Telehealth demonstration project: build it and see who comes

A telehealth demonstration project that has been running in New Zealand's Bay of Plenty region over the last 18 months is soon to come to an end, having experienced good uptake in Maori health clinics but coming across a number of challenges for district nurses and residential aged care.

The project, funded by the Ministry of Business, Innovation and Employment (MBIE) to demonstrate the capability of telehealth to improve healthcare delivery as part of the roll-out of the Ultra-Fast Broadband and Rural Broadband initiatives, was designed to see what would happen if a dedicated project facilitator was put in place to actively provide assistance to healthcare providers to get started using telehealth.

While there are several other regions using telehealth – including Canterbury, which provides services to the west coast, and throughout Northland – this project aimed to get a better understanding of what the drivers of the broadband roll-out would be in the health sector.

Project facilitator Ernie Newman said the Bay of Plenty region was chosen as the national demonstrator, with a focus on primary and community care rather than hospitals. The Tairawhiti region then came onboard, with the project concentrating on the long stretch of coastline on the east coast between Opotiki and Gisborne.

“The National Health IT Board and the Ministry of Business, Innovation and Employment are partners as well, so we’ve had 18 months to see what can be done if you put a project facilitator in place and go around offering people assistance to actually get telehealth started, then leave them and see what emerges and see what doesn’t,” Mr Newman said.

“The terminology I use sometimes is 'build it and see who comes'. It’s a matter of targeting health sector people who face issues with isolation and who are change-receptive, and giving them video facilities. They’ve usually already got the connectivity and they’ve already got the computer – and all the project has to do is give them a high-speed, high-definition camera on long-term loan and work with them on how to build video into their business models and clinical pathways.”

The project is using the free version of Cisco's Jabber rather than Skype, for security and quality reasons. The quality of Jabber cameras is excellent, Mr Newman said, but there is a concern about the long-term support Cisco is planning to provide to the platform.

“The hard part is to inculcate this into clinical workflows and practices. Software is the least of our worries. There are other systems there that could pick it up if by any chance Jabber falls over.”

While video conferencing has been used in the hospital sector for a number of years, predominantly for case conferencing and education, this project was aimed at healthcare provision beyond the hospital sector.

“We didn’t look to reinvent what was already happening so that’s why our mission has been to go out into GP practices, Maori health clinics, hospices, aged care, and other health premises where we can see the potential for the use of this technology,” Mr Newman said. “We’ve had a focus particularly on areas where remoteness is an issue.”

This is where the project has had some early successes, such as the Matakana Island video doctor service. The small island situated in Tauranga Harbour has a population of about 300 and was formerly visited by a GP from the mainland every fortnight.

Now, the GP is accessible by video every weekday. Mr Newman said this had proven both more economical for the health system and more flexible for the island residents, who no longer have to take as many trips onshore.

Opotiki Telehealth Community

Another success has been the Opotiki Telehealth Community, where every GP now has video capability, both in their clinics and at home. The small Opotiki Community Health Centre, which has a handful of in-patient beds predominantly for maternity patients, is staffed by nurses who periodically get an emergency case.

Nurses can contact the duty GP after hours at his or her home, and they can also directly link to the emergency department at Whakatane Hospital if needed. “That’s being used quite regularly now and is resulting in much better decisions about how to handle those cases,” Mr Newman said.

“Also, it’s providing a lot of comfort to the patient and their family because they can see that the doctor is not just an inanimate voice at the end of a one-way phone call. That one’s working pretty well.”

Several other of the small health clinics and Maori medical centres dotted along the coastline between Opotiki and Gisborne are also hooked up.

“If you take the long way around East Cape it's about 340 kilometres to Gisborne,” he said. “There are a couple of population centers but you’re talking about a dairy, gas station and a pub and nothing much else.

“Most of those centres have a health clinic operated by, in most cases, a Maori health provider organisation. There are nine of these, and we have put video capability into all of those nine. Much of the time they are staffed just by a nurse with doctors who rotate and visit a different clinic each day.

“The benefit of telehealth is that the nurse can then call up the doctor if they need to over video, and the doctor and the nurse together can evaluate the patient and they can share the decision about the pathway for them.”

While Tauranga Hospital has extensive video capability for internal staff, the project hopes to encourage some hospital-based services, particularly for mental health and long-term conditions, to also be delivered by telehealth into the community.

It is also working well for patients with diabetes to receive dietary advice and to keep in regularly contact with care teams, as well as with smoking cessation programs.

“With those sorts of programs, the patient benefits from a brief video session every week, rather than just a longer one once every three months,” he said. “They can come down to the clinic and they can meet with the person running the program by video.

“And increasingly other hospital services are starting to come in behind that. We’ve got hopes that a lot of long-term conditions can be monitored with a balance between physical visits and video.

“What we’re doing is not rocket science. It’s simply applying some resources for busy clinicians who otherwise would be too preoccupied with business as usual. We’re giving them the encouragement and support to innovate, in the expectation of starting a chain reaction.”

Challenges in aged and home care

Not everything the project has tried has worked, with a number of challenges in district nursing and aged care. Mr Newman said the use of video by district nurses was one area the project hoped to see good uptake, but bandwidth in residential areas has proved a problem.

“There's a lot of health premises where bandwidth is available and is running really well, and the reason we’ve been able to connect all of those clinics is that there is now fibre optic right around there which was put in for the government's rural broadband initiative to strengthen the cell phone network in rural areas.

“That fibre optic cable enables a wireless link to be set up from the nearest link point through to the health clinic, and support very acceptable video quality. But we haven’t yet got the cellular network to a point that they can take video into a patient’s home and have a reasonable chance of being able to video back to base with the patient in the picture.

“The rural cellular network has strengthened the voice network, but to get the data on it requires a directional aerial on the roof of the premises pointing at the nearest cell site. That’s workable for health clinics, because they’re using this with some regularity. But obviously in a domestic situation, the cost of that purely to support a visiting nurse doesn’t add up. We’re not quite ready for that yet.”

For aged care, the main barrier seems to be that GPs still prefer to see a patient in person, even if that means transporting an elderly, frail person away from their bed. This is a complicated sector of healthcare that has a number of unique challenges, Mr Newman said.

“To my mind, video for aged care facilities should be universal. My personal view is that every aged care facility should have video, and every GP working in the aged care service ought to be able to connect from time to time by that means. But it's not that easy to actually convince busy GPs to give it a try.

“There are a number of reasons for that including the remuneration model, and the sense that it looks a lot more complicated to connect with a patient by video than to have them join their place in the queue in the doctor's rooms. And medico-legal risks have not really been addressed.

“All of those are valid concerns, and until we can get around those telehealth in aged care facilities is going to be quite challenging, but I see that as an area of real potential for telehealth.”

Now that the designated timeframe for the Telehealth Demonstration Project has come to an end, it seems likely that the government will encourage the District Health Boards to take over responsibility for promoting telehealth, Mr Newman said. The next steps are still being discussed, but what the project has been able to investigate is what works and what doesn't at the moment.

“It’s all about creating and building up the networks so that over time it will become an expectation that every health premises is video connected just as you’d expect them to have a telephone.”

Posted in New Zealand eHealth

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