Video-mediated Communication in Hospice Interdisciplinary Team Meetings:
Examining Technical Quality and Content
George Demiris PhDa, Debra Parker Oliver PhDb, MSW, Elaine Wittenberg-Lyles PhDc,
Karla Washington PhDd
a
University of Washington, Seattle, WA
b
University of Missouri, Columbia, MO
c
University of North Texas, Denton, TX
d
University of Louisville, Louisville, KY
ABSTRACT
This study aims to determine how videoconferencing
quality impacts the style and content of
communication between members of hospice
interdisciplinary teams and patients and their
families. We videotaped video-calls between hospice
teams and family caregivers based on the use of lowcost videophones. We assessed their audio and video
quality using both a form that was filled out on site
and a protocol for retrospective analysis. The tapes
were transcribed and a content analysis was
performed to assess the themes of interaction. A total
of 70 video-calls were analyzed. The time spent on
general informal talk was significantly correlated to
the video and audio quality of the session (r=0.43 and
0.41 respectively, p<0.001). The time spent
addressing psychosocial issues and on caregiver
education correlated significantly to video and audio
quality. This study demonstrates the potential of
video-mediated communication that supports shared
decision making in hospice.
INTRODUCTION
Hospice care services are provided to over 1.3
million Americans each year, mostly delivered in
patients’ homes with the help of informal caregivers,
namely family members, friends or others who
assume an unpaid caregiving role1. The hospice
philosophy is founded on the principle that both the
patient and the informal caregiver comprise the unit
of care promoting self determination and their active
participation in the decision making process. In
addition to the emotional, physical and financial
burden associated with the disease of their loved one,
informal caregivers are expected to manage all
aspects of patient care often without formal
education, with minimal or no relief, leaving them
anxious and exhausted2. More than one-third of
hospice families have concerns about the amount of
information they receive regarding what to expect
when the patient is dying3 and identify gaps in their
communication with hospice providers.
Hospice agencies hold regular staff meetings that
involve members from different disciplines including
medicine, nursing, social work and spiritual care. The
goal of these interdisciplinary team (IDT) meetings is
to develop and coordinate plans of care for hospice
patients and their families. Medicare Conditions of
Participation mandate hospice agencies to hold IDT
meetings and prescribe their frequency and the
composition of teams. While in theory these meetings
are open to patients and caregivers to attend, due to
geographic distance, the frail condition of the patient
and caregiving demands, hospice patients and their
caregivers are mostly absent from these meetings4.
Technology has the potential to bridge
geographic distance and allow caregivers and patients
to “virtually” participate in IDT meetings. While
participation may be possible with a regular
telephone, the visual contact present with a video
component has been found to be important to
communication. The transmission of video can assist
by providing 1) cognitive cues used to determine
understanding5, 2) turn-taking cues afforded by head
turning, posture and eye gaze6 and 3) social or
affective cues that reveal the participants’ emotional
state or interpersonal attitudes which are manifested
in facial express, posture or eye gaze7,8. Furthermore,
the visual feedback is needed in group
communication to identify all participants and the
size of the group as well as the person taking turns to
speak. Thus, the video component improves the flow
of the conversation as speakers do not have to
introduce themselves every time they speak. Given
the need for a video-conferencing platform that
would be applicable and relevant to both rural and
urban settings and would not require upgrading the
residential infrastructure or train families in its use,
low-cost commercially available videophones that
operate over regular phone lines, are the most
appropriate tool.
AMIA 2009 Symposium Proceedings Page - 135
This study explores the use of commercially
available videophones as a tool to overcome existing
barriers and bring caregivers of hospice patients into
the hospice interdisciplinary team meetings. It aims
to detect whether the video-mediated communication
facilitates or impedes the communication between
teams and caregivers. Specifically, the study explores
how videoconferencing quality impacts the style and
content of communication in team meetings and
whether there is a correlation between the overall
audio- and video-quality of video-calls and the
themes of communication during these meetings. The
theoretical model underlying the development of this
intervention is modified from Saltz and Schaefer’s
framework9 for family participation on health care
teams. This framework identifies four components of
an IDT model inclusive of family: context, structure,
process and outcomes. The organization context
influences team structure, which in turn impacts team
processes, which ultimately determine how teams
evaluate outcomes. Saltz and Schaefer suggest that
family involvement may influence process elements
of team functioning, especially assessment, care
planning, and implementation of plans9. The Saltz
and Schaefer model maintains that, when family
input into problem-solving or decision making is
lacking, care plans suffer due to incorrect
assumptions about the patient/family perspectives
that influence the process9.
METHODS
Data were collected from consenting hospice
patients and caregivers in two rural hospice programs
in the Midwest. All caregivers and patients had to be
enrolled in hospice, without cognitive impairment, be
consenting to participate, and over 18 years of age.
The intervention enabled family members of hospice
patients to participate in the team meeting,
connecting them virtually using a plain old telephone
system (POTS) based videophone called Beamer
(Vialta Inc) to the hospice office. Following referral
by hospice staff, a graduate research assistant (GRA)
visited the family caregiver’s home for consent to
participate in the study and installed a videophone.
Family caregivers were provided a designated time
and date to use the videophone to participate in the
hospice team meetings. The videophone unit used in
the hospice agency office was the Beamer TV model
which was projected onto a large television screen for
the view of the entire hospice team. This connection
over the regular telephone allowed family members
to have a visual image of the team as well as a twoway conversation with them. The video calls were
videotaped by a video recorder connected to the
Beamer TV to capture what participants saw at both
ends. Additionally, a video camera was set up in the
corner of the hospice office and used to also
videotape the team meeting. The GRA provided a
seating chart of the participants, identified only by
their profession.
While there are international standards for
network and vendor interoperability, there are no
widely accepted standards for performance
evaluation of videoconferencing applications. In
order to assess the audio-and video-quality of the
team meetings we used assessment tools utilized by
both participants on site and for retrospective
analysis. For on-site assessment of the quality of the
video calls we used a previously developed
instrument for assessing the technical quality of a
"virtual visit" in home care10, a video-based
interaction between health care providers and patients
or caregivers. The form includes identification of the
caregiver, date, starting and ending time of the videocall. The main section of the form contains five items
regarding the technical quality of the video-call. The
first two items refer to the observations made by the
GRA in regard the frequency of difficulties with
audio and image at the team's site. The next two
items address problems with video and sound at the
caregiver's end, as reported to the team during the
video-call.
The last item addresses possible
disconnection(s) and their frequency of occurrence.
This section allows for the definition of a score for
the overall technical quality of each video-call
(ranging from 0 to 50). This instrument has been
tested for reliability and validity and used to rate the
technical quality of video-calls in home care
settings10. The form was completed by the GRA who
was present during the team meeting.
For retrospective analysis of the videotaped
meetings two raters were asked to review the tapes
and provide quality scorings for a set of
characteristics defined as essential for the quality of
videoconferencing by industry standards11:
• Video artifacts: Raters reviewed the tape to
identify possible video artifacts around the
subject's head and shoulders (e.g., blocks, image
distortions, or out-of-focus areas).
• Sharpness: Raters reviewed the tape to detect
whether details and fine lines can be distinguished.
• Contrast, brightness, and color saturation
• Color depth: The raters looked for color banding
in the backgrounds and on the subjects’ faces and
compared to the video resolution test for color.
• Stability: Raters evaluated whether images were
stable with no motion in the background due to
video artifacts, or video noise.
• Background Clarity: Raters evaluated whether
the background was out of focus, whether it was
rich in color and texture.
AMIA 2009 Symposium Proceedings Page - 136
• Audio Clarity: The raters evaluated how clear the
audio was, and whether noise occurred.
• Audio Stability: The raters evaluated whether the
audio quality was consistent or whether
interruptions or other audio degradation occurred.
For each of the parameters above, the raters were
asked to assign a score from 1 to 5 (1 being poor and
5 excellent quality). The form enabled the calculation
of an overall score for video-quality and a total score
for audio-quality. The maximum total score is 40 (30
for the video subscale and 10 for the audio-scale). If
there were disagreements between the raters, these
were discussed until consensus was reached.
In order to study the content and style of
communication, the video recordings were coded by
two coders in order to measure reliability in coding
decisions. The “utterance” (e.g., a simple sentence,
an independent clause, nonrestrictive dependent
clause, multiple predicate) served as the unit of
analysis for coding. The coding procedure referred to
a content analysis of the verbal communication
between patients and providers. The protocol used for
the content analysis was based on a previously
developed and tested protocol used for the study of
virtual visits in home care12 and modified for the
hospice context.
This protocol includes the following themes:
• General informal talk
• Discussing patient’s clinical status
• Addressing pain medication issues
• Addressing technical issues
• Addressing psychosocial issues
• Caregiver education
• Addressing administrative issues
For each of the protocol items, five elements
were provided: a label, a definition of the theme,
indicators on how to flag the theme, description of
qualifications or exclusions and examples. Inter-rater
reliability for the coding of utterances between the
two coders was addressed by calculating Cohen’s
Kappa. In addition the videotaped segments were
timed and the duration of each segment and theme
was recorded.
RESULTS
Participants in this study consisted of 30 family
caregivers of hospice patients and three hospice
interdisciplinary teams, comprised primarily of
nurses, chaplains, social workers, and medical
directors. Hospice staff consisted of a total of 43
hospice interdisciplinary team members, 36 females
and seven males. There were 17 nurses, three social
workers, three chaplains, two medical directors, and
18 other members such as volunteer coordinators and
medical students.
A total of 86 video-call attempts were
documented. Of these, 70 (81.4%) were established
and 16 (18.6%) were cases in which a call was not
established (e.g., a connection could not be
established leading to a second attempt, the caregiver
did not answer the call). The average technical
quality of the established calls was 45.78 (91.56%)
with the lowest score being 30 (60% of the highest
possible score) and the highest 50 (100%) and a
standard deviation of 4.97. The average video call
duration was 7 minutes (with the shortest lasting 1
minute and the longest 15 minutes). Once the call
was established, the connection was not lost in any of
the cases. More technical problems pertained to audio
than video, and of these, most problems were
reported pertaining to audio at the caregiver’s end.
When asked if there were questions that the team
did not ask that they would have asked if they were
meeting in person, the GRA reported three cases
(4.2% of all conducted video-calls) in which that was
the case, and all other cases (95.8%) where this did
not apply. The GRA rated the overall technical
quality in average as very good (on a scale from 1 to
5 average score was 4.14, SD 0.82, Min 2, Max 5.
Overall usefulness of the video calls was rated in
average 4.20 (SD 0.78, Min 2, Max 5).
When reviewing the videotaped sessions, the two
raters indicated overall good audio and video quality.
Table 1 lists the mean scores for all parameters of
video and audio quality. The inter-rater reliability for
the coding of utterances was high. Cohen’s kappa for
agreement between the two coders was 0.92.
Table 1: Evaluation of the video-call quality (n=70
videocalls)
Mean (SD)
Video Quality
1=Bad;
2=Poor;
3=Fair;
4=Good; 5=Excellent
Video artifacts
4.04 (0.87)
Sharpness
4.11 (0.77)
Contrast, brightness, saturation
4.03 (0.74)
Color depth
4.12 (0.76)
Stability
4.29 (0.79)
Background Clarity
4.08 (0.76)
Total Score for Video Quality 24.67 (4.09)
Subscale (6-30)
Audio Quality
1=Unacceptable;
2=Problematic;
3=Neutral;
4=Acceptable; 5=Excellent
Audio Clarity
4.26 (0.70)
Audio Stability
4.29 (0.67)
Total Score for Audio Quality 8.54 (1.36)
Subscale (2-10)
AMIA 2009 Symposium Proceedings Page - 137
Table
2
displays
the
categories
of
communication and the time spent in average on each
of these categories. The greatest amount of time
during a video-call was spent on discussing the
patient’s clinical status. Caregiver education, issues
of pain management and the discussion of
administrative issues were not addressed in all visits.
Time spent addressing technical issues involved
camera readjustment, adjusting the volume, change
of seating arrangements of participants (e.g., move
closer or further away from the camera).
Table 2: Time spent on communication themes (70
video-call sessions)
Average
Min.
Max.
Duration
Time
Time
(in min.)
Spent
Spent
(in
(in
min.)
min.)
General informal 1.4
1.1
5.4
talk
(SD 0.92)
Discussing
3.90
6.8
8.7
patient’s clinical (SD 0.07)
status
Addressing pain 1.41
0
5.4
medication
(SD 0.14)
issues
Addressing
0.77
0
1.9
technical issues
(SD 0.07)
Addressing
2.41
1.2
4.3
psychosocial
(SD 0.49)
issues
Caregiver
1.02
0
4.2
education
(SD 0.07)
Addressing
0.39
0
1.1
administrative
(SD 0.14)
issues
The score resulting from the technical quality
form assessed by the GRA on site correlated to both
the sub-scale for the audio quality (r=0.74) and the
sub-scale for the video quality (r=0.64) assessed by
the two raters. Table 3 lists the correlations between
the quality scores and time spent on the various
themes of communication. The time spent on general
informal talk (“small talk”) is significantly positively
correlated to the video and audio quality of the
videoconferencing session. The time spent addressing
technical issues, as expected, is negatively linked to
the video and audio quality (the better the overall
quality is, the less time people spend trying to
address technical issues). The time spent addressing
psychosocial issues and caregiver education also
correlates significantly to video and audio quality.
Table 3: Correlation Matrix
Total
Total
Videotechnical
Quality
quality
Sub-score
score
(assessed
(assessed
by the two
on site)
raters)
Time Spent
On:
General
0.63**
0.43**
informal
talk
patient’s
0.11
0.16
clinical
status
pain
medication
issues
technical
issues
Total
AudioQuality
Sub-score
(assessed
by the two
raters)
0.41**
0.14
0.11
0.14
0.09
-0.31**
-0.44**
-0.38**
psycho0.43*
0.28*
social
issues
Caregiver
0.64*
0.57*
education
Addressing 0.13
0.12
admin.
issues
*p<0.05; **p<0.01; ***p<0.001
0.27*
0.62*
0.11
DISCUSSION
In this intervention the videophone provides a context
for participation of family caregivers, eliminating
numerous logistical barriers. Principles inherent
within hospice provide the team with a supportive
structure that acknowledges patient/family feedback
as valuable. In addition, the videophone provides
opportunity for temporary team membership.
Patients/families are viewed as “specialists,” with
important information and knowledge required for
assessment, care planning, and evaluation. The
interdisciplinary process, as discussed by Bronstein13,
outlines successful collaboration between hospice
staff, patients, and families: The team will become
interdependent with patient/family goals and will
create new activities and roles for patients/families
within the team, requiring flexibility among
individual members’ role definitions.
This study demonstrates that the level of audio
and video quality of a videoconferencing session
impacts the content of the session. This provides an
AMIA 2009 Symposium Proceedings Page - 138
insight into the way health care team members handle
audio and video degradation as they tend to shorten
the time spent on several issues such as small talk or
administrative issues but do not seem to compromise
the amount of time required to discuss the clinical
status of the patient. Psychosocial issues are an
important component of an IDT meeting in hospice
and were addressed in most sessions. Health care
providers often focus on the patient’s or family
member’s description about personal matters and use
it as a framework to determine how to communicate
at their level and express empathy14. Addressing
psychosocial issues and conducting informal talk
enables care providers to invite caregivers’
revelations about factors that influence their
caregiving experience. Health care providers can
reduce anxiety by displaying empathy and engaging
caregivers in discussing matters of importance to
them. Thus, the fact that time spent on this important
component is related to the audiovisual quality
indicates the challenge in balancing the need for high
quality videoconferencing sessions that will not
compromise the quality of the interaction between
participants and the need to use low cost equipment
that operates over regular phone lines and thus may
be applicable to rural and underserved areas.
This study also highlights the need for new tools
that capture the quality of video-mediated
communication among multiple stakeholders/ team
members. Most assessment forms assume two
stakeholders (the local and remote partner). The
challenge of video-mediated team discussions is the
fact that team members may have in addition to
diverse professional backgrounds, different levels of
familiarity with technology and personal preferences
pertaining to audio and video-settings, making the
subjective evaluation of a video-call by the entire
team difficult to capture. As technology advances,
new ways to support and enhance communication
between health care teams and individual patients and
their families are identified.
[2] Boland, D., & Sims, S. (1996). Family caregiving
at home as a solitary journey. Image J Nurs Sch
1996; 28(1):55-58.
[3] Teno JM, Clarridge BR, Casey V, Welch LC,
Wetle T, Shield R, et al. (2004). Family perspectives
on end-of-life care at the last place of care. JAMA
2004; 291(1): 88-93.
[4] Parker Oliver D, Porock D, Demiris G, Courtney
KL. (2005). Patient and family involvement in
hospice interdisciplinary teams: A brief study. The
Journal of Palliative Care 2005; 21(4): 270-276.
[5] Clark H, Brennan S. Grounding in
communication. In Resnick LB, Levine J, Teasley S.
Eds. Perspectives on socially shared cognition.
Washington, DC, APA Press 1991; pp.127-149.
[6] Clark H, Schaefer E. Contributing to discourse.
Cogn Sci 1989; 13:259-292.
[7] Argyle M, Lalljee M, Cook M. The effects of
visibility on interaction in the dyad. Human Relations
1968; 28: 289-304.
[8] Duncan S. Some signals and rules for taking
speaker turns in conversation. Journal of Personal
and Social Psychology 1972; 23: 283-292.
[9] Saltz CC, Schaefer, T. Interdisciplinary teams in
health care: integration of family caregivers. Soc
Work Health Care 1996; 22(3): 59-69.
[10] Demiris G, Speedie S, Finkelstein S, Harris I.
Communication patterns and technical quality of
virtual visits in home care. Journal of Telemedicine
and Telecare 2003; 9(4):210-215.
[11] Finger R. Measuring Quality in Videoconferencing Systems. Business Communications
Review 1998; 6: 51-55.
[12] Demiris G, Speedie SS, Finkelstein SM. The
nature of communication in virtual home care visits,
Proc AMIA Symp. 2001; 135-138.
[13] Bronstein, L. R. (2003). A Model for
Interdisciplinary Collaboration. Soc Work 2003;
48(3): 297-306.
[14] Parrott R, Huff T, Kilgore M, Williams M. Peer
discussion on training physicians to be competent
communicators: support for a multiple discourse
approach. South Med J 1997;90: 709-19.
ACKNOWLEDGMENT
This project was funded by the NIH National Cancer
Institute, grant R21CA120179 Patient and Family
Participation in Hospice Interdisciplinary Teams
(Parker Oliver, PI).
REFERENCES
[1] National Hospice and Palliative Care
Organization. NHPCO 2008 Facts and Figures:
Hospice Care in America. Journal. [updated 2008
Aug 23; cited 2009 March 12]. Available from
http://www.nhpco.org .
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