diabetes , 
 late complications hereof , and diabetic foot ulcers in particular present 
 increasing challenges in terms of amputations , sick leaves , reduced functioning , 
 and escalating financial costs .
the patients ' quality of life 
 decreases dramatically with the occurrence of diabetic foot ulcers .
currently , 
 most treatment is carried out by nonexperts such as visiting nurses and general 
 practitioners [ 2 , 3 ] despite the fact that studies 
 demonstrate the importance of specialized knowledge in the treatment of chronic 
 wounds [ 3 , 4 ] . to enable the experts to monitor 
 an increasing number of patients more regularly , telemedicine
delivery of healthcare and the exchange of 
 healthcare information across distances  ) has been suggested as a way of 
 creating alternative treatment methods .
previous 
 studies have documented coherence between expert assessments of ulcers based on 
 digital images versus live assessment [ 7 , 8 ] .
even low - resolution images may 
 sometimes be sufficient [ 9 , 10 ] .
digital photographs have also 
 proven valuable in learning situations , for example , when giving directions for 
 wound care .
only a preliminary set of 
 experiences exists in using the emerging umts ( universal mobile telephony system ) technology 
 for telemedicine , for example , for teleconsultations from a moving ambulance , but so far the results are 
 promising .
conclusions 
 from other studies demonstrate that expert - guided treatment makes nurses use 
 more advanced wound care remedies with better healing outcomes as a result [ 2 , 3 ] and it leads to increased patient satisfaction through less travel and reduced waiting time [ 1315 ] .
dansky and bowles have even 
 suggested that communicating with the expert over a distance facilitates a more 
 optimal dialog , which empowers the patients who participate more actively in 
 their care planning .
furthermore , dansky and bowles found a significant learning curve for nurses 
 and expect that the nurses will become increasingly comfortable and efficient 
 as the technology becomes pervasive [ 1618 ] .
another outcome of the kaiser 
 permanente tele - home health research project was that the patients became more 
 actively involved in attending their own health care needs and the remote 
 visits were characterized as convenient because the patients felt comfortable 
 with discussing personal problems and in receiving care at home .
treatment of diabetic ulcers has 
 turned out to be applicable to both synchronous   and asynchronous telemedicines .
willbright found that telemedicine 
 made the specialist nurse more empowered and enabled to independently develop 
 treatment plans .
most of 
 these studies have utilized a static installation in the patient 's home or a 
 store - and - forward solution for enabling the visiting nurse to receive advice 
 from experts .
thus , the telemedical solutions have either connected the patient 
 with the visiting nurse , or the visiting nurse with the expert . to a large 
 extent
, the treatment can be perceived as collaboration between these three 
 stakeholders ( the patient , the visiting nurse , and the expert ) . for this 
 reason ,
enabling the three partners to be simultaneously engaged in the 
 communication taking place may increase the extent to which the expert 
 knowledge can be utilized directly in the treatment .
furthermore , a direct 
 dialog between people with different perspectives may enable a more holistic 
 view and thereby result in a more tailored treatment . to pursue 
 this goal , we investigated the technological possibilities for supporting a new 
 organization of the treatment where the expert , the visiting nurse , and the 
 patient in collaboration could discuss the situation and plan the treatment . in this 
 article , we present the results of a pilot test , the aim of which was to 
 investigate the possibility of having the expert participating in the home 
 consultations by the use of technology and in cooperation with the visiting 
 nurse and the patient . in this article
, we define  experts  as either a nurse 
 or a doctor specialized in treatment of diabetic foot ulcers in our study 
 located at aarhus hospital , denmark .
the visiting nurses referred to in this article are associated with local community 
 centers in the residential area of the respective patients and they were nonexperts 
 in diabetic foot ulcers .
we explore 
 the subjective satisfaction of patients and healthcare professionals to test 
 the hypothesis that a telemedical consultation can be a viable alternative to a 
 visit to the outpatient clinic . in order for a telemedical consultation
to be 
 characterized as a viable alternative to a visit to the outpatient clinic , all 
 participants must experience the telemedical treatment as satisfactory in terms 
 of ( 1 ) the clinicians being provided with sufficient clinical information for 
 clinical assessments and decisions to be made accurately , ( 2 ) the visiting 
 nurses feeling supported and secured during the sessions , and ( 3 ) the patient 
 being satisfied with the consultations . in the following , the findings related 
 to these three issues are presented .
during a 
 2-year process of participatory design , initial problems and potential 
 solutions in the field of treatment of diabetic foot ulcers were investigated . 

participatory design ( pd ) is a research approach , derived from action - based research 
 that is applied to the development of technological and organizational 
 solutions to real - world problems [ 21 , 22 ] .
pd is a qualitative study , in 
 which the aim is to have close cooperation with the users during the process in 
 order to ensure that the ( technological ) result can be understood and handled 
 in practice by the users . in our study ,
the group of 
 participants consisted of hospital doctors and nurses specialized in diabetic 
 foot ulcers , visiting nurses , patients , and relatives .
the pd process contained 
 field studies , workshops with the users , experiments in both laboratories and hospitals , and specification of an electronic ulcer record .
the pd process resulted in the 
 creation of a telemedical system for supporting the pilot test carried out 
 during summer 2005 .
five 
 patients who were all mentally well functioning and following a course of 
 treatment in the outpatient clinic were selected for inclusion by the experts  the same hospital clinicians who had 
 participated in the pd process ( 1 doctor and 3 nurses ) .
after the patients gave 
 informed consent ( including permission to film the video consultations ) , we 
 contacted the management of the patient 's local center to inform about the 
 study and to obtain permission to involve the patient 's visiting nurse .
after 
 that , we informed the visiting nurse in more detail and a meeting was set up 
 for demonstration of the technology .
the 
 patients were offered 3 consecutive video consultations to substitute 3 visits 
 to the outpatient clinic all conducted by the same team of clinicians .
a 
 telemedical course of treatment was initiated by an intensive consultation in 
 the outpatient clinic , where the experts created the patient file in the online 
 ulcer record and uploaded high - resolution images of the ulcer as well as 
 obtaining measurements such as peripheral blood pressure , blood sugar .
furthermore , the first of the three telemedical consultations was prescheduled 
 by the researchers with both the visiting nurse , the patient and the hospital 
 experts . the 
 telemedical setup consisted of umts video telephones ( motorola a920 ) and a 
 custom designed online ulcer record .
prior to the consultations , the visiting 
 nurse used the video phone to take pictures of the ulcer and transmit them to 
 the ulcer record .
as the video phones currently available on the market may not 
 yet provide a sufficient image quality , the images from the phone were 
 supplemented with images from a standard digital camera ( nikon coolpix5400 ) . 

these high - resolution images were uploaded to the ulcer record upon return to 
 the office and therefore not available during the online consultations , but 
 they were used as a safety precaution .
( the experts were able to view those 
 pictures later in cases of uncertainty .
no changes were made to the assessment 
 or the treatment on the background of these images , however . ) at the agreed 
 time of consultation , the visiting nurse made a video call from the home to the 
 doctor and to an expert nurse at the hospital .
the experts used ( 1 ) the still images and the video 
 stream from the video phones , ( 2 ) images from the previous consultation , and ( 3 ) the cooperation of the visiting nurse in order to evaluate the ulcer and to 
 prescribe further treatment .
after the consultation , the experts wrote their 
 summary of the consultation in the online web - based record .
each 
 consultation was video filmed by the researchers both in the patient 's home and 
 at the hospital and transcribed afterwards .
after completion of the telemedical 
 experiments , the researchers conducted semistructured interviews of one - hour 
 duration with each of the 5 visiting nurses at their local center and with the 
 patients in their homes ( which also involved a relative in 3 out of the 5 cases ) .
furthermore , we conducted a focus group interview with the 3 expert nurses to 
 gain a guided discussion ( all expert nurses had been informally interviewed 
 individually after each consultation ) and one individual semistructured 
 interview with the doctor . as a final measure to circumvent amicable bias due 
 to the personal presence of the researchers in the interviews , all participants 
 were asked to indicate their satisfaction with every consultation in a 
 questionnaire .
the total data 
 material consisted of transcripts of field studies , workshops , experiments , 
 interviews , and video consultations as well as the questionnaires and a 
 specification of the electronic ulcer record .
the material was analyzed 
 systematically where data were categorized in themes arising during the 
 analysis , both concerning the participants satisfaction , as described in this 
 article as well as themes described in other articles elsewhere .
the 15 consultations 
 were performed as planned . using umts for telemedicine was a challenge .
the technical difficulties did not , however , 
 prevent the pilot test to be carried out as planned , and the clinical results 
 of the test are presented in this article .
a wide range of clinical situations 
 were encountered ranging from a noncritical healing ulcer to more complicated 
 ulcers , and at one consultation the decision was a hospital admission . in 
 another case , a patient was referred to the outpatient clinic for face - to - face 
 specialist evaluation ; however , the clinical conclusion based on the 
 telemedical consultation remained unchanged .
the consultations lasted from 5 to 18  minutes , including the dialogs between nurses and patients and also including scheduling a time for the ensuing video consultation .
the course of 3 following consultations for each patient lasted from 2 weeks to 6 weeks .
the overall results 
 from the study demonstrate that the alternate course of treatment proved satisfactory 
 from the viewpoint of all 3 stakeholders .
the experts were both satisfied with 
 the new course of treatment and they felt secure in being responsible for the 
 treatment performed on a distance .
the patients ( and relatives ) felt 
 secure and characterized the treatment as an improvement because they were able 
 to remain at home .
after the 
 consultations , the experts expressed satisfaction with the clinical basis for 
 their decision making .
both the information provided in the form of pictures 
 and communication with the patient and the cooperation with the visiting nurse 
 constituted important basis for the experts ' decision making .  the presence of 
 the visiting nurse in the patient s home compensates in full for not having the 
 patient in front of you ,  the doctor said in the interview . by cooperating with 
 the visiting nurse and being precise when asking questions , the experts were 
 able to gather the information they would normally observe themselves , 
 including the color , temperature , and smell of the foot ulcer .
the high - resolution 
 images from the digital camera were  even better than the human eye as they 
 compared in quality to using a magnifying glass ,  explained the doctor in the 
 interview .
however , as these pictures were uploaded following each 
 consultation , the experts had only access to high - resolution images from the 
 previous consultations at the time of the consultation .
for this reason , the 
 less optimal images from the video phones provided the main basis for the 
 decisions , and if these images were not optimal in terms of , for example , 
 lightning or sharpness , the visiting nurse observations were particularly 
 useful .
the possibility of comparing pictures of an ulcer from one visit to the 
 next also supported the assessment of healing progress .
an important decision 
 to make for the experts was how much responsibility could be delegated to the 
 visiting nurse .
the expert nurses had the possibility to get a feeling of the 
 visiting nurses skills and if extra help was needed in carrying out the 
 prescribed treatment .
the expert nurse noted that she could value the visiting 
 nurses level of competences just by looking at the way she handled the 
 instruments .
these observations lead the expert nurse towards what kind of 
 instruction the visiting nurses needed or what she was able to ask from her . 

the doctor also assessed the competence of the visiting nurse , and described it 
 in this way : 
i m used to asking 3 questions and then i can almost grade them 
 ( the visiting nurses ) .  in the beginning of 
 the pilot test , the roles of the participants in the telemedical consultations 
 were not defined prior to each consultation . during the pilot tests , a firmer 
 structure for
for instance , the experts 
 became more aware of the fact that they had to combine their own views with 
 that of the visiting nurse , and that the consultations were most efficient if 
 one person took the lead .
for these reasons , the experts made it a practice to hold a preconsultation to coordinate their impression before hearing the visiting nurse .
they were conscious , however , not to put forward their impression at the actual consultation until they had heard what the visiting nurse had to say in order to be able to combine their own impression from the images with the subjective opinion of the visiting nurse .
furthermore , the ongoing dialog  once connected  brings forth issues that have an impact on the 
 decisions , for instance , aspects of the patient s daily living .
the direct 
 dialog with the visiting nurse provides the expert with a more detailed 
 knowledge about the patient and the capabilities of the patient s surroundings ( e.g. , the service levels at the local center ) .
these issues would have been 
 more difficult to pursue in a hospital setting , where the knowledge of the 
 visiting nurse is absent .
consequently , in terms of the expert s basis for 
 decisions , the video consultation provided a feasible alternative to a visit in 
 the outpatient clinic ; and in some cases , the decision basis may even be more 
 holistic .
the visiting nurses 
 were all positive towards the video consultations , which is in line with 
 previous studies ( see , e.g. , ) .
four out of five visiting nurses emphasized that 
 participating in the project had increased their professional skills , by 
 receiving information and instructions from the hospital .
in contrast to the 
 situation today , the direct contact with the experts means that a treatment 
 plan may be decided and any discrepancies sorted out immediately .
the visiting 
 nurse is also instructed about new treatments which he / she understands more 
 readily on the basis of expert reflections and explanations . in this way , the 
 dialog facilitates a decision process based on mutual understanding rather than 
 the expert giving direct instructions .
this ensures that the visiting nurse can 
 relate to the treatment plan , which promotes satisfaction with the cooperation . 
 in the interview
, this particular visiting nurse was asked , if she at times 
 took offence by receiving instructions on her professional field .
she answered :  no , i think there has been room for me to express my opinions 
if i had had a 
 different opinion i would have had the possibility for discussing it .
 the visiting nurses 
 also agreed that the treatment procedures would improve when working in a team 
 with the experts .
when i work on my own , i sometimes 
 doubt if the treatment is sufficient , or if a doctor should see the ulcer .
to 
 be on the safe side i sometimes send the patient to the hospital , but when the 
 patient returns , it is still the same treatment that was prescribed in the 
 first place .
this means that i misjudged the situation  that would not happen with this set - up . 
the 
 visiting nurse became the central coordinating actor combining the two roles as 
 the 
 one nurse quoted :  with the doctor i 
 find out which treatment is necessary , and with the patient i find out if that 
 is what we need .
 it ( her role ) is more  here and now ,  more present .
 what they need on the hospital is what the 
 visiting nurse can see in the home  ( quote vn ) .
furthermore , the nurses 
 expressed that the knowledge attained through the cooperation with the experts 
 would also benefit their other patients . in this sense , the telemedical organization 
 could enable more tailored treatment for the individual patient , which 
 ultimately may increase the quality of the treatment .
the patients expressed 
 that being able to stay at home during treatment was a great advantage . in consistency 
 with other studies [ 13 , 27 ] ,
patients complain about spending many hours 
 waiting for transportation to the hospital , waiting in the outpatient clinic , 
 and again waiting for transportation home .
the video consultation 
 focused not just on the ulcer , but included the patient as well . when the 
 consultation is performed in the patient s home , patients are more 
 self - confident and more apt to ask about personal issues , such as sleeping 
 problems , pain , medication .
i find it reassuring  it is not always that you get to ask 
 the questions you have when you go up there ( to the hospital)it is easier 
 when you are in your home .
 another patient described the consultation in the 
 following way :  the contact between the visiting nurse and the experts is good .
they work as a team .  by having access to the expert and the visiting nurse at 
 the same time , the patients are able to receive immediate answers to their 
 questions and at the same time follow the visiting nurse getting instructions 
 from the expert .
the online dialog was 
 accepted by the patients :  it is easier to make contact , when there is a 
 picture , in which you can see the person instead of only a phone .
i think the doctor cared for me as a person , he showed interest in me .
 the 
 patients and relatives felt both satisfied and secured by being treated at a 
 distance .
in a few situations , 
 the patients were surprised about how serious problems were taken .
for 
 instance , during one consultation a patient had signed up for a midsummer eve arrangement , 
 but the experts found it necessary to rest the foot as much as possible and 
 suggested a wheel chair . in the interview , the patient said that if he had not 
 talked to the expert ,  i would just have walked to the party .  a similar 
 statement
was given by the visiting nurse in the interview :  i would not have 
 reacted towards the newly arisen blister and , furthermore , i would have treated 
 the blister in a very different way than the one prescribed by the expert 
 nurse . 
our study indicates 
 that treatment of diabetic ulcers in the home can be effectively supported by 
 means of telemedicine . from the point of view of all three stakeholders 
 ( patient , visiting nurse , and expert ) ,
the simultaneous dialog facilitates 
 satisfactory means for handling the cooperation and treatment . to the experts , the 
 communication with the patient in his own home environment brings to light 
 personal issues enabling a better and more individual treatment
this may also 
 have preventive effects as demonstrated in the case of the person attending the 
 midsummer eve party .
contrasting indirect telemedical solutions , where digital 
 images are obtained and forwarded to the expert by email ( store - and - forward ) , 
 our setup allows the participants to informally discuss , reflect upon , and 
 solve discrepancies immediately in order for the treatment decision to be 
 initiated straight away .
furthermore , the mobile setup makes it unnecessary to 
 install and maintain equipment in the patient s home . while the studies by , 
 for instance
, bowles and dansky   investigate online connections between patient 
 and expert directly , without the attendance of the visiting nurse who has the 
 responsibility for carrying out the treatment between the expert consultations , 
 our setup allows both the expert and the visiting nurse to participate actively 
 in the expert consultations .
this forges 
 a synergetic combination of the different stakeholders competences . at the 
 same time
, the web - based online ulcer record facilitates a more traditional 
 store - and - forward setup , and this study shows that the combination of these two 
 methods is valuable in that the doctor and expert nurse could use the record 
 for obtaining an overview of the situation and history , while at the same time 
 collaborating with the visiting nurse and patient about the present situation . as reported by others [ 8 , 28 ] ,
an important spinoff effect is that the 
 competence of the visiting nurse may increase during this telemedical 
 consultation facilitating the spread of knowledge from expert to the community . in our study , the same 
 team of clinicians conducted all 3 consultations with each patient , especially the 
 patients experienced this to be a major advantage .
thus , an important question to be 
 investigated in future studies is the challenge of enabling experts to follow 
 up on the basis of other persons descriptions and examinations .
it is also of vital 
 importance that the initial visit to the outpatient clinic prior to the 
 telemedical course of treatment should serve to get to know the patient in 
 terms of the patient s ability to participate in a course of treatment built on 
 video consultations , which involves a thorough examination of the patient 
 including measures such as peripheral blood pressure .
thereby , the patient 
 obtains high quality and continuity in the treatment . both expert nurses and 
 visiting nurses gained new roles in the telemedical setup . from the beginning 
 of the study ,
the expert nurses were worried about not having the patient face to 
 face and not having  the finger in the ulcer ,  whereas the expert doctor tended 
 to be more open to the concept , possibly because doctors are more used to 
 delegating work tasks to others .
the final focus group interview after the 
 pilot test revealed that also the expert nurses were now confident with the new 
 role as a consultant working through another nurse .
communication through 
 video phones puts constraints to the natural flow of the conversation in terms 
 of delays and difficulties to interpret nonverbal cues and expressions . for 
 this reason ,
all participants had to be conscious about their expressions and 
 we recommend attention and training in this way of communication before 
 implementing similar telemedical services .
the visiting nurse was 
 invited into the experts reflections , which meant that her role went from 
 carrying out the prescribed treatment on her own and without formal influence 
 to be a fully fledged member of a collaborating team .
working through guidance 
 from the experts , the visiting nurses became more engaged , secure , and 
 responsible in carrying out the treatment .
the competences and skills of the 
 visiting nurse are likely to increase from each consultation , resulting in 
 increased job satisfaction and qualifications .
in all consultations 
 performed during our pilot test , the three criteria for the consultation to be 
 characterized as a viable alternative to a visit in the outpatient clinic were 
 met .
the experts expressed satisfaction with their basis for decisions , the 
 visiting nurses felt supported , and the patients experienced the new way of 
 receiving treatment as an advantage .
furthermore , the simultaneous 
 communication between expert , visiting nurse , and patient enabled the 
 clinicians to provide a more holistic and tailor - made treatment , indicating that the 
 telemedical consultations are a viable way of performing the treatment .
 the aim of this study was to investigate whether video consultations in the home can support a viable alternative to visits to the hospital outpatient clinic for patients with diabetic foot ulcers . and furthermore whether patients , relatives , visiting nurses , and experts at the hospital will experience satisfaction and increased confidence with this new course of treatment . 
 participatory design methods were applied as well as field observations , semistructured interviews , focus groups , and qualitative analysis of transcriptions of telemedical consultations conducted during a pilot test . 
 this study shows that it is possible for experts at the hospital to conduct clinical examinations and decision making at a distance , in close cooperation with the visiting nurse and the patient . 
 the visiting nurse experienced increased confidence with the treatment of the foot ulcer and characterized the consultations as a learning situation . 
 all patients expressed satisfaction and felt confidence with this new way of working . 
1. INTRODUCTION
2. METHODS
3. RESULTS
4. DISCUSSION
5. CONCLUSION