שנת סיום: 2020

כותרת עבודת הדוקטורט:

Characterization of the Non-Medical Factors Associated with the Decision-Making Process of the Physicians in a Pediatric Telemedicine Service

מנחים: ד"ר שולי ברמלי-גרינברג, פרופ' אורנה בראון אפל

Abstract

Background

“Telemedicine” is the use of communications networks for delivering health care services and medical education from one geographic location to another. Telephone consultation mainly serves as a triage, in which medical urgency is determined and appropriate treatment recommendations are made.

In emergency medicine, including telephone-triage, decision-making takes place during a crisis, under conditions of uncertainty, lack of time and lack of information.

Telephone triage may compromise patient safety, particularly if urgency is underestimated and the patient is not seen by a physician or with a delay in time. Although medical decision making is ideally a matter of symptoms, tests, and probabilities, many reports suggested that it is in fact a social transaction prone to medically extraneous influences, or "non- medical" ("extra-medical") factors.

Aim

The main aim of this study was to identify and analyze the possible role of non- (extra) medical factors in physicians' decision-making process in telemedicine setting.

In order to assess the milieu in which the physicians have to make decisions, we first wanted to explore the experiences, attitudes and challenges of the physicians in a Pediatric Telemedicine Service, which operates in Israel.

Lastly, we wanted to find out whether patient' safety is maintained in the pediatric telemedicine service we examined, in particular when considering the findings of our previous studies.

Hypothesis

We expect to identify non-medical factors involved in the physicians' decision-making process in telemedicine. Since in telemedicine, the physician does not have the standard "medical" measures to examine the patient- "non-medical" factors may gain weight in this setting. On the other hand, one might think, that under these circumstances, doctors would prefer to rely on purely medical information. In addition, we expect that the patient safety will be maintained.

Methods

In 2009, a unique pediatric telemedicine service was established in Israel, named 'Pediatricians online service of Clalit', under the auspices of 'Clalit' Healthcare Services. The main goal of this service is to act as a medical triage, deciding which cases are urgent enough to warrant a referral to the Emergency department (ED), and which cases should be taken care of by the community- clinics during their operating hours.

Two research methods were used: qualitative and quantitative. In addition, in the interview section, theoretical clinical scenarios were presented to the physicians working in pediatric telemedicine service, evaluating their response to each case.

Qualitative research: Interviews were conducted with 15 physicians who have worked in the "Pediatrician Online service of Clalit" during the years 2014-2017. The interview questionnaire included questions about the doctor himself, his professional training and experience, and the difficulties he faces while working in the telemedicine setting. The physicians were specifically asked about the extent to which various nonmedical factors may influence (or not) their judgment and therapeutic decisions in this setting.

At the end of the qualitative questionnaire, the physicians were presented with three hypothetical clinical scenarios outlining typical pediatric cases (some with pure medical factors, and some with additional non-medical factors), and they were asked to say what was their therapeutic decision in each case.

Quantitative research: we analyzed a random sample of 339 recorded phone consultations between doctors who worked at this pediatric online service, and the parents who applied for the service, during the years 2014-2017. For each consultation- we examined the medical information and the "non-medical" factors that could be obtained during the conversation and from the files, in reference to the medical diagnoses and treatment decisions which were taken.

Conclusions

Physicians working in the pediatric telemedicine setting face various risks, difficulties and challenges. Non-medical factors have a role in the doctor's decision-making process, in the telemedicine milieu. These factors play a role in all parts of the decision-making process, in making the diagnosis, and deciding on the appropriate treatment, and they can potentially assist the doctors in this unique and challenging arena getting the appropriate decision which best suits the patient they are treating. Despite the special difficulties and obstacles existing in telemedicine setting, which mainly stems from the fact that the physician is not able to perform a full physical examination, the diagnoses' appropriateness/ "accuracy", and decisions' reasonability of the physicians are very high. This may be attributed also, to several measures which were developed by the online- physicians, in order to help them achieving overall high safety in Telemedicine Setting.

Scientific contribution and practical implications

The novelty of this study, on all its three parts, is that the decision making process of the physicians in the unique setting of (pediatric) telemedicine is investigated using different approaches and levels of inquiries. The need to optimize the clinical decision making is especially essential in the unique and challenging setting of telemedicine in general and tele-triage in particular, which impose barriers that may delay care.

To the best of our knowledge, this study is the first of its kind to investigate the decision-making process of physicians (and not nurses) in the field of telemedicine, in the area of pediatrics, where diagnosis can be even more difficult because of the child's inability to express exactly what he is suffering from. In addition, this study focuses on investigating the non-medical factors, in addition to the medical factors that have been studied in the past.

The study shows, that decision making in the telemedicine setting is quiet challenging for the physicians, having various risks and difficulties. Nevertheless, the physicians working in this setting have developed special means and tools which help them to reach a decision, including the use of non-medical-contextual factors. As shown in this study, the physicians in this pediatric telemedicine setting are succeeding in making a correct diagnoses and deciding on appropriate, "reasonable" treatment-decisions, thus maintaining an overall excellent patient safety.

Decision makers should be aware of the challenges and obstacles that exist in the telemedicine setting, requiring special expertise and training of doctors. Therefore, there should be appropriately trained medical personnel for tele- triage decisions. Despite the overall high safety in Pediatric Telemedicine-triage service shown in this study, one must still strive to find ways to further enhance doctors’ ability in reaching an accurate diagnosis and best possible treatment decisions, in order to assure appropriate patient safety needed in this new challenging settings.