Plan of the Talk

1. Broadband NurseAn evaluation of a one-way video-conferencing health information and advice servicePeter WilliamsCIBER: City University[& David Nicholas; Paul Huntington; Barrie Gunter]

2. 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

3. 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

4. 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

5. ‘Living Health’ Service • Text based information database • GP appointments’ booking service • InVision - video nurse from NHS direct call-centre

6. Accessing InVision (1)

7. Accessing InVision (2)

8. Accessing InVision (3) Clicking on continue generates a “Session Request”.

9. Accessing InVision (4) Pressing the Red button now generates a “Cancellation”. Normally, this page would be seen for 20 - 30 seconds at most.

10. 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.

11. 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.

12. 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)

13. 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)

14. Findings: 1 Usage

15. 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) 150 10.9% • Service Closed (i.e. when no trained staff are on duty) 93 6.7% • Total Completed Sessions16311.8%

16. Session Breakdown 20 Aug 2001 - 17 Feb 2002 Direction of progression (100%) 43.7% 0% 6.1% 12.5% 14.6% 13.3% 0% 9.9% Number of users opening session (select OK on Home page) Users experiencing system failing to begin connection Users unable to begin session due to all operators busy Users whose session has timed out without connecting to a Nurse. Users successfully connecting to live operator Users disconnecting after receiving Ref # but before connecting to a Nurse Users cancelling session before Ref. # is returned System closed down/operator problems Users experiencing system failure during a connected session.

17. Session Requests 20 Aug - 30 Nov: 92 requests/wk 20 Aug - 17 Feb: 81 requests/wk Pilot end 81/wk

18. 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.

19. 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:

20. 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’

21. Findings: 2 Reasons for usage Note: findings compared to telephony-only survey by NHS Direct, Dudley call centre

22. For whom phoning?

23. 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%) • Diagnosis15 (23%) • General information (i.e. medicines that do not contain animal products etc.)9 (14%)

24. Did the Nurse show you…? 20.7% of sessions showed images (13.8% is a subset of the 20.7%)

25. Findings: 3 Opinion/attitude/perceptions

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

27. Was the advice helpful? 1 person

28. Why was the advice helpful? Multiple answers allowed One answer allowed

29. Caller Comments You feel reassured by her body language... 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 hospitals and the like. Comfortable, as it was in confidence… like a GP appointment Being able to see the nurse made me feel more relaxed Very good idea - ideal for outside surgery hours

30. Nurse Comments It saves a lot of explanation It’s great being able to just show something I wish I had remembered that image - but I didn’t think till afterwards If you just describe something many are bound to make mistakes ...

31. Perceived benefits Callers • Convenience (home doc etc.) • Seeing nurse (engagement, intimacy etc.) Staff: • Using images • Using gestures

32. Problems Callers • Disconnections • Misunderstanding of procedure Staff: • Security • Inhibitions • Iniquity of service • Inappropriate images (e.g. cyanosis) • Inappropriate information requests • Usability (few examples only)

33. 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

34. 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 Updatethe magazine of theChartered 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