***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background To investigate organisational factors influencing the implementation challenges of re design ing services for people with long term conditions in three locations in Engl and , using remote care ( telehealth and telecare ) .  Methods Case- studies of three sites forming the UK Department of Health ’s Whole Systems Demonstrator ( WSD ) Programme . Qualitative research techniques were used to obtain data from various sources , including semi-structured interviews , observation of meetings over the course programme and prior to its launch , and document review . Participants were managers and practitioners involved in the implementation of remote care services .  Results The implementation of remote care was nested within a large pragmatic cluster r and omised controlled trial ( RCT ) , which formed a core element of the WSD programme . To produce robust benefits evidence , many aspect of the trial design could not be easily adapted to local circumstances . While remote care was successfully rolled-out , wider implementation lessons and levels of organisational learning across the sites were hindered by the requirements of the RCT . Conclusions The implementation of a complex innovation such as remote care requires it to organically evolve , be responsive and adaptable to the local health and social care system , driven by support from front-line staff and management . This need for evolution was not always aligned with the imperative to gather robust benefits evidence . This tension needs to be resolved if government ambitions for the evidence -based scaling-up of remote care are to be realised Background There is much interest in virtual consultations using video technology . R and omized controlled trials have shown video consultations to be acceptable , safe , and effective in selected conditions and circumstances . However , this model has rarely been mainstreamed and sustained in real-world setting s. Objective The study sought to ( 1 ) define good practice and inform implementation of  video outpatient consultations  and ( 2 ) generate transferable knowledge about challenges to scaling up and routinizing this service model . Methods A multilevel , mixed- method study of Skype video consultations ( micro level ) was embedded in an organizational case study ( meso level ) , taking account of national context and wider influences ( macro level ) . The study followed the introduction of  video outpatient consultations in three clinical services ( diabetes , diabetes antenatal , and cancer surgery ) in a National Health Service trust ( covering three hospitals ) in London , United Kingdom . Data sources included 36 national-level stakeholders ( exploratory and semistructured interviews ) , longitudinal organizational ethnography ( 300 hours of observations ; 24 staff interviews ) , 30 videotaped remote consultations , 17 audiotaped face-to-face consultations , and national and local documents . Qualitative data , analyzed using sociotechnical change theories , addressed staff and patient experience and organizational and system drivers . Quantitative data , analyzed via descriptive statistics , included uptake of video consultations by staff and patients and microcategorization of different kinds of talk ( using the Roter interaction analysis system ) . Results When clinical , technical , and practical preconditions were met , video consultations appeared safe and were popular with some patients and staff . Compared with face-to-face consultations for similar conditions , video consultations were very slightly shorter , patients did slightly more talking , and both parties sometimes needed to make explicit things that typically remained implicit in a traditional encounter . Video consultations appeared to work better when the clinician and patient already knew and trusted each other . Some clinicians used Skype adaptively to respond to patient requests for ad hoc encounters in a way that appeared to strengthen supported self-management . The reality of establishing video outpatient services in a busy and financially stretched acute hospital setting proved more complex and time-consuming than originally anticipated . By the end of this study , between 2 % and 22 % of consultations were being undertaken remotely by participating clinicians . In the remainder , clinicians chose not to participate , or video consultations were considered impractical , technically unachievable , or clinical ly inadvisable . Technical challenges were typically minor but potentially prohibitive . Conclusions Video outpatient consultations appear safe , effective , and convenient for patients in situations where participating clinicians judge them clinical ly appropriate , but such situations are a fraction of the overall clinic workload . As with other technological innovations , some clinicians will adopt readily , whereas others will need incentives and support . There are complex challenges to embedding video consultation services within routine practice in organizations that are hesitant to change , especially in times of austerity Objective To assess the effect of home based telehealth interventions on the use of secondary healthcare and mortality . Design Pragmatic , multisite , cluster r and omised trial comparing telehealth with usual care , using data from routine administrative data sets . General practice was the unit of r and omisation . We allocated practice s using a minimisation algorithm , and did analyses by intention to treat . Setting 179 general practice s in three areas in Engl and . Participants 3230 people with diabetes , chronic obstructive pulmonary disease , or heart failure recruited from practice s between May 2008 and November 2009 . Interventions Telehealth involved remote exchange of data between patients and healthcare professionals as part of patients ’ diagnosis and management . Usual care reflected the range of services available in the trial sites , excluding telehealth . Main outcome measure Proportion of patients admitted to hospital during 12 month trial period . Results Patient characteristics were similar at baseline . Compared with controls , the intervention group had a lower admission proportion within 12 month follow-up ( odds ratio 0.82 , 95 % confidence interval 0.70 to 0.97 , P=0.017 ) . Mortality at 12 months was also lower for intervention patients than for controls ( 4.6 % v 8.3 % ; odds ratio 0.54 , 0.39 to 0.75 , P<0.001 ) . These differences in admissions and mortality remained significant after adjustment . The mean number of emergency admissions per head also differed between groups ( crude rates , intervention 0.54 v control 0.68 ) ; these changes were significant in unadjusted comparisons ( incidence rate ratio 0.81 , 0.65 to 1.00 , P=0.046 ) and after adjusting for a predictive risk score , but not after adjusting for baseline characteristics . Length of hospital stay was shorter for intervention patients than for controls ( mean bed days per head 4.87 v 5.68 ; geometric mean difference −0.64 days , −1.14 to −0.10 , P=0.023 , which remained significant after adjustment ) . Observed differences in other forms of hospital use , including notional costs , were not significant in general . Differences in emergency admissions were greatest at the beginning of the trial , during which we observed a particularly large increase for the control group . Conclusions Telehealth is associated with lower mortality and emergency admission rates . The reasons for the short term increases in admissions for the control group are not clear , but the trial recruitment processes could have had an effect . Trial registration number International St and ard R and omised Controlled Trial Number Register IS RCT N43002091 Abstract Objectives To test the hypotheses that , compared with conventional outpatient consultations , joint teleconsultation ( virtual outreach ) would incur no increased costs to the NHS , reduce costs to patients , and reduce absences from work by patients and their carers . Design Cost consequences study alongside r and omised controlled trial . Setting Two hospitals in London and Shrewsbury and 29 general practice s in inner London and Wales . Participants 3170 patients identified ; 2094 eligible for inclusion and willing to participate . 1051 r and omised to virtual outreach  and 1043 to st and ard outpatient appointments .  Main outcome measures NHS costs , patient costs , health status ( SF-12 ) , time spent attending index consultation , patient satisfaction . Results Overall six months costs were greater for the virtual outreach consultations ( £ 724 per patient ) than for conventional outpatient appointments ( £ 625 ) : difference in means £ 99 ( $ 162 ; € 138 ) ( 95 % confidence interval £ 10 to £ 187 , P=0.03 ) . If the analysis is restricted to re source items deemed “ attributable ” to the index consultation , six month costs were still greater for virtual outreach : difference in means £ 108 ( £ 73 to £ 142 , P < 0.0001 ) . In both analyses the index consultation accounted for the excess cost . Savings to patients in terms of costs and time occurred in both centres : difference in mean total patient cost £ 8 ( £ 5 to £ 10 , P < 0.0001 ) . Loss of productive time was less in the virtual outreach group : difference in mean cost £ 11 ( £ 10 to £ 12 , P < 0.0001 ) . Conclusion The main hypothesis that virtual outreach would be cost neutral is rejected , but the hypotheses that costs to patients and losses in productivity would be lower are supported Objective : to assess the impact of telecare on the use of social and health care . Part of the evaluation of the Whole Systems Demonstrator trial . Participants and setting : a total of 2,600 people with social care needs were recruited from 217 general practice s in three areas in Engl and . Design : a cluster r and omised trial comparing telecare with usual care , general practice being the unit of r and omisation . Participants were followed up for 12 months and analyses were conducted as intention-to-treat . Data sources : trial data were linked at the person level to administrative data sets on care funded at least in part by local authorities or the National Health Service . Main outcome measures : the proportion of people admitted to hospital within 12 months . Secondary endpoints included mortality , rates of secondary care use ( seven different metrics ) , contacts with general practitioners and practice nurses , proportion of people admitted to permanent residential or nursing care , weeks in domiciliary social care and notional costs . Results : 46.8 % of intervention participants were admitted to hospital , compared with 49.2 % of controls . Unadjusted differences were not statistically significant ( odds ratio : 0.90 , 95 % CI : 0.75–1.07 , P = 0.211 ) . They reached statistical significance after adjusting for baseline covariates , but this was not replicated when adjusting for the predictive risk score . Secondary metrics including impacts on social care use were not statistically significant . Conclusions : telecare as implemented in the Whole Systems Demonstrator trial did not lead to significant reductions in service use , at least in terms of results assessed over 12 months . International St and ard R and omised Controlled Trial Number Register IS RCT N43002091 OBJECTIVES To determine the uptake of multiple eHealth facilities enabled by the NHS Scotl and Electronic Clinical Communications Implementation Programme ( ECCI )  and to ascertain primary and secondary care users ' perceptions . DESIGN Prospect i ve monthly measurement of 37 indicators of roll-out and adoption . Retrospective question naire survey of users . SETTING Scottish health board regions . Quantitative implementation indicators were gathered in primary and secondary care across all 16 regions . Question naire data were obtained from recorded users in five representative regions ( 112 general practice s , 92 secondary care units ) . OUTCOME MEASURES Change in uptake levels of ECCI facilities over a 15-month period . Users ' perceptions of benefits , facilitators and barriers . RESULTS All health boards participated in the monthly data set collection . The response rate to the survey was 62 % in primary care and 37 % in secondary care . Across Scotl and as a whole , the process of implementation was gradual . While there were marked gains in the availability of ECCI facilities over the observation period , rates of adoption lagged behind and varied across alternative facilities . Electronic results were widely used , with most laboratories offering them and around half of general practice s receiving them . More modest rates of adoption were observed for e-discharge letters , e-referrals , e-clinic letters and clinical e-mail . E-booking was used very little . Among engaged users responding to the survey , electronic access to test results was the most frequently utilised facility and electronic outpatient booking the least . Perceived benefits of ECCI facilities included convenience , ease of use , time-saving and provision of an audit trail . Perceived barriers included the need to duplicate data entry where new systems were not universally implemented , technological difficulties , time , training and re sources . CONCLUSIONS Significant progress was observed in the implementation of ECCI facilities across Scotl and . Users reported that these improved communication and were beneficial , but system reliability , incompatibility and duplication of data hindered more widespread uptake . Data were collected at a transitional phase of the programme . Whilst , among users of ECCI facilities , perceptions of the programme and its potential benefits were generally positive , its full impact will not become evident until the new electronic tools are implemented nationally and have been more fully integrated into normal work routines Background It is expected that increased dem and s on services will result from exp and ing numbers of older people with long-term conditions and social care needs . There is significant interest in the potential for technology to reduce utilisation of health services in these patient population s , including telecare ( the remote , automatic and passive monitoring of changes in an individual 's condition or lifestyle ) and telehealth ( the remote exchange of data between a patient and health care professional ) . The potential of telehealth and telecare technology to improve care and reduce costs is limited by a lack of rigorous evidence of actual impact . Methods / Design We are conducting a large scale , multi-site study of the implementation , impact and acceptability of these new technologies . A major part of the evaluation is a cluster-r and omised controlled trial of telehealth and telecare versus usual care in patients with long-term conditions or social care needs . The trial involves a number of outcomes , including health care utilisation and quality of life . We describe the broad evaluation and the methods of the cluster r and omised trial Discussion If telehealth and telecare technology proves effective , it will provide additional options for health services worldwide to deliver care for population s with high levels of need . Trial Registration Current Controlled Trials IS RCT OBJECTIVE To determine patient perceptions of joint teleconsultations ( JTC )  , with particular reference to reasons underlying , and factors contributing to , patient satisfaction and dissatisfaction with this mode of health delivery . BACKGROUND Telemedicine has been welcomed as one 
    Output:
    
Patient responses to e-consultation were mixed .
Patients reported satisfaction with services and improved self-care , communication , and engagement with clinicians .
Evidence for the acceptability and ease of use was strong , especially for those with long-term conditions and patients located in remote regions .
However , patients were concerned about the privacy and security of their data .
For primary health care staff , e-consultation delivers challenges around time management , having the correct technological infrastructure , whether it offers a comparable st and ard of clinical quality , and whether it improves health outcomes .
E-consultations may improve aspects of care delivery , but the small scale of many of the studies and low adoption rates leave unanswered questions about usage , quality , cost , and sustainability .