Rural Health Implementation Rural Health Implementation GroupGroup

TelemedicineTelemedicine

Rural Health ConferenceRural Health Conference20 September 201120 September 2011

Dr Alan Axford, Chair RHIG Telemedicine GroupDr Alan Axford, Chair RHIG Telemedicine GroupDelyth Lewis, Telemedicine ManagerDelyth Lewis, Telemedicine Manager

delyth.lewis2@wales.nhs.uk

Background -TelemedicineBackground -Telemedicine

• Telemedicine in routine use in Ceredigion Telemedicine in routine use in Ceredigion since 2000since 2000

• Telemedicine Service established South Telemedicine Service established South (West) Wales Cancer Network 2005(West) Wales Cancer Network 2005

Background – Rural HealthBackground – Rural Health

• Rural Health Implementation Group: Rural Health Implementation Group:

– Set up to support the Rural Health PlanSet up to support the Rural Health Plan

– Ensure use of telemedicine is maximised across Ensure use of telemedicine is maximised across rural Wales (Hywel Dda, Powys and Betsi rural Wales (Hywel Dda, Powys and Betsi Cadwaladr Health BoardsCadwaladr Health Boards

– Secondment of Telemedicine Service Manager for Secondment of Telemedicine Service Manager for Hywel Dda Health Board and South Wales Cancer Hywel Dda Health Board and South Wales Cancer Network Network

AimsAims

• Explore potential of telemedicine across rural WalesExplore potential of telemedicine across rural Wales

• Encourage further development of telemedicine Encourage further development of telemedicine servicesservices

• Raise awareness of rural health Telemedicine Raise awareness of rural health Telemedicine services in Walesservices in Wales

• Assess capability of primary care network bandwidth Assess capability of primary care network bandwidth to support videoconferencingto support videoconferencing

• Facilitate videoconference training programme for Facilitate videoconference training programme for NHS staff. NHS staff.

ObjectivesObjectives

• Identify current successful telemedicine services Identify current successful telemedicine services

• Share good practice Share good practice

• Provide videoconference training workshopsProvide videoconference training workshops

• Provide support/advice to health boards in their Provide support/advice to health boards in their development/implementation of telemedicine servicesdevelopment/implementation of telemedicine services

• Create and maintain web based electronic map of Create and maintain web based electronic map of existing rural health telemedicine servicesexisting rural health telemedicine services

• Conduct feasibility study on use of web cameras in Conduct feasibility study on use of web cameras in four pilot GP practicesfour pilot GP practices

Anticipated outcomesAnticipated outcomes

• Improved local access to healthcare for patients in rural areasImproved local access to healthcare for patients in rural areas

• Quicker diagnosis and treatment plan for patients. Quicker diagnosis and treatment plan for patients.

• Equality of healthcare service to patients in rural areasEquality of healthcare service to patients in rural areas

• Reduce waiting times for specialist opinionReduce waiting times for specialist opinion

• Reduce travelling time and expenses of staff attending Reduce travelling time and expenses of staff attending meetings.meetings.

• Increased opportunity for staff participation in education Increased opportunity for staff participation in education meetings = more people with a broader range of experience.meetings = more people with a broader range of experience.

• Increased educational sessions and sharing good practice.Increased educational sessions and sharing good practice.

• Reduced costs of service delivery by lowering cost of accessing Reduced costs of service delivery by lowering cost of accessing specialist opinion.specialist opinion.

• Reduced CO2 emissionsReduced CO2 emissions

DefinitionsDefinitionsTelemedicine Telemedicine

The practice of medicine using technology to provide clinical The practice of medicine using technology to provide clinical services at a geographically separate site. Service can be services at a geographically separate site. Service can be delivered in “real time” using interactive videoconferencing, or delivered in “real time” using interactive videoconferencing, or through “store and forward” which relies on the transmission of through “store and forward” which relies on the transmission of images and data for review immediately or at later time.images and data for review immediately or at later time.

Telecare Telecare The use of technology to provide monitoring of real time The use of technology to provide monitoring of real time emergencies and lifestyle changes over time in order to manage emergencies and lifestyle changes over time in order to manage the risk associated with frailty and independent livingthe risk associated with frailty and independent living

TelehealthTelehealthThe use of technology to provide remote monitoring of people The use of technology to provide remote monitoring of people living with a chronic condition and to support self management living with a chronic condition and to support self management and delivery of care.and delivery of care.

TelemedicineTelemedicine• What it is:What it is:

– Now, not in the futureNow, not in the future– Available and cost effective support for traditional medicine Available and cost effective support for traditional medicine

and healthcare deliveryand healthcare delivery– Additional resource not a replacementAdditional resource not a replacement– Reliable, secure and high quality resource Reliable, secure and high quality resource (Videoconferencing (Videoconferencing

hosted on Welsh Health Video Network – calls are free!)hosted on Welsh Health Video Network – calls are free!)

– Evidence based world wideEvidence based world wide11

– Tried and tested in Wales – ahead of most parts of UK Tried and tested in Wales – ahead of most parts of UK other than Scotlandother than Scotland

11Berman M, Fenaughty F. Technology and managed care: patient benefits of telemedicine in a rural health care networkBerman M, Fenaughty F. Technology and managed care: patient benefits of telemedicine in a rural health care network

http://ideas.repec.org/a/wly/hlthec/v14y2005i6p559-573.html

Telemedicine isn't terrifying!Telemedicine isn't terrifying!

Telemedicine in NHS WalesTelemedicine in NHS Wales

• What has been done to date:What has been done to date:– Use of videoconferencing for:Use of videoconferencing for:

• ““Virtual” multidisciplinary team meetingsVirtual” multidisciplinary team meetings• Management and clinical meetings Management and clinical meetings • Education and training sessions Education and training sessions • Clinical applicationsClinical applications

– Profession - professionProfession - profession– Profession - patientProfession - patient– (Medical and non medical e.g. AHP, ECG technicians etc)(Medical and non medical e.g. AHP, ECG technicians etc)

• Transmission of data e.g. digital radiology images, Transmission of data e.g. digital radiology images, histopathology images, live echocardiography ultrasound histopathology images, live echocardiography ultrasound

– Use of electronic “store and forward” for Use of electronic “store and forward” for diagnosis/triage of dermatology images diagnosis/triage of dermatology images

ImpactImpactQuality:Quality:

• Access to specialist services closer to homeAccess to specialist services closer to home• More efficient use of specialist staff – consulting not More efficient use of specialist staff – consulting not

commuting!commuting!• Reduced waiting times for expert consultationsReduced waiting times for expert consultations• Reduced patient journeys for expert consultations Reduced patient journeys for expert consultations • Faster implementation of treatment plansFaster implementation of treatment plans• Ground breaking projects/services in rural WalesGround breaking projects/services in rural Wales• Remote supervision of generalist staff Remote supervision of generalist staff • Staff meet CPD requirement regardless of working locationStaff meet CPD requirement regardless of working location• Expert GP meet governance complianceExpert GP meet governance compliance• Multidisciplinary Team participation not limited by distanceMultidisciplinary Team participation not limited by distance

ImpactImpact

Costs:Costs:• Reduced travel costs for patient/cliniciansReduced travel costs for patient/clinicians• Reduced CO2 emissions for healthcareReduced CO2 emissions for healthcare• Reduced costs for CPD/study leaveReduced costs for CPD/study leave• Potential for reduced service delivery costs Potential for reduced service delivery costs

Virtual Multidisciplinary Team Meetings

78 miles

Multidisciplinary Team :SurgeonPhysicianOncologistsRadiologistHistopathologistAllied Health ProfessionalsSpecialist NursesClinical Trials NurseOncology NursePalliative Care NurseMedical SecretaryCancer Services Co-ordinator

Neurology Telemedicine ClinicsBefore : • Neurology clinics held every three months.• Service too infrequent to meet local demand.• Consultant Neurologist 150 miles return journey to undertake clinic (4 hours by car)• Amended consultant contract – travel time included within job plan.• Risk of tertiary centre withdrawing specialist service to outreach site (two different Health Boards).

New Service Model:

Delivering Pre and Post Laryngectomy Speech Therapy for

Head and Neck Cancer Patients Patient videoconsultations to Speech and Language Therapist in tertiary centre

• Aberystwyth – Singleton 156 miles return journey• Withybush – Singleton 114 miles return journey

Welsh Health Video Network

Paediatric Cardiac Telemedicine

Transmission of echocardiography images (live and recorded)

Pre Telemedicine – options for provision of specialist support for second opinion:

Swansea -• Consultant Cardiologist required to travel to Swansea (often at night by on call consultant) – 42 miles.• Videos being posted/couriered to Cardiff for review.

Mid Wales -• Patient transfer by ambulance to Cardiff - 110 miles (?3+ hours)• DVD/video couriered to Cardiff for review - 100 miles (?3+ hours)

Unsatisfactory - delay in diagnosis and treatment of the patient.

Singleton Hospital, Swansea

Bronglais Hospital, Aberystwyth

Glangwili Hospital, Carmarthen

Welsh Health Video Network

(minutes)

University Hospital Wales, Cardiff

Paediatric Cardiac TelemedicineTransmission of echocardiography images (live

and recorded)

Palliative Care Telemedicine

Ty Geraint Palliative Care

Resource Centre

Dedicated videoconference

suite

• Access to ad hoc advice – weekly videoconference meetings between community based staff and hospital team

• Reduced the need for staff to travel for

advice/support – more time with patients• Extended to palliative care units at:

- Ty Bryngwyn (Llanelli) - Ty Olwen (Morriston) - Y Bwthyn (Bridgend)

• Used for educational sessions across Network

Cardigan Hospital

Teledermatology Pigmented Skin Lesion & Rash

General Practitioner

Specialist Nurse

GP Surgery Ceredigion

Consultant

DermatologistsCarmarthen/Llanelli Hospital

Patient

Use of referral templates

Utilising secure portal to transfer referrals/receive diagnosis electronically

Teleophthalmology: Teleophthalmology: community retinal scanningcommunity retinal scanning

Using videoconferencing to conduct emergency assessment of eye injuries (Tywyn to Bronglais Hospital) Connecting retinal scanning/slit lamp equipment to videoconference for remote diagnosis

Teleophthalmology: remote Teleophthalmology: remote image reportingimage reporting(Not implemented)(Not implemented)

Investigate use of electronic referral system (local or NWIS) for remote ophthalmology image reporting 

Minor Injuries UnitMinor Injuries Unit Staff in community hospitals using videoconferencing to undertake patient consultations to acquire advice/diagnosis from A&E departments at Cardigan/Tywyn Hospitals

Case Study 1Case Study 1• 66 year old male patient with head and neck cancer66 year old male patient with head and neck cancer

• Lives in GwyneddLives in Gwynedd

• Surgery at specialist centre 212 miles return Surgery at specialist centre 212 miles return journeyjourney

• Post laryngectomy specialist speech and Post laryngectomy specialist speech and swallowing rehab not available locallyswallowing rehab not available locally

• Attendance at specialist centre expensive in time Attendance at specialist centre expensive in time and money at vulnerable timeand money at vulnerable time

• Offered consultations by videoconferencing at a Offered consultations by videoconferencing at a local hospitallocal hospital

Equity of service to patients in rural WalesEquity of service to patients in rural Wales

Travelling time saved per consultation = Travelling time saved per consultation = 4 hours4 hours

Miles saved per consultation = Miles saved per consultation = 154 miles154 miles

Travel cost saved per consultation = Travel cost saved per consultation = £20£20

CO2 emissions saved per consultation = CO2 emissions saved per consultation = 55kg -55kg -

Savings over 4 consultations = Savings over 4 consultations =

•16 hours time16 hours time

• 616 miles616 miles

• £80 travelling cost£80 travelling cost

• 220kg -220kg -

Case Study 2Case Study 2• Emergency Paediatric Cardiac admission to Bronglais Emergency Paediatric Cardiac admission to Bronglais

Hospital (9pm)Hospital (9pm)• Echocardiography ultrasound - required second opinionEchocardiography ultrasound - required second opinion• Options – Options –

– Ambulance transfer of patient to specialist centre in Cardiff – Ambulance transfer of patient to specialist centre in Cardiff – 110 miles 110 miles (£300 + 3 hours minimum)(£300 + 3 hours minimum)

– DVD recording of images couriered by taxi to specialist DVD recording of images couriered by taxi to specialist centre in Cardiff - 110 miles centre in Cardiff - 110 miles (£120 3+ hours minimum)(£120 3+ hours minimum)

– Transmission of live echocardiography ultrasound via Transmission of live echocardiography ultrasound via videoconferencing to specialist centre videoconferencing to specialist centre (no call costs + ?30 (no call costs + ?30 minutes)minutes)

Equity of service to patients in rural WalesEquity of service to patients in rural Wales

Travelling time saved per consultation = Travelling time saved per consultation = 3 hours (min)3 hours (min)

Miles saved per consultation = Miles saved per consultation = 110 miles110 miles

Travel cost saved per consultation = Travel cost saved per consultation = £300 (£120)£300 (£120)

CO2 emissions saved per consultation = CO2 emissions saved per consultation = 20.9kg - 20.9kg - 11//33

Patient’s treatment managed locally and commenced Patient’s treatment managed locally and commenced immediately.immediately.

Parents able to discuss diagnosis and treatment plan with local Parents able to discuss diagnosis and treatment plan with local and specialist team simultaneously within hours of admission.and specialist team simultaneously within hours of admission.

Specialist consult enabled arrangements for surgery at Liverpool Specialist consult enabled arrangements for surgery at Liverpool to be made.to be made.

(Figures calculated on one journey – not return)(Figures calculated on one journey – not return)

ObstaclesObstacles• Under-utilisation of facilities – accessibility, no priority for Under-utilisation of facilities – accessibility, no priority for

videoconferencing meetingsvideoconferencing meetings

• Lack of training, awareness and potential of Lack of training, awareness and potential of videoconferencing usevideoconferencing use

• Reluctance to use technologyReluctance to use technology

• Availability of local on site supportAvailability of local on site support

• Videoconferencing restricted to secondary care - Videoconferencing restricted to secondary care - lack of lack of evidence ? sufficient bandwidth for primary care videoconferencingevidence ? sufficient bandwidth for primary care videoconferencing

SuggestionsSuggestions

• Provide training workshops for healthcare professionalsProvide training workshops for healthcare professionals

• Nomination of ‘super users’/enthusiasts at local sites to Nomination of ‘super users’/enthusiasts at local sites to provide support to usersprovide support to users

• Improve use of existing equipment – priority to Improve use of existing equipment – priority to videoconference bookingsvideoconference bookings

• Nomination of Health Board member with responsibility Nomination of Health Board member with responsibility for telemedicinefor telemedicine

• Create website with telemedicine information e.g. user Create website with telemedicine information e.g. user guides and directory of videoconferencing equipment guides and directory of videoconferencing equipment availableavailable

• Undertake feasibility study to gather evidence regarding Undertake feasibility study to gather evidence regarding primary care bandwidthprimary care bandwidth

http://maps.google.co.uk/maps/ms?ie=UTF8&hl=en&oe=UTF8&msa=0&msid=211497540860849954742.000498f3b78c6be5028cd&z=8

Based on information Based on information

gathered by gathered by

Telehealth SubGroup Telehealth SubGroup

to dateto date

Proposal to develop Proposal to develop more sophisticated more sophisticated electronic map with electronic map with Welsh Government Welsh Government

cartography departmentcartography department

Progress to dateProgress to date• Meetings with health board representatives -> subsequent presentationsMeetings with health board representatives -> subsequent presentations

• Early successes notable in Hywel Dda Health Board probably due to Early successes notable in Hywel Dda Health Board probably due to their maturity and experience in use of telemedicinetheir maturity and experience in use of telemedicine

• Funding of teledermatology equipment (HDda)Funding of teledermatology equipment (HDda)

• Funding of Primary Care Web Camera Feasibility studyFunding of Primary Care Web Camera Feasibility study

• Videoconference training workshopsVideoconference training workshops

• Support to Dermatology Network for development of current Support to Dermatology Network for development of current teledermatology service (HDda)teledermatology service (HDda)

• Support to Paediatric Network to establish telemedicine service (HDda)Support to Paediatric Network to establish telemedicine service (HDda)

• Support to TeleRehab project (BCUHB)Support to TeleRehab project (BCUHB)

Full details available in Evaluation Report (January-June 2011) to be Full details available in Evaluation Report (January-June 2011) to be published published

Potential telemedicine Potential telemedicine developmentsdevelopments

• Establishment of national Telemedicine forum Establishment of national Telemedicine forum (clinical (clinical champions and health board members)champions and health board members)

• Collaboration with organisations to develop national Collaboration with organisations to develop national telemedicine systems, telemedicine systems, eg Welsh Clinical Communications eg Welsh Clinical Communications Gateway electronic referral system (teledermatology, Gateway electronic referral system (teledermatology, teleophthalmology, tissue viability etc.)teleophthalmology, tissue viability etc.)

Success dependant on successful engagement with:Success dependant on successful engagement with:• Health BoardsHealth Boards• Service usersService users• Support organisations, Support organisations, eg NHS Wales Informatics Service, eg NHS Wales Informatics Service,

Welsh Health Video Network, NLIAH etcWelsh Health Video Network, NLIAH etc

Potential telemedicine Potential telemedicine developmentsdevelopments

• DermatologyDermatology• Diabetes Diabetes (and podiatry assessments/vascular surgery pre-(and podiatry assessments/vascular surgery pre-

assessments)assessments)

• Speech and Language TherapySpeech and Language Therapy• Palliative CarePalliative Care• NeuroRehab NeuroRehab • MS Cymru Telemedicine MS Cymru Telemedicine (launch November 2011)(launch November 2011)

• TeleRehab TeleRehab (including internet videoconferencing connectivity) (including internet videoconferencing connectivity)

• Ophthalmology Ophthalmology • Tissue Viability ServiceTissue Viability Service• Primary Care Web Camera Feasibility Study outcomesPrimary Care Web Camera Feasibility Study outcomes

ConclusionConclusion

• Telemedicine is here nowTelemedicine is here now

• Effective in quality and cost spheresEffective in quality and cost spheres

• Welcomed by patients – especially in rural areasWelcomed by patients – especially in rural areas

• Supported by Welsh GovernmentSupported by Welsh Government

• Resources available –Resources available –

– Support of Telemedicine Service ManagerSupport of Telemedicine Service Manager

– Support of Rural Health Implementation GroupSupport of Rural Health Implementation Group

• Here to help if you needHere to help if you need

“…“…That it [the stethoscope] will ever come That it [the stethoscope] will ever come into general use, notwithstanding its value, into general use, notwithstanding its value, is extremely doubtful because its is extremely doubtful because its beneficial application requires much time beneficial application requires much time and gives a good bit of trouble, both to the and gives a good bit of trouble, both to the patient and the practitioner. Its hue and patient and the practitioner. Its hue and character are foreign and opposed to all character are foreign and opposed to all our habits and associationsour habits and associations.”.”

Quote - The London Times 1834