1. Rural Health Implementation Group Telemedicine Rural Health Conference 20 September 2011 Dr Alan Axford, Chair RHIG Telemedicine Group Delyth Lewis, Telemedicine Manager delyth.lewis2@wales.nhs.uk

2. Background -Telemedicine Telemedicine in routine use in Ceredigion since 2000Telemedicine in routine use in Ceredigion since 2000 Telemedicine Service established South (West) Wales Cancer Network 2005Telemedicine Service established South (West) Wales Cancer Network 2005

3. Background – Rural Health Rural Health Implementation Group:Rural Health Implementation Group: –Set up to support the Rural Health Plan –Ensure use of telemedicine is maximised across rural Wales (Hywel Dda, Powys and Betsi Cadwaladr Health Boards –Secondment of Telemedicine Service Manager for Hywel Dda Health Board and South Wales Cancer Network

4. Aims Explore potential of telemedicine across rural WalesExplore potential of telemedicine across rural Wales Encourage further development of telemedicine servicesEncourage further development of telemedicine services Raise awareness of rural health Telemedicine services in WalesRaise awareness of rural health Telemedicine services in Wales Assess capability of primary care network bandwidth to support videoconferencingAssess capability of primary care network bandwidth to support videoconferencing Facilitate videoconference training programme for NHS staff.Facilitate videoconference training programme for NHS staff.

5. Objectives Identify current successful telemedicine servicesIdentify current successful telemedicine services Share good practiceShare good practice Provide videoconference training workshopsProvide videoconference training workshops Provide support/advice to health boards in their development/implementation of telemedicine servicesProvide support/advice to health boards in their development/implementation of telemedicine services Create and maintain web based electronic map of existing rural health telemedicine servicesCreate and maintain web based electronic map of existing rural health telemedicine services Conduct feasibility study on use of web cameras in four pilot GP practicesConduct feasibility study on use of web cameras in four pilot GP practices

6. Anticipated outcomes Improved local access to healthcare for patients in rural areasImproved local access to healthcare for patients in rural areas Quicker diagnosis and treatment plan for patients.Quicker diagnosis and treatment plan for patients. Equality of healthcare service to patients in rural areasEquality of healthcare service to patients in rural areas Reduce waiting times for specialist opinionReduce waiting times for specialist opinion Reduce travelling time and expenses of staff attending meetings.Reduce travelling time and expenses of staff attending meetings. Increased opportunity for staff participation in education meetings = more people with a broader range of experience.Increased opportunity for staff participation in education meetings = more people with a broader range of experience. Increased educational sessions and sharing good practice.Increased educational sessions and sharing good practice. Reduced costs of service delivery by lowering cost of accessing specialist opinion.Reduced costs of service delivery by lowering cost of accessing specialist opinion. Reduced CO2 emissionsReduced CO2 emissions

7. Definitions Telemedicine The practice of medicine using technology to provide clinical services at a geographically separate site. Service can be delivered in “real time” using interactive videoconferencing, or through “store and forward” which relies on the transmission of images and data for review immediately or at later time. Telecare The use of technology to provide monitoring of real time emergencies and lifestyle changes over time in order to manage the risk associated with frailty and independent living Telehealth The use of technology to provide remote monitoring of people living with a chronic condition and to support self management and delivery of care.

8. Telemedicine What it is:What it is: –Now, not in the future –Available and cost effective support for traditional medicine and healthcare delivery –Additional resource not a replacement –Reliable, secure and high quality resource (Videoconferencing hosted on Welsh Health Video Network – calls are free!) –Evidence based world wide 1 –Tried and tested in Wales – ahead of most parts of UK other than Scotland 1 Berman M, Fenaughty F. Technology and managed care: patient benefits of telemedicine in a rural health care network http://ideas.repec.org/a/wly/hlthec/v14y2005i6p559-573.html http://ideas.repec.org/a/wly/hlthec/v14y2005i6p559-573.html

9. Telemedicine isn't terrifying!

10. Telemedicine in NHS Wales What has been done to date:What has been done to date: –Use of videoconferencing for: “Virtual” multidisciplinary team meetings“Virtual” multidisciplinary team meetings Management and clinical meetingsManagement and clinical meetings Education and training sessionsEducation and training sessions Clinical applicationsClinical applications –Profession - profession –Profession - patient –(Medical and non medical e.g. AHP, ECG technicians etc) Transmission of data e.g. digital radiology images, histopathology images, live echocardiography ultrasoundTransmission of data e.g. digital radiology images, histopathology images, live echocardiography ultrasound –Use of electronic “store and forward” for diagnosis/triage of dermatology images

11. Impact Quality: Access to specialist services closer to homeAccess to specialist services closer to home More efficient use of specialist staff – consulting not commuting!More efficient use of specialist staff – consulting not commuting! Reduced waiting times for expert consultationsReduced waiting times for expert consultations Reduced patient journeys for expert consultationsReduced patient journeys for expert consultations Faster implementation of treatment plansFaster implementation of treatment plans Ground breaking projects/services in rural WalesGround breaking projects/services in rural Wales Remote supervision of generalist staffRemote supervision of generalist staff Staff meet CPD requirement regardless of working locationStaff meet CPD requirement regardless of working location Expert GP meet governance complianceExpert GP meet governance compliance Multidisciplinary Team participation not limited by distanceMultidisciplinary Team participation not limited by distance

12. Impact Costs: Reduced travel costs for patient/cliniciansReduced travel costs for patient/clinicians Reduced CO2 emissions for healthcareReduced CO2 emissions for healthcare Reduced costs for CPD/study leaveReduced costs for CPD/study leave Potential for reduced service delivery costsPotential for reduced service delivery costs

14. Virtual Multidisciplinary Team Meetings 78 miles Multidisciplinary Team : Surgeon Physician Oncologists Radiologist Histopathologist Allied Health Professionals Specialist Nurses Clinical Trials Nurse Oncology Nurse Palliative Care Nurse Medical Secretary Cancer Services Co-ordinator

15. Neurology Telemedicine Clinics Before : Neurology clinics held every three months. Service too infrequent to meet local demand. Consultant Neurologist 150 miles return journey to undertake clinic (4 hours by car) Amended consultant contract – travel time included within job plan. Risk of tertiary centre withdrawing specialist service to outreach site (two different Health Boards). New Service Model:

16. Delivering Pre and Post Laryngectomy Speech Therapy for Head and Neck Cancer Patients Patient videoconsultations to Speech and Language Therapist in tertiary centre Aberystwyth – Singleton 156 miles return journey Withybush – Singleton 114 miles return journey Welsh Health Video Network

17. Paediatric Cardiac Telemedicine Transmission of echocardiography images (live and recorded) Pre Telemedicine – options for provision of specialist support for second opinion: Swansea - Consultant Cardiologist required to travel to Swansea (often at night by on call consultant) – 42 miles. Videos being posted/couriered to Cardiff for review. Mid Wales - Patient transfer by ambulance to Cardiff - 110 miles (?3+ hours) DVD/video couriered to Cardiff for review - 100 miles (?3+ hours) Unsatisfactory - delay in diagnosis and treatment of the patient.

18. Singleton Hospital, Swansea Bronglais Hospital, Aberystwyth Glangwili Hospital, Carmarthen Welsh Health Video Network (minutes) University Hospital Wales, Cardiff Paediatric Cardiac Telemedicine Transmission of echocardiography images (live and recorded)

19. Palliative Care Telemedicine Ty Geraint Palliative Care Resource Centre Dedicated videoconference suite Access to ad hoc advice – weekly videoconference meetings between community based staff and hospital team Reduced the need for staff to travel for advice/support – more time with patients Extended to palliative care units at: - Ty Bryngwyn (Llanelli) - Ty Olwen (Morriston) - Y Bwthyn (Bridgend ) Used for educational sessions across Network Cardigan Hospital

20. Teledermatology Pigmented Skin Lesion & Rash General Practitioner Specialist Nurse GP Surgery Ceredigion Consultant Dermatologists Carmarthen/Llanelli Hospital Patient Use of referral templates Utilising secure portal to transfer referrals/receive diagnosis electronically

21. Teleophthalmology: community retinal scanning  Using videoconferencing to conduct emergency assessment of eye injuries (Tywyn to Bronglais Hospital)  Connecting retinal scanning/slit lamp equipment to videoconference for remote diagnosis Teleophthalmology: remote image reporting (Not implemented)  Investigate use of electronic referral system (local or NWIS) for remote ophthalmology image reporting Minor Injuries Unit  Staff in community hospitals using videoconferencing to undertake patient consultations to acquire advice/diagnosis from A&E departments at Cardigan/Tywyn Hospitals

22. Case Study 1 66 year old male patient with head and neck cancer66 year old male patient with head and neck cancer Lives in GwyneddLives in Gwynedd Surgery at specialist centre 212 miles return journeySurgery at specialist centre 212 miles return journey Post laryngectomy specialist speech and swallowing rehab not available locallyPost laryngectomy specialist speech and swallowing rehab not available locally Attendance at specialist centre expensive in time and money at vulnerable timeAttendance at specialist centre expensive in time and money at vulnerable time Offered consultations by videoconferencing at a local hospitalOffered consultations by videoconferencing at a local hospital

23. Equity of service to patients in rural Wales Travelling time saved per consultation = 4 hours Miles saved per consultation = 154 miles Travel cost saved per consultation = £20 CO2 emissions saved per consultation = 55kg - Savings over 4 consultations = 16 hours time16 hours time 616 miles 616 miles £80 travelling cost £80 travelling cost 220kg - 220kg -

24. Case Study 2 Emergency Paediatric Cardiac admission to Bronglais Hospital (9pm)Emergency Paediatric Cardiac admission to Bronglais Hospital (9pm) Echocardiography ultrasound - required second opinionEchocardiography ultrasound - required second opinion Options –Options – –Ambulance transfer of patient to specialist centre in Cardiff – 110 miles (£300 + 3 hours minimum) –DVD recording of images couriered by taxi to specialist centre in Cardiff - 110 miles (£120 3+ hours minimum) –Transmission of live echocardiography ultrasound via videoconferencing to specialist centre (no call costs + ?30 minutes)

25. Equity of service to patients in rural Wales Travelling time saved per consultation = 3 hours (min) Miles saved per consultation = 110 miles Travel cost saved per consultation = £300 (£120) CO2 emissions saved per consultation = 20.9kg - 1 / 3 Patient’s treatment managed locally and commenced immediately. Parents able to discuss diagnosis and treatment plan with local and specialist team simultaneously within hours of admission. Specialist consult enabled arrangements for surgery at Liverpool to be made. (Figures calculated on one journey – not return)

26. Obstacles Under-utilisation of facilities – accessibility, no priority for videoconferencing meetingsUnder-utilisation of facilities – accessibility, no priority for videoconferencing meetings Lack of training, awareness and potential of videoconferencing useLack of training, awareness and potential of videoconferencing use Reluctance to use technologyReluctance to use technology Availability of local on site supportAvailability of local on site support Videoconferencing restricted to secondary care - lack of evidence ? sufficient bandwidth for primary care videoconferencingVideoconferencing restricted to secondary care - lack of evidence ? sufficient bandwidth for primary care videoconferencing

27. Suggestions Provide training workshops for healthcare professionalsProvide training workshops for healthcare professionals Nomination of ‘super users’/enthusiasts at local sites to provide support to usersNomination of ‘super users’/enthusiasts at local sites to provide support to users Improve use of existing equipment – priority to videoconference bookingsImprove use of existing equipment – priority to videoconference bookings Nomination of Health Board member with responsibility for telemedicineNomination of Health Board member with responsibility for telemedicine Create website with telemedicine information e.g. user guides and directory of videoconferencing equipment availableCreate website with telemedicine information e.g. user guides and directory of videoconferencing equipment available Undertake feasibility study to gather evidence regarding primary care bandwidthUndertake feasibility study to gather evidence regarding primary care bandwidth

28. http://maps.google.co.uk/maps/ms?ie=UTF8&hl=en&oe=UTF8&msa=0 &msid=211497540860849954742.000498f3b78c6be5028cd&z=8 Based on information gathered by Telehealth SubGroup to date Proposal to develop more sophisticated electronic map with Welsh Government cartography department

29. Progress to date Meetings with health board representatives -> subsequent presentationsMeetings with health board representatives -> subsequent presentations Early successes notable in Hywel Dda Health Board probably due to their maturity and experience in use of telemedicineEarly successes notable in Hywel Dda Health Board probably due to their maturity and experience in use of telemedicine Funding of teledermatology equipment (HDda)Funding of teledermatology equipment (HDda) Funding of Primary Care Web Camera Feasibility studyFunding of Primary Care Web Camera Feasibility study Videoconference training workshopsVideoconference training workshops Support to Dermatology Network for development of current teledermatology service (HDda)Support to Dermatology Network for development of current teledermatology service (HDda) Support to Paediatric Network to establish telemedicine service (HDda)Support to Paediatric Network to establish telemedicine service (HDda) Support to TeleRehab project (BCUHB)Support to TeleRehab project (BCUHB) Full details available in Evaluation Report (January-June 2011) to be published

30. Potential telemedicine developments Establishment of national Telemedicine forum (clinical champions and health board members)Establishment of national Telemedicine forum (clinical champions and health board members) Collaboration with organisations to develop national telemedicine systems, eg Welsh Clinical Communications Gateway electronic referral system (teledermatology, teleophthalmology, tissue viability etc.)Collaboration with organisations to develop national telemedicine systems, eg Welsh Clinical Communications Gateway electronic referral system (teledermatology, teleophthalmology, tissue viability etc.) Success dependant on successful engagement with: Health BoardsHealth Boards Service usersService users Support organisations, eg NHS Wales Informatics Service, Welsh Health Video Network, NLIAH etcSupport organisations, eg NHS Wales Informatics Service, Welsh Health Video Network, NLIAH etc

31. Potential telemedicine developments DermatologyDermatology Diabetes (and podiatry assessments/vascular surgery pre- assessments)Diabetes (and podiatry assessments/vascular surgery pre- assessments) Speech and Language TherapySpeech and Language Therapy Palliative CarePalliative Care NeuroRehabNeuroRehab MS Cymru Telemedicine (launch November 2011)MS Cymru Telemedicine (launch November 2011) TeleRehab (including internet videoconferencing connectivity)TeleRehab (including internet videoconferencing connectivity) OphthalmologyOphthalmology Tissue Viability ServiceTissue Viability Service Primary Care Web Camera Feasibility Study outcomesPrimary Care Web Camera Feasibility Study outcomes

33. Conclusion Telemedicine is here nowTelemedicine is here now Effective in quality and cost spheresEffective in quality and cost spheres Welcomed by patients – especially in rural areasWelcomed by patients – especially in rural areas Supported by Welsh GovernmentSupported by Welsh Government Resources available –Resources available – –Support of Telemedicine Service Manager –Support of Rural Health Implementation Group Here to help if you needHere to help if you need

34. “… That it [the stethoscope] will ever come into general use, notwithstanding its value, is extremely doubtful because its beneficial application requires much time and gives a good bit of trouble, both to the patient and the practitioner. Its hue and character are foreign and opposed to all our habits and associations.” Quote - The London Times 1834