Video mediated meetings with patients were introduced in outpatient care at a hospital in Sweden. New behaviours and tasks emerged due to changes of roles, work processes and responsibilities. The study investigates effects of digital transformation, in this case how video visits in outpatient care change work processes and introduces new tasks, in order to further improve the concept of video visits.Through real-time, social interactional features of preparing for and conducting video visits, the study examines clinicians’ perceived limitations and disturbances, and how the conditions between patients and clinicians may change when using video visits instead of face-to-face meetings in outpatient care.Qualitative methods have been used including 14 observations of video visits at two different clinics and 14 followup interviews with clinicians. Transcriptions of interviews and field notes were thematically analysed, discussed and synthesised into themes.Disturbances and limitations related to the technology were related to time; a flexibility to schedule the meeting unbound of place, frustrations when the other part was late for the scheduled meeting, and that more experienced users of video visits usually waited longer before logging in. They were also related to sound; problems getting the sound to work satisfactory during the video visits, and problems with the image. Disturbances and limitations related to the surroundings were related to both the patient’s and the clinician’s environment; the principle of video technology in itself may affect the experience and the content of the consultation, and the surrounding chosen changes the conditions for and reduces the participants’ field of view.We could see 1) a transformation of roles and responsibilities when turning from face-to-face meetings to video visits, 2) that video visits add new circumstances, with a risk of introducing disturbances and limitations, that in turn affects the content of the meeting, 3) that avoiding negative disturbances during a video visit, requires a sensibility from the clinician’s side as well as a trust in the patient’s judgement, 4) that both expected and unexpected disturbances and limitations during a video visit affect the clinician’s behaviour, feelings, the content of the meeting and how the clinician’s relate to the different components of the concept, and 5) that there is a change of roles introduced when conducting video visits, eg, the clinician taking the first line support if both (s)he and the patient encounter problems with the technology. Over the last few decades, telemedicine has evolved as a solution for the healthcare sector to meet the challenges of an increasing patient population ,2. One tThe technology used, together with its principles and procedures employed when conducting video visits, can produce limitations and add disturbances that may, positively or negatively, affect how the meeting is conducted and its outcome. A video visit implies a geographical separation between clinician and patient (cf ) with a The aim of this study was to explore the disturbances and limitations experienced by clinicians when conducting video visits and how these disturbances and limitations affected roles, content, and perceptions. We explored what happened when the space of care was spatially shared between two environments and mediated by video, with the overarching goal of improving the concept of video visits, thereby meeting the need for a more efficient care. The study was conducted in an outpatient care center at a university hospital in Sweden.The study was qualitative and explorative in its approach. Interviews with clinicians and observations of video visits were conducted to generate data. The focus was on the situatedness in the use of video visits and situated actions when clinicians conducted such visits. Additionally, informal and formal settings in everyday work and ad hoc individual conversations related to video visits were observed and used to understand the phenomenon of video visits and their role in a wider context.Theoretical perspectives in symbolic interactionism provided a source of inspiration and a starting point, with frameworks suitable for analyzing the social reality and understanding human behavior and human feelings. The social interaction can be influenced by moods, weather, locations, and environments. The individual defines the situation both consciously and unconsciously and human behavior is seen in relation to the whole context . DiversiClinicians develop skills based on physical consultations, and their face-to-face visits become the norm for clinical meetings . The cliIn our study, we explored video visits by gathering examples of disturbances, both negative and positive, and limitations . We examined what gave rise to the disturbance, how the disturbance was interpreted, and its consequences. This includes understanding the video visits as present situations happening in a context including space and place, even though the participants are located at a distance from each other.Ethical approval for the study was given by the Regional Ethical Review Board in Stockholm before data gathering (reference number: 2016/1027-31). The clinicians obtained written informed consent for participation and for publication  from patients, relatives, and guardians. Participants were offered video visits instead of physical meetings. The consent form was either sent by email or given by hand to the patient/relatives. The clinicians signed a written consent for participation following review by the researcher.Two patient flows were involved in this study, named Clinic A and Clinic B. Both clinics treated patients with obesity. The clinics had congruent goals, agendas, and philosophies for their treatment. The content of care was mainly based on a humanistic perspective of health and disease, with lesser focus on biomedical data such as weight and body composition. However, these variables were still used as treatment outcome assessments. Video visits at the clinics were part of a treatment program that included several consecutive meetings aimed at helping patients to successfully implement lifestyle changes. Clinicians supported patients in their efforts to achieve behavioral and lifestyle changes. Between visits, patients were asked to work actively on lifestyle changes by themselves. Both clinics shared the same view about using video visits as complements to face-to-face visits and for follow-ups. The staff consisted of doctors, nurses, psychologists, nutritionists, occupational therapists, and physiotherapists. Clinicians at Clinic B also had competence in cognitive behavior therapy. Differences between the clinics are described in The concept used for the video visits was developed for less complex meetings in outpatient care. The technology included an ordinary video conferencing tool with encrypted communication, capable of producing adequate quality for seeing and hearing each other and for sharing documents. The technology could not be used to connect sensors used for monitoring parameters, and the quality of the video was not high enough to provide details of, for example, skin issues. A complex video visit, such as when a neurologist needs to see small detailed movements during care for patients with Parkinson’s disease or demonstrate exercises to a patient , may reqIn preparation for the study, two clinics were selected to participate. They were identified from the second author’s work of introducing video visits in outpatient care settings at hospitals. One clinic was selected because it had successfully adopted the concept of video visits earlier in the year. The other clinic was selected because it had shown interest and carried out test video visits, but had not yet started. Two clinicians from the first clinic, already conducting video visits, and six clinicians from the second clinic, who wanted to start video visits, agreed to participate in the study.At both clinics, the staff selected patients or relatives for video visits. Video visits were only offered to patients who had physically presented to the clinic at the beginning of their treatment. The clinicians offered video visits to the selected patients either during a physical meeting or through a telephone contact. The patients had the opportunity to accept or decline video visits. During the study period, there were patients who declined. The clinicians who conducted the video visits had previously met face-to-face with the patients. Selecting patients for video visits and the criteria used in the process have been described in a paper sent for publication .If patients accepted a video visit, the clinicians asked them if they wanted to participate in the research study. The question was asked of the patient/relative during a face-to-face meeting, a phone call, or a previous video visit . The staff, patients, and any guardian provided written informed consent to participate in the research.The data collection consisted of a total of 13 observations and 14 interviews; see Each observation started before the actual video visit and included the time for the clinician’s immediate preparation. The researcher was located in the same room as the clinician and was visually and verbally presented to the patient/relative at the beginning of the video visit, giving each patient a chance to withdraw his or her consent. During the video visit, the researcher observed the meeting from a position out of sight of the webcam, that is, the patient/relative could not see the researcher. The observations were partly exploratory and partly structured. Some aspects, such as start and end time, patient’s location, and number of participants, were predetermined and noted in the observation protocol. These were combined with field diaries that contained the exploratory observation notes. The observations were not recorded, photographed, or filmed.The interviews were in-depth, contextual, and semi-structured and were conducted with the clinicians after, and in addition to, each video visit. Of the 14 interviews, 13 were conducted face-to-face and one by phone. One of the interviews occurred without an observation, since the patient withdrew consent to participate in the study as the observation was about to start. The interview was still conducted after the video meeting. The interviews were recorded and transcribed verbatim.In addition, the researcher attended formal encounters  as a passive observer and participated in informal gatherings , taking field notes to capture the clinical discourse and clinicians’ perceptions and thoughts about video visits and without interfering in the discussions taking place. All data were gathered during a contiguous period of 3 months during 2016.The analysis process followed a qualitative approach , in whicSpreadsheets were used to organize and sort the data. To find and keep track of patterns in the material, themes were separated into different rows in the spreadsheet, and each interview and the corresponding observation was sorted into different columns. Pieces of the text were sorted to the appropriate cells. The principle of spreadsheets was also used to analyze and find patterns in the quantitative data  planning aspects, external circumstances, and technical issues. The clinicians always sent the number and code for the web-based video room to the patient before the meeting took place, but the routine differed among the clinicians with regard to how far in advance they sent the code in relation to the scheduled meeting. Some sent the information when the meeting was booked, and some sent it the same day as the meeting. The patients learned their clinicians’ routines.In one of our observations, the clinician sent the information to the patient several hours later than usual. The information was actually sent after the meeting was scheduled to start. This caused the patient to become worried and confused about the time of the video visit . When a patient physically arrives at a clinic, he or she reports to the reception. This may give the patient a sense of security about not being forgotten. In another of our observations, the video visit started 20 minutes late because a previous face-to-face meeting ended later than planned. This was distressing to the clinician, who did not see any opportunity to notify the subsequent patient of the unexpected delay. When the meeting started, the clinician perceived frustration from the patient and relative. Further, the patient had plans after the meeting, leading to a shorter meeting than that for which the clinician had planned .Being late due to external circumstances could also be related to the weather or to technical problems:One of the clinicians at Clinic A arrived at the clinic 5 minutes before the video visit was scheduled to start because of heavy snowfall causing problems in the morning traffic. The clinician started to read the patient journal. Nine minutes after the scheduled time, the clinician entered the room dedicated for video visits, logged into the web-based video room, and noticed that the patient has not yet logged in. The clinician wanted to call the patient but there was no contact number with the hospital’s central server on the computer, and the patient’s phone number could not, therefore, be reached. Instead, the clinician had to take out the Siths card from the computer, walk back to her office to find the patient’s contact details on her own computer, and then go back to the video visit room and log in to the computer again. The clinician called the patient, who had still not logged in. It turns out that they were logged into different web-based video rooms, something that, in principle, should not be possible. After 23 minutes, they managed to connect. In this case, the meeting started late because the clinician was late and also because the patient was logged into the wrong meeting room. These delays caused a ripple effect of delays, and thus, frustration and stress were experienced by all participants. Valuable time was lost and the meeting was shorter than planned.If they were not delayed, the clinicians at Clinic A usually logged into the web-based video room approximately 4–10 minutes before the meeting was scheduled to start. The clinicians who were more experienced at using video visits (at Clinic B) usually waited longer before logging into the web-based video room but also gave the following, somewhat contradictory, explanation for logging in 2–5 minutes in advance:If I log in 5 minutes in advance […] then I may have replied to an email or so, but also 2 minutes, that is too short a time to start with something, and then you just sit there and look at the screen, which feels a bit meaningless.Clinic B, Int_11The same clinician noted in the interview that she became restless while sitting and waiting for the video visit to start. She likened it to waiting for a bus and stated that she starts to think about other things and then suddenly realizes that the patient has logged in. Another clinician, from the same clinic, reported similar reflections. She reportedly felt stressed if she logged in too early because she then had difficulties doing other tasks, since she needed to keep an eye on the screen to be able to see when the patient logged in .Another clinician reflected that, if a patient was delayed for a face-to-face meeting, then they could do other things because they were in their own office and could be notified by reception when the patient arrived. In a video visit, the clinician had to actively check the screen now and then while waiting .Hence, video visits introduced limitations related to time management while waiting for the patient to log in. One strategy clinicians at Clinic B developed to overcome this was to log in as late as possible.what?” more often. In some cases, system usability caused problems, in others, it was connectivity. In both cases, clinicians had to take on the role of first-line support, trying to figure out the cause of the problem: “The clinician asked if the patient has an icon for sound on the phone. The patient nodded and the clinician said: ‘try to push it […] I can see that the sound is not on, from your side” .On several occasions, there were problems getting the sound to work satisfactorily during video visits, affecting both the clinicians and the video visit itself. Problems with sound affected communication in that clinicians had to repeat themselves and ask “Problems with the sound caused irritation: “it’s happened so many times that the sound hasn’t been working and it is a frustration” . In one case, the clinician made a joke of it and blamed the bad weather and they then talked about a technical solution, discussing volume settings and differences between conducting video visits using a mobile phone and a laptop .Problems with the technology not working as expected created barriers to the adoption of video visits. At the same time, when the sound did not work as expected, clinicians created situation-based solutions to these in situ problems. At Clinic A, clinicians would bring a phone to the video visit room: “The sound didn’t work and it’s happened once before […] but now I’ve solved this by having a phone with a speaker during the video visit” . The in situ problem thus led to a pre-conceived notion of sound problems, for which the clinicians planned in advance. We observed that sound-related problems were shared with colleagues during breaks, resulting in clinicians who had never performed a video visit taking a phone when they began to carry out video visits.Video visits differed from phone consultations in that the clinician and patient could see each other. During video visits, the image was sometimes missing at the beginning of the visit or it sometimes disappeared during the visit for various reasons. This affected the clinician and the video visit in different ways.One example illustrates how this could affect the clinician: “If the screen closes down all the time […] if you have poor connectivity, it might shut down like that and it can be a bit annoying because then maybe you’re talking about that instead ‘oh, now you’ve disappeared, but now you’re back’” . In one case, the same clinician conducted a video visit and anticipated bad connectivity. She adapted the video visit to technical circumstances by planning the session’s content differently, knowing that visits like these tended to be “more choppy,” and she also lowered her own expectations; thus, the video visit became more “undemanding.”Video problems could occur if the user was inactive on the computer, resulting in a locked screen mode, but with the web-based video meeting room still running. The clinician and the patient/relative could still hear each other but not see each other. For a clinician new to video visits, this could be disturbing, not knowing what happened or how to get back into the meeting. To avoid this, the experienced clinician moved the mouse quickly and entered the log in code, without affecting the meeting.the patient’s surrounding, in the next section), but such a disturbance could also be caused by technology; for example, if the bandwidth goes down. Another reason for the patient/relative disappearing from sight involved the clinician sharing a presentation, eg, of a growth curve, or when a clinician opened a medical journal or calendar on the screen, thereby hiding the video conferencing window. This kind of planned disturbance could still cause inconveniences or confusion when the shared presentation was ended or the other windows were closed. The patient/relative could, if using a mobile phone or tablet, be in a different surrounding with other disturbances and limitations than before .In one of our observations, a patient/relative suddenly disappeared from the screen but it was not related to being inactive. In this case, it may have been intentional . The same clinician also said,You can kind of take part in their private life. Then, whether it’s important, I can’t say. I think it can have a kind of effect for the compliance … maybe becomes positive when I say... what a nice color, and you see that everybody becomes happy. It’s really something personal, and it’s just small comments... I think it can be important for compliance, but I don’t know if it has any effect on the treatment.”Clinic B, Int_13The clinician experienced this differentially in comparison to face-to-face visits and perceived it as a positive aspect of video visits. The extent to which the patient saw this as a positive or negative disturbance or limitation was not stated.the patient’s surroundings and the clinician’s surroundings. The surroundings are related to both place and space.We identified disturbances and limitations related directly or indirectly to the surroundings used during video visits, which are presented based on the themes Video visits imply that the patient and clinician are in geographically different locations. Using videos as a tool for communication brings a new field of view to the healthcare meeting: the patient’s/relative’s physical environment. When the clinician sees the patient in his or her environment and, at the same time, uses the sense of hearing, the patient’s/relative’s surroundings are brought to the meeting. What is happening in a specific situation, that can be both seen and not seen, is interpreted and affects both the clinician and patient, their actions, the content of the meeting, and its outcome.Hence, the principle of video technology, which makes it possible to see and hear, may affect the experience and content of the consultation, as can be seen in the following example:I’ve no idea, don’t ask me. ” They continued to talk about the weight gain, about what may have happened, and so on. Suddenly the screen turned black for a while and when it came back the audio on the phone was off (the phone was being used because of audio problems with the video connection). The clinician called the relative and they came back into the meeting, but soon, the screen again turned black, this time for a couple of minutes. When the clinician called back, the relative said they needed to end the meeting because the patient became sick and required care .The clinician is conducting a video visit with the relative of a younger patient. After 10 minutes’ discussion, it becomes clear that the patient has gained a relatively large amount of weight since the last meeting. When the clinician asks “why?,” the relative said, “In the follow-up interview, the clinician said that she found it difficult to be sure whether it was a technical problem that caused the interruption or it was caused intentionally by the relative or the patient because of an unwillingness to discuss his or her recent weight gain. The clinician said that she found it peculiar that the patient suddenly became sick, but since she could neither see nor hear the patient during the video visit, she did not know what was going on in the patient’s surroundings .In another example, the patient’s surroundings provided a space that was unknown to the clinician other than that the patient would be in school: The video visit began and the patient, a teenager, was outside. From knowing that the patient would be in school, the clinician assumed the patient was in the schoolyard. The clinician felt that the patient had a roving eye, and thus assumed the patient “felt uncomfortable in the situation and uncertain; either [the patient] was scanning the environment […] or was just uncomfortable with the situation of sitting and looking into the camera” .The clinician was not aware of whether there were other people in the surrounding area. However, the clinician’s assumption of a schoolyard may have affected the interpretation of the patient’s behavior, creating a sense of disturbance in the consultation: “I believe that [the patient] was perhaps a little bit stressed” . As a result, the clinician did not ask further questions about sensitive subjects and “did not stay with every question as long as usual” . Also, the clinician knew the patient was going back to class “so there was a time aspect as well, somehow the teacher was expecting him back.”The environment may be a disturbing component of the meeting, in an interplay with what the clinicians can see, what they interpret about the unseen environment from the patient’s behavior, and time, all of which are bound to the patient’s environment. These three issues affected the actions of the clinician and limited the content of the consultation. In some cases, the clinician asked beforehand where the patient would be during the video visit. In one case, the patient answered the video call when in a locker room. The clinician asked if they might be disturbed, but the patient, a teenager, said the risk of disturbance was low. However, the patient and clinician agreed to use a code word if someone entered the locker room during the video visit, so they could close down the meeting without the person entering understanding the meeting’s content.During one observation, the patient was in a parked car. Something happened during the video visit, something the clinician in the follow-up interview described as a “glitch,” which she interpreted as someone entering the car. Since the meeting time was almost over, the clinician ended it a little more quickly than she would have done if it had been a face-to-face meeting. The clinician noticed that she did not receive the same focus after the “glitch,” and she felt that the patient was indicating that the meeting time was almost over .In another example, the patient, a child, was participating in a video visit at home when all of a sudden the child looked to the side several times and began to smile and laugh. The clinician asked the patient if there was another person who wanted to participate in the meeting. The patient said the younger sibling’s name . The clinician perceived this as a disturbance and said that the patient made signs to the sibling to send them out of the room:I saw […] what happened there, talking about what you see and can’t see […] but then I wonder, [The relative] was clear with, ok now I’ll leave you […] you can sit in peace and quiet […], but now the sibling […] I could say that, the next time, maybe ask [the relative] […] to talk to [the sibling] and say that this is [the patients’] time so he doesn’t feel that [the sibling] is standing there and listening.Clinic A, Int_7These examples imply that the place itself may not only affect the meeting; rather, the meeting can be affected by events that occur in that place. Two of the interviews exemplified how the clinicians planned for this beforehand:You can prepare when you book the video visit, [and ask the patient] which environment do you feel safe in […] where do you feel you can talk freely? Is it at home or […] a private room at the library or whatever?Clinic A, Int_8To minimize moments of distraction in the same way as if you were meeting here, you close the space around you so it’s only you and the patient. If he was sitting in a kitchen with younger siblings around, then I would recommend that he goes to a calm place where it’s easier for him to focus. Whether it’s his room or anywhere else, that doesn’t matter.Clinic A, Int_7The clinicians at Clinic A all conducted video visits in one room dedicated to such visits, also used as a patient kitchen during face-to-face meetings. At Clinic B, the clinicians conducted video visits in their own rooms. This resulted in clinicians at Clinic A having to perform the extra task of double-checking the availability of the room before scheduling a video visit, something that was perceived as a disturbance or a barrier for video visits.A video visit adds in the patient’s and/or relative’s environment and surroundings, but through the video technology used, it also changes the conditions and reduces the patients’ field of view. For clinicians at Clinic B, who were using their own rooms and were more experienced, insights about the field of view also affected their behavior. For example, we observed two cases in which clinicians brought coffee into the video visit. When asked about this, the clinician stated that this would never happen if the patient had visited face-to-face as that would not be professional. However, since the clinician knew that the coffee was not visible to the patient, it was perceived as acceptable to have it in the room during the video visit.Another example was when a clinician took off her shoes during a meeting . In the follow-up interview, the clinician stressed that this was not something that would happen in a face-to-face visit; then, she would always keep her shoes on. Also, one clinician said that she did not need to bother about a clean desk, as long as it was out of sight of the patient: “they don’t see my desk and that’s pretty nice, because then I can have it a little messier” . She also noted not having to put private belongings somewhere else; a suitcase was standing in the middle of the room during the video visit and her coat was on a hanger. If a patient was visiting face-to-face, these objects would be hidden. This was seen as a part of being a professional, in the sense that patients should not be exposed to items from the clinician’s personal life including pictures, coats, and bags. Similarly, one of the clinicians at Clinic B said that when she used video visits, she used the opportunity to stand up at her (height adjustable) desk while using the computer. The awareness of the patient’s field of view and how the surroundings and behavior could change compared to a face-to-face meeting reportedly came with experience, when the focus was not on becoming familiar with the technology.Our results show that a number of disturbances and perceived limitations related to the technology and surroundings occurred during video visits. These, in turn, affected how both the clinicians acted before and during video visits and the content of the visits themselves. Disturbances and perceived limitations were added to the healthcare consultation when using video communication. These disturbances and perceived limitations were caused by the technology and the patients’ and clinicians’ locations during the consultation (cf ). Our fiFrom our results, we can see that place still matters when using telemedicine solutions (cf ). The chBoth the place and the patient’s feelings in that place are important. As long as the patient feels secure and comfortable with the situation, and as long as the clinician interprets the situation as such, the patient can be at home, at work, in school, outside, at the library, in a car, or at a bus stop. Therefore, the place itself may not be a problem, as long as the risk of interruption can be minimized. However, choosing a place outside may introduce disturbances and limitations to the meeting . Patients who are new to video visits may not be aware of how their choice of space may influence the meeting. Clinicians can guide their patients in choosing a place, but the final responsibility lies in the hands of the patient. We have observed patients who were in the schoolyard, in a car, and at home in the kitchen or the bedroom. Hence, the environment and specific place where the video visit is conducted is complex and is affected by many factors that need to be accounted for (cf ). We havThere is a responsibility to select and provide a secure and comfortable environment in which the video visit can be conducted. In traditional face-to-face meetings, this responsibility is entirely the clinician’s. However, introducing video visits transfers part of this responsibility to the patient, that is, to choose a space in an environment where the patient can feel safe and comfortable for the purpose of meeting. Video visits also introduce new environmental consideration, not only in terms of being able to see and hear each other, but also what may happen in those places.The clinicians video visit experience are aware of what can happen if the patient has not selected an optimal place for the video visit, and they can offer advice before a patient uses video visits for the first time. Clinicians who are only starting to use video visits as an alternative to physical meetings may be occupied getting everything to work, focusing on the technology, and may need support on this matter .The video visits take place in a specific situation during a treatment program, and every visit can be seen as a social interaction between the clinician and the patient. The care is patient-centered and the meetings are based on topics the patient selects. During a meeting, the clinician thus not only adapts the content of the video visit to the patient but also to other external circumstances, that is, parts of what is happening that are not planned in advance (cf ). TherefThe place, or rather what is happening in the place, that the patient has chosen can have a significant effect on the meeting and the treatment program cf ,13,15). ,15. 13,1The limitations of the invisible space at the clinician’s location may be an advantage for the clinician. The physical place or the room used for video visits does not have to be designed for patient visits. Only the space visible to the video camera needs to provide a professional clinical environment. Hence, there are fewer requirements for the environment that is not part of the meeting space. In addition, the opportunity to see the environment and context of the patient’s life was considered a positive consequence of video visits because it can provide insights into the patient’s personality and the feeling of gaining a closer contact with the patient. However, this may also affect the patient in making his or her home less of a private sphere .Implementing video visits in outpatient care requires new ways of working . Also, new tasks are introduced when using new technologies , and a new division of labor is introduced . These changes threaten and disrupt spatial, professional, and organizational orders in the work and organization (cf ). These In general, video visits, in comparison to face-to-face meetings, provide flexibility in time and space. This flexibility means that video visits may increase clinicians’ power over their own working time, giving them more control over their working situation. In the long run, this could reduce stress. However, video visits may also lead to stress if the visits are not easy to carry out and can thus lead to disturbances and limitations. Our analysis showed that being late caused an in situ disturbance and a perceived limitation for the clinician of not being able to communicate the delay to the patient, since there was no process or functionality for this. If the patient had been physically at the clinic, a receptionist or secretary would probably have been able to inform the patient about the delay. The feeling of not being able to notify the patient was stressful and frustrating for the clinician. The clinicians also sensed frustration from their patients in that specific situation. Hence, the virtual meeting place lacks functionality that is usually available in a physical meeting place, such as a meeting room with all its services. The place itself is important and affects the satisfaction, attitudes, and work performance of all the participants, not only the patient (cf ).The awareness of being late or being on time is reciprocal. When the patient was not logged in at the scheduled time, this created uncertainty regarding if the patient had forgotten the video visit, the patient had not received the credentials to access the virtual room, or the patient was experiencing problems with technology. This uncertainty may have increased the need for the clinician to be on time and thus reduced temporal flexibility. Logging in earlier imposed a limitation on performing other duties, which in some cases led to feelings of stress and restlessness. The clinicians who were comfortable with the technology and with video visits, and who knew that their patients could also operate the technology, preferred to log in only a couple of minutes before the scheduled time of the video visit. Thus, temporal flexibility increased as participants became more comfortable with the concept.Flexibility of place is more obvious, but has different dimensions. While logged in and waiting for the patient to log in, the clinician’s spatial flexibility and opportunities to engage in other tasks are reduced to the space captured by the video conferencing system. To notice when the patient logs in, the clinician needs to pay attention to the video conferencing window on the screen, which limits the clinician’s ability to engage in other tasks. Such limitations can be reduced if the clinician is experienced and is using his or her own office, making it possible to complete other tasks while waiting. Technical functionality could further reduce these limitations, for example, by sending a notification when the patient has logged in.Flexibility of time and place is hence relative and exhibits different dimensions that relate to the clinician’s experiences while using video visits. This therefore affected the selection criteria used when choosing patients who are considered suitable for video visits . This also needs to be considered when developing tools for, or the process of, performing video visits.Even when the clinician and patient were both logged in on time, difficulties with managing the technology, which were not unusual, could delay or otherwise affect the start of the consultation session (cf ). When tDisturbances and limitations, whether known or unknown beforehand, also affected the expectations and experiences of the video visit, for both the clinician and the patient. This in turn affected the content of the meeting. Anticipated disturbances and limitations were based on the clinician’s own experiences or on their colleagues’ thoughts and experience. Both anticipated and unanticipated disturbances and limitations affected the clinician’s behavior and feelings, and the content of the meeting and how the clinicians related to the different components of the concept: the technology, his or her role, the patient and his or her role, the surroundings, and the content of the treatment. Through experience, clinicians developed know-how that they were able to take to the next video visit and share with their colleagues. This experience was also used when developing selection criteria to include or exclude patients for video visits. The same know-how should be used to develop advice for the patient to use when he or she selects the place for the meeting (see above about the transformation of responsibility). Clinicians could provide this as a hand-out when offering video visits to patients.Know-how about disturbances and limitations made it possible to adapt the video visit in advance to the technical and practical circumstances and changed personal expectations about the video visit and its outcome. Adapting the video visit to known circumstances is usually based on an individual’s or colleague’s experience of sudden disturbances; for example, knowing that audio will occasionally fail, clinicians always take their mobile phones to the meetings.Further research is required to understand the full effects of video visits. Our study provides one piece of the puzzle and can guide other researchers in studying the disturbances and limitations of the digital transformation in similar or other settings. The transformation of responsibility and a focus on patient empowerment are interesting topics in today’s digital world that need further exploration. Another area that may be relevant to study, which is not addressed in this paper, is ergonomics, especially when the consultations are more complex, with a need for more detailed information.


Recent data suggest that most people experiencing alcohol problems have problems of mild to moderate severity. Relative to alcoholics, these drinkers have a shorter problem-drinking history, greater social and economic stability, and greater personal resources. This article describes a cognitive-behavioral treatment approach designed specifically for problem drinkers with low levels of physical dependence on alcohol who choose to reduce their drinking. After describing various drinking-reduction techniques, the article reviews empirical evidence for drinking-reduction training. The increasing availability of drinking-reduction interventions holds considerable promise for reducing alcohol-related dysfunction among problem drinkers. Ninth Special Report to the U.S. Congress on Alcohol and Health . This consideration may take into account the history of the drinker, an assessment of physical dependence on alcohol, and any medical or other drawbacks to moderate alcohol use see , such asTo be able to monitor and evaluate changes in drinking, problem drinkers first must be aware of the quantity of alcohol they drink and any relevant drinking patterns. Thus, two central components of the drinking-moderation approach are daily self-monitoring of alcohol consumption and goal setting. Self-monitoring may consist of simply recording the number of standard drinks consumed for each drinking occasion and calculating weekly totals, or it also may include monitoring the duration of drinking; drinking situations, companions, and consequences; and use of reduction strategies.The second fundamental strategy in drinking-moderation training is the setting of specific drinking-reduction goals. Ideally, drinking-reduction goals are selected by the drinker to maximize motivation, personal control, and responsibility, although “safe” drinking guidelines are also typically provided for the drinker to take into consideration. Goals typically include a maximum number of standard drinks per week, day, and drinking occasion as well as the desired frequency of abstinent days per week. More detailed goals, based on the individual needs of the drinker, may include no drinking or limited drinking during high-risk situations , a maximum drinking rate , and eliminating or changing beverage type or strength . For drinking-reduction goals to be feasible, it may be necessary for the drinker to set a series of short-term drinking-reduction goals, such that attaining each short-term goal brings the drinker closer to his or her long-term goals. Although specific moderation goals will vary for each drinker, the overarching goal for all drinkers is to reduce alcohol consumption and, when alcohol is consumed, to minimize alcohol-related risks.With self-monitoring and goal setting as a foundation, drinkers learn and practice a variety of cognitive-behavioral strategies see  for chanWith regard to gauging treatment response, it is difficult to provide specific guidelines that are appropriate for all problem drinkers. Instead, response to treatment is most appropriately assessed by the client and therapist in the context of the drinker’s pretreatment drinking history and individualized alcohol-consumption goals. Outcome may be conceptualized in terms of drinking frequency , drinking quantity , a weekly goal , lack of negative consequences from drinking and, perhaps most important, lowered risk for future problems from drinking. The authors’ clinical experience suggests that some clients who are unable to reduce their drinking and their risk for drinking-related problems after 2 to 3 months of focused treatment become amenable to more intensive and abstinence-based treatment.Empirical evaluation of the effectiveness of drinking-reduction training for problem drinkers has taken place during the past several decades. One program of research by Miller and colleagues at the University of New Mexico involved a long-term followup of four samples of problem drinkers who received moderation treatment based on goal-setting and self-monitoring strategies . OutcomeSanchez-Craig and her colleagues  have evaAlthough no single, strong predictor of successful response to drinking-moderation treatments has been identified, several client characteristics frequently emerge as having some predictive value . In thisDrinking-reduction interventions appear to have particularly positive benefits among problem-drinking women. Three reports , 1996 haAs the previous review has indicated, empirical research on cognitive-behavioral drinking-reduction approaches indicates that these strategies are useful in helping problem drinkers reduce their alcohol consumption. Research has examined the effectiveness of modifying drinking-moderation training to bibliotherapySince 1980, 10 studies have evaluated the use of bibliotherapy as a drinking-reduction intervention with problem drinkers. The self-help books used in these studies typically have included instructions on self-monitoring, goal-setting, and drinking-reduction strategies e.g., .In 5 of the 10 studies using bibliotherapy to reduce alcohol consumption, bibliotherapy was compared with more intensive, therapist-directed treatment. In four of the five studies , a behavIn four other studies, client use of a self-help manual and/or materials on how to reduce drinking was compared with receipt of general advice and/or information on alcohol effects. In each case, persons receiving the self-help materials had superior outcomes to persons receiving the general information packets .Finally, in the 10th study, In a related study, The administration of interventions via the telephone has been used for many years as an adjunct to the traditional provision of health services . As described earlier, Several evaluations of drinking-moderation interventions e.g.,  have incThree additional modifications and enhancements to drinking-reduction treatment are under investigation in the authors’ research: a program specifically designed for women, a program that includes involvement of the drinker’s spouse, and an outreach program for heavy drinkers in rural areas. The rationale for and the treatment components of each of these programs are described briefly in the paragraphs that follow.The research reviewed earlier in this article indicates that a number of women experience alcohol-related problems and that interventions focused on drinking reduction appear to be especially effective for heavily drinking women. One research effort in this area  has focuSpouse-involved treatment has been investigated as a treatment enhancement for alcohol-dependent populations e.g., . InvolviPeople living in rural areas—representing approximately 25 percent of the U.S. population—face a variety of barriers to health care services. Those barriers include geography, no or little insurance, poverty, and limited access to public transportation . FurtherEpidemiological research indicates that alcohol use is associated with negative consequences among significant numbers of drinkers and that most of those drinkers experience problems of mild to intermediate severity. For many problem drinkers, interventions focusing on drinking moderation are both palatable and effective. Indeed, some data e.g.,  suggest


Purpose: Alcohol use during pregnancy is a significant public health concern. Nearly all U.S. states have enacted policies targeting alcohol use during pregnancy, but there has been little research examining their impact, particularly across racial/ethnic groups.Methods: Using data from the Behavioral Risk Factor Surveillance System and about eight state-level, pregnancy-specific alcohol policies from 1985 to 2016, the aim of this study was to examine the differential effects of these policies on drinking among pregnant women by race/ethnicity.Results: We found evidence of differential effects for priority treatment, prohibitions on criminal prosecution, and civil commitment policies. In relation to priority treatment policies, effects benefited versus harmed different racial/ethnic groups depending on whether the priority treatment policies were for pregnant women only or if they gave priority to both pregnant women and pregnant women with children.Conclusions: Findings from this study suggest that benefits and harms from these policies do not appear to be equitably distributed across different racial/ethnic groups. Research considering the impact of alcohol/pregnancy policies should consider differential effects by race/ethnicity. By 1990, 20 states had at least one alcohol/pregnancy policy; by 2013, the number of states grew to 43.13 Supportive policies provide information, early intervention, or services. Punitive policies use coercion to compel behavior change. Both types could reduce drinking, but punitive policies could also deter pregnant women from disclosing use to those who could help them reduce or stop drinking.15 Although both supportive and punitive alcohol/pregnancy policies have increased over time, state-level policy environments have become increasingly punitive.11Scholars have characterized alcohol/pregnancy policies as supportive or punitive .12,13 Su16 Our own research found that although the intent of alcohol/pregnancy policies may be to reduce drinking during pregnancy, very few policies do, and there is little consistency across drinking outcomes. MWS and CACN policies were associated with decreased drinking during pregnancy, but PTPWC was associated with increased drinking.Despite the fact that alcohol/pregnancy policies have been in effect for 40 years, little research examines their impact. Cil found evidence suggesting that MWS may be associated with decreased drinking during pregnancy.17 This study examines differential effects of alcohol/pregnancy policies on drinking among pregnant women by race/ethnicity.Prior research has not examined potential differential effects of alcohol/pregnancy policies across race/ethnicity. Previous findings for the whole population could mask differential effects, showing up as no overall effect because effects are in opposite directions or because policies only affect subgroups. Investigating potential differential effects is also important because research has emphasized that population-level interventions that improve health overall do not necessarily reduce (and may increase) disparities across racial/ethnic groups.18–20 In addition, being reported to CPS and having a child removed is more common among Black than White and Hispanic women.21–23 Fears about CPS may thus differentially decrease disclosure of alcohol use in settings where disclosure may facilitate access to treatment and other services, thereby leading Black and Hispanic women to be less likely to receive help. Thus, we expect that health benefits of alcohol/pregnancy policies  will be greatest among White women and that, to the extent that alcohol/pregnancy policies have negative health effects , they will be greatest among Hispanic and Black women.Our study explores several general hypotheses. Approaches to population health that rely on individual agency and ability to apply knowledge and information to one's own behaviors, such as warning signs, may increase disparities.This study uses data from the following sources: Behavioral Risk Factor Surveillance System (BRFSS) data from 1985 to 2016 for alcohol outcomes, race/ethnicity, and individual-level control variables; NIAAA's Alcohol Policy Information System (APIS) and other legal databases for alcohol/pregnancy policies; and secondary sources for state-level characteristics.5–7 Participation rates were more than 70% in 1993 and closer to 50% through the 2000s. Our analytic sample consists of female BRFSS respondents of reproductive age (age 18–44) who indicated that they were currently pregnant and provided data on drinking, pooled across 1985–2016 .BRFSS is an annual telephone survey that tracks health status and health behaviors of U.S. adults. It has been conducted annually since 1984, with pregnancy status assessed since 1985. BRFSS has included alcohol use questions since the first survey, although alcohol data were not collected during even years in the 1990s. The CDC has used BRFSS data for national estimates of drinking during pregnancy since 1991.24 Specific alcohol/pregnancy policies tracked in APIS include policies pertaining to CC, legal significance for CACN, PCP, PTP, PTPWC, RRDTx, RRCPS, and MWS. APIS data were augmented with original legal research using Westlaw and HeinOnline, two online legal databases. The process for obtaining and coding these data is detailed elsewhere.11APIS provides information on alcohol-related policies in the United States.25 and original legal research.State-level characteristics were obtained from secondary sources, including U.S. census, U.S. CDC, APIS, National Highway Traffic Safety Administration, National Beverage Control Association, published research,3 BRFSS alcohol consumption data are measured for past 30 days. We created indicators of: (1) any drinking ; (2) binge drinking ; and (3) heavy drinking  Although alcohol consumption questions were asked consistently, there were some question wording changes over time. Our modeling approach (fixed effects for year) controls for measurement changes.Drinking outcomes were selected based on the official U.S. recommendation of abstinence from alcohol use during pregnancy and literature finding increased risks of poor outcomes with binge and higher volume drinking.State-level alcohol/pregnancy policies included the five supportive and three punitive policies described earlier. Each policy is dichotomous, coded as 0 if it was not in effect for a state in a given year and 1 if it was in effect for a state in a given year.BRFSS queries both ethnicity and race; responses were used to categorize respondents as: White (reference), Black, Hispanic, or Other. The Other category included non-Hispanic respondents who endorsed Asian/Pacific Islander, Native American/Alaska Native, Mixed race, or Other and those for whom race was missing (including Don't Know).Individual-level covariates from BRFSS included age , marital status , education , income , tobacco , and physical activity .State-level covariates included state- and year-specific poverty (continuous), per capita cigarette sales , and two general population alcohol policies on which data are available for the study time period: Blood Alcohol Concentration laws  and indicators for states with retail monopolies on wine or spirits (dichotomous).Although our sample included over 57,000 pregnant women, small cell sizes for some racial/ethnic categories, rare drinking outcomes, and the overall complexity of models prohibited running models stratified by race/ethnicity, an approach that could help isolate effects of policies for specific subgroups. Instead, to illustrate effects for subgroups, we calculated predicted probabilities/predictive margins of outcomes when policies were and were not in effect and confidence intervals around average marginal effects (MEs) of policies by race/ethnicity in sample-weighted logistic regression models testing interactions of each policy and race/ethnicity for each outcome.29 Model coefficients were expressed as odds ratios (ORs), and we conducted Wald tests (χ2 distribution with 3 degrees of freedom) to examine overall effects of interaction terms and to determine whether differential effects of policies by race/ethnicity were present. Analyses were conducted in Stata v.15.Models  included fixed effects for state and for year and adjusted for individual- and state-level covariates, including all other alcohol/pregnancy policies. Consistent with prior research examining effects of state-level policies on individual behavior with BRFSS data, standard errors were adjusted to reflect clustering by state.The majority of the analytic sample was White (70.1%); the next largest racial/ethnicity category was Hispanic (11.9%). The remainder was split between Black (9.4%) and the Other category (8.7%). A little more than a 10th of the sample (11.1%) endorsed any drinking; 2.2% endorsed binge drinking; and 2.2% heavy drinking. About half (47.2%) were living in states when RRDTx were in effect; 6.7% were living in states when CC policies were in effect. The percent exposed to other policies was in between. The unweighted distribution of the sample by race/ethnicity and policy exposure for each outcome is shown in p=0.037), Hispanics , and the Other category . As indicated by the main effect of MWS in p=0.023). Although the ME on binge drinking was greatest among Hispanics, the relationship between MWS and binge drinking was only marginally significant relative to Whites , and the overall effect of the interaction was not statistically significant.p=0.014) and decreased probability of any drinking among Hispanics . Based on the overall test of the interaction, there was evidence of differential effects of PTP on any drinking . Relative to Whites, PTP was associated with increased odds of any drinking among Blacks  and decreased odds of any drinking among Hispanics .PTP was associated with increased probability of any drinking among Blacks  and Hispanics  but decreased probability of any drinking among Blacks . PTPWC was also associated with decreased probability of heavy drinking among Blacks . There was evidence of differential effects by race/ethnicity on any drinking . As indicated by a significant main effect, PTPWC was associated with increased odds of any drinking for Whites . Relative to Whites, PTPWC was associated with decreased odds of any drinking among Blacks . Although the increased probability of any drinking was largest among Hispanics, PTPWC was not associated with significantly increased odds of any drinking among Hispanics relative to Whites. There was no evidence of differential effects of PTPWC by race/ethnicity on heavy drinking, despite the significant ME for Blacks.PTPWC was associated with increased probabilities of any drinking among Whites . They were also associated with decreased probability of any drinking among Blacks  and increased probability of binge drinking among the Other category . As indicated by a significant main effect, PCP were associated with decreased odds of any drinking among Whites , but there was no evidence to suggest differential effects on any drinking by race/ethnicity based on the test of the interaction.PCP were associated with significantly decreased probability of any and heavy drinking among Whites =16.54, p=0.001] and heavy drinking . Relative to Whites, PCP among the Other category were associated with increased odds of binge drinking . As indicated by a significant main effect, PCP were associated with decreased odds of heavy drinking among Whites ; relative to Whites, PCP were associated with increased odds of heavy drinking among those in the Other category .There were significant interactions between PCP and race/ethnicity for both binge .CACN were associated with significantly decreased probabilities of binge and heavy drinking among Blacks  Significant interactions were present in models examining binge  and heavy drinking . Relative to Whites, CC was associated with decreased odds of binge drinking  among Hispanics. CC was also associated with a decreased odds of heavy drinking among Hispanics  relative to Whites.CC was associated with significantly decreased probabilities of any and binge drinking among Hispanics  to be stronger for White than Black and Hispanic women and health harms from these policies  to be stronger for Black and Hispanic than White women. Some findings for supportive policies support this pattern, for example, White, but not Black, women reporting less binge drinking when MWS were in effect ; Black, but not White, women reporting more any drinking when PTP is in effect; and White and Black, but not Hispanic, women reporting less any drinking when PCP is in effect . Other findings do not support this pattern: Hispanic women benefited similarly to White women when MWS were in effect and benefited more than White women when PTP was in effect. This pattern suggests that the general hypothesis may apply for White versus Black women for supportive policies, but does not apply to Hispanic women.21–23 respond to this threat by reducing drinking. Black and Hispanic women could also be less likely to report their drinking when these policies are in effect, out of fear of punishment. This explanation is supported by previous research that found increased adverse birth outcomes and decreased prenatal care utilization when punitive policies were in effect.30 Future research using measures beyond self-reports can help disentangle this pattern. These findings must be interpreted with caution due to smaller proportion of Hispanics in the sample and the relative rarity of CC policies. Furthermore, CACN and CC policies are problematic on ethical grounds31; any reductions in self-reported drinking with respect to punitive policies must be investigated with more robust measures of health outcomes and other measures of health benefits that may offset inherent harms.For punitive policies, however, findings do not support this hypothesis. While White women's drinking is not affected by CACN or CC, Black and Hispanic women reported less drinking when CACN policies were in effect and Hispanic women reported less drinking when CC policies were in effect. This pattern suggests that Black and Hispanic women, who may be more likely than White women to be punished for alcohol use during pregnancy,While not related to main hypotheses, the pattern of findings for different Priority Treatment policies is worth noting. In addition to findings in opposite directions across race/ethnicity for PTP only, there were also findings in opposite directions across race/ethnicity for PTPWC. However, patterns differed across priority treatment policies; White and Black women benefited from different priority treatment policies. This suggests that different priority treatment policies benefit versus harm different subgroups, perhaps by giving priority to some groups but not others, and that bringing children to treatment may be especially important for Black women. Additional research could explain this pattern and assess whether the pattern could be addressed through other mechanisms, such as increasing treatment availability for pregnant women.To our knowledge, this is the first study of differential effects of a range of alcohol/pregnancy policies on drinking behavior by race/ethnicity, despite such policies being in effect for over four decades. Limitations include limited numbers of pregnant women in some racial/ethnic categories exposed to some policies; self-reported alcohol use measures that could involve differential underreporting of alcohol use due to social characteristics and studied policies; and no measures of policy enforcement or women's awareness of policies. In addition, alcohol use during pregnancy is not the only health outcome related to alcohol/pregnancy policies. Research should examine differential effects on outcomes such as prenatal care, treatment utilization, and birth outcomes.Research considering the impact of alcohol/pregnancy policies should consider differential effects by race/ethnicity, as subgroup analyses indicate that benefits and harms of policies do not appear equitably distributed across race/ethnicity.


IntroductionThe use of telemedicine by deployed healthcare providers to improve patient care has been increasing in recent foreign conflicts and humanitarian missions. These efforts have mostly been limited to email consultation with long response lag times. The United States Military has developed several modalities of telemedicine for use in austere environments, ranging from video conferencing, email, and store-and-forward technology. As of now, these efforts have required large pieces of equipment and many technical support personnel and have a delayed response time. Our study aimed to test the overall feasibility of use, the effects on time to intervention, and user confidence in a highly portable, real-time video set-up to aid in teleconsultations at the early stages of care for a simulated traumatic injury.Materials and methodsSubjects or operators taking direct care of the simulated patient were junior emergency medicine (EM) residents or military trained medics. Video teleconsultation was completed by either senior EM residents in their final year of training or board-certified EM physicians. The subjects taking direct care of the simulated patient were blinded to whether their video device was actively sending images or not. All participants communicated verbally using hand-held radios. The total number of interventions and time to event analysis was completed and survey data were collected, assessing confidence levels on procedures performed and patient care. ResultsWe demonstrated the accessibility, ease of use, and overall practicality of this telemedicine platform. A trend was found towards decreased time to evacuation for patients with a live video feed. Alternatively, the data showed no significant difference in the addition of video as opposed to solely radio in terms of the number of interventions, time to interventions, or operator or teleconsultant confidence in the care delivered or procedures performed.ConclusionsThis study demonstrated the overall feasibility and ease of use of a highly portable telemedicine platform with live video capabilities. A trend was found toward earlier evacuation decisions when using the live video. Follow-up studies may consider examining more challenging simulations or prolonged field care utilization of this technology. The recent US military's worldwide mission has increased to include more remote and austere regions, requiring complex and commonly prolonged medical care provided by medics -2. IncreTelemedicine is not a new technology; rather, it was largely developed by the National Aeronautics and Space Administration, Lockheed Martin, and the Indian Health Services in the 1970s. These organizations teamed up to provide real-time video, data, and audio interaction in an attempt to extend the capabilities of modern medicine to rural settings . EvidencThe US military developed several modalities of telemedicine for use in austere environments, ranging from video conferencing and store-and-forward technology to the application of virtual reality technologies to educational and clinical scenarios -9. An imThis particular SMART team was a US army unit designed for short duration deployments and included the equipment necessary for audio, video, and document transmission in austere locations. This team set up low-bandwidth satellite equipment to help mobile army surgical hospital teams in austere environments utilize email and X-ray telemedicine services. While extremely helpful, this required a significant amount of equipment, specialized training, and staff. The drawbacks to this team were not insignificant; it required a technology specialist on site, a portable power generator, a color scanner printer, and specialized training for the deployment of the specific team . AnotherPositive impacts during various deployments to date, as well as evidence from myocardial ischemia and stroke data, show that telemedicine, if utilized correctly, can increase access to specialty care, improve health outcomes, and can avoid unnecessary evacuations -4,10-12.This pilot feasibility study differs in that the video technology involved the use of a single helmet camera (GoPro) with real-time video, a phone and tablet with data/voice capability, a two-way radio, and no technology support specialists on site. This study sought to test a “plug-and-play system” that would fit in a small bag, where the deployed medical provider received audio feedback from the teleconsultant, and the consultant could visualize the condition of the patient in real time via a helmet camera. To date, there are no such systems available or studied. There is also scarce literature as to the use of real-time helmet cameras in the medical field.The goal of the study was to determine the overall feasibility of a light-weight, portable, real-time video teleconsultation system. The secondary outcomes of this study were to determine the impact of a real-time, video feed teleconsultation on the completion of critical actions while caring for a simulated trauma patient, impacts on patient evacuations, and provider confidence at the point of care.This was a double-blinded, within-subject crossover trial. The study took place in a level 1 trauma center with real patient rooms converted for simulation purposes. Subjects participating in the simulation comprised medics, medical students, and junior resident EM physicians acting as hands-on operators along with senior EM residents in their last year of training or staff EM physicians acting as teleconsultants. Informed consent was obtained for all 25 participating subjects.Two similar simulation cases were created and involved commonly seen traumatic injuries, including an extremity injury with active hemorrhage and a thoracic injury causing a pneumothorax Figure .The operators completed the two simulation cases with a proctor in the room. All participants were allotted 10 minutes per case, at which point the simulation was ended. They had access to similar basic medical equipment, fluids, antibiotics, blood products, and ultrasound.The two simulation rooms were not visible to the teleconsultant other than by the operator helmet video. The camera was set up at a wide point of view at 170 degrees with 4K resolution at 60 frames per second and utilized Bluetooth, along with either wireless or cellular signals for connectivity. The teleconsultant was given a portable tablet with a high definition screen. Image delay was less than one second and only limited by the hospital network or cellular data service. Both the camera and the tablet were dust-proof, shock-proof, waterproof, and had battery lives of four to eight hours depending on usage. The cost of the telemedicine equipment was under 1000 dollars Figure .The operators always had access to the teleconsultant by two-way radio. The intervention arm had the helmet-mounted camera transmitting real-time video to the teleconsultant. The operators always had the helmet camera attached and turned on but were not told if live images were being sent to a teleconsultant. The teleconsultant was advised that they could not tell the operator if they had a video feed during the case or ask them what they were seeing.During the simulated cases, each operator was evaluated on various patient outcomes to include: time to identification of life threats, time to critical interventions, and time to evacuation decision. Participants were surveyed in various aspects of the intervention, including video quality, confidence in the technology, and confidence in decision-making. Data were analyzed by a statistician, blinded to the use of video, using the Cox-proportional hazards model.There were no technical difficulties encountered during the simulated trauma cases. This included when the hospital wireless signal was not functional and the equipment ran solely on cellular data for video transmission. No significant difference was found with the addition of video as opposed to solely two-way radio communication in terms of the number of interventions or time to interventions Figures -4.There was a trend in most cases, favoring those with video to perform procedures faster and to evacuate more quickly. In cases without video, 14 patients were evacuated in the maximum allotted time (10 minutes), as opposed to 18 cases with video. This would imply a delay in evacuation when the teleconsultant had no video feed. The subgroup analysis based on operator level (medics vs. junior physicians) revealed no significant difference. There was no significant difference in operator or teleconsultant confidence in terms of patient care or procedures performed .Telemedicine studies have demonstrated improved patient care, health outcomes, and confidence level of providers -4,10-12.Of note, there were no technological difficulties during the study, and video clarity was not compromised even with a wireless network disruption. Portability was tested by utilizing both the hospital wireless network and cellular data for connectivity. It is envisioned that a system like this could be utilized now, with EMS services in areas that have 4G cellular connectivity. This could give the hospital-based medical team time to prepare for a sick patients' arrival or give additional medical guidance to EMS units. As global satellite technology continues to advance in speed and size of data transmission, it is easy to anticipate a similar system being utilized in austere settings, even with limited or poor cellular access. Further feasibility studies are required for this to become a reality.There are multiple reasons that may have led to this studies lack of significant differences in patient outcomes. This was designed as a feasibility study and was limited in terms of the number of participants and not powered to look for significant differences in outcomes. The simulated injuries were very apparent and straightforward, which may not have challenged the operators enough, leading to less reliance on the teleconsultant. In addition, all of these operators had undergone tactical combat casualty care training within the past two years. This is a military course designed to prepare personnel for the initial phase of resuscitation . As suchIt was unclear from this study why the teleconsultants did not feel more confident with live video images of the simulation. Prior studies on telemedicine have shown that healthcare providers using telemedicine tend to believe it improves health outcomes and the care provided -16. ThisFurther study on this topic should include a larger subject group as well as more complex simulated injuries and illness. It may also be targeted towards prolonged field care, for example, intubated patients with multiple injuries and critical care needs in simulated, austere environments or with prolonged transport times. Additional study is also needed to examine the feasibility of this equipment in real-world settings, such as the real-time video feeds of traumatically injured patients prior to their arrival at trauma centers.LimitationsAs with many pilot studies, this study utilized a small group of subjects in a short time frame, limiting its power and external validity. Also, today’s live-feed video and wireless technology are changing rapidly such that in the time frame it took to complete the study, the camera used had already undergone two iteration changes by the manufacturer, with live-feed upgrades. The utilization of both wireless and cellular data to stream real-time video demonstrates this system’s remarkable adaptability but also limits its widespread use to areas with this type of data connectivity.Telemedicine will continue to be integrated into the healthcare system and help meet challenging medical needs. To date, most telemedicine systems require bulky, expensive, and stationary equipment. This study demonstrated the overall feasibility of using portable, lightweight, real-time video technology in teleconsultation. Further research on the portable, real-time video teleconsultation of acutely ill patients is needed to better assess how this resource could best be utilized in austere settings.


Cognitive-behavioral theories explain alcoholism as a learned behavior that can be changed using the same behavior modification interventions employed to alter other learned behaviors. Treatment interventions teach clients the skills they need to confront or avoid everyday situations that may lead to drinking. Understanding what motivates people to drink abusively involves knowing their drinking behaviors and patterns and their perceptions, or cognitions, about themselves and about alcohol. Cognitive-behavioral psychology incorporates all of these elements, expanding the basis of traditional behavior theory beyond an exclusive focus on observable behaviors to include thoughts and emotions. Although it has broadened the scope of behavior theory, this perspective still employs many behavioral techniques to help clients who have psychological problems to change. As applied to alcoholism,Behavioral approaches deal exclusively with observable behaviors and the observable antecedents and consequences that control behavior. Behavioral approaches do not consider unobservable events, such as thoughts or emotions, that a therapist can know only through the client’s self-reports or through inferences from the client’s behavior.Cognitive-behavioral approaches, on the other hand, freely include internal events, such as thoughts and feelings that are known only through self-reports, in conceptualizing the factors that precipitate and maintain behavior. These approaches make use of learning techniques  to modify the client’s behavior, thoughts, and feelings.Cognitive-behavioral theory views alcohol dependence as a maladaptive means of coping with problems  or meeting certain needs. From this point of view, alcoholic drinking is a sequence of learned behaviors acquired in the same manner as any other learned behaviors: through imitating role models, as a result of experiencing the positive effects of alcohol , or based on expectations that alcohol will have one or more of these effects . After rIn addition to the view of alcoholism as a learned phenomenon, other theories have been developed to account for its origins. One of these focuses on genetics as a factor in the development of alcohol dependence. Even from this perspective, however, the way in which a genetic vulnerability is expressed is dependent upon a person’s psychosocial experiences . As a reThe cognitive-behavioral approach to alcoholism treatment focuses on the factors that precipitate and sustain drinking. Antecedents are the events that occur prior to drinking and either set the occasion for it or initiate a chain of behaviors that culminates in drinking. Different types of antecedent factors may lead to a person’s drinking . They caOther factors may contribute to a client’s alcoholism by maintaining the drinking behavior pattern after it has begun; these include various positive consequences that reinforce drinking. Like the antecedents, consequences can be grouped into several categories: social, such as praise from friends; emotional, such as reduced anxiety or enhanced emotional expression; cognitive, such as increased positive thoughts about oneself; and physiological, such as decreased pain or reduced withdrawal symptoms .Cognitive-behavioral treatment addresses these events that occur after drinking. It involves arranging alternative, less desirable consequences for drinking  and arranging positive consequences for sobriety .One complication in treating those with alcohol problems can be the clients’ inability to implement the changes specified in a treatment plan because of their behavioral deficits. That is, these clients may never have acquired the appropriate coping behaviors or skills, or, having learned them at one time, they cannot retrieve the skills either from lack of practice or from some inhibition. Whatever the reason for them, behavioral deficits are considered to be a significant obstacle to recovery from alcoholism . For cliThe coping skills training approach to alcoholism treatment addresses a client’s behavioral deficits, responses to antecedents, and the consequences of drinking. Training is based primarily on principles of social learning theory, which considers cognitive, environmental, and behavioral factors . The empThe first step in this process is a functional analysis of the client’s drinking behaviors to determine the relationships between drinking and its antecedents and consequences. Knowledge of these relationships helps to clarify drinking’s role in the client’s life and provides a focus for efforts to change behavior. Although clients rarely can articulate exactly what causes them to drink, they often are able to identify personal or environmental events that tend to precede or follow their drinking. The therapist can obtain this information through a clinical interview or by using structured assessment instruments, such as the Inventory of Drinking Situations (IDS)  discusseOnce the client’s drinking pattern and the influences that support it have been clarified, the therapist can identify the skills the client must learn to alter the chain(s) of events leading to drinking. These skills also will help the client address the consequences if drinking occurs. The therapist’s functional analysis of the client’s drinking patterns may identify internal events that play a role in drinking. Some events are likely to be alcohol related, such as thoughts of alcohol and outright cravings, and clients must be taught skills to respond to them effectively. For example, clients are encouraged to develop a list of activities they could engage in to distract themselves until a craving passes. They also are given practice in challenging their thoughts about drinking by reviewing the risks entailed and considering alternative ways to respond to these thoughts. Clients routinely may have tended to resolve problem situations, even when they were unrelated to drinking, in ways that automatically resulted in drinking. Training in problem-solving and decisionmaking skills can improve the clients’ ability to cope more effectively and anticipate the consequences of their actions.Clients’ coping skills also may be improved by stress management training, a treatment component that can include relaxation training , systematic desensitization , and cognitive strategies  . Other iTherapists also may have to help their clients fill the leisure time they gain when they stop drinking. Unless free time is used appropriately, it could lead to boredom and attendant cravings for alcohol or to activities that increase the chances of drinking. Thus, clients should sample various leisure activities to find those that they enjoy, that are incompatible with drinking, and that also could be used from time to time as rewards for specific accomplishments along the road to sobriety.Finally, it is unlikely that therapists will be able to identify all the factors relevant to a client’s drinking or anticipate all possible high-risk situations. Therefore, each client should develop a set of emergency plans for confronting any unforeseen situations that may arise. These plans usually include coping skills developed over the course of treatment, such as managing thoughts about alcohol, developing problem-solving skills, and telephoning people in one’s social support network. In addition, clients need to formulate plans for coping with persistent problems that cannot be resolved and are likely to present continuing challenges to sobriety.In many cases, the therapist’s functional analysis of the client’s drinking behaviors identifies problems encountered in interactions with others. Consequently, clients have to learn to resist offers to drink or related forms of social pressure from coworkers, friends, or even family members. In addition, clients may be deficient in very basic social skills, leaving them isolated and without adequate social support, which are common antecedents to drinking. These clients benefit from training in starting conversations, nonverbal communication (body language), giving compliments, being assertive, refusing requests to do things for others that will overburden them, communicating emotions, and improving functioning in an intimate relationship. Clients also can learn to handle criticism so that neither giving it nor receiving it will arouse strong negative emotions that could lead to a relapse. Finally, training may be necessary in the development and nurturance of a social support network, which would enhance the likelihood of their maintaining sobriety.The cognitive-behavioral approach concerns not only the content of therapy but also the manner in which it is delivered . Verbal Although good pedagogy suggests that learning should proceed from the simplest skills to the more complex, some treatment situations require that therapists first provide training in complex skills, which are essential for abstinence, to prevent relapse and early dropout from treatment. Clients who live at home and receive outpatient treatment, for example, are likely to encounter high-risk situations daily that require complex skills. It often is necessary for therapists to teach their clients how to manage their anger or how to manage their thoughts about drinking prior to teaching more basic skills, such as starting conversations or nonverbal communication.Methods of cognitive-behavioral skills training also may be influenced by whether therapy takes place in an individual or group context. In coping skills training, group therapy provides a convenient setting for skills modeling, rehearsal, and feedback, and it allows clients to share experiences they have had using the skills that they are being taught. Individual therapy provides greater attention to people for whom group therapy may not be recommended  as a learning experience and an opportunity to formulate more effective plans for coping with similar situations in the future.The IDS, developed by Family members seem to be well positioned to support a client’s recovery process. They may, however, have little knowledge about alcohol dependence, may be misinformed about how to respond to their loved one’s condition, and may have developed troublesome behavior patterns of their own that could sabotage the client’s recovery. Family members generally require education about alcohol and its effects as well as opportunities to discuss the impact that a loved one’s alcoholism has had on their lives.Coping skills training approaches have been developed for alcoholic couples  as a deterrent to drinking and to identify a significant other who will support them in taking the medication each day. Finally, clients are offered behavioral marital counseling as a means of reducing stress at home, improving communications within the family, and enhancing support for sobriety.The community reinforcement approach combines several interventions. Recognizing the powerful role of social contingencies in the recovery process, this approach provides social skills training; a “buddy,” whose role is to support the client’s efforts at maintaining sobriety; counseling regarding leisure and recreational activities; and an alcohol-free social club that sponsors activities and provides a safe place for clients to “hang out.” Unemployed clients are referred to a supportive “job club,” where they can organize their résumés, learn about job leads, and practice interview techniques. Clients also are taught strategies for coping with urges to drink and refusing offers to drink. They are encouraged to take disulfiram  with actual alcohol consumption or pairing images of drinking with images of unpleasant scenes or experiences. Effectiveness of the procedures is enhanced when they are combined with other cognitive-behavioral strategies . AversioCue exposure therapy seeks to diminish a client’s responsiveness to antecedent factors that lead to drinking . It invoAlthough not strictly a cognitive-behavioral approach, this technique is included here because it incorporates behavioral procedures, such as shaping and reinforcing clients’ statements about the need for change, and has as a goal the development of strategies for changing behavior.Poor motivation for change is an age-old problem, particularly in the field of alcoholism treatment, where clients’ ambivalence has led to a troublesome lack of treatment compliance. Recently, a systematic approach called motivational interviewing has been developed to enhance client motivation. It is based on principles of cognitive therapy and the client-centered approach developed by the psychologist Carl Rogers . Its goaMotivational interviewing starts with the therapist recognizing and accepting client ambivalence. Proceeding through what may be characterized as a gradual shaping process, the therapist tries to move the client toward acknowledging current problems, developing a desire to change them, and identifying strategies that will enable this change.The therapist first discusses problems that the client has perceived or concerns that others have voiced, providing empathic feedback, which communicates an understanding and acceptance of the client. These interventions attempt to establish a climate in which the client feels safe enough to identify and explore areas of dissatisfaction with his or her life. Using this process, the therapist avoids arguing with the client, confronting the client’s resistance head on, or labeling the client as an alcoholic. The therapist instead assumes a reflective attitude to allow exploration of both sides of the client’s ambivalence without unduly arousing defensiveness. Throughout the course of the discussion, the therapist provides frequent summaries of what the client has said to focus attention on the problems that are being uncovered and to highlight whatever motivational statements the client has made along the way.Through a gradual application of this process, the client is made increasingly aware of problems that he or she may have been ignoring; through this awareness, the client is brought to the point of accepting the need for change and then to formulating a strategy for making behavior changes. Subsequent checkup visits may be used to maintain the client’s motivation and to determine whether the client has followed through with agreed-upon change strategies.Cognitive-behavioral approaches to alcoholism were developed from behavior change principles that have been applied to a wide range of disorders, and their application to alcohol problems has been guided by empirical research findings . Such fiIn addition, other considerations support the use of cognitive-behavioral treatment methods for alcoholic clients, specifically in the early stages of their recovery from alcohol dependence. Even after they have completed detoxification, for example, clients may experience persistent cognitive impairment, such as faulty memory, from the effects of alcohol. The impairment often coincides with the time during which treatment is given. In view of such impairment, it has been suggested e.g.,  that cliAnother consideration is put forward by some advocates of dynamically oriented therapies that seek to develop clients’ insight through the exploration of conflicts and other sources of emotional distress. There is concern that the discomfort typically associated with uncovering longstanding psychological problems and emotional material may increase the probability of relapse and therefore should be avoided in the early stages of recovery . An inteIn a comprehensive review of research on alcoholism treatment outcome, Two of the interventions described above have not yet been widely used or extensively tested, although promising outcomes have been reported. Studies of motivational interviewing, which is a relatively new technique, have provided early indications of effectiveness . Cue expCognitive-behavioral treatments have scientific origins and have maintained a tradition of empirical validation of clinical procedures. This scientific examination of treatment techniques may turn out to be an important advantage in the emerging climate wherein third-party payers scrutinize treatment outcome and cost-effectiveness. In a review of the effectiveness and cost-effectiveness of various treatments for alcoholism , those tIn a cognitive-behavioral conceptualization of alcohol dependence, drinking is regarded as a learned behavior that can be altered by identifying its antecedents and consequences and by modifying the drinker’s responses to them. The treatment approaches described in this article are modeled in a variety of ways on this basic precept. With the possible exceptions of aversion therapy and cue exposure therapy, these various approaches have been found to be both effective and cost-effective. However, because no single approach has been found effective for most alcoholics, patient-treatment matching see  has receTo date, treatment outcome research has failed to identify any single approach that is superior across the varied spectrum of alcoholic clients. As a result, the alcoholism treatment field is looking increasingly to patient-treatment matching research to identify treatment approaches that will provide the most benefit to subgroups of clients with particular needs .The patient-treatment matching literature is still in its infancy, with relatively few empirical studies. Nevertheless, some reports identify client characteristics indicating which clients could benefit most from what cognitive-behavioral and behavioral approaches. In one such series of reports, Findings from other matching studies that employed cognitive-behavioral treatments  experience better outcomes with coping skills counseling.Clients who are less educated, have substantial urges to drink, or experience high anxiety benefit most from communication skills training.Clients who can identify specific high-risk situations do better with relapse prevention treatment.Single men benefit most from the community reinforcement approach.Clients with poor motivation benefit more from motivational interviewing than from skills-based counseling.The emerging literature has thus identified several client characteristics that potentially could serve as the basis for matching clients to cognitive-behavioral treatments, but more work is needed to determine their practicality in clinical settings. The National Institute on Alcohol Abuse and Alcoholism is sponsoring an ongoing multisite cooperative study  that wilRonald M. Kadden— CooneyNLKaddenRMLittMDGetterHMatching alcoholics to coping skills or interactional therapies: Two-year follow-up resultsJournal of Consulting and Clinical Psychology5959860119911655847KaddenRMCooneyNLGetterHLittMDMatching alcoholics to coping skills or interactional therapies: Posttreatment resultsJournal of Consulting and Clinical Psychology5769870419892557364KaddenRMLittMDCooneyNLBusherDARelationship between role-play measures of coping skills and alcoholism treatment outcomeAddictive Behaviors1742543719921332433LongabaughRRubinAMalloyPBeattieMCliffordPRNoelNDrinking outcomes of alcohol abusers diagnosed as antisocial personality disorderAlcoholism: Clinical and Experimental Research187787851994MattsonMEAllenJPLongabaughRNicklessCJConnorsGJKaddenRMA chronological review of empirical studies matching alcoholic clients to treatmentDonovanDMattsonMJournal of Studies on AlcoholSupp 1219941629Project MATCH Research GroupProject MATCH: Rationale and methods for a multisite clinical trial matching alcoholic patients to treatmentAlcoholism: Clinical and Experimental Research176113011451993


OBJECTIVES/SPECIFIC AIMS: Diabetic retinopathy is an increasingly prevalent disease, difficult to screen for across the globe. We have developed and began optimizing an innovative technique to visualize and quantify retinal blood flow, to elucidate the role of the choroid in retinal pathologies such as diabetic retinopathy or choroidopathy. METHODS/STUDY POPULATION: Preliminary retinal was obtained from a surgical retina video library . Videos of different organs were recorded while vessels were occluded via a blood pressure cuff, using consumer-grade digital video cameras . All other retinal videos were taken using a fundus camera  modified to support the above digital video cameras. All videos were processed using experimental software . RESULTS/ANTICIPATED RESULTS: Video imaging of the retina was optimized for lighting conditions and software requirements. Parameters were defined for the software imaging pipeline, such as frequency range of interest, sampling rate, and noise minimization. Software was developed to stabilize frames, accounting for eye saccades. Use of a biosensor enabled accurate measurement of pulse waveform, increasing signal-to-noise ratio. The optimal light requirements were determined such that adequate exposure of the retina is reproducible yet still comfortable for use in human subjects. DISCUSSION/SIGNIFICANCE OF IMPACT: This novel technique allows for an inexpensive, noninvasive, and reproducible ocular blood flow imaging platform. By optimizing this technique, we can proceed with our future plans for a pilot study to compare our imaging technique with the current standard, paving the way for future clinical studies.