Broadband NurseAn evaluation of a one-

way video-conferencing health information and advice service

Peter WilliamsCIBER: City University

[& David Nicholas; Paul Huntington; Barrie Gunter]

Plan of the Talk

• Introduction and context• The pilot DiTV services• The Living Health / InVision service• Objectives/methodology of study• Results:

– Usage

– Reasons for usage

– Attitudes/opinions

• Conclusions/areas for further study

Introduction and context

• Government believes DiTV could be the platform to provide health information and advice to the consumer

• Four pilot projects funded to see if this is the case

• Success measured by take-up, attitude/opinion and outcome

• First major academic study of DiTV

The pilot DiTV services

Communicopia• Video-on-demand “NHS direct digital”• Online immunisation records-keeping

Channel health• Interactive pregnancy information accompanying

sky broadcast

Dktv• Interactive links to community health services, • Video-on-demand service

‘Living Health’ Service

• Text based information database• GP appointments’ booking service• InVision - video nurse from NHS direct call-

centre

Accessing InVision (1)

Accessing InVision (2)

Accessing InVision (3)

Clicking on continue generates a “Session Request”.

Accessing InVision (4)

Pressing the Red button now generates a “Cancellation”. Normally, this page would be seen for 20 - 30 seconds at most.

Accessing InVision (5)

Pressing the Red button after having received the Welcome Page, is defined as a “Disconnection”. Instead of receiving this page, customers could get Service Busy or Closed messages.

Accessing InVision (6)

A “Completed Session” requires the nurse to input the InVision reference number into the application in order for the broadcast to be seen on the customer’s TV.

The Study: Aims/Objectives

Exploratory study to look at extent and how system was exploited, and its future viability. Concerned with:

• User numbers• Reasons for use• Information needed - type; depth and range• The degree to which needs met• Reaction to seeing the nurse• How the professionals coped• Ease of use (callers and nurses)

The Study: Methods

• Computer log analysis• Telephone survey (29 of 163)• Interviews: InVision staff (8 - of 35)• Interviews: users (6 of 163)• Interviews: Living Health (but not InVision)

users• CAS reports (65 of 163)

Findings: 1

Usage

Access statistics

• Total Session Requests 1380• Customer Cancellations during Initialisation (i.e. before an

InVision welcome page is generated) 615 44.6%• Customer Disconnection after Initialisation (Pressing a

cancellation button after having received the InVision welcome page, is defined as a “Disconnection”.) 191 13.8%

• Session Time Outs (calls cancelled due to NHS Direct not answering calls within 10 minutes, causing the reference number to become invalid) 168 12.2%

• Service Busy (i.e. all the call operators occupied) 15010.9%

• Service Closed (i.e. when no trained staff are on duty) 936.7%

• Total Completed Sessions 163 11.8%

(100%) 43.7% 0% 6.1% 12.5% 14.6% 13.3% 0% 9.9%

Number of users openingsession (select OK on Home page)

Users cancellingsession before Ref.# is returned

Users experiencingsystem failing tobegin connection

System closeddown/operator problems

Users unable tobegin session dueto all operatorsbusy

Users whose session has timed outwithout connecting toa Nurse.

Users disconnecting after receiving Ref # but before connecting to a Nurse

Users experiencingsystem failure duringa connected session.

Users successfullyconnecting to liveoperator

2096

915

0

128

262 306 278

0

207

0

500

1000

1500

2000

2500

TotalSessions

Cancelled InitialisationError

Closed Busy Disconnect Timed Out Error Completedsession

Direction of progression

Session Breakdown20 Aug 2001 - 17 Feb 2002

108115

159

140149

162

65

79

6959

34

48

73 74 74

50

90

5853

6065

43

63

72

5866

0

20

40

60

80

100

120

140

160

180

Session Requests

81/wk

20 Aug - 30 Nov: 92 requests/wk

20 Aug - 17 Feb: 81 requests/wk

Pilot end

710 10 11

17

28

8 5 69 10

4 41

61

102 3

7 61 3

1 6 4

0

20

40

60

80

100

120

140

160

180

Completed Sessions

20 Aug - 30 Nov: 163 sessions* (10.9/wk)

1 Dec - 17 Feb: 44 sessions (4.0/wk)

20 Aug - 17 Feb: 207 sessions (8.0/wk)

Pilot end

*Note: figure includes 27 completed sessions disconnected by the caller. The system originally logged these as Disconnections, but they are now recorded as Completed Sessions.

InVision v NHS Direct

• InVision: 163 calls, pop 84,000 = 1.9 calls per 1000 (per 3 months)

• NHS Direct telephone, Dudley: 1.5 - 2 per month)• NHS Direct telephone nationally:

Month Newcastle Northumberland

1 8.5 6.7

2 13.4 11.5

3 18.0 11.5

Factors Affecting Usage

Small user population: No chatting to next door about it

Discouragement of casual users: “NHS direct InVision is a confidential service intended to provide callers with medical advice or information and to help direct them to other NHS services they may need. It should be used for its intended purpose only”

Lack of publicity: No marketing support from September 2001

Unfamiliarity: new form of communication InVision more complicated: requires several

steps System problems: ‘Downtime’

Findings: 2

Reasons for usage

Note: findings compared to telephony-only survey by NHS Direct, Dudley call centre

43.3% 44.8%46.7%

37.9%

10.0%

17.3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Telephony inVision

Yourself Child Another Adult

For whom phoning?

CAS Query Breakdown

[InVision only]

• Treatment advice (i.e. for a specific new situation, or for recurring one that is not being treated) 45 (70%)

• Reassurance (i.e. about the seriousness of a particular condition) 23 (36%)

• Diagnosis 15 (23%)• General information (i.e. medicines that do not

contain animal products etc.) 9 (14%)

20.7%

0.0%

13.8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Photographs Graphics Videos

Did the Nurse show you…?

20.7% of sessions showed images(13.8% is a subset of the 20.7%)

Findings: 3

Opinion/attitude/perceptions

65.5%

42.2%

31.0%

1.1%

56.7%

3.4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Telephony inVision

Very happy Happy Unhappy Very unhappy

How did you feel about how Nurse worked through details of the problem?

96.6%

2.3% 3.4%

97.7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Telephony inVision

Yes No

Was the advice helpful?

1 person

64.3%

0.0%

25.0%33.0%

0%

52.3%

21.4%

11.4%

21.4%

7.10%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Telephony inVision

Felt reassured, less worried

Helped me realise no need to contact other services

It helped me contact the right service

Learned how to deal with the problem myself

Learned how to prevent the problem in future

Why was the advice helpful?

One answer allowed Multiple answers allowed

You feel reassured by her body language...

Comfortable, as itwas in confidence…

like a GP appointment

More personal…More informative...

Much better than the telephone service - one to one is just like going to the doctors,

you are able to see the person yourself

It’s is a brilliant service that if adopted nationwide could save

a lot of queues in hospitalsand the like.

Being able to see the nurse made me

feel more relaxed

Very good idea -ideal for outsidesurgery hours

Caller Comments

It’s great being able to just show something

It saves a lot of explanation

If you just describe somethingmany are bound to make

mistakes ...

I wish I had remembered that image - but I didn’t think till afterwards

Nurse Comments

Perceived benefits

Callers• Convenience (home doc etc.)• Seeing nurse (engagement, intimacy etc.)

Staff:• Using images• Using gestures

Problems

Callers• Disconnections• Misunderstanding of procedure

Staff:• Security• Inhibitions• Iniquity of service• Inappropriate images (e.g. cyanosis)• Inappropriate information requests• Usability (few examples only)

Summary / areas for further study

• Summary– Under-utilised but well received service– Full potential not exploited (i.e.images)– Perception of benefits different between caller

& nurse• Further study

– case study of condition-specific patient– suitability of media and information delivery– ‘social presence’ and value of communication

Bibliography

• Nicholas D, Williams P, Huntington P, Gunter, B. (2003) Broadband nursing: a multi-method evaluation of a one-way video-conferencing health information and advice service: 'In-vision'. Journal of Documentation 59(3) pp341-358

• Nicholas D, Williams P, Huntington P, Gunter B (2002) Broadband nursing: how have the public reacted to being able to talk to an on-screen nurse for advice? Library and Information Update the magazine of the Chartered Institute of Library and Information Professionals Magazine 1(4) pp50-51

• Nicholas D, Huntington P, Williams P, Gunter, B. Monopoli M (2002) The characteristics of users and non-users of a digital interactive television health service: case study the Living Health Channel Journal of Informatics in Primary Care 10(2) pp73-84