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Feasibility study of multidisciplinary oncology rounds by videoconference for surgeons in remote locales

Feasibility study of multidisciplinary oncology rounds by videoconference for surgeons in remote... Background: This study was undertaken to assess the feasibility of using videoconferencing to involve community-based surgeons in interactive, multidisciplinary oncology rounds so they may benefit from the type of community of practice that is usually only available in academic cancer centres. Methods: An existing videoconference service provider with sites across Ontario was chosen and the series was accredited. Indirect needs assessment involved examining responses to a previously conducted survey of provincial surgeons; interviewing three cancer surgeons from different regions of Ontario; and by analyzing an online portfolio of self-directed learning projects. Direct needs assessment involved a survey of surgeons at videoconference-enabled sites. A surgical, medical and radiation oncologist plus a facilitator were scheduled to guide discussion for each session. A patient scenario developed by the discussants was distributed to participants one week prior to each session. Results: Direct and indirect needs assessment confirmed that breast cancer and colorectal cancer topics were of greatest importance to community surgeons. Six one-hour sessions were offered (two breast, two colorectal, one gynecologic and one lung cancer). A median of 22 physicians and a median of eight sites participated in each session. The majority of respondents were satisfied with the videoconference format, presenters and content. Many noted that discussion prompted reflection on practice and that current practice would change. Conclusions: This pilot study demonstrated that it is possible to engage remote surgeons in multidisciplinary oncology rounds by videoconference. Continued assessment of videoconferencing is warranted but further research is required to develop frameworks by which to evaluate the benefits of telehealth initiatives. oncology services and some medical oncology services are Background Optimal care of the cancer patient is increasingly predi- offered at Ontario's regional cancer centres, an analysis of cated on multidisciplinary management. While radiation referral patterns for cancer surgery in Ontario identified Page 1 of 7 (page number not for citation purposes) BMC Medical Informatics and Decision Making 2003, 3 http://www.biomedcentral.com/1472-6947/3/7 that teaching centres (which include some cancer centres) oconference services were planned to be offered through performed less than 40% of the surgical procedures for the services of the NORTH Network, a telemedicine breast cancer and colorectal cancer [1]. Therefore the com- project based at Sunnybrook and Women's College munity-based general surgeon plays a key role in caring Health Sciences Centre with satellite videoconference for patients with cancer and ensuring that they have access suites in a number of locations across central and north- to multidisciplinary consultation and treatment when ern Ontario. This feasibility study was part of a larger necessary [2,3]. Effective communication between the dif- study approved by the University of Toronto Health Sci- ferent care settings is crucial to this process. ences Ethics Review Committee. Problem-solving and interaction with colleagues is a basic A needs assessment was conducted using both direct and component of medical practice. This need is amplified indirect methods. Each NORTH Network-enabled site was when the involvement of multiple professionals is contacted to confirm the name and contact information required for optimal care. Discussions with colleagues in for general surgeons. Direct needs assessment involved a "communities of practice" build mutual trust and foster survey of general surgeons at these sites to identify the the exchange of not only explicit knowledge that is easily most convenient days of the week and times at which to codified in documents such as guidelines, but tacit knowl- offer the videoconference rounds, and interest in specific edge, which prompts the individual to reflect upon their topics. Indirect needs assessment was carried out using practice [4–6]. It has been suggested that, to promote three strategies. First, responses to a previously conducted knowledge transfer, organizations need to actively nurture survey of provincial surgeons were examined. In that sur- the development of communities of practice by legitimiz- vey surgeons were asked to specify their clinical and infor- ing participation, negotiating their strategic content, mation needs in relation to the care of cancer patients. bringing together complementary expertise, and provid- Second, the Royal College of Physicians and Surgeons of ing support in the form of guidance and resources. Canada WebDiary database was analyzed to identify the cancer-related self-directed learning projects most often A growing body of literature describes the successful use of undertaken by Ontario general surgeons using this online multi-point videoconferencing to facilitate communica- portfolio [18]. Third, open-ended unstructured telephone tion between health care professionals, including oncolo- interviews were conducted with three cancer surgeons gists and surgeons; support the care of patients; and offer from different regions of Ontario. One of these interviews continuing education across great distances [7–15]. Many involved a surgeon residing in Ottawa. He was inter- health care groups in Canada have successfully used tele- viewed for his expertise and knowledge in the concepts of medicine [16]. The Canadian Coordinating Office for knowledge transfer, organizational learning and surgeon Health Technology Assessment recently prepared a review education. The purpose of this interview was to discuss of the use of multipoint videoconferencing [17]. All pro- the organization and format of the pilot study rounds and grams resulted in improved communication, leading to how to best evaluate them. The two remaining interviews informal learning opportunities and enhanced profes- involved a surgeon from North Western Ontario (Fort sional skills for primary care practitioners through interac- Francis) and a surgeon from North Eastern Ontario (Sault tion with practitioners at tertiary referral centres. Ste Marie). As regional liaisons to the Surgical Oncology program, these individuals were selected to discuss the The Cancer Care Ontario Surgical Oncology Network con- usefulness and format of videoconference multidiscipli- ducted this study to assess the feasibility of using video- nary oncology rounds. As general surgeons practising in conferencing technology to bring together physicians in remote regions of Ontario their feedback was representa- various care settings in a format resembling multidiscipli- tive of the surgeons targeted by this feasibility study. nary hospital-based rounds or "tumour boards". The goal is to enable community based surgeons to benefit from Based on the topics identified by the needs assessment as the type of community of practice that is usually only of interest to general surgeons, surgical, radiation and available in academic cancer centres. medical oncologists associated with two tertiary care can- cer centres were invited to participate as discussant pan- elists for six videoconference rounds. They were provided Methods The development and pilot study of Tele-Oncology with a description of the venue and tips on videoconfer- Rounds Ontario (TORO) consisted of a needs assessment, ence etiquette. Another surgical oncologist was invited to content and technology planning, implementation, and serve in the role of facilitator for each event. evaluation. In the absence of a "how-to" manual on vide- oconferencing the series was designed according to infor- With a completed schedule for six planned events, the mation provided by a variety of stakeholders who were series was accredited by the Royal College of Physicians consulted during the development of this program. Vide- and Surgeons of Canada through Continuing Education, Page 2 of 7 (page number not for citation purposes) BMC Medical Informatics and Decision Making 2003, 3 http://www.biomedcentral.com/1472-6947/3/7 Faculty of Medicine, University of Toronto as a Section 1 In 1998 the Surgical Oncology Network conducted a Accredited Group Learning Activity according to the needs assessment survey of surgeons in Ontario. Half of framework of educational options for the College's Main- the 612 respondents (39% response rate) agreed that tenance of Certification program [18]. access to surgical oncologists for consultation would be useful. Frequently mentioned resources requested Promotional material was created and distributed by reg- through written comments included oncology rounds, ular mail to potential participants at the selected video- regional meetings and continuing education (CE); and conference sites. Technical/education support staff at each guidelines for when patients should be referred to formal site were also contacted to request internal advertising of cancer centres. the series. The online portfolio offered by the Royal College of Phy- Several weeks prior to each session the presenting surgical sicians and Surgeons of Canada was searched for instances oncologist was asked to develop a patient scenario that in which physicians recorded learning related to cancer involved cancer surgery, presented treatment decision- care. This was carried out in lieu of mailing a survey to sur- making challenges, and would foster multidisciplinary geons to identify their perceived learning needs. The anal- discussion. The multidisciplinary panel (radiation oncol- ysis identified the topics most often pursued for ogist and medical oncologist) were asked to review and continuing education on cancer care, and what associated edit the patient scenario. One week prior to each event the factors may have prompted a change in practice. A total of patient scenario was distributed to prospective partici- 1,203 cases were recorded between 1994 and 2001. Most pants by fax and posted to the project web site. The sce- records involved the category of management (52.9%) of nario consisted of a description of the theoretical case, breast (25.5%), colorectal (14.0%), gynecologic (12.7%) learning objectives, and several multiple choice questions. and prostate cancer (11.4%). Questions were most often stimulated as a result of browsing the medical literature Following a review of the medical literature and commu- (27.5%), in response to the management of a current nication with researchers in departments of continuing patient (19.0%) or after review of the management of education at six academic institutions, an evaluation form more than one patient (16.0%). To better identify impor- was developed to assess participant satisfaction with the tant topics for discussion at videoconference rounds, the format of the videoconference (image, sound, interac- questions of general surgeons in Ontario were analyzed tion), the content, and the presenter, and the extent to for common issues and topics. Of 71 questions posed by which participants considered the discussion useful to general surgeons in Ontario using WebDiary during the their practice. Statements in each of these categories were specified time period, 56 (79%) involved breast cancer or graded on a five-point Likert scale, where a score of 5 indi- colorectal cancer. cated strong agreement with the statement and a score of 1 expressed strong disagreement. Respondents were Direct Needs Assessment invited to provide written comments on whether the Prospective participants at video-conference enabled sites TORO discussion might change their practice and, if so, (n = 51) were surveyed to learn about specific topics of how; what factors or resources would enable a change in interest and preferred dates/times. The 13 (25.5%) practice; and general comments. respondents suggested a variety of topics, including breast, colorectal, lung, thyroid, pancreatic, gastrointesti- Evaluation form responses were examined using the Sta- nal and esophageal cancer, and malignant skin lesions. tistical Package for the Social Sciences (SPSS) version 10.0 The clear preference for session time was at the end of the (SPSS, Chicago, IL, USA). Written comments were sum- working day. marized and assessed for trends. Planning and Implementation The Cancer Care Ontario Surgical Oncology Network Results Indirect Needs Assessment offered a series of six oncology rounds to cancer surgeons Telephone interviews were held with three regional repre- by videoconference during the 2001–2002 academic year. sentatives of the Surgical Oncology Network, including Each one-hour session consisted of interactive discussion those from the North West, North East, and Eastern based on a patient scenario. Topics included breast cancer Ontario, who agreed that videoconferencing could facili- (2 sessions), colorectal cancer (2 sessions), gynecologic tate the development of learning communities for cancer and lung cancer (1 session each). improved exchange of knowledge related to cancer, partic- ularly in remote regions of the province. Staff at the NORTH Network were notified in advance of the date and time for all six sessions. They handled com- munication with the videoconferencing bridge service and Page 3 of 7 (page number not for citation purposes) BMC Medical Informatics and Decision Making 2003, 3 http://www.biomedcentral.com/1472-6947/3/7 Table 1: Proportion of Videoconference Participants Who Submitted Evaluation Forms Session Topic Participants (n) Evaluations Submitted (n, %) October 2001 Breast cancer 20 10 (50.0) November 2001 Colorectal cancer 22 10 (45.5) December 2001 Gynecologic cancer 21 14 (67.7) January 2002 Breast cancer 29 13 (44.8) February 2002 Colorectal cancer 25 13 (52.0) March 2002 Lung cancer 14 7 (50.0) --- --- Mean 21.8 Mean 11.2 Median 21.5 Median 11.5 technical support staff at each site, and attended the ses- Further, surgeons but no oncologists indicated that infor- sion at the central discussant site to coordinate connectiv- mation obtained at these sessions would change their cur- ity. The TORO coordinator recorded and summarized the rent practice. discussion at each session, later incorporating citations for relevant published trials or guidelines. The summary was Respondents were invited to provide general comments, distributed to the oncology panelists for review and edited and describe specific changes to practice and perceived according to their feedback. The discussion summary was barriers to implementing changes. Written remarks were distributed with the patient scenario for the subsequent few. Respondents suggested strategies for improving the sessions by fax and by posting to the project web site. sessions, for example "more didactic teaching" and "less opinion, more facts". One respondent asked that we A median of 22 physicians participated in each session, "encourage participants to speak loudly" and be more excluding the discussant panel members and the facilita- observant of "raised hands" of those participants wishing tor (Table 1). A median of eight sites participated in each to add to the discussion. Others noted that videoconfer- session, excluding the central discussant panel site. encing provided an "excellent forum for CE", that it was "nice to hear how other northern centres deal with this Evaluation disease", and that the session was "very interesting and The proportion of participants returning completed eval- enjoyable because of the interaction". Several respondents uation forms for each session was 44.8% to 67.7%. Over- noted that they would more often consider, and refer all, 74.6% of participants agreed or strongly agreed they patients for, preoperative radiation therapy and were generally satisfied with the event. The majority of chemotherapy. respondents were satisfied or very satisfied with the vide- oconference format, all discussants and the content of Discussion each session (Table 2). Nearly 75% of respondents agreed This study investigated the feasibility of conducting multi- or strongly agreed that the session topic was relevant to disciplinary oncology rounds by videoconference to facil- their practice, and that the presenter established good rap- itate interaction between oncologists in the tertiary care port with the audience (85.0%), stimulated critical think- setting and community-based general surgeons, who ing (73.2%), and encouraged interaction (83.6%). More conduct a large proportion of cancer surgery and link than half of the participants agreed that discussion pro- patients to oncology services. A needs assessment involv- vided useful insights for practice, and one quarter of ing direct and indirect methods clearly established that respondents suggested their practice would change. breast cancer and colorectal cancer were the topics most relevant to general surgeons. Apart from the discussant Responses were examined by session topic and by partici- panel and facilitator, one or two oncologists participated pant specialty (Table 3). Participants were satisfied with in each session, and two gynecologists participated in the the sessions on breast, colorectal and gynecologic cancer session on gynecologic cancer, so the median participa- topics, and 30% to 43% agreed or strongly agreed that dis- tion rate represents approximately 40% of the target pop- cussion revealed information not accessible elsewhere. ulation of general surgeons associated with the Oncologists were more satisfied than general surgeons videoconference-enabled sites. For the most part, the overall (88.3% versus 75.0%) but more general surgeons same individuals tended to participate in each session. than oncologists reported that information revealed was not accessible elsewhere, discussion provided useful tips Satisfaction with the videoconferencing format, content for practice, and discussion caused reflection on practice. and speakers was high. Overall, discussion prompted Page 4 of 7 (page number not for citation purposes) BMC Medical Informatics and Decision Making 2003, 3 http://www.biomedcentral.com/1472-6947/3/7 Table 2: Summary of Participant Evaluation of Videoconference Oncology Rounds Factor Strongly agree (n, %) Strongly disagree (n, %) No response VIDEOCONFERENCE 5 4 3 2 1 99 Presenter clearly visible 32 (47.8) 30 (44.8) 3 (4.5) -- 2 (3.0) --- Slides/visual aids clearly visible 15 (22.4) 22 (32.8) 12 (17.9) 7 (10.4) 5 (7.5) 6 (9.0) Presenter clearly audible 24 (35.8) 21 (31.3) 17 (25.4) 3 (4.5) 1 (1.5) 1 (1.5) Interaction with speaker possible 24 (35.8) 28 (41.8) 14 (20.9) --- 1 (1.5) --- Interaction with other participants possible 14 (20.9) 26 (38.8) 12 (17.9) 9 (13.4) 2 (3.0) 4 (6.0) CONTENT Presentation time was sufficient 22 (32.8) 34 (50.7) 9 (13.4) 2 (3.0) --- --- Discussion time was sufficient 16 (23.9) 34 9(50.7) 15 (22.4) 2 (3.0) --- --- Topic was relevant to my practice 29 (43.3) 21 (31.3) 12 (17.9) 1 (1.5) 2 (3.0) 2 (3.0) PRESENTER Clearly presented the topic 19 (28.4) 35 (52.2) 12 (17.9) 1 (1.5) --- --- Demonstrated thorough knowledge of topic 29 (43.3) 34 (50.7) 3 (4.5) 1 (1.5) --- --- Established good rapport with audience 22 (32.8) 35 (52.2) 9 (13.4) --- --- 1 (1.5) Stimulated critical thinking 19 (28.4) 30 (44.8) 13 (19.4) 3 (4.5) 1 (1.5) 1 (1.5) Encourged questions and participation 25 (37.3) 31 (46.3) 10 (14.9) 1 (1.5) --- --- OVERALL Overall, was satisfied with event 16 (23.9) 34 (50.7) 14 (20.9) 3 (4.5) --- --- OUTCOME Information revealed not accessible elsewhere 1 (1.5) 22 (32.8) 21 (31.3) 16 (23.9) 5 (7.5) 2 (3.0) Discussion provided useful tips for practice 5 (7.5) 31 (46.3) 19 (28.4) 6 (9.0) 3 (4.5) 3 (3.5) Discussion caused reflection on practice 13 (19.4) 34 (50.7) 8 (11.9) 10 (14.9) 1 (1.5) 1 (1.5) EFFECT ON PRACTICE Yes No Not sure Problems No response Will current practice change? 17 (25.4) 40 (59.7) 4 (6.0) 4 (6.0) 4 (6.0) Table 3: Summary of Participant Evaluation by Session Topic and Participant Specialty Factor Proportion By Topic Agree Proportion by Specialty Agree or Strongly Agree (%) or Strongly Agree (%) Breast Colorectal Gynecologic Lung Surgeons Oncologists (n = 23) (n = 23) (n = 14) (n = 7) (n = 60) (n = 6) OVERALL Overall, was satisfied with event 78.3 73.9 78.6 57.2 75.0 88.3 OUTCOME Information revealed not accessible elsewhere 30.4 30.4 42.8 42.9 36.7 16.7 Discussion provided useful tips for practice 52.2 60.8 64.3 14.3 58.4 16.7 Discussion caused reflection on practice 73.9 69.5 85.7 28.6 71.6 50.0 WILL CURRENT PRACTICE CHANGE Yes 21.7 30.4 35.7 --- 28.3 --- No 65.2 52.2 57.1 71.4 55.0 100.0 reflection on practice and 25% of respondents suggested These results cannot be generalized to the larger popula- that their practice would change. Reflection on practice tion of general surgeons in Ontario or elsewhere due to and changes in practice were more likely to occur for the self-selected participation of those attending the ses- responding surgeons than for oncologists. Although writ- sions, and the small number of participants. For most ses- ten responses were few, several participants at different sions, only half of the participants returned evaluation sessions noted that they would more frequently consider forms, despite the fact that this was a requirement for preoperative chemotherapy and radiation therapy as part receipt of continuing education credits toward the RCPSC of their management plan. Maintenance of Certification program. Page 5 of 7 (page number not for citation purposes) BMC Medical Informatics and Decision Making 2003, 3 http://www.biomedcentral.com/1472-6947/3/7 It should be noted that this feasibility study was part of a such programs need to sufficiently mature for assessment larger study that did not take place due to an insufficient to be meaningful. Therefore, an initial assessment associ- number of consenting participants. The larger study ated with a pilot study, such as the one described in this planned to conduct pre- and post-videoconference series manuscript, can indicate the feasibility of an initiative, surveys to examine self-directed learning attitudes and while a more complex evaluation strategy, including behaviour based upon Oddi's validated self-directed examination of technical issues, impact on practice, and learning inventory [19]; dialogue analysis of videotaped cost, is more suitable for long term assessment. videoconference rounds to examine instances of self- reflection, community building and informal learning Conclusions according to Wenger's communities of practice frame- Ontario surgeons participating in videoconference oncol- work [20]; and follow-up semi-structured, grounded ogy rounds reported satisfaction with the format, noting interviews with participants to assess impact on behaviour that participation stimulated reflection on practice and and practice. that, in some cases, current practice would change. There- fore ongoing assessment of the use of videoconferencing Our inability to more thoroughly assess the impact of par- for continuing education and the development of profes- ticipation in videoconference multidisciplinary oncology sional communities of practice is warranted. However fur- rounds revealed a variety of factors that challenge valid ther research is required to develop frameworks and evaluation of remote collegial interaction. These same suitable, phase-specific methods by which to evaluate the challenges were noted in the medical literature on video- impact of telehealth initiatives. conference applications. The use of telemedicine has been primarily driven by perceived need and practical attempts Competing Interests to deliver health care in an efficient and timely manner, None declared. rather than a theoretical knowledge base established by empirical research [21]. For this reason there is a lack of Authors' Contributions appropriate evaluation frameworks by which to assess AG developed, implemented and evaluated the pilot and value the benefit of telehealth initiatives [22]. The project, and drafted the manuscript. AS facilitated all ses- International Network of Agencies for Health Technology sions. VG provided guidance on developing, implement- Assessment (INAHTA) recently reviewed the factors that ing and evaluating the sessions, and edited the could be considered when assessing telemedicine applica- manuscript. DD conceived the pilot project. All authors tions [23]. They argued that controlled scientific studies of read and approved the final manuscript. telemedicine initiatives may only be helpful in establish- ing the efficacy of the technology, but the results of such References 1. Iscoe N, To T, Gort E and Tran M: Cancer Surgery in Ontario studies will not be widely generalizable or useful in other ICES Practice Atlas Toronto, Institute for Clinical Evaluative Sciences; 1997. contexts if the application is sustainable and evolves into 2. Van der Schueren E, Kesteloot K and Cleemput I: Federation of long-term use. Furthermore, measurement of changes in European Cancer Societies. Full Report. Economic evalua- tion in cancer care: Questions and answers on how to allevi- participant behaviour or patient outcomes poses major ate conflicts between rising needs and expectations and methodologic challenges because the number of subjects tightening budgets Eur J Cancer 2000, 36:13-36. 3. Bahn CH: The surgeon as gatekeeper Am J Surg 1993, 165:550- may be small and the power of the study low, necessitat- ing a reliance on surrogate indicators of effectiveness. This 4. West E, Barron DN, Dowsett J and Newton JN: Hierarchies and explains why a systematic review of studies assessing tele- cliques in the social networks of health care professionals: Implications for the design of dissemination strategies Soc Sci medicine applications found that the majority were pilot Med 1999, 48:633-646. projects evaluating short-term outcomes and most were of 5. Frankford DM, Patterson MA and Konrad TR: Transforming prac- low quality [24]. tice organizations to foster lifelong learning and commit- ment to medical professionalism Acad Med 2000, 75:708-717. 6. Wenger E: Communities of practice. Learning, meaning and The INAHTA review noted that definitive assessment of a identity Cambridge, UK, Cambridge University Press 1998. 7. Ricke J and Bartelink H: Telemedicine and its impact on cancer telemedicine application may take a considerable time management Eur J Cancer 2000, 36:826-833. and be complicated by both changes to the technology 8. Callas PW, Ricci MA and Caputo MP: Improved rural provider and to the healthcare system, suggesting the need for a access to continuing medical education through interactive videoconferencing Telemed J E Health 2000, 6:393-399. series of rapid, less detailed evaluations to provide deci- 9. Ilver IN and Selva-Nayagam S: Evaluation of a telemedicine link sion makers with timely interim advice. Indeed, at the between Darwin and Adelaide to facilitate cancer management Telemed J 2000, 6:213-218. time of this writing, the Surgical Oncology program had 10. London JW, Morton DE, Marinucci D, Catalano R and Comis RL: The undergone an organizational restructuring and videocon- implementation of telemedicine within a community cancer ferenced oncology rounds were no longer offered. It also network J Am Med Inform Assoc 1997, 4:18-24. 11. Hunter DC, Brustrom JE, Goldsmith BJ, Davis LJ, Carlos M, Ashley E, suggested that telemedicine applications should be evalu- Gardner G and Gaal I: Teleoncology in the Department of ated according to their phase of implementation because Defense: A tale of two systems Telemed J 1999, 5:273-282. Page 6 of 7 (page number not for citation purposes) BMC Medical Informatics and Decision Making 2003, 3 http://www.biomedcentral.com/1472-6947/3/7 12. Atlas I, Granai CO, Gajewski W, Steinhoff MM, Steller M, Falkenberry S, Legare R, Szvalb S, Prober A, Zafrir H and Farbstein J: Videocon- ferencing for gynaecological cancer care: an international tumour board Journal of Telemed Telecare 2000, 6:242-244. 13. Kunkler IH, Rafferty P, Hill D, Henry M and Foreman D: A pilot study of tele-oncology in Scotland Journal of Telemed Telecare 1998, 4:113-119. 14. Doolittle GC and Allen A: Practising oncology via telemedicine Journal of Telemed Telecare 1997, 3:63-70. 15. Larcher B, Berloffa F, Demichelis F, Eccher C, Favaretti C, Galvagni M, Martini G, Sboner A, Graiff A and Forti S: An evaluation of the use of and user satisfaction with a teleconsultation system in oncology practice Journal of Telemed Telecare 2002, 8:28-30. 16. Picot J: Forty years of change in the use of information and communications technologies in a publicly administered health care system Telemed J 1998, 4:199-205. 17. Noorani HZ and Picot J: Assessment of Videoconferencing in Telehealth in Canada. Canadian Coordinating Office of Health Technology Assessment Technology Report No. 14. Ottawa, Canadian Coordinating Office of Health Technology Assessment 2001. 18. Parboosingh J: Learning portfolios: Potential to assist health professionals with self-directed learning Journal of Continuing Education in the Health Professions 1996, 16:75-81. 19. Davis D, O'Brien MA, Freemantle N, Wolf FM, Mazmanian P and Tay- lor-Vaisey A: Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA 1999, 282:867-874. 20. Thomson O'Brien MA, Freemantle N, Oxman AD, Wolf F, Davis DA and Herrin J: Continuing education meetings and workshops: effects on professional practice and health care outcomes Cochrane Database Syst Rev 2001, 2:CD003030. 21. Roine R, Ohinmaa A and Hailey D: Assessing telemedicine: a sys- tematic review of the literature CMAJ 2001, 165:765-771. 22. Lehoux P, Sicotte C, Denis JL, Berg M and Lacroix A: The theory of use behind telemedicine: how compatible with physicians' clinical routines? Soc Sci Med 2002, 54:889-904. 23. Stead WW: Telehealth: The need for evaluation redux J Am Med Inform Assoc 2002, 9:89-91. 24. Ohinmaa A, Hailey D and Roine R: Elements for assessment of telemedicine applications Int J Tech Assess Health Care 2001, 17:190-202. Pre-publication history The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1472-6947/3/7/prepub Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." 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Feasibility study of multidisciplinary oncology rounds by videoconference for surgeons in remote locales

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Springer Journals
Copyright
Copyright © 2003 by Gagliardi et al; licensee BioMed Central Ltd.
Subject
Medicine & Public Health; Health Informatics; Information Systems and Communication Service; Management of Computing and Information Systems
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1472-6947
DOI
10.1186/1472-6947-3-7
pmid
12816548
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Abstract

Background: This study was undertaken to assess the feasibility of using videoconferencing to involve community-based surgeons in interactive, multidisciplinary oncology rounds so they may benefit from the type of community of practice that is usually only available in academic cancer centres. Methods: An existing videoconference service provider with sites across Ontario was chosen and the series was accredited. Indirect needs assessment involved examining responses to a previously conducted survey of provincial surgeons; interviewing three cancer surgeons from different regions of Ontario; and by analyzing an online portfolio of self-directed learning projects. Direct needs assessment involved a survey of surgeons at videoconference-enabled sites. A surgical, medical and radiation oncologist plus a facilitator were scheduled to guide discussion for each session. A patient scenario developed by the discussants was distributed to participants one week prior to each session. Results: Direct and indirect needs assessment confirmed that breast cancer and colorectal cancer topics were of greatest importance to community surgeons. Six one-hour sessions were offered (two breast, two colorectal, one gynecologic and one lung cancer). A median of 22 physicians and a median of eight sites participated in each session. The majority of respondents were satisfied with the videoconference format, presenters and content. Many noted that discussion prompted reflection on practice and that current practice would change. Conclusions: This pilot study demonstrated that it is possible to engage remote surgeons in multidisciplinary oncology rounds by videoconference. Continued assessment of videoconferencing is warranted but further research is required to develop frameworks by which to evaluate the benefits of telehealth initiatives. oncology services and some medical oncology services are Background Optimal care of the cancer patient is increasingly predi- offered at Ontario's regional cancer centres, an analysis of cated on multidisciplinary management. While radiation referral patterns for cancer surgery in Ontario identified Page 1 of 7 (page number not for citation purposes) BMC Medical Informatics and Decision Making 2003, 3 http://www.biomedcentral.com/1472-6947/3/7 that teaching centres (which include some cancer centres) oconference services were planned to be offered through performed less than 40% of the surgical procedures for the services of the NORTH Network, a telemedicine breast cancer and colorectal cancer [1]. Therefore the com- project based at Sunnybrook and Women's College munity-based general surgeon plays a key role in caring Health Sciences Centre with satellite videoconference for patients with cancer and ensuring that they have access suites in a number of locations across central and north- to multidisciplinary consultation and treatment when ern Ontario. This feasibility study was part of a larger necessary [2,3]. Effective communication between the dif- study approved by the University of Toronto Health Sci- ferent care settings is crucial to this process. ences Ethics Review Committee. Problem-solving and interaction with colleagues is a basic A needs assessment was conducted using both direct and component of medical practice. This need is amplified indirect methods. Each NORTH Network-enabled site was when the involvement of multiple professionals is contacted to confirm the name and contact information required for optimal care. Discussions with colleagues in for general surgeons. Direct needs assessment involved a "communities of practice" build mutual trust and foster survey of general surgeons at these sites to identify the the exchange of not only explicit knowledge that is easily most convenient days of the week and times at which to codified in documents such as guidelines, but tacit knowl- offer the videoconference rounds, and interest in specific edge, which prompts the individual to reflect upon their topics. Indirect needs assessment was carried out using practice [4–6]. It has been suggested that, to promote three strategies. First, responses to a previously conducted knowledge transfer, organizations need to actively nurture survey of provincial surgeons were examined. In that sur- the development of communities of practice by legitimiz- vey surgeons were asked to specify their clinical and infor- ing participation, negotiating their strategic content, mation needs in relation to the care of cancer patients. bringing together complementary expertise, and provid- Second, the Royal College of Physicians and Surgeons of ing support in the form of guidance and resources. Canada WebDiary database was analyzed to identify the cancer-related self-directed learning projects most often A growing body of literature describes the successful use of undertaken by Ontario general surgeons using this online multi-point videoconferencing to facilitate communica- portfolio [18]. Third, open-ended unstructured telephone tion between health care professionals, including oncolo- interviews were conducted with three cancer surgeons gists and surgeons; support the care of patients; and offer from different regions of Ontario. One of these interviews continuing education across great distances [7–15]. Many involved a surgeon residing in Ottawa. He was inter- health care groups in Canada have successfully used tele- viewed for his expertise and knowledge in the concepts of medicine [16]. The Canadian Coordinating Office for knowledge transfer, organizational learning and surgeon Health Technology Assessment recently prepared a review education. The purpose of this interview was to discuss of the use of multipoint videoconferencing [17]. All pro- the organization and format of the pilot study rounds and grams resulted in improved communication, leading to how to best evaluate them. The two remaining interviews informal learning opportunities and enhanced profes- involved a surgeon from North Western Ontario (Fort sional skills for primary care practitioners through interac- Francis) and a surgeon from North Eastern Ontario (Sault tion with practitioners at tertiary referral centres. Ste Marie). As regional liaisons to the Surgical Oncology program, these individuals were selected to discuss the The Cancer Care Ontario Surgical Oncology Network con- usefulness and format of videoconference multidiscipli- ducted this study to assess the feasibility of using video- nary oncology rounds. As general surgeons practising in conferencing technology to bring together physicians in remote regions of Ontario their feedback was representa- various care settings in a format resembling multidiscipli- tive of the surgeons targeted by this feasibility study. nary hospital-based rounds or "tumour boards". The goal is to enable community based surgeons to benefit from Based on the topics identified by the needs assessment as the type of community of practice that is usually only of interest to general surgeons, surgical, radiation and available in academic cancer centres. medical oncologists associated with two tertiary care can- cer centres were invited to participate as discussant pan- elists for six videoconference rounds. They were provided Methods The development and pilot study of Tele-Oncology with a description of the venue and tips on videoconfer- Rounds Ontario (TORO) consisted of a needs assessment, ence etiquette. Another surgical oncologist was invited to content and technology planning, implementation, and serve in the role of facilitator for each event. evaluation. In the absence of a "how-to" manual on vide- oconferencing the series was designed according to infor- With a completed schedule for six planned events, the mation provided by a variety of stakeholders who were series was accredited by the Royal College of Physicians consulted during the development of this program. Vide- and Surgeons of Canada through Continuing Education, Page 2 of 7 (page number not for citation purposes) BMC Medical Informatics and Decision Making 2003, 3 http://www.biomedcentral.com/1472-6947/3/7 Faculty of Medicine, University of Toronto as a Section 1 In 1998 the Surgical Oncology Network conducted a Accredited Group Learning Activity according to the needs assessment survey of surgeons in Ontario. Half of framework of educational options for the College's Main- the 612 respondents (39% response rate) agreed that tenance of Certification program [18]. access to surgical oncologists for consultation would be useful. Frequently mentioned resources requested Promotional material was created and distributed by reg- through written comments included oncology rounds, ular mail to potential participants at the selected video- regional meetings and continuing education (CE); and conference sites. Technical/education support staff at each guidelines for when patients should be referred to formal site were also contacted to request internal advertising of cancer centres. the series. The online portfolio offered by the Royal College of Phy- Several weeks prior to each session the presenting surgical sicians and Surgeons of Canada was searched for instances oncologist was asked to develop a patient scenario that in which physicians recorded learning related to cancer involved cancer surgery, presented treatment decision- care. This was carried out in lieu of mailing a survey to sur- making challenges, and would foster multidisciplinary geons to identify their perceived learning needs. The anal- discussion. The multidisciplinary panel (radiation oncol- ysis identified the topics most often pursued for ogist and medical oncologist) were asked to review and continuing education on cancer care, and what associated edit the patient scenario. One week prior to each event the factors may have prompted a change in practice. A total of patient scenario was distributed to prospective partici- 1,203 cases were recorded between 1994 and 2001. Most pants by fax and posted to the project web site. The sce- records involved the category of management (52.9%) of nario consisted of a description of the theoretical case, breast (25.5%), colorectal (14.0%), gynecologic (12.7%) learning objectives, and several multiple choice questions. and prostate cancer (11.4%). Questions were most often stimulated as a result of browsing the medical literature Following a review of the medical literature and commu- (27.5%), in response to the management of a current nication with researchers in departments of continuing patient (19.0%) or after review of the management of education at six academic institutions, an evaluation form more than one patient (16.0%). To better identify impor- was developed to assess participant satisfaction with the tant topics for discussion at videoconference rounds, the format of the videoconference (image, sound, interac- questions of general surgeons in Ontario were analyzed tion), the content, and the presenter, and the extent to for common issues and topics. Of 71 questions posed by which participants considered the discussion useful to general surgeons in Ontario using WebDiary during the their practice. Statements in each of these categories were specified time period, 56 (79%) involved breast cancer or graded on a five-point Likert scale, where a score of 5 indi- colorectal cancer. cated strong agreement with the statement and a score of 1 expressed strong disagreement. Respondents were Direct Needs Assessment invited to provide written comments on whether the Prospective participants at video-conference enabled sites TORO discussion might change their practice and, if so, (n = 51) were surveyed to learn about specific topics of how; what factors or resources would enable a change in interest and preferred dates/times. The 13 (25.5%) practice; and general comments. respondents suggested a variety of topics, including breast, colorectal, lung, thyroid, pancreatic, gastrointesti- Evaluation form responses were examined using the Sta- nal and esophageal cancer, and malignant skin lesions. tistical Package for the Social Sciences (SPSS) version 10.0 The clear preference for session time was at the end of the (SPSS, Chicago, IL, USA). Written comments were sum- working day. marized and assessed for trends. Planning and Implementation The Cancer Care Ontario Surgical Oncology Network Results Indirect Needs Assessment offered a series of six oncology rounds to cancer surgeons Telephone interviews were held with three regional repre- by videoconference during the 2001–2002 academic year. sentatives of the Surgical Oncology Network, including Each one-hour session consisted of interactive discussion those from the North West, North East, and Eastern based on a patient scenario. Topics included breast cancer Ontario, who agreed that videoconferencing could facili- (2 sessions), colorectal cancer (2 sessions), gynecologic tate the development of learning communities for cancer and lung cancer (1 session each). improved exchange of knowledge related to cancer, partic- ularly in remote regions of the province. Staff at the NORTH Network were notified in advance of the date and time for all six sessions. They handled com- munication with the videoconferencing bridge service and Page 3 of 7 (page number not for citation purposes) BMC Medical Informatics and Decision Making 2003, 3 http://www.biomedcentral.com/1472-6947/3/7 Table 1: Proportion of Videoconference Participants Who Submitted Evaluation Forms Session Topic Participants (n) Evaluations Submitted (n, %) October 2001 Breast cancer 20 10 (50.0) November 2001 Colorectal cancer 22 10 (45.5) December 2001 Gynecologic cancer 21 14 (67.7) January 2002 Breast cancer 29 13 (44.8) February 2002 Colorectal cancer 25 13 (52.0) March 2002 Lung cancer 14 7 (50.0) --- --- Mean 21.8 Mean 11.2 Median 21.5 Median 11.5 technical support staff at each site, and attended the ses- Further, surgeons but no oncologists indicated that infor- sion at the central discussant site to coordinate connectiv- mation obtained at these sessions would change their cur- ity. The TORO coordinator recorded and summarized the rent practice. discussion at each session, later incorporating citations for relevant published trials or guidelines. The summary was Respondents were invited to provide general comments, distributed to the oncology panelists for review and edited and describe specific changes to practice and perceived according to their feedback. The discussion summary was barriers to implementing changes. Written remarks were distributed with the patient scenario for the subsequent few. Respondents suggested strategies for improving the sessions by fax and by posting to the project web site. sessions, for example "more didactic teaching" and "less opinion, more facts". One respondent asked that we A median of 22 physicians participated in each session, "encourage participants to speak loudly" and be more excluding the discussant panel members and the facilita- observant of "raised hands" of those participants wishing tor (Table 1). A median of eight sites participated in each to add to the discussion. Others noted that videoconfer- session, excluding the central discussant panel site. encing provided an "excellent forum for CE", that it was "nice to hear how other northern centres deal with this Evaluation disease", and that the session was "very interesting and The proportion of participants returning completed eval- enjoyable because of the interaction". Several respondents uation forms for each session was 44.8% to 67.7%. Over- noted that they would more often consider, and refer all, 74.6% of participants agreed or strongly agreed they patients for, preoperative radiation therapy and were generally satisfied with the event. The majority of chemotherapy. respondents were satisfied or very satisfied with the vide- oconference format, all discussants and the content of Discussion each session (Table 2). Nearly 75% of respondents agreed This study investigated the feasibility of conducting multi- or strongly agreed that the session topic was relevant to disciplinary oncology rounds by videoconference to facil- their practice, and that the presenter established good rap- itate interaction between oncologists in the tertiary care port with the audience (85.0%), stimulated critical think- setting and community-based general surgeons, who ing (73.2%), and encouraged interaction (83.6%). More conduct a large proportion of cancer surgery and link than half of the participants agreed that discussion pro- patients to oncology services. A needs assessment involv- vided useful insights for practice, and one quarter of ing direct and indirect methods clearly established that respondents suggested their practice would change. breast cancer and colorectal cancer were the topics most relevant to general surgeons. Apart from the discussant Responses were examined by session topic and by partici- panel and facilitator, one or two oncologists participated pant specialty (Table 3). Participants were satisfied with in each session, and two gynecologists participated in the the sessions on breast, colorectal and gynecologic cancer session on gynecologic cancer, so the median participa- topics, and 30% to 43% agreed or strongly agreed that dis- tion rate represents approximately 40% of the target pop- cussion revealed information not accessible elsewhere. ulation of general surgeons associated with the Oncologists were more satisfied than general surgeons videoconference-enabled sites. For the most part, the overall (88.3% versus 75.0%) but more general surgeons same individuals tended to participate in each session. than oncologists reported that information revealed was not accessible elsewhere, discussion provided useful tips Satisfaction with the videoconferencing format, content for practice, and discussion caused reflection on practice. and speakers was high. Overall, discussion prompted Page 4 of 7 (page number not for citation purposes) BMC Medical Informatics and Decision Making 2003, 3 http://www.biomedcentral.com/1472-6947/3/7 Table 2: Summary of Participant Evaluation of Videoconference Oncology Rounds Factor Strongly agree (n, %) Strongly disagree (n, %) No response VIDEOCONFERENCE 5 4 3 2 1 99 Presenter clearly visible 32 (47.8) 30 (44.8) 3 (4.5) -- 2 (3.0) --- Slides/visual aids clearly visible 15 (22.4) 22 (32.8) 12 (17.9) 7 (10.4) 5 (7.5) 6 (9.0) Presenter clearly audible 24 (35.8) 21 (31.3) 17 (25.4) 3 (4.5) 1 (1.5) 1 (1.5) Interaction with speaker possible 24 (35.8) 28 (41.8) 14 (20.9) --- 1 (1.5) --- Interaction with other participants possible 14 (20.9) 26 (38.8) 12 (17.9) 9 (13.4) 2 (3.0) 4 (6.0) CONTENT Presentation time was sufficient 22 (32.8) 34 (50.7) 9 (13.4) 2 (3.0) --- --- Discussion time was sufficient 16 (23.9) 34 9(50.7) 15 (22.4) 2 (3.0) --- --- Topic was relevant to my practice 29 (43.3) 21 (31.3) 12 (17.9) 1 (1.5) 2 (3.0) 2 (3.0) PRESENTER Clearly presented the topic 19 (28.4) 35 (52.2) 12 (17.9) 1 (1.5) --- --- Demonstrated thorough knowledge of topic 29 (43.3) 34 (50.7) 3 (4.5) 1 (1.5) --- --- Established good rapport with audience 22 (32.8) 35 (52.2) 9 (13.4) --- --- 1 (1.5) Stimulated critical thinking 19 (28.4) 30 (44.8) 13 (19.4) 3 (4.5) 1 (1.5) 1 (1.5) Encourged questions and participation 25 (37.3) 31 (46.3) 10 (14.9) 1 (1.5) --- --- OVERALL Overall, was satisfied with event 16 (23.9) 34 (50.7) 14 (20.9) 3 (4.5) --- --- OUTCOME Information revealed not accessible elsewhere 1 (1.5) 22 (32.8) 21 (31.3) 16 (23.9) 5 (7.5) 2 (3.0) Discussion provided useful tips for practice 5 (7.5) 31 (46.3) 19 (28.4) 6 (9.0) 3 (4.5) 3 (3.5) Discussion caused reflection on practice 13 (19.4) 34 (50.7) 8 (11.9) 10 (14.9) 1 (1.5) 1 (1.5) EFFECT ON PRACTICE Yes No Not sure Problems No response Will current practice change? 17 (25.4) 40 (59.7) 4 (6.0) 4 (6.0) 4 (6.0) Table 3: Summary of Participant Evaluation by Session Topic and Participant Specialty Factor Proportion By Topic Agree Proportion by Specialty Agree or Strongly Agree (%) or Strongly Agree (%) Breast Colorectal Gynecologic Lung Surgeons Oncologists (n = 23) (n = 23) (n = 14) (n = 7) (n = 60) (n = 6) OVERALL Overall, was satisfied with event 78.3 73.9 78.6 57.2 75.0 88.3 OUTCOME Information revealed not accessible elsewhere 30.4 30.4 42.8 42.9 36.7 16.7 Discussion provided useful tips for practice 52.2 60.8 64.3 14.3 58.4 16.7 Discussion caused reflection on practice 73.9 69.5 85.7 28.6 71.6 50.0 WILL CURRENT PRACTICE CHANGE Yes 21.7 30.4 35.7 --- 28.3 --- No 65.2 52.2 57.1 71.4 55.0 100.0 reflection on practice and 25% of respondents suggested These results cannot be generalized to the larger popula- that their practice would change. Reflection on practice tion of general surgeons in Ontario or elsewhere due to and changes in practice were more likely to occur for the self-selected participation of those attending the ses- responding surgeons than for oncologists. Although writ- sions, and the small number of participants. For most ses- ten responses were few, several participants at different sions, only half of the participants returned evaluation sessions noted that they would more frequently consider forms, despite the fact that this was a requirement for preoperative chemotherapy and radiation therapy as part receipt of continuing education credits toward the RCPSC of their management plan. Maintenance of Certification program. Page 5 of 7 (page number not for citation purposes) BMC Medical Informatics and Decision Making 2003, 3 http://www.biomedcentral.com/1472-6947/3/7 It should be noted that this feasibility study was part of a such programs need to sufficiently mature for assessment larger study that did not take place due to an insufficient to be meaningful. Therefore, an initial assessment associ- number of consenting participants. The larger study ated with a pilot study, such as the one described in this planned to conduct pre- and post-videoconference series manuscript, can indicate the feasibility of an initiative, surveys to examine self-directed learning attitudes and while a more complex evaluation strategy, including behaviour based upon Oddi's validated self-directed examination of technical issues, impact on practice, and learning inventory [19]; dialogue analysis of videotaped cost, is more suitable for long term assessment. videoconference rounds to examine instances of self- reflection, community building and informal learning Conclusions according to Wenger's communities of practice frame- Ontario surgeons participating in videoconference oncol- work [20]; and follow-up semi-structured, grounded ogy rounds reported satisfaction with the format, noting interviews with participants to assess impact on behaviour that participation stimulated reflection on practice and and practice. that, in some cases, current practice would change. There- fore ongoing assessment of the use of videoconferencing Our inability to more thoroughly assess the impact of par- for continuing education and the development of profes- ticipation in videoconference multidisciplinary oncology sional communities of practice is warranted. However fur- rounds revealed a variety of factors that challenge valid ther research is required to develop frameworks and evaluation of remote collegial interaction. These same suitable, phase-specific methods by which to evaluate the challenges were noted in the medical literature on video- impact of telehealth initiatives. conference applications. The use of telemedicine has been primarily driven by perceived need and practical attempts Competing Interests to deliver health care in an efficient and timely manner, None declared. rather than a theoretical knowledge base established by empirical research [21]. For this reason there is a lack of Authors' Contributions appropriate evaluation frameworks by which to assess AG developed, implemented and evaluated the pilot and value the benefit of telehealth initiatives [22]. The project, and drafted the manuscript. AS facilitated all ses- International Network of Agencies for Health Technology sions. VG provided guidance on developing, implement- Assessment (INAHTA) recently reviewed the factors that ing and evaluating the sessions, and edited the could be considered when assessing telemedicine applica- manuscript. DD conceived the pilot project. All authors tions [23]. They argued that controlled scientific studies of read and approved the final manuscript. telemedicine initiatives may only be helpful in establish- ing the efficacy of the technology, but the results of such References 1. 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Ohinmaa A, Hailey D and Roine R: Elements for assessment of telemedicine applications Int J Tech Assess Health Care 2001, 17:190-202. Pre-publication history The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1472-6947/3/7/prepub Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 7 of 7 (page number not for citation purposes)

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