Telemedicine services: from idea to implementation

In Europe, musculoskeletal disorders constitute a major problem in terms of self-reported symptoms. ¹ In the Netherlands, the prevalence of self-reported neck and shoulder pain in the workplace is 23%, which is similar to the mean European prevalence. ² These complaints are associated with enormous costs and individual suffering. For the Netherlands, the total costs of upper extremity disorders are estimated to be Euro 2.1 billion per year. ³ Also, pain complaints unrelated to work are a major problem in industrialized countries and the number of people with these complaints is growing rapidly. Nineteen percent of Europeans experience chronic pain complaints, which is about 75 million people in total. Thirteen percent experience pain with a moderate intensity and 6% pain with a severe intensity. ⁴

The capacity of health-care systems in industrialized countries is insufficient to treat all subjects with chronic musculoskeletal pain via conventional, face-to-face methods. This means that new methods of treatment need to be developed. The availability of public wireless networks creates the possibility of mobile health-care services, such as tele-monitoring or teletreatment. It is likely that teletreatment services will be more efficient because a single therapist can treat several subjects simultaneously and intramural care can be replaced by less costly extramural care. Such services may also be more effective because subjects can train in their home or work environment and are not constrained to the available treatment hours of the therapist. Thus subjects can train much more intensely, which should produce better results.

One example of a teletreatment system is the myofeedback-based teletreatment service, MyoTel. This treatment is based on research showing that subjects with chronic pain have different muscle activation patterns compared to asymptomatic controls, which is reflected in the prolonged activation of muscles after a task, i.e. they have reduced ability to relax their muscles. ^5–8 Subjects are not aware of this muscle activation as it often concerns rather low levels of activation. Nevertheless, according to the Cinderella hypothesis ⁹ these low levels of activation may contribute significantly to the development and maintenance of chronic pain, when occurring over long periods. This is because the structures, the low threshold motor units, that are continuously activated during low level activation are the ones that are in danger and are subject to degenerative processes. ¹⁰ A viable therapeutic approach is therefore to find ways to provide the low threshold motor units with room for relaxation and recovery, thereby breaking their typical activation patterns. Based on these findings, an ambulatory myofeedback treatment, focusing on creating awareness of this absence of sufficient muscle rest was developed and subjected to various evaluation studies. ^11–13 The evaluation studies show that the treatment leads to a significant reduction of pain and disabilities. However, effectiveness was hampered due to the fact that the therapist had to download and interpret the data immediately to be able to discuss this with the subject. In addition, the face-to-face visits were time consuming due to the need to travel and to download the data. This time consumption is not only costly, it also limits the geographical area in which subjects can be treated. Based on this, the service was further developed into a teletreatment service, and a prototype was tested in the Netherlands in 10 patients with work-related neck and shoulder problems. ¹⁴ The results of this study showed that the service had similar effectiveness with regard to the outcome measures of pain and disability compared to the face-to-face treatment. The technology used for the service enabled data transmission from the patients to a mobile base unit via a Bluetooth link and subsequently via a telecommunication network to a server. The server was accessible to authorized professionals to enable them to inspect the stored patient data. It also created the possibility of real time teleconsultation.

The MyoTel project addresses the next phases necessary to investigate the acceptability of the service in two different groups of patients: patients with work-related neck and shoulder problems (in the occupational health-care system) and patients with a chronic whiplash injury (in the rehabilitation care system) in four different countries (The Netherlands, Sweden, Germany and Belgium). The series of articles presented in this issue describe the essential aspects to address in order to develop successful teletreatment applications.

Remote care nearby. This paper describes a method involving three key elements for the realization of successful telemedicine applications and demonstrates this method for the teletreatment service. The three aspects described are: (1) clinical content; (2) design; and (3) outcome. Concerning the clinical content it is important that a telemedicine application is able to quantitatively monitor the relevant aspects of a patient's health status. In the case of telemedicine services the conventional face-to-face feedback has to be, at least partly, replaced by feedback provided by technology. It is essential that feedback is provided in such a way that it enables the patients to change their behaviour. Concerning the design it appears that the different stakeholders involved speak different languages, that there is a lack of knowledge about aspects related to acceptance and a lack of good methods for defining the user requirements. Using scenarios to describe the future services seems to be a promising approach to overcome these barriers. Concerning the outcome, evaluation of telemedicine services in everyday clinical practice so far has focused mainly on technical performance and user satisfaction. However, large scale clinical evaluation studies are now needed.

Following the method described in the first paper, the second and third papers focus on the design and development of the myofeedback service.

A scenario guideline for designing new teletreatments: a multidisciplinary approach is a paper in which a guideline is described. This guideline can be used to develop a scenario for a telemedicine service. A scenario is a good starting point for developing a common shared vision among stakeholders and can also be used as a starting point to elucidate the requirements for the application it describes.

The myofeedback-based teletreatment system and its evaluation describes the system from both a user and functional perspective, as well as its technical evaluation based on a small scale clinical trial. A revised version of the Information Systems Success Model by DeLone and McLean ¹⁵ was used, thereby focusing on the success categories of system use and user satisfaction.

Papers 4–7 address the outcome evaluation and follow the staged approach of DeChant et al. ¹⁶

The clinical effectiveness of a myofeedback-based teletreatment service in patients with non-specific neck and shoulder pain: a randomized controlled trial deals with the results of a randomized controlled trial performed to investigate the effectiveness and efficiency of teletreatment compared to conventional care in subjects with non-specific neck and shoulder pain.

Relation between patient satisfaction, compliance and the clinical benefit of a teletreatment application for chronic pain investigates the ease of use and usefulness of the teletreatment service in terms of patient satisfaction, compliance, clinical benefit and their mutual relationships in the treatment of chronic pain.

Clinical evaluation of a myofeedback-based teletreatment service applied in the workplace: a randomized controlled trial describes the results of another randomized controlled intervention study. This trial was performed in female computer users with neck and shoulder pain at work.

Prognostic factors for the effect of a myofeedback-based teletreatment service investigates potential prognostic factors for clinically relevant improvement in pain intensity and pain-related disability following teletreatment. The rationale for this investigation was to determine significant factors in setting up clinical prediction rules for the use of teletreatment services.

Success of a telemedicine service is not only dependent on successful design and outcome evaluation. This is illustrated by the fact that most telemedicine innovations never reach the market. By giving business model innovation a priority from the beginning of a project and developing the business model in steps, the failure rate of new telemedicine services may be reduced. This is because such business model designs are expected to be more viable as a result of better alignment with available resources and capabilities, and with their external environments. ¹⁷

The last paper of this special issue addresses the business model for the teletreatment service.

Deployment of e-health services – a business model engineering strategy has the objective of designing a viable business model for commercially deploying the teletreatment service using an iterative, multi-method and combined qualitative and quantitative action design approach.

The information in the present special issue demonstrates how research results from basic and applied physiology can be brought to a therapeutic application. Although there are significant differences in the four participating countries with respect to the way that their health-care systems operate, the present teletreatment approach provides benefits in every country, both from a clinical as well as an economic point of view. This research demonstrates the enormous potential of telemedicine in outpatient treatment of musculoskeletal pain.