CASE STUDY: DHBs discuss the all-too-human impediments to telemedicine

Dr John Garrett, liaison paediatrician for Canterbury and West Coast DHBs talks about the continuing investment in video conferencing technology, even as he draws a picture of underutilisation that needs to be overcome

While telemedicine and health-related video conferencing is becoming more common in the country, there is still a significant degree of variation in adoption and delivery and quite a lot of under-utilisation.

“Relative to the country’s size and population, I think we use telemedicine infrequently. The Canterbury and West Coast DHBs (district health boards) are two that have the most activity in telemedicine in the country,” says Dr John Garrett, liaison paediatrician for Canterbury and West Coast DHBs.

Telemedicine in the two DHBs have been enabled by Polycom equipment, which has been slowly phased in to the functioning of the boards over the last few years.

“Here (Canterbury and West Coast DHBs) we have a number of services using telemedicine actively at the moment in a number of different ways. They include patients being seen for outpatient appointment, that is patients from the Coast being treated from Christchurch,” says Garrett.

The support that is provided remotely includes speciality care for acutely unwell people, and has been extended to cover retrieval services as well.

“Christchurch provides a retrieval service for adult patients who need to be brought over here for high level care and for neonatals who need to come everyday. And both of those services have a video conferencing element that they can include in going to pick up a patient. At the moment that’s not happening anywhere else in NZ.

“We are at a stage now where we know that the networks and the systems work and deliver what we want them to do. We are at the stage where we are going to try and expand the work that is being done because it’s relatively small in terms of numbers at the moment. There is a lot more we can do with telemedicine,” says Garrett.

Dr John Garrett, liaison paediatrician for Canterbury and West Coast DHBs.
Dr John Garrett, liaison paediatrician for Canterbury and West Coast DHBs.

Change in practice

Canterbury DHB has about 35 video conferencing units, and a number of software-based units. The Westcoast DHB has a little over 30 video conferencing units, and equipment additions continue for both of the health boards. However, factors for under-utilisation go beyond the presence of technology.

“It demands a change of practice from clinicians...We are used to seeing people face-to-face and providing them care. That’s the traditional way of doing things.

"There is an expectation that we try and provide everyone with equal access to care. That’s an ideal but it is not possible, because there are some people who live a long way away from where the specialists are. We are trying to find a way to even out the access to care. And it is just a matter of allowing everyone to see that that’s possible with telemedicine.

“Clinicians have got to recognise that some of the patients travel a long way, they have got to recognise that sometimes when they see the patients, they don’t even need to examine them, and that they can do that by video conference. So it is getting them to change their thinking about it,” says Garrett.

There is work to be done to get patients to accept the conferencing element as well, but generally this is not too hard, since they are the ones who have to travel and take the time off from work.

“To increase adoption DHBs should also make sure that all the background services are in place. The reality is that at the moment they probably are not. Booking a video conference appointment is still a lot more complicated than doing it face-to-face. Mostly because you have got to book two locations for the one appointment and those two locations might be in different DHBs.

“It gets a bit more complex if the patient goes to the local GP to be seen by a hospital doctor. But we are working on a few of those things now to try and make it all work well.

“If I had to guess there might be 10,000 patients who could be seen every year in Canterbury by video conference. Right now we are seeing closer to a 1000 than 10000. So we have got potentially a lot more we could do,” says Garrett.

The two DHBs are working to empower all the clinical staff who are already sold on the video conferencing idea by giving them access to equipment and making processes easy for when they want to work on the technology.

To get those who are not convinced yet, they are working on a couple of other angles.

“The South Island DHBs are trying to develop one new, better and combined patient administration system. A system that tracks patients on waiting lists, books them into clinics and co-ordinates everything for them. At the moment, there are five DHBs with potentially five different systems, and it gets really difficult to look after people who might be in two different DHBs.

That’s quite a big project, but that one that is fundamental, says Garrett.

The DHBs are also working to map patients – place their location on a map – so clinicians can see where they have to travel from for each appointment as part of their medical history. This, they hope, will make clinicians re-think the necessity of each appointment, and maybe move some to become video conferences.

“The National Health IT Board is trying to do a bit of work to look at how funding might work for telemedicine consultations – to try to incentivise it. That does not exactly involve paying you more for doing it, but trying to work around how individual DHBs charge other DHBs if they see their patients.

“At the moment there is no real incentive for a big DHB to see patients by telemedicine, because it doesn’t cost them to have them come to the DHB in person. The sending DHB pays for that. It is kind of backwards that way, and we are trying to turn that around, more likely that funding wont’ get in the way,” says Garrett.

The secret sauce

Garrett warns that while telemedicine involves a lot beyond mere technology, the equipment needs to be world-class in order to enable the transformation of health provision.

“You have to be very careful with the quality of the equipment that you choose. You need to be sure that you have got high quality video conferencing so that picture quality is good, and high definition. You need to make sure that there is no video lag, pixelation or lag. You can’t see patients if your video conferencing technology does not work well.

“That means the equipment needs to be good and the network needs to be good. We are mostly good with that between hospitals. Most hospitals are well connected in terms of data speed and capacity. It is not so easy to be sure about that once you get into the community,” says Garrett.

When clinical staff move out of the hospital’s network they become dependent on the speeds provided by the ISPs and this might not always be adequate, consistent or reliable.

“It would be interesting to see what 4G does. But I suspect that it might also be not adequate or not consistently adequate. We are getting to the point where there are number of networks off the coast. For a while it was just one; now there are three, and more are getting active. We do have a problem where we don’t have interoperability between those networks and that is the equivalent of not being able to directly call a Vodafone number from a telecom number.

“We probably need to find a way through that to make sure that we can keep making and building out networks in NZ to continue to enable more advances in telemedicine,” states Garrett.

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