Quality Attributes in Telemedicine Video Conferencing

Video conferencing is used increasingly in many telemedicine applications, including medical personnel education, peer consultation, patient education, and direct patient care. Advances in technology and changes in medical care delivery have enhanced the ability to develop effective telemedicine video conferencing systems. Measures of effectiveness for technology systems rely on identified requirements for system quality. In this research, we propose a comprehensive model of quality attributes for telemedicine video conferencing systems. The quality attribute model is developed from an extensive literature review, direct observations of telemedicine encounters, and structured interviews with telemedicine experts. The model contains four quality attribute groups: Technical, Usability, Physical Environment, and Human Element. Interview citations are used to justify the importance of these individual quality attributes. Both researchers and practitioners can make use of the model to understand, design, and evaluate telemedicine video conferencing systems. 1. Telemedicine Video Conferencing As an integral component of telehealth, high bandwidth video conferencing is used in medical personnel education, peer consultation, patient education, as well as direct patient care. Telemedicine video conferencing has experienced rapid growth in the last five years primarily due to advances in technology (e.g., increased bandwidth; new cameras, monitors, and coder/decoders (CODECs)) and changes in the medical care environment (e.g., increased outpatient care, remote surgeries) [5]. From a patient care perspective, medical video conferencing patient consultations are now frequently used in the domains of dermatology, cardiology, wound care, neurology, drug screening, diabetic training, and psychiatry. High bandwidth video conferencing is necessary for many medical exams requiring invasive procedures (e.g., telesurgery), real-time motion-detection (e.g., cardiac monitoring, ultrasonography), and real-time specimen analysis (e.g., scan and pan pathology). There 0-7695-1435-9/02 $1 i International Conference on System Sciences (HICSS-35’02) is widespread interest in utilizing this technology, as an economical method to provide expert medical service to patients in remote or awkward locations, like prison systems. However, in spite of increasing use and interest in video conferencing, generalized standards of quality that encompass the patient consultation experience have not emerged. Standards exist for health care in the form of legislative and regulatory pronouncements (e.g., Joint Accreditation of Healthcare Organizations), for telecommunication and information systems (e.g., International Multimedia Telecommunications Consortium, Inc. – ITU-T sector standards for multimedia teleconferencing, T.120, H.320, H.323, and H.324), and for general systems quality (e.g., International Standards Organization 9000:2000). Such standards provide a relevant foundation for quality requirements in the telemedicine field. However, these guidelines do not provide sufficient detail to facilitate the actual evaluation of a telemedicine system as an antecedent to patient outcome assessment. Nor do they provide an integrated model for the utilization of videoconferencing in telemedicine which can be used to develop a quality management program and assess gaps. Lastly, they do not provide the constructs necessary for researchers to methodically study medical video conferencing quality and to develop associated research tools. This void is recognized by telemedicine researchers who encourage the prospective, as well as retrospective, analysis of telemedicine by exploring such issues as: what variables should be measured and what factors have constrained or limited telemedicine success [18]. 2. Quality Attributes in Telemedicine Quality attributes are vital in system development because they establish requirements criteria that guide subsequent design, implementation, and testing activities [2]. System quality has long been recognized as a critical component of system success [6]. Quality is a multi-dimensional construct that does not contain a universal set of attributes, but instead is domain specific. 7.00 (c) 2002 IEEE 1 Proceedings of the 35th Hawaii International Conference on System Sciences 2002 Proceeding 0-7695-143 Figure 1: Medical Video Conferencing Equipment In revisiting their seminal work on information system success, DeLone and McLean [6] urge researchers to pay careful attention to context in defining and measuring each component of success (system quality, information quality, service quality, system use, user satisfaction, and net benefits) and assessing interrelationships between success constructs. Research also indicates that users prefer to tailor success constructs and measures to the type of system under evaluation to facilitate understanding and application [12]. Therefore, decomposition of a multi-dimensional construct, like system quality, under the auspice of domain characteristics and boundaries will provide a high degree of relevance and understanding to researchers and practitioners. A taxonomy of telemedicine system quality provides researchers and practitioners with a connecting framework to facilitate system success by considering the extent, nature, and appropriateness for quality attribute levels in each situation of use. Without an understanding of system quality in the telemedicine environment, the potential for successful implementation of telemedicine systems is diminished. The purpose of our research is to propose a taxonomy of telemedicine system quality for direct patient care using high bandwidth video conferencing (hereafter referred to as medical video conferencing). Figure 1 provides a view of the environment of medical video conferencing used in this study. Of all the uses of medical video conferencing mentioned (e.g., education and peer consultation), the use of video conferencing for direct medical care requires the highest degree of video conferencing quality, given its direct and immediate 0-7695-1435-9/02 $ s of the 35th Annual Hawaii International Conference on System Sciences (HICSS-35’02) 5-9/02 $17.00 © 2002 IEEE impact on patient care. Quality attribute models facilitate research by providing construct perspective, common terminology, and understanding of quality variables involved in a phenomenon. From a practitioner perspective, comprehensive knowledge of the characteristics of any system is essential to its implementation and utilization. Unlike other forms of information systems and technology, in health informatics the patient is the icon that underpins each dimension of success and justifies each decision [1]. In reference to medical videoconferencing, a national telemedicine policy maker participating in this study stated: “Start with the patient, what the clinical situation is...one of the reasons why projects fail to survive is they end up dealing exclusively with the technology. In my opinion, the technology is purely a conduit towards being able to do a clinical consultation. The projects that do start with the technology seem to fail. The ones that start with the patient, the clinical need of the patient, and then they fit the appropriate technology the clinical need of the patients seem to do well.” Deploying systems in the health care setting involves multiple stakeholders from both the clinical and managerial perspective working towards the maintenance and improvement of human life. The pluralistic effort required to fulfill this objective demarcates health informatics as a discipline that necessarily integrates both social/human and scientific/technical factors for study [1, 13]. Integrating human and environmental elements introduces complexity into an information systems paradigm that is still dominated by data driven methodologies, tools, and techniques that produce technical solutions to 17.00 (c) 2002 IEEE 2 Proceedings of the 35th Hawaii International Conference on System Sciences 2002 Proceedings of 0-7695-1435-9/ organizational problems and acknowledge humans (via user reference) in techno centric terms [1]. Despite the complexity associated with inclusion, studies supporting human factors can be a major factor in IS success and should not be ignored [3, 8, 11, 15]. In response to this issue, we adopt a socio-technical perspective in presenting a taxonomy of medical video conferencing quality. We enumerate attributes from the perspective of medical professionals using telemedicine for direct patient care. Our goal is to facilitate understanding and management of the comprehensive set of quality attributes affecting direct patient care in the context of medical video conferencing encounters. We keep this model at the level of patient encounter use and do not directly expose policy, legislative, or other organizational level social influences. 3. Research Design and Quality Attribute