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Hospital Healthcare Europe

Consulting your doctor via TV screen: How telehealth networks can improve patient care in remote rural areas

22 July, 2010  

Technology is helping to make better use of expert resources and cut patient travel and thus the carbon footprint of the National Health Service in Scotland

Dr James Ferguson
Clinical director for the Scottish
Centre for Telehealth (SCT)

With a population of 5.2 million spread over a diverse and varied landscape, Scotland raises a number of challenges when offering a fast and effective medical response to patients in some of the more remote areas of the country. Road journeys can be long and laborious, often affected by weather in the winter and some people in the outlying islands are reliant on boat transfers or flights.
The development of a telehealth network, via a number of projects in several parts of the country, is adding a new dimension to diagnosis and treatment for patients. This helps to avoid long or even unnecessary,journeys by patients and also
significantly reduces the carbon footprint generated by healthcare.
Benefits are becoming apparent for patients in the remote rural areas and there are already early signs that telehealth may eventually have a part to play in gridlocked urban conurbations.
The Scottish Centre for Telehealth (SCT) supports a range of projects throughout Scotland, focusing on the long-term objectives of unscheduled care, management of long-term
conditions, paediatrics, remote and rural support and education.
Projects contribute towards preventative, anticipatory care; sustainable and safe local medical services; care in local communities rather than in a hospital setting; and improved standards and speed of care and improved access to services. Areas covered include home monitoring of blood pressure (BP), a transient ischaemic attack (TIA) and minor stroke service, the Scottish telestroke programme, paediatric telemedicine, phototriage, chronic obstructive pulmonary disease (COPD) rehabilitation, telecardiology, tele-endoscopy and teleneurology.
Under the ‘Better Health, Better Care – Action Plan’, the SCT is guiding the development of telehealth for clinical, managerial and educational purposes across Scotland. This involves working across boundaries with industry, with local authorities and NHS boards to develop recognised models for redesigning care and to help evaluate the potential benefits of new technologies. The aim is to make Scotland a recognised global leader in telehealth.

Scottish Cicso HealthPresence trial
An important part of the project is the Scottish HealthPresence trial, which is a collaboration between the SCT, IT firm Cisco and NHS Boards with the aim of demonstrating the viability of an innovative service linking patient and clinician at a distance and to evaluate clinical outcomes. Cisco HealthPresence was installed in the Emergency Department at Aberdeen Royal Infirmary (ARI) in January 2008 and has been trialled since for a variety of clinical presentations.
The latest phase has been to see undifferentiated general medical services patients who had been referred to the GMED
out-of-hours service based at ARI. The aim was to answer the question “Can clinicians triage and develop a management plan for undifferentiated primary care cases using Cisco HealthPresence?”
Patients were seen in the booth, and also seen conventionally
face to face. Over three months, some 114 patients presenting with bites, burns, infections and throat problems were seen
with early positive results. They were evaluated with the HealthPresence and rechecked with a face-to-face encounter with diagnosis and treatment rendered via the HealthPresence.
In 7% of the cases that were rechecked, the physicians indicated that the management plan changed. Of the remaining patients, the majority indicated that they were “completely confident” using HealthPresence alone. This small study implies that the HealthPresence consultations are safe and appropriate and may serve to improve effectiveness in the delivery of healthcare.[1]

Argyll and Bute Telecardiology Project
Elsewhere, in a remote part of Scotland, cardiac patients are having their condition assessed via the Argyll and Bute Telecardiology Project, a collaboration between the Argyll and Bute Community Health Partnership (CHP) in the far west of
Scotland and the cardiology services at Glasgow Royal Infirmary.
Established in May 2009, it means patients who suffer chest pains or develop a range of heart problems can be assessed remotely and quickly at a cardiac clinic at the Mid Argyll Hospital in Lochgilphead via a video conferencing link to a consultant cardiologist in Glasgow.
The early signs from the pilot indicate that patients are being effectively and cost-efficiently assessed and without the stress of having to make the 120km journey to Glasgow. With the telecardiology initiative, patients can undergo simple tests and be assessed; we can institute treatment early and decide if they are going to need simple drug treatment or get them to Glasgow for a more detailed examination and angiography. It will hopefully mean we can more efficiently select those patients that need to come into hospital.
Within the fortnightly telecardiology clinic, exercise tolerance tests, echocardiography and ECG testing can be carried out. Following testing, a cardiovascular nurse will link with the consultant cardiologist at Glasgow Royal Infirmary, by video conference allowing all members of the team to view and discuss the patient, their results and the next stage of  treatment. If required, the cardiologist can see the patient in Glasgow for further discussions, treatment or diagnostic
Within the first three months, eight patients had been treated in this way at Lochgilphead, saving more than 2,000km of travelling. The service will be evaluated after a year to include patient and staff questionnaires, and a review of patient numbers, outcomes and patient travel to Glasgow. But the initial response has been positive.

TIA & Stroke Telemedicine Service to Orkney
Before the Unscheduled Care TIA & Stroke Telemedicine Service to Orkney, the patient pathway for acute TIA was to be referred to Aberdeen for consultation with the stroke physician at the
next available clinic, which could take up to two weeks after onset of symptoms, meaning delays in referral for radiological or vascular investiga-tions. Using video consultations, it is now possible the specialist will see all TIA patients within 24 hours, commence secondary prevention treatment immediately and avoid two flights and an overnight stay in Aberdeen for the patient.
All GP practices in Orkney and the remote consulting site in Aberdeen Royal Infirmary have a Codec and monitor in place, though with no CT scanner on Orkney, thrombolysis following
a stroke is not an option. However, the time from onset of symptoms to consultation with the specialist in Aberdeen can be greatly reduced by having access to the on-call physician using the video conferencing link. The Tele TIA service has seen 18 patients within 24 hours, leading to appropriate treatment starting promptly. Three patients were found not to have suffered TIA and thus avoided transfer to Aberdeen.

ENT tele-endoscopy
A feasibility study to establish whether ENT tele-endoscopy would be a suitable method of service delivery for patients who live in the Shetland Islands saw ten clinics conducted over 17
months using ISDN-based videoconferencing a bandwidth of 384 kbit/s. A total of 42 patients were seen from Aberdeen via videoconferencing for a head and neck cancer assessment.
Feasibility was confirmed after the first 20 patients, following positive feedback and the absence of any significant clinical or technical problems. Forty-two journeys were avoided, each journey saving 123kg CO2 per person. A preliminary cost analysis showed that the threshold at which tele-ENT became cheaper than travel was a workload of 35 patients a year.
This shows that a national telemedicine service for the initial assessment of potential malignancy has the potential to reduce unnecessary transfers to specialist centres, with accompanying
reductions in carbon emissions.[2]

Phototriage in suspected cancer referrals
A pilot phototriage system for urgent suspected cancer referrals ran for six months where patients suitable for triaging were sent by their GP to one of two community based centres for photographing. The digital images were triaged by a  ermatology consultant with the patient directed to the most appropriate clinic. The results from the first 108 patients showed that 64% of all urgent skin lesion cases were referred via phototriage with 10 days mean time from referral to phototriage. This saw rapid assessment for patients with skin cancer with triage permitting patients with suspicious lesions to be fast-tracked for surgery or clinical assessment.

BP home monitoring project
The Dufftown Medical Group BP home monitoring project showed that home monitoring is as good as traditional care and is more convenient to patients. Patients used the Omron M10-IT BP machine at home to agreed frequency of recordings.
Initially the machine will be handed in to the health centre with data downloaded and reviewed by the clinical team and an advice sheet about further treatment returned to the patient with the machine but under Phase 3 of the project the
patient will download their BP data onto a secure website to be accessed and assessed by a GP.

Piloted in the North of Scotland between December 2005 and March 2006, teleneurology has since become part of routine service delivery with clinics running every two months from Aberdeen to Orkney.

Limitations and future developments
The work through the SCT has also been important in identifying areas that are less suited to telemedicine. A pilot established that telemedicine was not a suitable format for management and treatment of uveitis (inflammation inside the
eye). However, telemedicine has proved a critical tool in helping shift the balance of care across Scotland.
It can expand the range of services available locally and meets the objectives of’ Delivering for Health’ and ‘The Better Health Better Care’ discussion document, which identifies the need
for patients to access “locally delivered services wherever possible, linked by new technology to specialist centres to provide additional support and information where this is required”.
The benefits for the patient are clear: they can be diagnosed in remote rural areas without the stress and inconvenience of long journeys.
Ultimately, there is no reason why telemedicine cannot also be applied in the large conurbations as well, because moving about in the big cities can also be time consuming.
elemedicine makes the system more effective and makes more efficient use of specialist expertise. With a more challenging economic climate facing the NHS – and other health systems across Europe – health professionals and managers are going to have to take a closer look at tackling inefficient practices. Telemedicine is a cost effective way of doing that, not just in Scotlandbut across Europe.

1. David Heaney, Jan Caldow, Christine McClusky, Gerry King,
Karyn Webster, Fiona Mair, James Ferguson. The Introduction of a New Consulting Technology into the National Health Service (NHS) for Scotland, Telemedicine and e-Health 2009;15(6):546-51.
2. Cathy Dorrian, Jim Ferguson, Kim Ah-See, Catriona Barr, Kushik Lalla, Marjon van der Pol, Lynda McKenzie and Richard Wootton, Head and neck cancer assessment by flexible
endoscopy and telemedicine. J Telemed Telecare 2009;15(3):118-121.