Original article

.....................................................................................................................................................

" The reliability and acceptability of

telemedicine for patients with schizophrenia
in Korea
Young Moon Chae*, Hyun Joo Park*, Joong Geun Cho*,
GeumDuk Hong* and Keun-ah Cheon{
*Graduate School of Health Science and Management, Yonsei University; {Department of Psychiatry, College of Medicine,
Yonsei University, Seoul, Korea

Summary
Weconductedapilot study toevaluatetelemedicinefor patients withschizophrenia. Thetelemedicinesystem
was connected over the ordinary telephone network at 33kbit/s. Acomputer-based patient record was used
to viewpatient summaries and to allownursing notes to be entered at the patient’s home. Fifteen patients
with schizophrenia were assessed over the telemedicine systemand 15 patients were assessed face to face,
using the Brief Psychiatric Rating Scale (BPRS). Our low-bandwidth telemedicine systemappeared to be as
reliable as higher-bandwidth ISDNsystems. In addition, the patients’ acceptance of the telemedicine
interview, interms of comfort, easeof self-expression, quality of interpersonal relationshipandusefulness, was
goodinmost cases. The only factors significantly affecting the patients’ level of acceptance of their particular
type of interviewwere the assessment type (i.e. whether the patient had had a telemedicine assessment or
not) and their BPRS score. Since the systemwas of lowcost and was easy to interface with a notebook
computer, it could be used support other home-health nursing services.

Introduction
...............................................................................
In1983, a government mental healthproject beganin
Korea with the aimof institutionalizing mental
patients. This resulted in low-quality, overcrowded
mental institutions throughout the country.
Subsequently the Ministry of Health and Welfare
changeditspolicyandacommunitymental healthlaw
was enacted in 1995. Since many patients live in rural
areas or insupervisedhostel accommodationinremote
regions, therewas aneedtoimproveaccess tospecialist
psychiatric services. We therefore introduced a pilot
telemedicine systemto provide specialist psychiatric
services topatients livingat homeor inisolatedhostels
in Koyang City.
Psychiatry appears to be an ideal specialty for
teleconsultation because of the importance of the
Accepted 22 December 1999
Correspondence: Professor Young Moon Chae, Graduate School of Health
Science and Management, Yonsei University, CPOBox 8044, Seoul, Korea
(Fax: +82 2392 7734; Email: ymchae@yumc.yonsei.ac.kr)
doctor–patient interaction1. Telemedicine has been
extensively applied in psychiatry since the 1970s2.
Most current telepsychiatry programmes are designed
toreachmedicallyunderservedpeople, suchasthosein
rural areas of South Australia3. Wheeler and Allen4
identified 25 active telepsychiatry programmes in
1998, comparedwithnine programmes in1994, inthe
USA, Australia and Norway.
An important issue for telepsychiatrists using a
video-link is its performance with regard to motion
handling and resolution. The research teamat the
Harvard Telepsychiatry Programhas done a
considerable amount of work on these issues. Baer
et al.5 demonstrated the reliability and acceptability of
telemedicine using ISDNat a bandwidth of 128kbit/s
in patients with obsessive–compulsive disorder. Zarate
et al.6 compared the reliability and acceptability of
telemedicine at two transmission rates (128 and
384kbit/s) in patients with schizophrenia, and found
that the lower transmission rate could be used reliably
for administering psychiatric rating and screening
scales. In South Australia, Baigent et al.7 examined
inter-rater reliability between psychiatrists who had

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Y MChae et al. Telemedicine for patients with schizophrenia
interviewed 63 mental patients in an observer/
interviewer split configurationbytelepsychiatryandin
a same-roomsetting. They found that diagnoses could
be made as reliably using a transmission rate of
128kbit/s as in the face-to-face interview.
It is not soclear, however, under what circumstances
and for which psychiatric conditions low-bandwidth
telemedicine systems can be used as a substitute for
face-to-face encounters. Since higher-bandwidth ISDN
is not available inthe houses of most patients inKorea,
we have implemented a telemedicine systemusing the
ordinary telephone network (the PSTN) and a
transmission rate of 33kbit/s. To determine its
effectiveness in delivering home health services for
mental patients, we chose the same disease
(schizophrenia, according to the criteria of DSM–IV8)
and research design as Zarate et al.6, so that we could
compare the reliability and acceptability of our low-
bandwidth approach with their findings.
M ethods
...............................................................................
Thirty subjects were randomly selected from198
patients treated at the Koyang Community Mental
Health Center (CMHC) in the three months from1
January 1999. The inclusion criteria for the study were
DSM–IV-defined schizophrenia, age 20–50 years,
capable of verbal communication, agreement to home
visiting and agreement to participate inthe study. The
reliability testing model developed by Baer et al.5 was
used to assess the agreement between the two rating
conditions. Inthis model, reliability was first
established in standard face-to-face interviews with 15
schizophrenic patients using the Brief Psychiatric
Rating Scale (BPRS)9. Both a doctor and a nurse
simultaneously scored the patients’ responses. In the
telemedicine interviews of 15schizophrenic patients, a
doctor at the Koyang CMHCasked the assessment
questionsviaatelephoneline, whilethesamenursesat
withthe patient in the patient’s home or halfway
house. Again, boththe doctor and nurse scored the
responses of each patient to the rating scale items. In
addition, acceptance questionnaires were completed
immediately after each interview.
Survey instrument
The BPRS was used to assess the reliability of
telemedicine. This scale has beenthe most widely used
clinician-basedmeasure of psychopathology inclinical
settings and psychiatric research over the past three
decades. While there are manyways inwhichtogroup
the 18 BPRS items, we used the same groupings as
Zarate et al.6 so that we couldcompare our results with
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theirs. They grouped the items of the BPRS into three
categories: 10items for general symptoms, sixitemsfor
positive symptoms and two items for negative
symptoms. Positive symptoms are those that should
not be present in a normal mental state (e.g.
hallucinations and delusions) while negative
symptoms are those that shouldbe present inanormal
mental statebut are lackinginthepatient (e.g. blunted
affect and emotional withdrawal). Eachitemwas rated
on a seven-point scale (ranging from‘not present’ to
‘extremely severe’).
Thepatients were alsoaskedtoratefour categories of
acceptance: comfort level during the interview, ability
to express themselves, the quality of the interpersonal
relationship and the usefulness of the interview. Each
questionnaire itemwas rated on a five-point scale
(ranging from‘much belowaverage’ to ‘much better
than average’).
Data analysis
Both raters (doctor and nurse) scored the patients’
responses, and the intraclass correlation coefficient for
the tworaters’ scores was calculatedfor eachBPRS item
to measure the inter-rater reliability of face-to-face
consultation and telemedicine, as Zarate et al.6 had
done. With this method, any decrement inthe
reliability index was attributed to the loss of
information in one or other assessment method. We
preferred the intraclass correlation to the kappa
statistic7 because we used the seven-point ordinal
variables of theBPRSinour study. Thekappastatisticis
non-parametric and is mainly used to measure the
agreement of nominal variables.
Relationships between patient characteristics and
ratings of the four categories of acceptance were
analysedbyFisher’s exact test because there were small
numbers of cases in the cells (fewer than five). In
addition, total acceptance scores and the total BPRS
scores for the face-to-face and telemedicine groups
were compared by the t-test. Finally, the factors
affecting patient acceptance were identified by
multiple regression using the total acceptance score as
the dependent variable.
Telemedicine system
Analogue video-phones (Telsee Phone systems, Pan
Tech. Corp., Korea) were located at the Koyang CMHC
and the patient’s home, and connection was made by
dialling the other site through an ordinary telephone
line. The systemcontained a video-input device (a
digital camera with both near- and far-end controls
with scanning and zooming capabilities), a video-
display device (either a computer monitor or a colour
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 YMChae et al. Telemedicine for patients with schizophrenia

televisionmonitor) andaudioinput–output equipment
(consisting of a microphone and speaker built into the
control keyboard).
A computer-based patient record (CPR) was also
developed to enable users to viewa summary of basic
demographic information, the problemlist and details
of current medication, recent visits and results
available for review. The CPR was integrated with the
telemedicine systemto allowthe doctor and nurse to
viewthe same patient summary during the
teleconference. The nurse could also document
encounters by entering nursing notes or reports into
the CPR using the notebook computer at the patient’s
home. Fig 1 shows an initial screen of a CPR for the
home visiting nurse.
Results
...............................................................................
Themeanagesof thesubjects studiedwere36years(SD
8) and 35 years (SD7) for the face-to-face and
telemedicine groups, respectively. The proportions of
men were 33%and 60%. The proportions of college
graduates were 47%and 25%. The proportions of
severely ill patients were 27%and 40%. Further details

Fig 1 An initial screen of a CPR for the home visiting nurse.

Table 1 Patient characteristics by assessment groups: number (%) of patients

Patient characteristics Face-to-face assessment Telemedicine assessment Total Pa

Age
Under 36 years 8 (53) 7 (47) 15 (50) 1.00
Over 36 years 7 (47) 8 (53) 15 (50)
Total 15 (100) 15 (100) 30 (100)

Sex
Male 5 (33) 9 (60) 14 (47) 0.27
Female 10 (67) 6 (40) 16 (53)
Total 15 (100) 15 (100) 30 (100)

Education
High school (or less) 8 (53) 6 (75) 14 (61) 0.40
College 7 (47) 2 (25) 9 (39)
Total 15 (100) 8 (100) 23 (100)

Severity of illness
Low 11 (73) 9 (60) 20 (67) 0.70
High 4 (27) 6 (40) 10 (33)
Total 15 (100) 15 (100) 30 (100)
aFisher’s exact test.

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Y MChae et al. Telemedicine for patients with schizophrenia

are given in Table 1. There were no significant the lowcorrelation coefficient (70.06) in the
differences (at P<0.05) between the two groups of excitement itemin the latter.
patients.

Reliability of telemedicine Acceptance of telemedicine

Ina comparison of agreement by intraclass correlation
for the 18 rating items between the two groups,
agreement was similar for three items; agreement in
telemedicine was higher thaninface-to-face interviews
for eight items; and it was lower for sevenitems (Table
2). The agreement correlation for the BPRS total score
for telemedicine (0.82) was significantly higher than
that for face-to-face interviews (0.67), perhaps due to
The acceptability of the telemedicine experience was
compared with that of the face-to-face interviewin
terms of comfort, ease of self-expression, quality of
interpersonal relationship and usefulness, on the same
scale. No significant differences were found between
patient characteristics and any of the acceptability
categories. Table 3 shows that the total telemedicine
acceptancescorewashigher(14.1) thantheface-to-face

Table 2 Comparison of agreement on the BPRS scores: intraclass correlations

Classification BPRS items Face-to-face assessment Telemedicine assessment

General symptoms Somatic concerns 0.38 0.54

Anxiety 0.58* 0.22
Guilt feelings 0.68** 0.80**
Tension 0.77** 0.68**
Mannerisms and posturing 0.71** 0.85**
Depressive mood 0.72** 0.65**
Motor retardation 0.82** 0.88**
Uncooperativeness 0.62* 0.53*
Blunted affect 0.66* 0.84**
Disorientation 0.77** 0.95**
Positive symptoms Conceptual disorganization 0.86** 0.85**
Grandiosity 0.74** 0.66**
Hostility 0.53* 0.56*
Suspiciousness 0.77** 0.81**
Hallucinatory experience 0.67** 0.42
Excitement 70.06 0.51

Negative symptoms Emotional withdrawal 0.76** 0.74**

Unusual thought content 0.75** 0.55**

BPRS total 0.67 0.82**

*P<0.05, **P<0.01.

Table 3 Comparison of the total mean (SD) acceptance scores between face-to-face and telemedicine assessments
Patient characteristics Face-to-face assessment Telemedicine assessment t P

Age
Under 36 years 12.6 (2.1) 14.3 (3.0) 1.25 0.23
Over 36 years 14.9 (2.6) 14.0 (1.9) 70.74 0.47

Sex
Male 13.2 (2.8) 14.1 (2.8) 0.59 0.57
Female 13.9 (2.5) 14.2 (1.9) 0.22 0.83

Education
High school (or less) 13.4 (2.3) 14.1 (2.4) 0.67 0.51
College 14.0 (2.9) 14.5 (3.5) 0.21 0.84

Severity of illness
Low 14.2 (2.8) 14.4 (2.7) 0.21 0.83
High 12.3 (0.5) 13.7 (2.1) 1.61 0.16

Total 13.7 (2.5) 14.1 (2.4) 0.25 0.61

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 YMChae et al. Telemedicine for patients with schizophrenia

score (13.7), although this difference was not
statistically different at the 5%level.
The overall proportion of patients who felt
comfortable withthe face-to-face consultation was
higher (87%) than with telemedicine (73%) (Table 4).
Unlike the comfort level, the overall percentage of
patients who felt at ease expressing themselves with
telemedicine was higher (73%) than with face-to-face
assessments (60%). In fact, telemedicine had a higher
proportion of patients feeling at ease expressing
themselves than in the face-to-face assessments in all
patient categories (Table 5). Similarly, the majority of
patients ratedthe telemedicine experience, but not the
face-to-face assessments, as providing a good qualityof
interpersonal relationship with the doctor (Table 6).
The overall proportions of patients who had a good
interpersonal relationship with the doctor were 87%
and 47%, respectively. However, almost no differences

Table 4 Relationshipbetween patient characteristics and comfort level: number (%) of patients
Face-to-face assessment Telemedicine assessment

Comfort Comfort

Patient characteristics Yes No Total P Yes No Total P

Age
Under 36 years 7 (87) 1 (13) 8 (100) 1.00 5 (71) 2 (29) 7 (100) 1.00
Over 36 years 6 (86) 1 (14) 7 (100) 6 (75) 2 (25) 8 (100)
Total 13 (87) 2 (13) 15 (100) 11 (73) 4 (27) 15 (100)

Sex
Male 3 (60) 2 (40) 5 (100) 0.95 6 (67) 3 (33) 9 (100) 0.60
Female 10 (100) 0 (0) 10 (100) 5 (83) 1 (17) 6 (100)
Total 13 (87) 2 (13) 15 (100) 11 (73) 4 (27) 15 (100)

Education
High school (or less) 6 (75) 2 (25) 8 (100) 0.47 5 (83) 1 (17) 6 (100) 0.46
College 7 (100) 0 (0) 7 (100) 1 (50) 1 (50) 2 (100)
Total 13 (87) 2 (13) 15 (100) 6 (75) 2 (25) 8 (100)

Severity of illness
Low 10 (91) 1 (9) 11 (100) 0.48 7 (78) 2 (22) 9 (100) 1.00
High 3 (75) 1 (25) 4 (100) 4 (67) 2 (33) 6 (100)
Total 13 (87) 2 (13) 15 (100) 11 (73) 4 (27) 15 (100)

Table 5 Relationshipbetween patient characteristics and ease of self-expression: number (%) of patients
Face-to-face assessments Telemedicine assessments

Ease of self-expression Ease of self-expression

Patient characteristics Yes No Total P Yes No Total P

Age
Under 36 years 3 (38) 5 (62) 8 (100) 0.12 4 (57) 3 (43) 7 (100) 0.28
Over 36 years 6 (86) 1 (14) 7 (100) 7 (88) 1 (12) 8 (100)
Total 9 (60) 6 (40) 15 (100) 11 (73) 4 (27) 15 (100)

Sex
Male 2 (40) 3 (60) 5 (100) 0.32 6 (67) 3 (33) 9 (100) 0.60
Female 7 (70) 3 (30) 10 (100) 5 (83) 1 (17) 6 (100)
Total 9 (60) 6 (40) 15 (100) 11 (73) 4 (27) 15 (100)

Education
High school (or less) 4 (50) 4 (50) 8 (100) 0.61 4 (67) 2 (33) 6 (100) 1.00
College 5 (71) 2 (29) 7 (100) 2 (100) 0 (0) 2 (100)
Total 9 (60) 6 (40) 15 (100) 6 (75) 2 (25) 8 (100)

Severity of illness
Low 7 (64) 4 (36) 11 (100) 1.00 6 (67) 3 (33) 9 (100) 0.60
High 2 (50) 2 (50) 4 (100) 5 (83) 1 (17) 6 (100)
Total 9 (60) 6 (40) 15 (100) 11 (73) 4 (27) 15 (100)

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Y MChae et al. Telemedicine for patients with schizophrenia

Table 6 Relationshipbetween patient characteristics and quality of interpersonal relationship with doctor: number (%) of patients
Face-to-face assessment Telemedicine assessment

Interpersonal relationship Interpersonal relationship

Patient characteristics Yes No Total P Yes No Total P

Age
Under 36 years 2 (25) 6 (75) 8 (100) 0.13 6 (86) 1 (14) 7 (100) 1.00
Over 36 years 5 (71) 2 (29) 7 (100) 7 (88) 1 (12) 8 (100)
Total 7 (47) 8 (53) 15 (100) 13 (87) 2 (13) 15 (100)

Sex
Male 4 (80) 1 (20) 5 (100) 0.12 8 (89) 1 (11) 9 (100) 1.00
Female 3 (30) 7 (70) 10 (100) 5 (83) 1 (17) 6 (100)
Total 7 (47) 8 (53) 15 (100) 13 (87) 2 (13) 15 (100)

Education
High school (or less) 5 (63) 3 (37) 8 (100) 0.32 5 (83) 1 (17) 6 (100) 1.00
College 2 (29) 5 (71) 7 (100) 2 (100) 0 (0) 2 (100)
Total 7 (47) 8 (53) 15 (100) 7 (89) 1 (12) 8 (100)

Severity of illness
Low 6 (55) 5 (45) 11 (100) 0.57 8 (89) 1 (11) 9 (100) 1.00
High 1 (25) 3 (75) 4 (100) 5 (83) 1 (17) 6 (100)
Total 7 (47) 8 (53) 15 (100) 13 (87) 2 (13) 15 (100)

Table 7 Relationshipbetween patient characteristics and usefulness of interview: number (%) of patients
Face-to-face assessment Telemedicine assessment

Usefulness Usefulness

Patient characteristics Yes No Total P Yes No Total P

Age
Under 36 years 6 (75) 2 (25) 8 (100) 1.00 6 (86) 1 (14) 7 (100) 0.57
Over 36 years 5 (71) 2 (29) 7 (100) 5 (63) 3 (37) 8 (100)
Total 11 (73) 4 (27) 15 (100) 11 (73) 4 (27) 15 (100)

Sex
Male 2 (40) 3 (60) 5 (100) 0.77 7 (78) 2 (22) 9 (100) 1.00
Female 9 (90) 1 (10) 10 (100) 4 (67) 2 (33) 6 (100)
Total 11 (73) 4 (27) 15 (100) 11 (73) 4 (27) 15 (100)

Education
High school (or less) 5 (63) 3 (37) 8 (100) 0.57 4 (67) 2 (33) 6 (100) 1.00
College 6 (86) 1 (14) 7 (100) 1 (50) 1 (50) 2 (100)
Total 11 (73) 4 (27) 15 (100) 5 (63) 3 (37) 8 (100)

Severity of illness
Low 8 (73) 3 (27) 11 (100) 1.00 8 (89) 1 (11) 9 (100) 0.24
High 3 (75) 1 (25) 4 (100) 3 (50) 3 (50) 6 (100)
Total 11 (73) 4 (27) 15 (100) 11 (73) 4 (27) 15 (100)

in usefulness were found between face-to-face and Table 8 Factors affecting patient acceptance
telemedicine assessments (Table 7).
Unstandardized Standardized
regression regression
Variable coefficient coefficient P
Factors affecting patient acceptance
To identify the factors affecting patient acceptance, Age 0.09 1.38 0.18
Sex 0.57 0.58 0.57
multiple regression analysis was performed using the Education 1.25 1.17 0.25
total acceptance score as the dependent variable. The Assessment type
BPRS score
1.68
70.09
1.83
73.11
0.08
0.005
R2 value was 0.32 and the F value was 2.28 (P<0.1)
(Table 8). The assessment type (telemedicine or face to R2=0.32, F=2.28 (P=0.079).

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face) and the BPRS scores were the only significant
factors (at P<0.1) associated withpatient acceptance of
telemedicine. The average acceptance score was 1.8
times higher for the telemedicine group than for the
face-to-face group, as indicated by the standardized
regression coefficient, when all other independent
variables were controlled. The results also suggested
that telemedicine was more accepted by the less
severely ill patients.
Discussion
...............................................................................
Wecomparedthereliabilityof telemedicineinterviews,
using low-bandwidth videoconferencing at 33kbit/s,
withthat of face-to-face interviews, inasystematicand
controlled manner. The two groups were similar in
terms of age, sex, education, severity of illness and
BPRS total scores. Our results regarding the reliability
of telemedicine were similar to those reported in
earlier studies using higher bandwidths. The intraclass
correlation for telemedicine was 0.82, which was
significantly higher than that of the face-to-face
interactions (0.67). The lower intraclass correlation for
face-to-face interviews may be explained by the low
correlationcoefficient (70.06) for the excitement item
on the BPRS. However, the anxiety reliability was very
low(0.22) for telemedicine, possibly because the
33kbit/s bandwidthand the consequent limitedimage
processing capability was insufficient for detailed
analysis of this specific symptom. Zarate et al.6
comparedthe reliability of bothtelemedicine andface-
to-face assessment with the BPRS with schizophrenic
patients and found intraclass correlations of 0.96 for
face-to-face assessments and 0.84 and 0.90 for
telemedicine assessments over 128kbit/s and384kbit/s
links, respectively. However, they were unable to
calculate an intraclass correlation for the excitement
itemat 128kbit/s owing to zero variance in their data.
The acceptabilityof the telemedicine experience was
compared with that of the face-to-face interviewin
terms of comfort, ease of self-expression, quality of
interpersonal relationship and usefulness. More
patients rated telemedicine as ‘more acceptable’ in
terms of ease of self-expression and quality of
interpersonal relationship than they did the face-to-
face assessments. Although the patients felt more
comfortablewithface-to-faceinterviews, nodifferences
were found with regard to usefulness, and the total
acceptance score for telemedicine (14.1) was higher
than that for face-to-face assessments (13.7). The
results suggested that telemedicine was better accepted
by patients than face-to-face interactions in many
cases, perhaps because it was less threatening.
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YMChae et al. Telemedicine for patients with schizophrenia
Kavanagh et al.3 suggested that telemedicine was less
threatening than many normal interviews because of
the ability of patients, if they desire, towalk out of the
roomor out of sight of the camera without personally
offending the interviewer. Patients’ acceptance of and
satisfaction with telepsychiatry have been reported in
other studies6,7,10.
To identify the factors affecting patient acceptance,
multiple regression analysis was performed using the
total acceptance score as the dependent variable.
Assessment type and the BPRS scores were the only
significant factors involved in determining patient
acceptance of telemedicine. The average acceptance
score was nearly twice as high in the telemedicine
group than in the face-to-face group, as indicated by
the standardized regression coefficient when all other
independent variables were controlled. The results also
suggested that telemedicine was more accepted by less
severely ill patients (as indicated by the BPRS).
Incomparison with ISDN, the advantages of the
present telemedicine systeminclude lower trans-
mission costs (about 50%), reduced equipment size,
simplicity of operation and ease of interface with a
notebookcomputer. Inaddition, anISDN-basedsystem
inKorea requires anISDNadapter (costing about $200,
200 euros) for the patient’s telephone and a special
interface device for a notebook computer. Because of
these advantages, the same approach could be used in
many other home health services. Allen et al.11
estimatedthat 46%of traditional home healthvisits in
the USA could be done by telemedicine, based on a
retrospective reviewof nursing charts. Theyfoundthat
older patients were better candidates for telemedicine
care thanyounger patients.
While the low-bandwidthsystemusedinthe present
study represents a cost-effective approach, there was a
problemwith shadowy ‘echoes’ appearing when the
subject moved, owing to the limited image-processing
capabilities of the equipment. Zarate et al.6 also
reported that negative symptoms were assessed less
reliably at the lower bandwidth, since movement
artefacts in the image were misinterpreted as reduced
movements indicative of motor slowing. On the other
hand, the positive symptoms of schizophrenia were
largely dependent on verbal responses and could be
reliably assessed even at the lower bandwidth. This
problemshouldbe investigatedfurther if our approach
is to be used in other applications, such as clinics for
the rural and urban poor, shelters for the homeless,
prisons, nursing homes and health-care delivery sites
with limited access to psychiatric services.
A CPR was developed to viewthe patient summary
and to document encounters at the patient’s home. It
provided a mechanismfor coordinating the efforts of
thevarious health-care professionals (e.g. doctor, nurse
2 2000
89
Y MChae et al. Telemedicine for patients with schizophrenia
and social worker) and facilitating communication
between them.
The present study had certain limitations. First, we
studied only a small number of subjects, and further
studies witha larger sample are needed to confirmthe
findings. Second, while our results suggested that
telemedicine was more accepted than face-to-face
interactions inmanycases, we donot knowwhythis is
so. It may be that telemedicine caused the patients to
behave differently(atesting effect) or it mayhave been
duetothe Hawthorneeffect. Further studyis neededto
investigate the reasons for patient acceptance. Third,
we could not measure the doctor’s acceptance of
telemedicine, which is an important behavioural
consideration, becauseonlyonedoctorwasinvolvedin
thestudy. Montani et al.12 foundthat telemedicinewas
acceptable to both the provider and elderly patients.
Further testing of our systemis therefore required at
other sites with sufficient subjects and doctors to
confirmthe effectiveness of the approach and to
generalize the findings.
Acknowledgements: We thank Dr JinSoonKimand Mr
Ke Chul Lee for their help. This researchwas supported
by a grant fromKoyang City and Kyunggi Province.
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