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Simulation and experiential training have been incorporated into medical school training for decades. The utilization of medical simulations has become an invaluable tool in healthcare education and training. However, circumstances such as limited resources, geographical constraints, or global health crises may hinder the feasibility of conducting in-person medical simulations. In these scenarios, virtual medical simulations emerge as a compelling alternative. While there are many ways to accomplish experiential-based learning, many faculty and students feel Socratic learning styles provide the best learning experience. As medical students had just finished a predominantly virtual preclinical year due to the COVID-19 pandemic, the research was interested in understanding students’ perceptions of virtual and in-person experiential learning activities. The primary goal of this study is to compare medical students’ perceptions of the quality and value of in-person versus virtual experiential learning during their pediatric clerkship.

Telemedicine is the combination of information technology (IT) and health care and is an area that has seen increase during the last few decades due to breakthroughs in IT. Today there are still parts of the health care system that can be counterproductive with regards to the time and commitment necessary. One such part is medical consultations for private individuals where many of the simpler ones are still carried out in-person. Presented in this thesis is the implementation of a prototype telemedicine system that could be used as a substitute for in-person doctor-patient consultation. Necessary 3rd party components and their implementations into one system are described on a general use level. The result is a web application that supports login and payment via trusted sources, booking of meetings and carrying them out with video and audio. The prototype is a continuation of a telemedicine web application idea that was put on ice by a company that already provides solutions for health controls and blood analysis. / Telemedicin är kombinationen av informationsteknik (IT) och hälsovård och är ett område som har sett en ökning de senaste årtiondena på grund av genombrott inom IT. Idag finns det fortfarande delar av hälsovården som kan vara kontraproduktiva med avseende på den tid och det åtagandet som krävs. En sådan del är medicinska konsultationer för privatpersoner där många av de simplare mötena fortfarande sker i person. Presenterat i denna avhandling är implementationen av ett distribuerat telemedicinsystem som kan användas som ett substitut för de konsultationer mellan doktor och patient som sker i person. Nödvändiga tredjeparts komponenter och deras implementationer in ett system är beskrivna på en allmän användningsnivå. Resultatet är en webbapplikation som stödjer login och betalning via en pålitligt källa, bokning av möten och utförandet av dem med bild och ljud. Den presenterade prototypen är en fortsättning på en telemedicinsk webbapplikationsidé som lagts på is av ett företag som redan erbjuder lösningar för hälsokontroll och blodanalys.

Background: While intravenous thrombolysis (IVT) in ischemic stroke can be safely applied in telestroke networks within 3 h from symptom onset, there is a lack of evidence for safety in the expanded 3- to 4. 5-h time window. We assessed the safety and short-term efficacy of IVT in acute ischemic stroke (AIS) in the expanded time window delivered through a hub-and-spoke telestroke network. Methods: Observational study of patients with AIS who received IVT at the Stroke Eastern Saxony Telemedical Network between 01/2014 and 12/2015. We compared safety data including symptomatic intracerebral hemorrhage (sICH; according to European Cooperative Acute Stroke Study II definition) and any intracerebral hemorrhage (ICH) between patients admitted to telestroke spoke sites and patients directly admitted to a tertiary stroke center representing the hub of the network. We also assessed short-term efficacy data including favorable functional outcome (i.e., modified Rankin Scale ≤ 2) and National Institutes of Health Stroke Scale (NIHSS) at discharge, hospital discharge disposition, and in-hospital mortality. Results: In total, 152 patients with AIS were treated with IVT in the expanded time window [spoke sites, n = 104 (26.9%); hub site, n = 48 (25.9%)]. Patients treated at spoke sites had less frequently a large vessel occlusion [8/104 (7.7) vs. 20/48 (41.7%); p < 0.0001], a determined stroke etiology (p < 0.0001) and had slightly shorter onset-to-treatment times [210 (45) vs. 228 (58) min; p = 0.02] than patients who presented to the hub site. Both cohorts did not display any further differences in demographics, vascular risk factors, median baseline NIHSS scores, or median baseline Alberta stroke program early CT score (p > 0.05). There was no difference in the frequency of sICH (4.9 vs. 6.3%; p = 0.71) or any ICH (8.7 vs. 16.7%; p = 0.15). Neither there was a difference regarding favorable functional outcome (44.1 vs. 39.6%; p = 0.6) nor median NIHSS [3 (5.5) vs. 2.5 (5.75); p = 0.92] at discharge, hospital discharge disposition (p = 0.28), or in-hospital mortality (9.6 vs. 8.3%; p = 1.0). Multivariable modeling did not reveal an association between telestroke and sICH or favorable functional outcome (p > 0.05). Conclusions: Delivery of IVT in the expanded 3- to 4.5-h time window through a telestroke network appears to be safe with equivalent short-term functional outcomes for spoke-and-hub center admissions.

Introduktion: World Health Organisation [WHO], Agenda 2030 och Sveriges mål om att bli bäst i e-hälsa lägger grunden för samhällets digitalisering samtidigt som WHO och Sverige trycker på att alla människor ska ha samma rätt till god och säker vård. Äldres förmåga att hantera e-hälsolösningar skiljer sig åt och beror på psykisk och fysisk förmåga. Syfte: Syftet med litteraturstudien är att beskriva hur äldres upplevelser av delaktighet i samhället påverkas av e-hälsotjänster. Metod: Studien genomfördes som en strukturerad litteraturstudie med kvalitativ ansats som resulterade i 10 vetenskapliga artiklar, vilka granskades med hjälp av en tematisk analys. Resultat: Den tematiska analysen resulterade i 3 teman: Stöd från omgivningen, Att minska eller hindra delaktighet, Delaktighet i samhället. Bland annat visade resultatet i studien att äldre ser e-hälsolösningar som en trygghet för att lättare kunna delta i den egna vården och i samhället. Äldre ser också att det finns ett stort behov av stöd vid hanteringen av e-hälsolösningarna på grund av åldersrelaterade försämringar i förmågan. Slutsats: E-hälsolösningarna är ett sätt för äldre att känna en känsla av sammanhang och delaktighet om de upplever begriplighet, hanterbarhet och meningsfullhet vid handhavandet. Det är av vikt att se till äldres behov när e-hälsolösningar införs. / Introduction: World Health Organisation‘s Agenda 2030 and Sweden's national goals to become a leader in e-health services give policy support for society's digitization, while at the same time supporting the right to good and safe care for all people. Older people’s capability to handle e-health solutions differs and depends on their mental and physical capacities. Aim: The purpose of this literature study is to describe how the older people’s experiences of participation in society are affected by e-health services. Method: The study was conducted as a structured literature study with a qualitative approach, based on 10 scientific peer-reviewed articles, which were reviewed using a thematic analysis. Results: The analysis resulted in three themes: Support from the environment, Reducing or preventing participation, and Participation in Society. The results of the study showed that older people see e-health solutions as a security to be able to participate more easily in their own care and in society. Older people also see that there is a great need for support when handling the e-health solutions due to age-related declines in capacity. Conclusion: It is important to consider the needs of the older people when e-health solutions are introduced. Older people using e-health solutions can feel a sense of coherence and participation if they experience comprehensibility, manageability and meaningfulness when handling them.

No / To evaluate the effectiveness of a telehealth system, using digital pen-and-paper technology and a modified smartphone, to remotely monitor and support the effectiveness of wound management in nursing home residents. METHOD: A randomised controlled pilot study was conducted in selected nursing homes in Bradford, which were randomised to either the control or evaluation group. All patients with a wound of any aetiology or severity, resident in the selected nursing homes were considered eligible to participate in the study. Residents in the control homes who had, or developed, a wound during the study period, continued to receive unsupported care directed by the nursing home staff (defined as 'standard care'), while those in the evaluation homes received standard care supported by input from the remote experts. RESULTS: Thirty-nine patients with a wound were identified in the 16 participating Bradford nursing homes. Analysis of individual patient management pathways suggested that the system provided improved patient outcomes and that it may offer cost savings by improving dressing product selection, decreasing inappropriate onward referral and speeding healing. Despite initial anxiety related to the technology most nursing-home staff found the system of value and many were keen to see the trial continue to form part of routine patient management. CONCLUSION: The current study supports the potential value of telemedicine in wound care and indicates the value that such a system may have to nursing-home staff and patients. DECLARATION OF INTEREST: This study was funded by a Regional Innovation Fund grant from the Yorkshire and Humberside Strategic Health Authority. The authors have no conflict of interest to declare with respect to the article or its contents.

Home-based telemonitoring in heart failure patients can reduce all-cause mortality and the relative risk of heart failure-related hospitalization compared to standard care. However, technology use depends, among other things, on user acceptance, making it important to include potential users early in development. In a home-based healthcare project (a feasibility project) a participatory approach was chosen in preparation for future development of contactless camera-based telemonitoring in heart disease patients. The project study patients (n = 18) were surveyed regarding acceptance and design expectations, and acceptance-enhancing measures and design suggestions were then drawn from the results. The study patients corresponded to the target group of potential future users. 83% of respondents showed high acceptance. 17% of those surveyed were more skeptical with moderate or low acceptance. The latter were female, mostly living alone, and without technical expertise. Low acceptance was associated with a higher expectation of effort and lower perception of self-efficacy and lower integratability into daily rhythms. For the design, the respondents found independent operation of the technology very important. Furthermore, concerns were expressed about the new measuring technology, e.g., anxiety about constant surveillance. The acceptance of a new generation of medical technology (contactless camera-based measuring technology) for telemonitoring is already quite high in the surveyed group of older users (60+). Specific user expectations concerning design should be considered during development to increase acceptance by potential users even more.

The following literature review was intended to review current research studies related to diagnostic evaluation using Telehealth for young children aged 0-7 seeking a diagnosis of autism spectrum disorder (ASD). The analyzed research created a comprehensive guide on the quality, quantity, and state of Telehealth research for ASD evaluation will result. Through the synthesis of available literature, the strengths, and weaknesses of different models of Telehealth ASD evaluation were assessed. The results of this literature review found that there is evidence to support Telehealth’s use in some aspects of evaluation, but not as a stand-alone methodology. Further research is required to show that Telehealth methods of evaluation withhold the same reliability, quality, and validity as traditional ASD evaluation methods.

Cette thèse enquête sur l’émergence d’espaces de soin à l’ère de la mondialisation numérique. Elle s’articule autour d’incursions au sein du Pan-African e Network Project (PAN), un réseau de cybersanté par l’entremise duquel des hôpitaux tertiaires situés en Inde offrent des services de téléconsultations et de formation médicale à des centres de santé africains. Des incursions sur la piste d’un projet en constante mutation, pour en saisir la polyvalence ontologique, la pertinence politique, la valeur thérapeutique. Le PAN, c’est une entreprise colossale, aux ramifications multiples. C’est le travail quotidien d’ingénieurs, médecins, gestionnaires. Ce sont des routines techniques, des équipements. À la fois emblème d’une résurgence de la coopération indo-africaine et expression d’une étonnante histoire cybermédicale indienne, le réseau incarne une Inde néolibérale, portée par l’ambition technique et commerciale de propulser la nation au centre de la marche du monde. Le PAN, c’est une ouverture numérique de la clinique, qui reconfigure la spatialité de la prise en charge de patients. C’est un réseau clé en main, une quête insatiable de maîtrise, une infrastructure largement sous-utilisée. C’est le projet d’une humanité à prendre en charge : une humanité prospère, en santé, connectée. De part en part, l’expérience du PAN problématise le telos cybermédical. Au romantisme d’une circulation fluide et désincarnée de l’information et de l’expertise, elle oppose la concrétude, la plasticité et la pure matérialité de pratiques situées. Qu’on parle de « dispositifs » (Foucault), de « réseaux » (Latour), ou de « sphères » (Sloterdijk), la prise en charge du vivant ne s’effectue pas sur des surfaces neutres et homogènes, mais relève plutôt de forces locales et immanentes. Le PAN pose la nécessité de penser la technique et le soin ensemble, et d’ainsi déprendre la question du devenir de la clinique autant du triomphalisme moderne de l’émancipation que du recueillement phénoménologique devant une expérience authentique du monde. Il s’agit, en somme, de réfléchir sur les pratiques, événements et formes de pouvoir qui composent ces « espaces intérieurs » que sont les réseaux cybermédicaux, dans tout leur vacarme, leur splendeur et leur insuffisance. / This thesis investigates the emergence of spaces of care in the era of digital globalization. It revolves around several lines of inquiry into the Pan-African e-Network Project (PAN), an eHealth network through which tertiary hospitals in India provide teleconsultation services and continuing medical education to health centres across the African continent. These lines of inquiry lead into a project in constant mutation in order to grasp its ontological versatility, outline its political relevance, assess its therapeutic value. PAN is a colossal, multifaceted enterprise. It involves the daily work of engineers, doctors, and managers who must tend to technical routines, hardware infrastructures, and patient treatments. At once the flagship of a resurgence in Indo-African cooperation and the consequence of India’s eHealth venture, the network is a poster child for neoliberal India, driven by technical and commercial ambitions that seek to position the nation at the heart of global developments. PAN also enacts a digital opening of the clinic, as it reconfigures the spatiality of healthcare access and delivery. A turnkey solution, it displays an insatiable quest for mastery; it is a massive yet largely underutilized infrastructure. PAN embodies an emergent object of political intervention: a prosperous, healthy, connected humanity. This examination of the Pan-African e-Network challenges teleological accounts of eHealth on several fronts. To the romantic conception of a fluid, seamless circulation of expertise and knowledge, it opposes the embeddedness, plasticity and sheer materiality of concrete practices. Whether one speaks of “apparatus” (Foucault), “networks” (Latour), or “spheres” (Sloterdijk), spaces of care have little to do with neutral, homogeneous surfaces, and rely on a multitude of local and immanent forces. PAN obliges us to consider technology and care together, untying the question of the “becoming of the clinic” from both the modern triumphalism of emancipation, and the phenomenological contemplation of an authentic experience of the world. The present challenge is to examine the practices, events, and forms of power that shape the “inner spaces” of eHealth networks, in all their turbulence, splendor, and inadequacies.

La téléréadaptation, tout comme d’autres champs en télésanté, est de plus en plus interpelée pour la prestation de services. Le but de ce projet de thèse est d’enrichir l’évaluation de la téléréadaptation afin que les connaissances qui en découlent puissent venir soutenir la prise de décision d’acteurs impliqués à différents niveaux en téléréadaptation. Le premier article présente une revue systématique dont l’objectif était de faire synthèse critique des études en téléréadaptation. La revue rassemble 28 études en téléréadaptation, qui confirment l’efficacité de la téléréadaptation pour diverses clientèles dans différents milieux. Certaines des études suggèrent également des bénéfices en termes de coûts, mais ces résultats demeurent préliminaires. Cette synthèse critique est utile pour soutenir la décision d’introduire la téléréadaptation pour combler un besoin. Par contre, les décideurs bénéficieraient aussi de connaissances par rapport aux changements cliniques et organisationnels qui sont associés à la téléréadaptation lorsqu’elle est introduite en milieu clinique. Les deux autres articles traitent d’une étude de cas unique qui a examiné un projet clinique de téléréadaptation dans l’est de la province de Québec, au Canada. Le cadre conceptuel qui sous-tend l’étude de cas découle de la théorie de structuration de Giddens et des modèles de structuration de la technologie, en particulier de l’interaction entre la structure, l’agent et la technologie. Les données ont été recueillies à partir de plusieurs sources (groupes de discussion, entrevues individuelles, documents officiels et observation d’enregistrements) suivi d’une analyse qualitative. Le deuxième article de la thèse porte sur le lien entre la structure, l’agent et la culture organisationnelle dans l’utilisation de la téléréadaptation. Les résultats indiquent que les différences de culture organisationnelle entre les milieux sont plus évidentes avec l’utilisation de la téléréadaptation, entraînant des situations de conflits ainsi que des occasions de changement. De plus, la culture organisationnelle joue un rôle au niveau des croyances liées à la technologie. Les résultats indiquent aussi que la téléréadaptation pourrait contribuer à changer les cultures organisationnelles. Le troisième article examine l’intégration de la téléréadaptation dans les pratiques cliniques existantes, ainsi que les nouvelles routines cliniques qu’elle permet de soutenir et la pérennisation de la téléréadaptation. Les résultats indiquent qu’il y a effectivement certaines activités de téléréadaptation qui se sont intégrées aux routines des intervenants, principalement pour les plans d’intervention interdisciplinaire, tandis que pour les consultations et le suivi des patients, l’utilisation de la téléréadaptation n’a pas été intégrée aux routines. Plusieurs facteurs en lien avec la structure et l’agent ont contraint et facilité l’intégration aux routines cliniques, dont les croyances partagées, la visibilité de la téléréadaptation, le leadership clinique et organisationnel, la disponibilité des ressources, et l’existence de liens de collaboration. La pérennité de la téléréadaptation a aussi pu être observée à partir de la généralisation des activités et le développement de nouvelles applications et collaborations en téléréadaptation, et ce, uniquement pour les activités qui s’étaient intégrées aux routines des intervenants. Les résultats démontrent donc que lorsque la téléréadaptation n’est pas intégrée aux routines cliniques, elle n’est pas utilisée. Par contre, la téléréadaptation peut démontrée certains signes de pérennité lorsque les activités, qui sont reproduites, deviennent intégrées aux routines quotidiennes des utilisateurs. Ensemble, ces études font ressortir des résultats utiles pour la mise en place de la téléréadaptation et permettent de dégager des pistes pour enrichir le champ de l’évaluation de la téléréadaptation, afin que celui-ci devienne plus pertinent et complet, et puisse mieux soutenir les prises de décision d’acteurs impliqués à différents niveaux en téléréadaptation. / Telerehabilitation, like other telehealth applications, has been increasingly used to provide health services. The goal of this thesis is to enrich the field of telerehabilitation evaluation such that it can better contribute to informed decision making of those involved in telerehabilitation at different levels. The first article is a systematic review of telerehabilitation studies and it was conducted in order to provide a critical synthesis of the current telerehabilitation literature. The revue included 28 studies of telerehabilitation, which, overall, confirmed the efficacy of telerehabilitation when used with a variety of clienteles in different settings. Some of the studies also suggest that there may be some cost benefits associated with telerehabilitation although the findings remain preliminary. Such a synthesis of the literature can contribute to some decisions regarding the pertinence of introducing telerehabilitation. However, decision makers also need information regarding the clinical and organizational changes that are associated with telerehabilitation when implemented in a clinical setting. The next two articles contain the results of a single case study that was centered on a telerehabilitation clinical project implemented in the eastern part of the province of Quebec, in Canada. A conceptual model was developed to guide this study, and it was based on Giddens’ Theory of Structuration and on models of technology structuration, in particular drawing upon the notion of the interaction between structure, agent and technology. Data was collected from several sources (focus groups, interviews, official documents and observation of recordings) and was analyzed using a qualitative analysis approach. The second article in this thesis examined the relationship between structure, agent and organizational culture with respect to telerehabilitation use. The results indicate that differences in organizational culture between the centres are more visible when telerehabilitation is used, which can in some cases lead to conflicts, while in other cases create opportunities for change. In addition, organizational culture also played a role in shared beliefs linked to the technology. Lastly, the results suggest that telerehabilitation could be used to bring about changes in organizational culture. The third article examined how telerehabilitation became integrated into existing clinical practices, how it contributed to the development of new routines and explored the sustainability of telerehabilitation. The results indicate that some activities, namely interdisciplinary care plans were integrated into clinical routines, while consultations and patient follow-up were not. Several factors related to the structure and agent were found to facilitate or hinder the integration of telerehabilitation into routine practices, including shared beliefs, the visibility of telerehabilitation activities, the clinical and organizational leadership, the availability of resources and the existence of collaborations. Sustainability was also observed when telerehabilitation use became more generalized and novel applications were developed, although this was only found to occur for activities which had integrated into routine practice. The results therefore suggest that when telerehabilitation is not integrated into routine practices, it will not be used, but that, on the other hand, telerehabilitation may be sustainable for activities which are repeated and then integrated into routine day-to-day clinical activities. Together, these studies put forth findings which can be useful when implementing new telerehabilitation programs. They also help elucidate directions for future research in order to enrich the field of telerehabilitation evaluation so that it may become more pertinent and comprehensive to support decision-makers involved at all levels of telerehabilitation.