Rural Health Implementation Group Telemedicine

Rural Health Conference 20 September 2011

Dr Alan Axford, Chair RHIG Telemedicine Group Delyth Lewis, Telemedicine Manager [email protected]

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

• 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 wide 1 – Tried and tested in Wales – ahead of most parts of UK other than Scotland 1 Berman 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: • “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:

• 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 Health Boards). – travel time included within job plan.

Risk of tertiary centre withdrawing specialist service to outreach site (two different 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

• Access to ad hoc advice – weekly videoconference meetings between community

Dedicated videoconference suite Ty Geraint Palliative Care Resource Centre

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

Use of referral templates

Patient

Utilising secure portal to transfer referrals/receive diagnosis electronically

Specialist Nurse

GP Surgery Ceredigion

Consultant Dermatologists

Carmarthen/Llanelli Hospital

Teleophthalmology: community retinal scanning Teleophthalmology: remote image reporting

(Not implemented)

Minor Injuries Unit

 Using videoconferencing to conduct emergency assessment of eye injuries  (Tywyn to Bronglais Hospital) Connecting retinal scanning/slit lamp equipment to videoconference for remote diagnosis  Investigate use of electronic referral system (local or NWIS) for remote ophthalmology image reporting  Staff in community hospitals using 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 of evidence ? sufficient bandwidth for primary care videoconferencing lack

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 pre assessments) • 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