Rural Health Implementation
Group
Telemedicine
Rural Health Conference
20 September 2011
Dr Alan Axford, Chair RHIG Telemedicine Group
Delyth Lewis, Telemedicine Manager
delyth.lewis2@wales.nhs.uk
Background -Telemedicine
• Telemedicine in routine use in Ceredigion
since 2000
• Telemedicine Service established South
(West) Wales Cancer Network 2005
Background – Rural Health
• Rural Health Implementation Group:
– Set up to support the Rural Health Plan
– Ensure use of telemedicine is maximised across
rural Wales (Hywel Dda, Powys and Betsi
Cadwaladr Health Boards
– Secondment of Telemedicine Service Manager for
Hywel Dda Health Board and South Wales Cancer
Network
Aims
• Explore potential of telemedicine across rural Wales
• Encourage further development of telemedicine
services
• Raise awareness of rural health Telemedicine
services in Wales
• Assess capability of primary care network bandwidth
to support videoconferencing
• Facilitate videoconference training programme for
NHS staff.
Objectives
• Identify current successful telemedicine services
• Share good practice
• Provide videoconference training workshops
• Provide support/advice to health boards in their
development/implementation of telemedicine services
• Create and maintain web based electronic map of
existing rural health telemedicine services
• Conduct feasibility study on use of web cameras in
four pilot GP practices
Anticipated outcomes
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Improved local access to healthcare for patients in rural areas
Quicker diagnosis and treatment plan for patients.
Equality of healthcare service to patients in rural areas
Reduce waiting times for specialist opinion
Reduce travelling time and expenses of staff attending
meetings.
Increased opportunity for staff participation in education
meetings = more people with a broader range of experience.
Increased educational sessions and sharing good practice.
Reduced costs of service delivery by lowering cost of accessing
specialist opinion.
Reduced CO2 emissions
Definitions
Telemedicine
The practice of medicine using technology to provide clinical
services at a geographically separate site. Service can be
delivered in “real time” using interactive videoconferencing, or
through “store and forward” which relies on the transmission of
images and data for review immediately or at later time.
Telecare
The use of technology to provide monitoring of real time
emergencies and lifestyle changes over time in order to manage
the risk associated with frailty and independent living
Telehealth
The use of technology to provide remote monitoring of people
living with a chronic condition and to support self management
and delivery of care.
Telemedicine
• What it is:
– Now, not in the future
– Available and cost effective support for traditional
medicine and healthcare delivery
– Additional resource not a replacement
– Reliable, secure and high quality resource
(Videoconferencing hosted on Welsh Health Video Network
– calls are free!)
– Evidence based world wide1
– Tried and tested in Wales – ahead of most parts of
UK other than Scotland
1Berman
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 in NHS Wales
• What has been done to date:
– Use of videoconferencing for:
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“Virtual” multidisciplinary team meetings
Management and clinical meetings
Education and training sessions
Clinical applications
– Profession - profession
– Profession - patient
– (Medical and non medical e.g. AHP, ECG technicians etc)
• Transmission of data e.g. digital radiology images,
histopathology images, live echocardiography ultrasound
– Use of electronic “store and forward” for
diagnosis/triage of dermatology images
Impact
Quality:
• Access to specialist services closer to home
• More efficient use of specialist staff – consulting not
commuting!
• Reduced waiting times for expert consultations
• Reduced patient journeys for expert consultations
• Faster implementation of treatment plans
• Ground breaking projects/services in rural Wales
• Remote supervision of generalist staff
• Staff meet CPD requirement regardless of working
location
• Expert GP meet governance compliance
• Multidisciplinary Team participation not limited by
distance
Impact
Costs:
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Reduced travel costs for patient/clinicians
Reduced CO2 emissions for healthcare
Reduced costs for CPD/study leave
Potential for reduced service delivery costs
Virtual Multidisciplinary Team Meetings
78 miles
Multidisciplinary Team :
Surgeon
Physician
Oncologists
Radiologist
Histopathologist
Allied Health Professionals
Specialist Nurses
Clinical Trials Nurse
Oncology Nurse
Palliative Care Nurse
Medical Secretary
Cancer Services Co-ordinator
Neurology Telemedicine Clinics
Before :
• 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
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.
Paediatric Cardiac Telemedicine
Transmission of echocardiography images (live
and recorded)
Singleton Hospital, Swansea
Bronglais Hospital, Aberystwyth
Glangwili Hospital, Carmarthen
University Hospital Wales, Cardiff
Palliative Care Telemedicine
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
Ty Geraint
Palliative Care
Resource Centre
Cardigan
Hospital
Teledermatology
Pigmented Skin Lesion & Rash
General
Practitioner
Use of referral templates
Patient
Specialist Nurse
GP Surgery Ceredigion
Utilising secure portal to
transfer referrals/receive
diagnosis electronically
Consultant
Dermatologists
Carmarthen/Llanelli Hospital
Teleophthalmology:
community retinal scanning
 Using videoconferencing to conduct
Teleophthalmology: remote
image reporting
(Not implemented)
 Investigate use of electronic referral
Minor Injuries Unit
 Staff in community hospitals using
emergency assessment of eye injuries
(Tywyn to Bronglais Hospital)
 Connecting retinal scanning/slit lamp
equipment to videoconference for
remote diagnosis
system (local or NWIS) for remote
ophthalmology image reporting
videoconferencing to undertake patient
consultations to acquire
advice/diagnosis from A&E departments
at Cardigan/Tywyn Hospitals
Case Study 1
• 66 year old male patient with head and neck
cancer
• Lives in Gwynedd
• Surgery at specialist centre 212 miles return
journey
• Post laryngectomy specialist speech and
swallowing rehab not available locally
• Attendance at specialist centre expensive in
time and money at vulnerable time
• Offered consultations by videoconferencing at
a local hospital
Equity of service to patients in rural Wales
Travelling time saved per consultation = 4 hours
Miles saved per consultation = 154 miles
Travel cost saved per consultation = £20
CO2 emissions saved per consultation = 55kg Savings over 4 consultations =
•16 hours time
• 616 miles
• £80 travelling cost
• 220kg -
Case Study 2
• Emergency Paediatric Cardiac admission to
Bronglais Hospital (9pm)
• Echocardiography ultrasound - required
second opinion
• Options –
– Ambulance transfer of patient to specialist centre
in Cardiff – 110 miles (£300 + 3 hours minimum)
– DVD recording of images couriered by taxi to
specialist centre in Cardiff - 110 miles (£120 3+
hours minimum)
– Transmission of live echocardiography ultrasound
via videoconferencing to specialist centre (no call
costs + ?30 minutes)
Equity of service to patients in rural Wales
Travelling time saved per consultation = 3 hours (min)
Miles saved per consultation = 110 miles
Travel cost saved per consultation = £300 (£120)
CO2 emissions saved per consultation = 20.9kg - 1/3
Patient’s treatment managed locally and commenced
immediately.
Parents able to discuss diagnosis and treatment plan with local
and specialist team simultaneously within hours of admission.
Specialist consult enabled arrangements for surgery at Liverpool
to be made.
(Figures calculated on one journey – not return)
Obstacles
• Under-utilisation of facilities – accessibility, no priority
for videoconferencing meetings
• Lack of training, awareness and potential of
videoconferencing use
• Reluctance to use technology
• Availability of local on site support
• Videoconferencing restricted to secondary care - lack
of evidence ? sufficient bandwidth for primary care
videoconferencing
Suggestions
• Provide training workshops for healthcare professionals
• Nomination of ‘super users’/enthusiasts at local sites to
provide support to users
• Improve use of existing equipment – priority to
videoconference bookings
• Nomination of Health Board member with responsibility
for telemedicine
• Create website with telemedicine information e.g. user
guides and directory of videoconferencing equipment
available
• Undertake feasibility study to gather evidence regarding
primary 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
gathered by
Telehealth SubGroup
to date
Proposal to develop
more sophisticated
electronic map with
Welsh Government
cartography department
Progress to date
• Meetings with health board representatives -> subsequent
presentations
• Early successes notable in Hywel Dda Health Board probably due
to their maturity and experience in use of telemedicine
• Funding of teledermatology equipment (HDda)
• Funding of Primary Care Web Camera Feasibility study
• Videoconference training workshops
• Support to Dermatology Network for development of current
teledermatology service (HDda)
• Support to Paediatric Network to establish telemedicine service
(HDda)
• Support to TeleRehab project (BCUHB)
Full details available in Evaluation Report (January-June 2011) to be
published
Potential telemedicine
developments
• Establishment of national Telemedicine forum (clinical
champions and health board members)
• Collaboration with organisations to develop national
telemedicine systems, eg Welsh Clinical Communications
Gateway electronic referral system (teledermatology,
teleophthalmology, tissue viability etc.)
Success dependant on successful engagement with:
• Health Boards
• Service users
• Support organisations, eg NHS Wales Informatics Service,
Welsh Health Video Network, NLIAH etc
Potential telemedicine
developments
• Dermatology
• Diabetes (and podiatry assessments/vascular surgery preassessments)
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Speech and Language Therapy
Palliative Care
NeuroRehab
MS Cymru Telemedicine (launch November 2011)
TeleRehab (including internet videoconferencing connectivity)
Ophthalmology
Tissue Viability Service
Primary Care Web Camera Feasibility Study outcomes
Conclusion
• Telemedicine is here now
• Effective in quality and cost spheres
• Welcomed by patients – especially in rural areas
• Supported by Welsh Government
• Resources available –
– Support of Telemedicine Service Manager
– Support of Rural Health Implementation Group
• Here to help if you need
“…That it [the stethoscope] will ever come
into general use, notwithstanding its value,
is extremely doubtful because its beneficial
application requires much time and gives a
good bit of trouble, both to the patient and
the practitioner. Its hue and character are
foreign and opposed to all our habits and
associations.”
Quote - The London Times 1834