Seuren Lucas Martinus, Wherton Joseph, Greenhalgh Trisha, Cameron Deborah, A'Court Christine, Shaw Sara E
Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom.
Faculty of Linguistics, University of Oxford, Oxford, United Kingdom.
J Med Internet Res. 2020 Feb 20;22(2):e16694. doi: 10.2196/16694.
Video consultations are increasingly seen as a possible replacement for face-to-face consultations. Direct physical examination of the patient is impossible; however, a limited examination may be undertaken via video (eg, using visual signals or asking a patient to press their lower legs and assess fluid retention). Little is currently known about what such video examinations involve.
This study aimed to explore the opportunities and challenges of remote physical examination of patients with heart failure using video-mediated communication technology.
We conducted a microanalysis of video examinations using conversation analysis (CA), an established approach for studying the details of communication and interaction. In all, seven video consultations (using FaceTime) between patients with heart failure and their community-based specialist nurses were video recorded with consent. We used CA to identify the challenges of remote physical examination over video and the verbal and nonverbal communication strategies used to address them.
Apart from a general visual overview, remote physical examination in patients with heart failure was restricted to assessing fluid retention (by the patient or relative feeling for leg edema), blood pressure with pulse rate and rhythm (using a self-inflating blood pressure monitor incorporating an irregular heartbeat indicator and put on by the patient or relative), and oxygen saturation (using a finger clip device). In all seven cases, one or more of these examinations were accomplished via video, generating accurate biometric data for assessment by the clinician. However, video examinations proved challenging for all involved. Participants (patients, clinicians, and, sometimes, relatives) needed to collaboratively negotiate three recurrent challenges: (1) adequate design of instructions to guide video examinations (with nurses required to explain tasks using lay language and to check instructions were followed), (2) accommodation of the patient's desire for autonomy (on the part of nurses and relatives) in light of opportunities for involvement in their own physical assessment, and (3) doing the physical examination while simultaneously making it visible to the nurse (with patients and relatives needing adequate technological knowledge to operate a device and make the examination visible to the nurse as well as basic biomedical knowledge to follow nurses' instructions). Nurses remained responsible for making a clinical judgment of the adequacy of the examination and the trustworthiness of the data. In sum, despite significant challenges, selected participants in heart failure consultations managed to successfully complete video examinations.
Video examinations are possible in the context of heart failure services. However, they are limited, time consuming, and challenging for all involved. Guidance and training are needed to support rollout of this new service model, along with research to understand if the challenges identified are relevant to different patients and conditions and how they can be successfully negotiated.
视频会诊越来越被视为面对面会诊的一种可能替代方式。对患者进行直接体格检查是不可能的；然而，可以通过视频进行有限的检查（例如，使用视觉信号或要求患者按压小腿并评估液体潴留情况）。目前对于此类视频检查的具体内容知之甚少。
本研究旨在探讨使用视频介导通信技术对心力衰竭患者进行远程体格检查的机遇和挑战。
我们使用会话分析（CA）对视频检查进行了微观分析，会话分析是一种研究沟通和互动细节的既定方法。在获得同意的情况下，对心力衰竭患者与其社区专科护士之间的七次视频会诊（使用FaceTime）进行了录像。我们使用会话分析来识别视频远程体格检查的挑战以及用于应对这些挑战的言语和非言语沟通策略。
除了一般的视觉概览外，心力衰竭患者的远程体格检查仅限于评估液体潴留情况（由患者或亲属触摸腿部水肿）、血压及脉搏率和节律（使用带有不规则心跳指示器的自动充气血压计，由患者或亲属自行测量）以及血氧饱和度（使用指夹式设备）。在所有七例中，这些检查中的一项或多项通过视频完成，为临床医生评估生成了准确的生物特征数据。然而，视频检查对所有相关人员来说都具有挑战性。参与者（患者、临床医生，有时还有亲属）需要共同应对三个反复出现的挑战：（1）充分设计指导视频检查的说明（护士需要用通俗易懂的语言解释任务并检查是否遵循了说明），（2）鉴于患者有参与自身体格评估的机会，兼顾患者（护士和亲属方面）对自主性的需求，（3）在进行体格检查的同时让护士能够看到（患者和亲属需要具备足够的技术知识来操作设备并使检查对护士可见，以及具备基本的生物医学知识来遵循护士的指示）。护士仍负责对检查的充分性和数据的可信度做出临床判断。总之，尽管存在重大挑战，但心力衰竭会诊中的部分参与者成功完成了视频检查。
在心力衰竭服务中视频检查是可行的。然而，它们存在局限性、耗时且对所有相关人员都具有挑战性。需要指导和培训来支持这种新服务模式的推广，同时需要开展研究以了解所识别的挑战是否与不同患者和病情相关以及如何成功应对这些挑战。
