Establishing Renal Clinical Telemedicine

An evaluation of The Queen Elizabeth Hospital Renal Dialysis Telemedicine Project 1994-1995

John Mitchell, BA (Hons), Dip Ed, M Ed Admin, AFAIM Benjamin Mitchell, BA (Psych.)
Executive Summary

  • It's being adopted well; we've become used to it; it's become part of the scene.(TQEH Haemodialysis Clinical Nurse Consultant, Jayne Carpenter)
  • People are not threatened, they are using it, and are comfortable with it. It's just a part of the Unit. (TQEH Renal Ward Clerk, Helen Denman)
  • Initially it was difficult and I was not zooming in on the patients and I was missing the raised eyebrow. Now I place their great big nose in the screen and can see all their facial expressions. (TQEH Pharmacist, Sharon Goldsworthy)

This evaluation study of The Queen Elizabeth Hospital's (TQEH) Renal Dialysis Telemedicine Project from mid 1994 to mid 1995 provides insights into the factors critical for the successful implementation of telemedicine in its first year. The report indicates that much planning, effort, co-operation and an appropriate culture within the Renal Unit were needed to achieve this high level of acceptance of telemedicine.

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.

While the SAHC's investment in the project has resulted in these international breakthroughs, the report also indicates that the successes achieved in the first year will not be sustained unless further funding and project management are provided for the second year.

Background

TQEH Renal Dialysis Telemedicine Project commenced in June 1994, based on the original planning document developed by Dr. Timothy Mathew and Dr. Alex Disney in 1993 (see Appendix 1).

The project was undertaken by TQEH Renal Dialysis Unit from May 1994 to June 1995 and included the installation of telemedicine facilities at its four renal dialysis centres at Woodville, Wayville (10 km from Woodville), North Adelaide (8 km) and Port Augusta (300 km). 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 SAHC in November 1993, a brave initiative given the embryonic state of telemedicine at that time. 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 (Appendix 2). Registered Nurse Julie Meyer was appointed Project Officer in October 1994. Dr. Disney, John Mitchell and Julie Meyer formed the project management team. Benjamin Mitchell, also from John Mitchell & Associates, provided research and training assistance.

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 term telemedicine implies the use of telecommunications to provide health care. The aspect of telemedicine trialed in the project was the use of videoconferencing. The definition of telemedicine is discussed in some depth in Chapter 2.

Major findings

The report demonstrates that telemedicine is a human activity, not a technological event, and that the technology is merely the vehicle for enabling the delivery of health care services. Hence, much of the focus during the project was on cultural issues such as staff and patients' perceptions and expectations, beliefs and motivation. The project management centred on responding to users' needs; providing a constant flow of information, support and training; adapting the technology to the workplace; and giving staff and patients sufficient time to see the benefits to themselves of telemedicine .

This story of negotiation and cultural change is uncomfortable news for those vendors who expect telemedicine equipment sales to boom merely because the equipment works. It also signals caution to those consultants who develop cost benefit analyses for telemedicine based on fanciful assumptions and projections about adoption rates and patterns as well as to health care administrators who might hope that telemedicine is easy to implement. The report shows that TQEH's successes with telemedicine cannot simply be transplanted to every other health care unit. While TQEH project can provide invaluable information about critical success factors and about how to introduce innovative technology, telemedicine projects in other units will need to address challenges similar to those that arose in this project. There are telemedicine facilities in Australia and overseas that failed to address these issues, and now lie idle.

The project demonstrates the need for the SAHC to investigate generic issues such as legal liability, payment for telemedicine clinical services and confidentiality of clinical sessions.

Chapter 1 describes the particular culture of the Renal Unit of TQEH and the management strategies used to implement telemedicine. Much effort was required to continually modify what was essentially boardroom videoconferencing equipment to suit the busy and sometimes frantic, high pressure context of a dialysis ward.

Key strategies used to introduce telemedicine included:

  • addressing staff and patients' concerns, particularly about confidentiality, privacy and the mobility of the equipment;
  • conducting awareness raising and induction activities as well as basic and advanced training;
  • consulting users and providing them with adequate information about the aims of the project;
  • developing adequate operational documentation;
  • continually modifying the technology;
  • promoting the concept;
  • and providing feedback from evaluation surveys and research.

Chapter 2 locates TQEH Renal Dialysis Telemedicine Project within the context of the international evolution of telemedicine, and more recently, the explosion of activity in this field. The chapter demonstrates that the challenges and unresolved issues faced in the project are similar to those faced elsewhere. The Chapter also demonstrates that TQEH Renal Dialysis Project is of interest, and value, internationally, due to the challenges met during the project.

Chapter 3 describes the evaluation methodology for the project. The main instruments used were six surveys and numerous interviews, observations, small group discussion and collection of data regarding actual usage. A case study evaluation was also conducted of the use of the desktop videoconferencing unit by a physician. As a result, the project has gathered one of the most comprehensive sets of data in the world on user acceptance and adoption issues within telemedicine.

The form of evaluation used during the project was participant evaluation, conducted by the project managers and designed to provide up-to-date information for the project management team, for immediate response.

The survey data in Chapters 4 and 5 reveal the hopes, concerns, impressions, surprises, disappointments and, ultimately, the acceptance of telemedicine by the staff and patients. The data emphasise the need for a continual dialogue with the users about the project's goals; for extensive training and practice in how to use the technology; and for modification of the equipment so that it is easy to move and use, reliable and able to provide quality images in a private setting.

The staff interviews in Chapter 6 illustrate the range of telemedicine users, from the clinician, registrar, clinical nurse consultant and registered nurse to the pharmacist, dietitian, social worker, nurse educator, technician and ward clerk. This range was much broader than originally anticipated and adds considerably to the cost effectiveness of the facilities.

The case study on the use of the desktop videoconferencing unit in Chapter 7 is of international significance, as this technology has only recently become available and there are no precedents for its use in the clinical setting.

It is explained in Chapter 8 why it was not possible to examine, in any detail, cost effectiveness issues during the project in the way suggested in the original project plan (Appendix 1), particularly due to the delayed start of the project at the final two sites, especially Port Augusta. However, the report demonstrates that the facilities are saving time and expenses for TQEH and patients and it clearly illustrates the role telemedicine can play in ensuring the quality and effectiveness of satellite centres not staffed by doctors. In the long term, the major savings from telemedicine may come from less obvious benefits such as improving the provision of services to patients, including dietitian and pharmacist services, so that the health of dialysis patients does not deteriorate to the point of requiring hospitalisation. The report also demonstrates that the cost effectiveness of telemedicine is enhanced by many intangible benefits such as improved staff development, staff cohesion, faster decision making and instant diagnosis.

Major objectives, 1995-1996

It is recommended that the following be the major objectives for the second year of the project, 1995-1996.

  1. Continue a longitudinal study of staff and patient acceptance and usage of the telemedicine approach, to improve quality and quantity of use, to provide intervention strategies and to inform a summary report in 1996.
  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. Provide advanced multi-media training for Project Director, nurse educator, and one staff member per site, as case studies.
  3. Continue to evaluate clinical applications of the telemedicine technology, including the desktop units, using an action research model .
  4. Performance targets and quality standards be established for users of the facilities, in consultation with the staff.
  5. Collaborative business arrangements be made with videoconferencing technology providers and suppliers, to provide support for research and development activities.
  6. Conduct a cost effectiveness study based on the findings from the report, "Establishing Renal Clinical Telemedicine."

Secondary objectives, 1995-1996

It is recommended that the following be the secondary objectives for the second year of the project.

  1. Develop a package of telemedicine services.
  2. Market telemedicine services to Darwin and to targeted Asian countries and develop a sample collaborative telemedicine activity with an Asian health organisation.
  3. Act as a demonstration project in telemedicine for TQEH and the SAHC.
  4. Maintain research of international applications of, and technological developments in, telemedicine.
  5. Enhance the national and international reputation of the project by extending the information on the Project's Home Page and submitting articles to international publications.
  6. Investigate incorporating renal unit patient data with the videoconferencing technology.
  7. The issue of confidentiality of the transmission be further investigated and new ways of ensuring total privacy be developed.
  8. The legality of clinical care provided by telemedicine be further investigated by the SAHC.
  9. The billing rate and the payment for individual services and the remuneration from the Medicare Benefits Schedule be investigated by the SAHC.
  10. The use of an electronic stethoscope, capable of operating with codecs, be investigated.
  11. A second promotional videotape be produced, focusing on clinical applications of the technology.
  12. Multipoint operations be trialed and evaluated, particularly for educational courses.
  13. Develop pilot activities with interstate bodies.

Next (Chapter 1. Description of Project and Management)