Best Practice in Telemedicine

An evaluation of The Queen Elizabeth Hospital Renal Dialysis Telemedicine Project 1995-1996

Written by John Mitchell, Managing Director, John Mitchell & Associates, October 1996

The Executive Summary and Chapter 1 follow.

Executive Summary

A memorable use involved an acute assessment of a problem. It was a Saturday morning, the patient was at Port Augusta (300km away) and was complaining of some unusual symptoms. On the face of it I was inclined to leave her in Port Augusta till Monday, then I decided to use telemedicine. I brought in a couple of colleagues [also nephrologists], so at 11 am on a Saturday morning we were talking with her and looking at her. She pointed out where she was getting problems. That helped us with a re-assessment of the problem and we made urgent contact with a neurologist who advised that we should be bringing the patient to Adelaide that day, rather than waiting for a few days. It also lead to us making immediate treatment suggestions. (Dr Alex Disney, TQEH, August 1996)

The second year of The Queen Elizabeth Hospital's (TQEH) Renal Telemedicine Network, from mid-1995 to mid-1996, was one of consolidation, evidenced by the wide base of users within the Renal Unit. The telemedicine network now no longer relies on a single champion leader, as the equipment is used for an average of 250-300 times every month, peaking at over 450 uses in one month, and thirty staff used the equipment more than 20 times in one twelve month period. Telemedicine has now become part of the daily business of the Renal Unit.

The Renal Unit's effective adoption of telemedicine and its stable patient base of around 85 patients spread over four sites, three in Adelaide and one at Port Augusta, together with a number of home dialysis patients, has provided the South Australian Health Commission (SAHC) with an ideal telemedicine laboratory. The laboratory is an excellent window into the steps needed to successfully embed telemedicine within a workplace and to develop best practice in the application of telemedicine.

Background

The telemedicine equipment was installed from September 1994 - February 1996 and included the implementation of telemedicine sites at TQEH in Woodville, and at satellite centres at Wayville (10km from TQEH), North Adelaide (8km) and Port Augusta (300 km).

The original aim of the project was to assess the feasibility and cost effectiveness of telemedicine as a means of improving the quality of patient care, further educating dialysis staff and monitoring dialysis processes and equipment at sites remote from the main dialysis institution.

The aims of the second year of the project, from mid-1995 to mid-1995, were to continue a longitudinal study of staff and patient acceptance and usage of the telemedicine approach; extend the skills base in telemedicine throughout the Renal Unit; continue to evaluate clinical applications of the telemedicine technology; conduct a cost effectiveness study; and develop pilot activities with interstate bodies.

Major findings

Achievements

The second year of operation of the Renal Dialysis Telemedicine Project, from mid-1995 to mid-1996, was characterised by the following achievements:

  • an extensive survey demonstrated that staff attitudes continued to be positive about telemedicine
  • staff usage increased in volume and in the types of applications
  • the number and regularity of clinical consultations increased
  • performance targets and quality controls were introduced for staff using the medium
  • the majority of patients were very positive about telemedicine
  • allied health staff were inventive in their use of the technology, particularly the pharmacist, social workers, dietitian and Aboriginal liaison officers
  • Aboriginal patients transferred to Adelaide were assisted in making important decisions by family members in Port Augusta, who used the technology to link to Adelaide
  • connections were established with the Tanami Network in the Northern Territory and the Endocrine and Diabetes Unit collaborated in the delivery of health planning advice to the Aboriginal communities in the Tanami
  • renal nursing education was provided by telemedicine to Port Augusta and Alice Springs on a regular basis.

External links

During the year, external links were made to a range of rural, interstate and overseas sites: to Whyalla, Berri and Broken Hill, for patient consultations and demonstrations; to Alice Springs, for planning meetings; to the Tanami Desert (Yuendumu and Kintore) for planning telemedicine initiatives; and to Melbourne, Toowoomba, Hawaii, Hong Kong and Singapore, for presentations to telemedicine conferences.

The network also received national and international prominence, evidenced by two lengthy articles in "The Australian" and the publication of an article in the international "Journal of Telemedicine and Telecare."

Best practice

Internationally, telemedicine has expanded greatly over the last three years and the literature, particularly in specific telemedicine journals, has grown in size and improved in quality. Hence, it is now possible for any one project such as TQEH's Renal Dialysis Telemedicine Network to learn from, compare itself with and, if it achieves some success, add to the body of knowledge about best practice in telemedicine. Based on a comparison of TQEH's Renal Telemedicine Network and the international literature (See Chapter Two), TQEH's project manifests some important aspects of best practice, including the attention to human and organisational issues, the achievement of high levels of adoption and usage, and the use of the technology in innovative ways by the full cross-section of staff.

Evidence throughout this report demonstrates that TQEH's Renal Telemedicine Network has demonstrated best practice in many human and organisational matters. In particular, it has modelled effective leadership, a regular flow of information about the technology, publicly articulated goals, feedback loops, adequate evaluation and quality monitoring systems. Importantly, the technology has been modified to suit the needs of the users, and is used in the workplace as an accepted and normal tool.

Unfinished business for the Renal Network includes developing telemedicine services for Asia and establishing regular links there; introducing more technological aids such as electronic stethoscopes; and finalising the cost effectiveness study commenced in early 1996.

Empowering patients and staff

In a distributed network such as TQEH's Renal Unit, with one central and three satellite centres, telemedicine can call into question the roles played centrally and locally. If it is not managed sensitively, it can threaten, destabilise and even upset staff and patients. It can also empower or disempower staff, depending on how the technology is used. However, the interviews reported on in Chapter Three suggest that telemedicine has

  • empowered patients, who now frequently request telemedicine consultations
  • empowered the staff at the central location, TQEH, including allied health staff and registrars
  • empowered staff at the satellite centres such as the clinical nurse and the nursing student at Port Augusta.

Staff uses

The account of tape recorded interviews with a cross section of Renal Unit staff demonstrates that telemedicine has become integrated in the daily operation and long term management of the Renal Unit (See Chapter Three). Some highlights are:

  • nine different types of clinical applications of telemedicine by the one nephrologist
  • regular use of telemedicine for outpatient appointments
  • the innovative uses of the desktop technology by the registrars
  • high level of patient acceptance of telemedicine
  • the pharmacist using the facility to manage drug regimes of country patients.

The staff interviews and survey also clarified that the main barrier to further use or improvement is time, not inclination.

The 1996 survey was the most comprehensive staff survey conducted so far: 64 staff were surveyed with 56 returns. Staff still believe that the system is important to the dialysis unit, feel positive towards telemedicine, believe it is easy to use, of average reliability, well supported and easy to access. (See Chapter Four)

New objectives

The telemedicine network is now entering its third year, providing the opportunity to aim for new levels of success. The third year is also an opportunity to provide regular national services to locations such as the Northern Territory and international links to South East Asia.

As a result of the experiences of the second year of operation, it is recommended that the objectives for 1996-97 be to:

  1. Provide measurably improved services for the Renal Unit's patients, including regular outpatient reviews, reduced travel to TQEH, earlier diagnosis of problems and the provision of comprehensive education and support.
  2. Collaborate with NWAHS telemedicine initiatives, consolidate the relationship with the Tanami Network and establish a telemedicine relationship with at least one Asian hospital.
  3. Develop world's best practice in the use of telemedicine and promote these standards and practices.
  4. Continually improve the skills and knowledge of the staff in the use of telemedicine.
  5. Seek funding from external sources such as G7 or the European Union, to develop innovative services such as emergency dialysis for patients who travel or for patients in remote areas.

Strategies to achieve these objectives are set out in Chapter 5.

TQEH's Renal Telemedicine Network is a fairly constant group of staff and a very constant pool of patients. Given this stable environment, and the success of telemedicine to date, the Renal network provides an ideal laboratory to pursue the realistic aim of developing and refining world's best practice in telemedicine.

Chapter 1 Background and Description

This chapter sets out the aims, objectives and major activities of the Renal Telemedicine Network in 1995-96.

Summary of achievements in 1995-96

The second year of operation of the Renal Dialysis Telemedicine Project, from mid-1995 to mid-1996, was characterised by the following achievements:

  • a major survey demonstrated that staff attitudes continued to be positive about telemedicine
  • staff usage increased in volume and in the types of applications
  • performance targets and quality controls were introduced for staff
  • patients were almost unanimously positive about the medium
  • allied health staff were particularly inventive in their use of the technology, particularly the pharmacist, social workers, dietitian and liaison officers
  • Aboriginal patients transferred to Adelaide were assisted in making important decisions by family members in Port Augusta, using the technology
  • the number and regularity of clinical consultations increased
  • connections were established with the Tanami Network in the Northern Territory
  • national publicity was given to the project through "The Australian", on two occasions
  • international recognition was demonstrated by the publication of an article by the project team in the "Journal of Telemedicine and Telecare".
  • renal nursing education was provided to Port Augusta and Alice Springs on a regular basis
  • external links were made to a range of rural, interstate and overseas sites.

Background

The plan for TQEH Renal Dialysis Telemedicine Project was prepared by Dr. Alex Disney and Dr. Timothy Mathew in December 1993, and John Mitchell in June 1994, setting out the aim, background, applications, costings, projected savings, research framework, the project team and responsibilities, key dates and milestones.

Funding for the project was provided by the South Australian Health Commission (SAHC) in November 1993 and the project officially commenced in June 1994, with TQEH's Senior Staff Nephrologist, Dr. Alex Disney, as Project Director and John Mitchell & Associates as Project Managers and Researchers. (Appendix 1). Renal nurse Julie Meyer was appointed Project Officer in October 1994.

The equipment was installed from September 1994- February 1995 and included the implementation of telemedicine sites at Woodville, and at satellite centres at Wayville (10km from Woodville), North Adelaide (8km) and Port Augusta (300 km).

The main equipment consists of four PictureTel System 4000 Rollabouts, 5 PictureTel PCS 50 desktop videoconferencing units, 3 miniature probe cameras and two document cameras.

The aim of the project was to assess the feasibility and cost effectiveness of telemedicine as a means of improving the quality of patient care, further educating dialysis staff and monitoring dialysis processes and equipment at sites remote from the main dialysis institution.

An evaluation report on the first year of operation of the network was published in September 1995, "Establishing Renal Clinical Telemedicine" (Mitchell and Mitchell.) This report covers the second year of operation from mid-1995 to mid-1996.

Objectives and outcomes

The objectives of the second year of TQEH Renal Dialysis Telemedicine Project, from mid-1995 to mid-1996 are set out below, together with a brief comment about outcomes. Many of the points listed below are discussed in more depth elsewhere.

Major objectives

1. continue a longitudinal study of staff and patient acceptance and usage of the telemedicine approach. (A report is contained in Chapter Four on staff attitudes. It was decided during the year that a similar survey of patients would not be conducted.)

2. provide training and technical support for a wider base of users within the Renal Unit, particularly for those medical staff issued with desktop units. (This was undertaken, but several clinicians only wished to have basic induction, not full training.)

3. continue to evaluate clinical applications of the telemedicine technology, including the desktop units, using an action research model and also to prepare a summary report such as this document, in June 1996. (Periodic management team meetings provided a forum for discussing clinical applications.)

4. conduct a cost effectiveness study based on the findings from this report. (A researcher from Adelaide University was engaged to undertake this study in early 1996, but difficulty in identifying quantitative data on patients' health at admission has delayed the completion of this report.)

5. develop pilot activities with interstate bodies. (Collaboration with the Tanami Network and the delivery of renal nurse education to Alice Springs were the major activities here. Negotiations were conducted with Darwin. )

Secondary objectives

6. develop a package of telemedicine services. (The Tanami links were a stimulus to the development of services. The main ones identified were planning advice, education such as the renal nursing course and, in the long term, clinical consultation.)

7. market telemedicine services to targeted Asian countries and develop a sample collaborative telemedicine activity with an Asian health organisation. (Planning discussions were held with the senior staff from the Dr. Sardijito General Hospital in Yogyakarta, regarding the possibility of trial links, using AAPCS satellite technology. Dr. Disney gave a presentation in Jakarta in October, 1995.)

8. act as a demonstration project in telemedicine for TQEH and the SAHC. (The Renal Network provided ongoing information to TQEH personnel, particularly from the Endocrine and Diabetes Service, and hosted numerous visits from SAHC-related personnel. The SAHC's Search Conference in 1995 was supported.)

9. maintain research into international applications of, and technological developments in, telemedicine. (An indication of this research is provided in the next chapter.)

10. improve quality and quantity of use by providing ongoing evaluation and intervention strategies (how these actions were undertaken is described throughout this report.)

11. investigate incorporating renal unit patient data with the videoconferencing technology. (This was postponed due to delay in the implementation of the Oacis database system in December 1996.)

12. performance targets and quality standards be established for users of the facilities, in consultation with the staff. (Performance agreements were developed in January 1996.)

13. collaborative business arrangements be made with videoconferencing technology providers and suppliers, to provide support for research and development activities. (Some equipment was loaned by Integrated Vision for trial purposes and two video links to PictureTel in Boston were held, to discuss recent technological developments.)

14. the issue of confidentiality of the transmission be further investigated and new ways of ensuring total privacy be developed. (Most efforts were put into the use of headphones by patients and medical staff.)

15. the legality of clinical care provided by telemedicine be further investigated by the SAHC. (The National Telemedicine Committee, convened by the SAHC, is investigating this matter.)

16. the billing rate and the payment for individual services and the remuneration from the Medicare Benefits Schedule be investigated by the SAHC. (As for 15.)

17. the use of an electronic stethoscope, capable of operating with codecs, be investigated. (Prices for these units made them prohibitive.)

18. a second promotional videotape be produced, focusing on clinical applications of the technology. (Delay in finalising a second sponsor to accompany PictureTel has seen this postponed to October 1996.)

19. multipoint operations be trialed and evaluated, particularly for educational courses. (This was undertaken in late 1995.)

20. enhance the national and international reputation of the network by extending the information on the Project's Home Page and submitting articles to international publications. (The Home Page attracted considerable international attention and an article was published in the international Journal of Telemedicine and Telecare.)

Evaluation methodology

During the first year of the project it became clear that a number of the initial aims of the projects were not able to be adequately assessed because the technology was not fully integrated into the working life of the unit. An important aspect of the evaluation of the first year of the project was the assessment of the adoption and integration of the technology, with a focus on acceptance and use. This focus has been continued, and the technology has been integrated to a level where it is possible to also evaluate the many initial aims of the telemedicine project.

The project nature of the network has contributed to our approach of action research, rather than applying a strict evaluation strategy. To have established a set of rigid criteria to be used as the only way of evaluating the effectiveness of telemedicine, may have prevented the discovery of many of the new applications and uses of the technology. As outlined in the chapter on international developments, telemedicine is still developing and is likely to continue to develop, alongside improvements in communications technologies, so an important part of any evaluation is the identification of new and effective practices with telemedicine.

With this understanding, the project has used a variety of quantitative and qualitative measures of the effectiveness of telemedicine. A variety of methods were used to collect information on these measures as follows:

  • a longitudinal analysis of user attitudes and beliefs towards the technology was continued using the survey instruments developed during the first year. The results are set out in Chapter Three.
  • details of the volume of uses were collected from monthly ISDN accounts.
  • observations of new and effective uses of the technology were made by members of the project management team and were reported at regular meetings.
  • telephone interviews were conducted using a structured questionnaire. The results formed the basis of a discussion paper presented at a network planning meeting.
  • other data was collected, using questionnaires and structured interviews as part of a cost-effectiveness study.
  • using structured questionnaires, interviews were conducted and recorded, with all major users of the telemedicine network, in preparing this report.

The next three chapters provide a report on the findings from this evaluation framework.

Total Calls

The following graph shows the number of calls for the period from April 1995 to July 1996. The graph shows that the average number of calls per month ranged from a peak of 450 to a low of 200, with an average around 300. For most months, the rate was within the band of 250-300. About 30 calls per month could be discounted as technical checks or routine calls to establish connection.

Internal Communication

Communication between the management team and the staff and patients was conducted on a twice weekly basis, primarily by the Network Officer, clinical nurse, Julie Meyer. She also conducted regular training courses for staff and provided a first point of contact for any issues or concerns.

Additionally, the following steps were undertaken:
copies of the first major report were circulated to staff in October 1995

  • a Guide to the use of the desktop videoconferencing units was developed in November 1995
  • a staff planning seminar was conducted in November 1995
  • performance agreements and quality control measures were developed in January 1996
  • a second newsletter was produced in February 1996
  • staff attitudes were surveyed in early 1996
  • staff and a sample of patients were interviewed about the cost effectiveness issue, from April-July 1996
  • results of the staff survey were circulated to staff in June 1996.

External links and marketing

A major objective for 1995-96 was to establish interstate and overseas links for the network. The Renal Unit's telemedicine facilities were used for the following external links during the twelve months from mid-1995:

  • Whyalla and Berri, for patient consultations
  • Broken Hill and the Tanami Desert (Yuendumu and Kintore), for consultations and demonstrations
  • Alice Springs, for renal nursing education
  • Melbourne, Toowoomba, Hawaii, Hong Kong and Singapore, for presentations to telemedicine seminars.

Marketing of the network was an objective for 1995-96, to develop future business opportunities for TQEH. The network was promoted nationally and internationally by the following means:

  • two lengthy articles on the network were published in "The Australian" in April 1996 and an article on the project appeared in a Spencer Gulf newspaper in mid 1996.
  • a presentation was made at the Australasian Teleconferencing Association Conference in Sydney, November 1995
  • the network supported the organisation of the LETA Conference stream on Technology in Health Education
  • the network's second major newsletter was distributed nationally
  • a brief article on the network appeared in the international publication, "e-med News"
  • copies of the report on the first year of operation were circulated internationally
  • presentations were made at TQEH to a range of visiting groups, including Commonwealth Government and overseas health personnel
  • SAHC personnel and suppliers such as PictureTel showed the videotape, Renal Telemedicine, around the world
  • the Web Site continued to attract many "hits" from around the world.

Improvements and initiatives

Operational improvements during the last twelve months included implementation of a computerised, networked booking system, using an off the shelf software program and TQEH's network. The documentation for the network was also extended.

Initiatives included use of the telemedicine equipment at TQEH for the production of videotapes on issues related to dialysis , for showing live across the system.

The network also prepared the following submissions:

  • an application was made to the G7 to fund four sub-projects on renal telemedicine and
  • an application was made to the Commonwealth Government to fund services for the Tanami Network

Technology Issues

The major issues relating to the technology during the twelve months were as follows:

  • the mobility of the rollabouts, especially their weight and size
  • whether the large monitor on the rollabout, which accounts for most of the rollabout's weight, could be replaced by a smaller, lighter monitor
  • the quality of image from the desktop units, particularly if the backdrop consisted of busy patterns and many colours
  • the cables continued to be of some concern
  • there is a preference for infra-red controls
  • a need was identified for separate or twin headsets for staff at the patient's site.

The technology for the telemedicine network was purchased in 1994 and while it still performs well, the manufacturer has improved the product with infra-red remote control keypads, which are particularly suitable for the renal situation. The manufacturer is now also offering a 30 frames per second option, as opposed to the 15 frames per second. Costs are the only barrier to upgrading the equipment.