Clinical Applications of Renal Telemedicine

An Evaluation of The Queen Elizabeth Hospital Renal Telemedicine Network, 1996-97

John Mitchell & Associates, October 1997

Executive Summary

This report, Clinical Applications of Renal Telemedicine, October 1997, is the third in a series of annual evaluations of The Queen Elizabeth Hospital's Renal Telemedicine Network. The report provides a commentary on the achievements of the objectives set for 1996-97, a summary of the highlights of the year, an account of the major research undertaken on the clinical applications of telemedicine, a summary of research into staff and patients' attitudes, a description of the major project for 1997-98 - telemedicine to the home - and a summary of the Network's plans for 1997-98.

Background

The telemedicine network of the Renal Unit from The Queen Elizabeth Hospital (TQEH) in South Australia includes permanent videoconferencing facilities at TQEH's dialysis unit in Adelaide and at three satellite centres, at Wayville (10km from TQEH), North Adelaide (8km) and Port Augusta(300km). The Renal Network also links to other sites in South Australia. During 1996, TQEH linked occasionally with the Aboriginal communities at Yuendumu and Kintore, over 2,000km north, in the Northern Territory.

Major Findings

In 1996-97, the third year of operation of the Renal Telemedicine Network, increases were seen in both the types of different applications and the numbers of external sites linked to.

Highlights

Other highlights were:

  • links to many other health sites including Broken Hill and Wilcannia in New South Wales, to Mount Gambier (430km from Adelaide) and Whyalla (397km), Clare (142km), Berri (236km from Adelaide), Loxton (255km) and Lyell McEwin Hospital at Salisbury (25km).
  • numerous visits by overseas personnel including a group of officials from the Ministry of Health, Malaysia, following the earlier visit of the Malaysian Minister of Health, and other visits during 1996-97 from China, Taiwan and Indonesia.
  • production of a second videotape called "Clinical Telemedicine" which has been shown extensively around the world including to the Prime Minister of Australia, on 30 May 1997.
  • upgrading of the main rollabout unit at TQEH, to operate at 384kbps, the equivalent of 6 lines, compared to the present two lines (128kbps)
  • weekly links to Royal Darwin Hospital
  • regular links to Royal Adelaide Hospital
  • tutorials for renal students at Port Augusta.

Achievement of Objectives

The objectives for 1996-97 are set out below in italics, with comments following:

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.

One strategy used to achieve this outcome was the clear definition of the range of possible clinical (includes allied health and nursing) applications of telemedicine. This resulted in the publication of the article, "Clinical Applications of Renal Telemedicine" (Mitchell, J. and Disney, APS) in the Journal of Telemedicine and Telecare, September 1997.

2. Collaborate with NWAHS telemedicine initiatives, consolidate the relationship with the Tanami Network and establish a telemedicine relationship with at least one Asian hospital.

The Renal Network collaborated with the NWAHS telemedicine initiatives, particularly in linking to the Tanami Network in the Northern Territory during 1996, culminating in the two-week links to Kintore in late October, early November 1996.

Telemedicine relationships with Asian hospitals was an aim of the intensive training provided by the Network to a range of overseas groups visiting the Telemedicine Network, including a group of seven officials from the Ministry of Malaysia, in December 1996.

3. Develop world's best practice in the use of telemedicine and promote the standards and practices.

The international reputation of the network was maintained by making presentations to the House of Representative Inquiry on Telemedicine; making presentations at conferences; use of the world wide web; preparation of newsletters and reports; preparing articles for journals; and representations to Governments.

4. Continually improve the skills and knowledge of the staff in the use of telemedicine.

A major focus during 1996-97 was placed on induction of staff and a comprehensive program of professional development was provided for experienced staff.

5. Seek funding from G7 or the European Union, to develop innovative services such as emergency dialysis for patients who travel or for patients in remote areas.

The Network's submission to G7/EU was unsuccessful, largely because the guidelines for G7 focused on emergency telemedicine and did not favour renal telemedicine.

An overall aim of the Renal Telemedicine Network in 1996-97 was to strive for world's best practice in telemedicine. No formal standards exist for such an endeavour, so the Network continued to monitor telemedicine networks in Australia and overseas, to establish some guidelines and benchmarks. As a result of monitoring the literature and from experience within the Network, a number of continuous improvement practices were developed during the year:

Research into Clinical Uses

One of the major questions for telemedicine practitioners is to what extent telemedicine technology can be used in clinical situations. Beginning in 1994, the Renal Unit at The Queen Elizabeth Hospital has explored the limits of the available technology for performing clinical procedures in its four dialysis centres, and in other rural hospitals and general practitioner clinics. In that period, the equipment has been used on over 6,000 occasions. Interviews and observations have been conducted, reports of incidents have been collected and two major reports have been completed since September 1994 (1,2). This report is the third in the series. The interviews and observations have involved medical, nursing, allied health staff and dialysis patients.

A major finding of the research is that the full range of staff, from surgeons and nephrologists to allied health staff and nurses, can use the technology for clinical purposes. A second major finding is that the technology enables staff to perform a wide range of clinical procedures, from routine outpatient consultations to monitoring infections to making decisions about retrieval or confirming decisions to operate. A third major finding is that telemedicine enables the Renal Unit to provide enhanced services where teams of staff at the different sites cooperate in ways that were not possible before the live, audio-visual link became available.

Survey of Patients and Staff

The annual, formal survey of staff and patient users of the Renal Telemedicine Network was conducted in mid 1997. A survey questionnaire was issued to all staff and patients, with 36 staff and 68 patients returning the questionnaires. A total of 10 staff and 10 patients were interviewed.

The results of the surveys and interviews are very encouraging and demonstrate that telemedicine has become embedded in the normal operation of the renal dialysis centres.

Telemedicine to the Home

'Telemedicine to the home' is a major new development in telemedicine around the world, made possible by the availability of economical technology such as desktop videoconferencing equipment, some of which can operate on the Plain Old Telephone Service (POTS) for basic videoconferencing. The Renal Unit has a number of peritoneal and haemodialysis patients who dialyse at home. There are also patients recovering from transplant operations who might conceivably benefit from monitoring from the hospital.

A four stage trial of telemedicine to the home is planned for 1997-98.

New Objectives

In terms of the life cycle of projects, TQEH's Renal Unit Telemedicine Network has moved through the emerging and growing stages, to a maturing stage, and is now diversifying with the advent of Oacis and home telemedicine. At this point in the network's development, it is critical that there be rigorous planning, clear goals, practical strategies and ongoing evaluation.

The objectives for 1997-98 are to:

  1. Continuously improve the Renal Unit's telemedicine services and systems, by addressing patient and staff concerns raised in the 1997 surveys and by developing optimum systems for induction, training, scheduling and support.
  2. Continue to monitor best practice in other telemedicine projects, to define benchmarks for the Network.
  3. Conduct a thorough trial of telemedicine to the home.
  4. Trial new technologies such as an electronic stethoscope, images at 384kbps, audio handsets for patients and POTS based videoconferencing and continue to evaluate the combined use of Oacis and videoconferencing.
  5. Participate in State, national and international forums for telemedicine, to benefit from a two-way flow of information and to promote the Renal Telemedicine Network.

Ch.1 Background to Network

TQEH's Renal Dialysis Telemedicine Project commenced in June 1994, based on the original planning document developed by Dr Alex Disney and Dr Timothy Mathew in 1993.

Videoconferencing and related equipment was installed at its four renal dialysis centres at TQEH Woodville and Wayville (10 km from Woodville) in September 1994 and at North Adelaide (8 km) and Port Augusta (300 km) in February 1995.

The Unit dialyses a total of 145 patients at these four centres, with each patient normally dialysing three times per week and attending an outpatients clinic once every two months. The Unit also cares for 29 patients who dialyse at home.

Funding for the project was provided by the South Australian Health Commission (SAHC) in November 1993, and funding support has been maintained since then by the SAHC. TQEH's Senior Staff Nephrologist, Dr Alex Disney, was appointed Project Director and John Mitchell, managing director of John Mitchell & Associates, was appointed Project Manager and Researcher, in June 1994. Registered Nurse Julie Meyer was appointed Project Officer in October 1994.

Aims

The original aims of the project were to assess the feasibility and cost effectiveness of telemedicine as a means of improving the quality of patient care, determine the need for the further education of dialysis staff, and monitor dialysis processes and equipment at sites remote from the main dialysis institution.

These aims were later expanded, based on experience, to include the development of strategies to accelerate user adoption and to maximise both the number of users within the Unit and the breadth of telemedicine applications. An additional aim was to assess the value of desktop videoconferencing for clinical consultations.

The Network now links to large number of sites around rural South Australia, to other sites interstate and periodically overseas.

Applications and Usage

The term telemedicine implies the use of telecommunications to provide health care. The Renal Network uses the telemedicine facilities for a variety of clinical, administrative and teaching purposes. The clinical uses are described in detail in Chapter 3.

The Renal Telemedicine Network uses rollabout videoconferencing systems in the dialysis wards at TQEH, Wayville, North Adelaide and Port Augusta. Desktop videoconferencing units are also on the desks of three clinicians, the registrars and the Ward Clerk at TQEH. Other technologies include miniature cameras for close up images, headsets to provide patients with some privacy during consultations, document cameras for transmitting graphics, and videocassette players.

After reaching some very high levels of usage in the early stages of the project, the level of usage of the equipment has now levelled out at about 125 per month. The range of users and uses also sets this project apart from many other more limited telemedicine activities.

Evaluation Studies

The Renal network has been extensively evaluated and reported upon in "Establishing Clinical Renal Telemedicine" ( Mitchell, J and Mitchell, B., September 1995), "Best Practice in Telemedicine" (Mitchell, J., 1996), "User Adoption Issues in Renal Telemedicine" (Journal of Telemedicine and Telecare, Mitchell, B., Mitchell, J. and Disney, A.P.S., 1996) and "Clinical Applications of Renal Telemedicine (Journal of Telemedicine and Telecare, Mitchell, J. and Disney, A.P.S., 1997).

The evaluation studies provides insights into the factors critical for the successful implementation of telemedicine in the early years and the strategic planning and management required to sustain the innovation. The studies indicate that much planning, effort, co-operation and an appropriate culture within the Renal Unit were needed to achieve a high level of acceptance of telemedicine.

Breakthroughs

The project made a number of international breakthroughs for the cause of telemedicine and for the South Australian Health Commission (SAHC): notably, the ability to conduct clinical consultations at low bandwidths (128kbps); the effective use of state-of-the-art desktop videoconferencing for clinical consultations; the use of telemedicine by the full gamut of staff and patients in a workplace; and the collection of considerable data related to user adoption of telemedicine.