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The severity of illness in psychiatry is rated using the Global Assessment of Functioning (GAF) scale. The GAF scale is often used in both research settings and in the clinic. The scale ranges from 1 to 100 and is subdivided into ten 10-point intervals, each with verbal rating instructions called anchor points and examples. GAF is an instrument that needs improvement. Studying clinicians' experiences with this rating system may be important for developing improvements. The aim of this study was to collect information from clinicians about their experiences with the GAF instrument, and to collect their ideas on how the GAF scale can be improved, particularly in the area of verbal instructions (i.e., anchor points and examples). Qualitative interviews were performed with 25 clinicians. Through this interview process, several weaknesses of the GAF scale were revealed. We found that clinicians have unique experiences that can be important for the development of a better GAF scale. Rating with the GAF scale also requires sufficient collection of patient information.

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BACKGROUND: Global Assessment of Functioning (GAF) is a scoring system for the severity of illness in psychiatry. It is used clinically in many countries, as well as in research, but studies have shown several problems with GAF, for example concerning its validity and reliability. Guidelines for rating are important. The present study aimed to identify the current status of guidelines for rating GAF, and relevant factors and gaps in knowledge for the development of improved guidelines. METHODS: A thorough literature search was conducted. RESULTS: Few studies of existing guidelines have been conducted; existing guidelines are short; and rating has a subjective element. Seven main categories were identified as being important in relation to further development of guidelines: (1) general points about guidelines for rating GAF; (2) introduction to guidelines, with ground rules; (3) starting scoring at the top, middle or bottom level of the scale; (4) scoring for different time periods and of different values (highest, lowest or average); (5) the finer grading of the scale; (6) different guidelines for different conditions; and (7) different languages and cultures. Little information is available about how rules for rating are understood by different raters: the final score may be affected by whether the rater starts at the top, middle or bottom of the scale; there is little data on which value/combination of GAF values to record; guidelines for scoring within 10-point intervals are limited; there is little empirical information concerning the suitability of existing guidelines for different conditions and patient characteristics; and little is known about the effects of translation into different languages or of different cultural understanding. CONCLUSIONS: Few studies have dealt specifically with guidelines for rating GAF. Current guidelines for rating GAF are not comprehensive, and relevant points for new guidelines are presented. Theoretical and empirical studies, and international expert panels would be valuable, as well as production of a manual with more information about scoring. Computerised assessment may well be the future.

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BACKGROUND: Global Assessment of Functioning (GAF) is well known internationally and widely used for scoring the severity of illness in psychiatry. Problems with GAF show a need for its further development (for example validity and reliability problems). The aim of the present study was to identify gaps in current knowledge about properties of GAF that are of interest for further development. Properties of GAF are defined as characteristic traits or attributes that serve to define GAF (or may have a role to define a future updated GAF). METHODS: A thorough literature search was conducted. RESULTS: A number of gaps in knowledge about the properties of GAF were identified: for example, the current GAF has a continuous scale, but is a continuous or categorical scale better? Scoring is not performed by setting a mark directly on a visual scale, but could this improve scoring? Would new anchor points, including key words and examples, improve GAF (anchor points for symptoms, functioning, positive mental health, prognosis, improvement of generic properties, exclusion criteria for scoring in 10-point intervals, and anchor points at the endpoints of the scale)? Is a change in the number of anchor points and their distribution over the total scale important? Could better instructions for scoring within 10-point intervals improve scoring? Internationally, both single and dual scales for GAF are used, but what is the advantage of having separate symptom and functioning scales? Symptom (GAF-S) and functioning (GAF-F) scales should score different dimensions and still be correlated, but what is the best combination of definitions for GAF-S and GAF-F? For GAF with more than two scales there is limited empirical testing, but what is gained or lost by using more than two scales? CONCLUSIONS: In the history of GAF, its basic properties have undergone limited changes. Problems with GAF may, in part, be due to lack of a research programme testing the effects of different changes in basic properties. Given the widespread use, research-based development of GAF has not been especially strong. Further research could improve GAF.

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Implementation of telemedicine has not been as rapid as was expected in the 1990s. Diffusion of technologies can be complex and is known to be influenced by many factors. Organizational problems are crucial for the future of telemedicine, but have been gravely underestimated. When a telemedicine service is established we have a virtual organization. Internal organizational consequences of telemedicine are very common and more effective use of the technology is likely to require organizational changes. For different applications of the technology there are similarities, and differences, in internal organizational consequences. Organizational matters connected with telemedicine are dealt with in a new book, The Organizational Challenge for Health Care from Telemedicine and E-health, the full text of which is available via the Internet. In the book, solutions are outlined for common organizational problems in telemedicine. Managers must actively lead organizational changes. Replacing simplified optimism with realism may be very important for the future of telemedicine.

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At present, most hospitals have a department of radiology where images are captured and interpreted. Decentralization is the opposite of centralization and means 'away from the centre'. With a Picture Archiving and Communication System (PACS) and broadband communications, transmitting radiology images between sites will be far easier than before. Qualitative interviews of 26 resource persons were performed in Norway. There was a response rate of 90%. Decentralization of radiology interpretations seems less relevant than centralization, but several forms of decentralization have a role to play. The respondents mentioned several advantages, including exploitation of capacity and competence. They also mentioned several disadvantages, including splitting professional communities and reduced contact between radiologists and clinicians. With the new technology decentralization and centralization of image interpretation are important possibilities in organizational change. This will be important for the future of teleradiology.

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Traditionally, hospitals have a radiology department, where images are taken and interpretation occurs. Teleradiology makes it possible to capture images in one location and transmit them elsewhere for interpretation. Organizational centralization of radiology interpretations is therefore of interest. Empirical data have been collected in qualitative interviews of 26 resource persons with substantial experience with picture archiving and communication systems and teleradiology, from 12 departments of radiology in Norway. The response rate was 90%. A total of 21 theoretically possible types of centralization of image interpretation were identified, representing combinations of three categories of geographical centralization, and seven categories of centralization according to function. Various advantages and disadvantages of centralization were identified. Organizational changes may be decisive for the future of teleradiology, but it may be wise to plan for change in small steps, since we know little about how broad future organizational changes based on teleradiology will be, or what will decide how far particular organizations will go.

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In a few years all radiology departments in Norwegian hospitals will have a picture archiving and communications system (PACS). This depends on telecommunications with great capacity for transmitting radiology images. The new technology questions the need for daily meetings between radiologists and clinicians, 'clinico-radiological conferences'. Qualitative interviews were performed with 23 resource persons experienced with problems related to PACS and teleradiology. The response rate was 91%. In all, 29% answered that the clinico-radiological conferences could be abolished, 52% replied no and 19% replied both yes and no. The clinico-radiological conferences could be abolished for some clinical departments, but only after consultation between radiology and clinical departments. If the conferences are abolished, clinicians and radiologists may spend more time on treatment and interpretation, with a probable productivity gain.

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Teleradiology requires cooperation between participating parties, but it cannot be assumed that such cooperation will work well. A survey was carried out of 12 radiology departments in Norway which used picture archiving and communication systems in connection with teleradiology. Qualitative interviews were carried out with 26 out of 29 resource persons (response rate 90%). The respondents identified 17 issues of importance for cooperation in teleradiology. None of the problems with cooperation seem large enough to prevent effective teleradiology cooperation in future. For organizations planning teleradiology of a larger volume, the cooperation issue is important. It is recommended that managers lead change processes in their organizations where the different issues of importance to cooperation are treated and the right measures are taken to realize the full potential of teleradiology. For telemedicine, it is important that future research includes investigations on cooperation for the different applications.

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Qualitative interviews were performed with 26 resource persons with experience of picture archiving and communication systems and teleradiology. The results reported here concern the different types of networks there was interest in establishing. Eight types of networks were considered to be of interest. The two main reasons for wanting the networks were related to clinical communication and improved exploitation of resources. Use of such networks means cooperation across organizational boundaries. Networks can play an organizational role and this raises questions concerning the future organization of radiology services.

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The present investigation, which was part of a larger study, was designed to answer the question 'Has telemedicine produced changes in the distribution of tasks between the general practitioner and specialist, or between the local hospital and university/central hospital?' Qualitative interviews were carried out with 30 persons involved in four telemedicine services in Norway: teledermatology, tele-otolaryngology, telepsychiatry, and a telepathology frozen-section service. The results indicated that telemedicine does not produce large changes in the distribution of tasks. The reported effects were largest and most complex for telepsychiatry, followed by teledermatology. Local variations in how telemedicine is practised may explain the variation in the findings between telemedicine applications.

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To investigate learning in telemedicine, qualitative interviews were conducted with 30 people working with telepsychiatry, teledermatology, a telepathology frozen-section service and tele-otolaryngology. More than 80% of the respondents said that they had learnt something new by using telemedicine. Most frequently the participants improved their knowledge of the specialty in which they were involved, but this was not the only way in which they learnt. The learning did not necessarily change behaviour, as two-thirds of the respondents felt that the learning had not permitted them to perform tasks for which they had previously needed assistance (although this varied somewhat with the type of telemedical work that respondents were engaged in). Two-thirds of respondents thought that something more could be done in telemedical work to promote their own learning, which shows the clear potential for learning by telemedicine. Learning could be promoted further by extending the use of the technology to other applications. To start working with telemedicine, initial instruction seems to be sufficient--a more extensive training programme appears unnecessary. In future, as many applications of telemedicine are implemented, health-care organizations may become important arenas for learning and leaders will have to focus on learning. The results of the present study clearly showed that working with telemedicine produces learning.

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Little is known either about how telemedicine changes the job situation or about how the working environment might be improved for those involved in telemedicine. To investigate these issues, qualitative interviews were carried out with 30 people in Norway working with telepsychiatry (12 respondents), teledermatology (six respondents), a telepathology frozen-section service (10 respondents) and tele-otolaryngology (two respondents). The median annual number of remote consultations in telepsychiatry was nine, in teledermatology 81 and in the telepathology frozen-section service nine. The positive aspects of working with telemedicine included less travelling, which gave more time for other work, less need to travel in poor weather, new contacts, an increased sense of professional security (because support was readily available) and the satisfaction of seeing partners in communication. At its present volume, telemedicine generally fits into daily work patterns quite well. Problems do occur, but they can be solved by appropriate organizational measures. Long-term scheduling of telemedical sessions may be important. Many telemedicine workers want to have the equipment in their own office. Working with telemedicine can be tiring and those interviewed wanted to limit the number of hours per week. A solution may be to use large clinics, such as university clinics, where the telemedical work could be distributed between several specialists. Large telemedicine clinics with a full-time dedicated staff would need careful consideration of working practices.

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