is located at the hospital of Constance, he could have been asked directly in an interview about the weakness of the questionnaire and about his personal opinion related to telepathology.
Finally the questionnaire was set up and mailed to 230 pathologist in July 1999. After two weeks time the pathologists, who did not answer, were either reminded by telephone to fill out the questionnaire or got a reminding letter. The comments, which were made at the reminding phone calls, were put down in a protocol and later added to the results as addi-tional remark. Assuming that reminded pathologists will not call for an addiaddi-tional ques-tionnaire in the case that the first one was lost, a copy of it was stored for downloading at the homepage of the University of Constance. Till the end of September 1999 seventy-two questionnaires had been returned to Constance.
Questionnaire to Telepathology Users
As a next step, pathologists who already use telepathology systems for consultation pur-poses were requested. The amount of telepathology users is not high. Often there is only one frequently used system per country named in the literature. Whereas static systems (kind of image sending e-mail system) are in the process of increased usage, robotic sys-tems still seem to be an exception (distinction see chapter 2). Therefore this part of the study was not geographically delimited to Germany but kept internationally, and both type of systems were included. The addresses of participating users had been selected from the literature or discovered when talking to project leaders.
The design and content of the questionnaire was mainly the same as the one of the non-telepathologists, but it was expanded by specific questions about the used system. Due to the low number of telepathology users, a pre-test was only executed with Professor Ober-holzer. Finally this questionnaire was sent to 140 telepathology users (in most of the cases tele-consultants, but also several clients). As at the study with non-users, after three weeks time the not answering persons got a reminding letter. In addition, at the 10th International Telepathology Congress in Aurich, Germany, in July 2000, several telepathology users were requested or reminded to fill in the questionnaire. Again, the questionnaire was also retrievable at the home-page of the University of Constance for down-loading. Till the end of August 2000 forty questionnaires were returned to Constance.
Definition and History of Telemedicine Page: 8