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Developing a National Telemedicine Network
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Developing a National Telemedicine Network

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Assoc. Professor Michael J Sullivan DCH FRACP PhD

Assoc. Professor Michael J Sullivan DCH FRACP PhD
Paediatric Haematologist/Oncologist
Chairman, New Zealand TelePaediatric Trust

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Developing a National Telemedicine Network Developing a National Telemedicine Network Presentation Transcript

  • Developing a national telemedicine network “Developing Collaborative Health Networks and Communities of Interest” “Enhancing access to quality clinical care for remote and rural regions”
    • A/Professor Michael J Sullivan DCH FRACP PhD
    • Paediatric Haematologist/Oncologist
    • Chairman
    • New Zealand TelePaediatric Trust
    • Dec 2009
    Health and Disability Award for Innovation 2004
  • NZTP Trust: A/Professor Michael Sullivan(Chair), Dr Rosemary Marks, Karyn Bycroft, Dr Nick Baker, Dr John Garrett, Dr Roger Tuck, Mollie Wilson, Peter Ross and Brian MacMath Vivid Solutions: Board: Patricia Wright (Chair), Dr Michael Sullivan, Mark O’Donnell, Michael Borestien, Simon Hayden (MD) New Zealand TelePaediatric Trust and Vividsolutions
  • Defining Telemedicine
    • Standard definition
    • Delivery of medical care at a distance by the remote transmission
    • of data, audio and video (many similar traditional definitions)
    • NZTPS Definition
    • The simultaneous or delayed transmission of audio, video
    • and clinical data, for the “shared but differential” delivery of clinical
    • care and education, to overcome barriers of distance and
    • achieve improved access to quality health care services.
    • (M J Sullivan 2008)
  • Telemedicine
    • Telemedicine types and models of service
    • 1. Real time, synchronous - videoconferencing
    • 2. Asynchronous Store and Forward
    • 3. Telemedicine service models
      • managed vs
      • non managed
  • Telemedicine - real time videoconferencing
    • Real-time Telemedicine -videoconferencing
    • Simultaneous transmission of video, audio and or data -synchronous
    • Videoconferencing
      • Point-to-point
      • Multipoint
    • Direct clinical care
      • Acute clinical care
      • Consultative clinical care
      • Shared care - team-to-team
    • Diagnostics
      • Real time diagnosis - tele-echocardiography
    • Telemetry
      • Real time data transmission
    • Education
      • Continuing Medical and Nursing education
      • Postgraduate education
      • Specialist education - intra-operative
    • Dedicated videoconferencing systems
  • Telemedicine - Store and Forward
    • Store and Forward Telemedicine
    • Asynchronous or delayed transmission of data, video
    • Data acquired at the distant site
    • Transmission by computer and internet
    • Non acute care so delayed/elective data analysis and interpretation at distant centre
    • Delayed/elective reporting and clinical advice
    • Clinical diagnosis
    • No acute clinical care and specialist consultation - ie ENT and Eyes
    • Pathology review and opinions
    • Radiology - distant consultation and review
    • Webcasting of medical and nursing education
    • Community health education
  • Telemedicine - Real time vs Store and Forward
    • Store and Forward
    • Asynchronous delayed transmission of data, video
    • Anytime - no scheduled meetings
    • Narrow bandwidth, requires broadband internet access only
    • Network infrastructure not required
    • Specific web interface preferred
    • No direct clinical contact possible
    • No immediate emergency assessment possible
    • Minimal interpersonal contact between health care providers
    • Real-time
    • Simultaneous transmission of video, audio and or data -synchronous
    • Direct patient contact
    • Direct clinical assessment
    • Direct and immediate personal communication between health care providers
    • Scheduled meeting times
    • Dedicated videoconferencing equipment
    • Minimum broad bandwidth for effective communication - 512k - 1Meg
  • Telemedicine - service models
    • Various service models exist
    • Not mutually exclusive
    • Several strategies may be required for any given organisation
    • Service specific
      • Specific locations - ED to ED, clinic to clinic
      • Actively managed vs passive or unmanaged
      • Integrated into specific clinical services
    • Telemedicine Bureau
      • Central telemedicine facility providing clinical care
    • Managed and supported
      • sector specific such as cancer services
      • regional or national
      • integrated and uniform platform
      • clinically managed
  • A National Telemedicine Network “ Communities of interest” and “ Supporting health care networks” New Zealand TelePaediatrics Service (now NZ TelePaediatric Trust and Vividsolutions)
  • NZTPS: A National Telemedicine Network CLINICAL CHALLENGES
  • “ Through the eyes of a child” Principles of Care for Children
    • National Review of Specialist Services for Children (1999)
      • “Needs of a child and the family are paramount”
      • “Specialist care should be as close to home as possible where safe and of appropriate standard”
      • “Access to Specialist care should be equitable”
      • But Specialist Skills are inequitably distributed
        • “critical mass”
        • “Centres of excellence”
        • “Multidisciplinary teams”
      • How can equitable access to specialist services be achieved?
      • Enhancing support to regions
      • Developing capacity and capability
  • TelePaediatrics and TeleMedicine
    • National Review of Specialist Services for Children (1999)
    • Telemedicine - a national network as an “enabling technology”
      • To support the care of children and families in their home centre
      • To support the local health care Professionals who provide specialist care
      • To develop new collaborative networks for professional development and education and research
    • Developing “Communities of Interest”
    • Building Capability and Capacity for care across health care sectors
    • Supporting education and training for staff recruitment and retention
  • NZTPS Development - 1999-2007
    • Founding partners 1999-2003
      • Starship Foundation - sponsorship and funding
      • Paediatric Society of NZ
      • 10 District Health Boards
    • NZTPS - is a Non Profit independent incorporated society
    • Governance; Board - broad health sector representation
    • Initial launch May 2003
      • 10 locations in 10 District Health Boards
      • Dedicated to Paediatrics and Child Health
    • “ Growth and Development 2005-2007”
      • completion of a national telemedicine network connecting all DHBs and small centres
      • 120 sites
      • multiple parallel non paediatric networks
      • uniform technology platform
      • Fully managed service
  •  
  • NZTPS - Network Coverage
  • NZTPS - Current usage
    • national telemedicine network >2000 hours month
    • Multiple user groups and communities
    • National medical and nursing workshops
    • Clinical Grand Rounds
    • Specialist training
      • Paediatrics, Mental Health
      • Surgery
      • ENT, Plastic Surgery
      • Microbiology, Pathology
      • Nursing, Allied Health,
    • Team-to-team clinical care and outreach
    • Research and special interest groups
    • Hospital to home palliative care
    • Mental Health clinical network
    • Rural health, GP and education
    • Community access programme
      • Digital strategy objectives and funding
    • Administration and human resources
  • NZTPS - Current usage
    • National Broadcasts; Starship Hospital Paediatric Grand Round and Paediatric Update, Paediatric Nurses Grand Round, Infectious Diseases Grand Round, Child and Adolescent Psych Grand Round, Adolescent Health Seminars, Hospital Play Specialists Inservice Training, Visiting Specialists’ Lectures
    • Specialist Groups; Paediatric Oncology Group, Genetics, Cardiology, ENT, Audiology, Play Specialists, Paeds Pharmacists, Radiation Technologists, Paedsleep, Physio Special Interest Group, Probiotics Committee, Eating Disorders, Social Workers, RACP and RACS management and special interest groups, Child Protection, DHB Management Groups, HIV Workgroup, Breast Care, Paedsleep, Family Options, Neonatal Physiotherapists, DSAC (Doctors for Sexual Abuse Care), PREDICT (Emergency Management), HIV
    • Education; FRACP Training (Paeds & Adult), Specialist Nurse Study Days, Plastic Surgery teaching, Laproscopic Surgery Training, Gynaecology Surgery Training, Community Paediatrics Training, Diploma of Child Health Training, Cardiothoracic Surgery Training, ‘Brain School’, Child and Adolescent Psychiatry Advanced Training, Midwifery Training and Continuing Education
    • Telehealth Solutions; Hospital to Home, Breast Screening, Echo-Cardiography.
    • Clinical; Paediatric Oncology, Child and Adolescent Psych consults, Diabetes insulin pump patient/family assessment, Child abuse consults, Specialist nurse advice (tracheostomy, renal care, respiratory, Cystic Fibrosis), Rheumatology Clinics, Immunology Consults, Clinical Consults (Renal, Haem, Oncology, Rheumatology, Immunology, Diabetes etc) Northland Breast Screening
    • Other; District Health Board Management Meetings, International and National Recruitment Interviews, Medical Legal consultations, Safe Kids NZ National launch, Parent to Parent National Launch, Live link to North Pole (Santa). Ministry of Health
  • NZTPS - Paediatric Special Projects
    • H2H - Direct hospital to home palliative care for children in rural areas
      • CHCH to Greymouth
      • CHCH to Oamaru
      • Auckland to Whitianga
    • National Paediatric Oncology Tumour Board
      • Monthly meetings
      • Auckland CHCH and Wellington
    • Paediatric Oncology Outreach Service
    • Neonatal Echocardiography - real time diagnostics CHCH to Auckland
    • National Congenital Disease Cardiac Users Group
    • Paediatric Specialist Education - evidence for improved training and exam pass rates for those in regional centres
  • NZTPS - Non Paediatric Special Projects
    • Mental Health (SISSAL)
      • South Island Mental Health Workforce Development
      • Managed service
      • Clinical consultation and Team to team care
      • All mental Health Centres and major rural Medical Centres in South Island
    • National Midwifery network
      • Training and education of midwives in regional and rural centres
    • West Coast - special remote regions
      • CHCH to Grey Base, Grey Base to Westport, Reefton, Hokitika,
      • Potential services - Oncology, Haematology, Renal, palliative care, Emergency etc
    • Community Access programme - Digital Strategy Parent-2-parent
      • Connect 22 national and regional offices of parent-2-parent
      • Access for community groups and support organisations
  • NZTPS - Projects in Development
    • South Island Rural Network
      • Connecting GPs
      • rural community nursing
      • Store and Forward and real time vc
    • Otago/Southland Medical Heamatology Oncology Network
      • Managed clinical care
      • MDT co-ordination
      • CME and nursing education
    • Ministry of Health - completed in 2008
      • National network connecting all MOH offices
      • Integrated into national network
    • Breast Care and Screening
      • Currently network breast screening in Northland to Whangerai
      • Developing national strategy to support breast screening
    • Pacific Outreach programme - MFAT sponsored Twinning programmes
      • Supporting education and professional development in the pacific
      • Build capability and workforce retention
    • Nepal - Child Cancer
      • Kanti Children’s Hospital Kathmandu
      • Twinning relationship
  • Evidence Based Real-time telemedicine for the clinical care of sick children
    • Neonatal Care NICU
    • Assessment of unwell neonate in secondary care setting
    • Ongoing clinical surveillance in secondary care setting
    • Emergency and Critical care PICU
    • Triage of unwell child and initiation of emergency care support
    • Clinical assessment of unwell child in secondary care centres by local and PICU consultants
    • Paediatric Haematology/Oncology
    • Clinical support and out reach care
    • Palliative care to rural and remote locations
    • Cardiology
    • Realtime echocardiography, store and forward diagnosis
    • Shared care Clinical support
    • Respiratory
    • Ongoing support and evaluation of chronic respiratory disorders - CF/Bronchiectasis
    • Child Psychiatry
    • Assessment of depression and anxiety disorders
    • Organ transplantation
    • Follow up care post Liver and Renal Trx
    • Neurodevelopmental assessment
    • Developmental exam and neurocognitive evaluation
    • Home and local centre developmental therapy
    • Speech and language therapy, developmental therapy to remote locations
    • Paediatric Endocrinology
    • Evaluation of growth disorders
    • Clinical support for diagnosed endocrine disorders
    • Paediatric Neurology
    • assessment of seizure disorders
    • Paediatrics and child health in Developing and resourced challenged countries
  • Telemedicine: TelePaediatrics
    • From Barriers to Solutions
      • Funding and resources
      • Technology
      • Service model
      • Clinical
  • Telemedicine: TelePaediatrics
    • Funding and resources: Barriers and Solutions
    • Funding and resource - barriers
      • No previous telemedicine network in NZ
      • No Central or Local Funding from Govt, MOH or DHB
      • Legacy of ISDN videoconferencing - call costs
      • Hardware capex costs
    • Funding and resource - solutions
      • Start up sponsorship - Starship Foundation
      • Proof of principle - initial fully sponsored service
      • Dual sponsor and subscription model
      • Starship foundation funded capital development
      • DHBs contracted as subscribers
      • Ongoing issues - transition to mixed subscriber and core funded model?
  • Telemedicine: TelePaediatrics
    • Technology: Barriers and Solutions
    • Technology Barriers
      • No previous telemedicine technology solution in health sector
      • 21 DHBs = 21 IT departments and networks, firewalls, firewalls, and firewalls
      • No uniform network infrastructure across health sector
      • Legacy systems - mostly on ISDN
      • No “off the shelf” network design solutions
      • Poor prior user experience - poor video, poor audio, unreliable, technical
    • Technology Solutions
      • National IP based infrastructure secure VPN 512k -1Meg bandwidth network
      • Individualised solution beyond the “front door” for each DHB
      • Internal Network overlay independent of DHB internal networksVLAN or patched
      • VC coexistence with other network applications and services
      • Uniform easy to use hardware, quality audio and video
  • Telemedicine: TelePaediatrics
    • Service development: Barriers and solutions
    • Service: barriers
      • No model previous for a national telemedicine network
      • Unsupported network failure
      • Previous local networks all unsupported all failed - early adopter fatigue
      • Poor user experience
      • Different systems and platforms
    • Service: solutions
      • User driven service - representative board and “long-haul innovators”
      • Managed service model - with help desk and local VC co-ordinator
      • Easy to use booking and connection, help desk 24/7
      • Relationship building and training
      • Single hardware vc technology platform,
      • Multiple scalable solutions
      • IP based network - national integration
  • Telemedicine: TelePaediatrics Clinical Barriers and Solution Clinical Barriers and Solution
    • Clinical barriers
      • “ asymmetry of need” : specialist vs local care needs and wants
      • “ outcomes driven medicine ” : but does it saves lives?
      • “ poverty of time” : consistent excuse but a good reason
      • “ 50 metre rule” : Proximity to clinical work place
      • “ funding environment” : payment for clinical time and call costs
      • “ telemed nightmares”: previous negative clinical experience bias
      • “ Time and access” : issues for education and teaching
    • Clinical solutions
      • Quality of care notion
      • Build “communities of Interest”
      • Identify “ clinical leaders and early adopters”
      • Beware of “adopter fatigue”
      • Support continuing medical and nursing workforce development
      • Remove cost barriers with subscription model
      • Quality of service - video, audio, easy of use
      • Overcome asymmetry of need by adapting service to specific specialty needs
      • Store and forward capability
  • Principles and Practice of Telemedicine
    • The Principles:
    • Telemedicine enables:
      • Quality of Care: not a replacement for non existent service
      • Capability development: enhance local care skills
      • Capacity development: develop the capacity of local service
      • Communities of interest: fosters development of health care networks
      • Symmetry of need and purpose: shared responsibility is crucial
      • Isolation barriers: overcome isolation for patients and health carers
      • Enhanced professional development and education
      • Human factors fill gaps and enhance quality
        • Even where data, audio and video quality are subopitmal,
        • Human factors; clinical experience, data interpolation and fuzzy logic
        • Compensate for the limits of technology -
        • Otherwise known as good clinical judgement
  • Principles and Practice of Telemedicine
    • The Practice:
    • Telemedicine is about “human interaction” and “the content”
    • It is NOT about “the technology”
    • Telemedicine only succeeds when barriers are addressed and overcome
      • human factors
      • service barriers
    • Failure to address barriers = telemedicine failure (technology gets the blame!)
  • Principles and Practice of Telemedicine
    • In practice:
    • Use simple, robust and reliable technology
    • Proximity to the clinical work environment is crucial - 25m Rule
    • Remove cost barriers for accessing the technology and the network - Subscription model
    • Actively manage the telemedicine network - unmanaged failure
    • Co-ordination of clinical care essential to deploy sustained telemedicine services
    • Co-ordinaton of the content and delivery of education enhances capacity building
    • Integration within existing specialist services means making it part of routine clinical care
    • Security of technology and data important but is not a barrier to use
    • Medicolegal responsibility is not a barrier, but responsibility for clinical care must be clear.
  • Telemedicine Principles Overcoming barriers to achieve equity of access to health care
    • Putting Telemedicine into your Practice
    • Evaluate your clinical practice and clinical service
    • Do you?;
      • Provide specialist care at a distance
      • Provide or participate in “shared care”
      • Provide a specialist or subspecialist service to patients at a distance
    • Shared Clinical Care
      • Notions of shared care - a single clinical care environment across geographic locations
      • Care beyond the “consultative” - ie traditional “phone consultation to single specialist led service”
      • Multidisciplinary care and multi-location care
      • Sustain and supporting longitudinal care for serious chronic and complex health needs
      • Notion of collective care; active and transparent networks beyond informal care
    • Personnel and work practice for successful telemedicine
      • Integrate distance care and shared care into your specific clinical service
      • Develop acute and non acute telemedicine networks
      • Team to team consultation for regional patient practice groups
      • Develop designated virtual telemedicine clinics for consultation and ongoing care
      • Consider nurse led telemedicine clinics - ie diabetes, cancer care, renal medicine, wound care, palliative care, aged care.
  • Telemedicine in Practice
    • Putting Telemedicine into Practice
    • Assess your clinical and education needs
    • Identify Clinical Champions and Leaders at both ends of the network
    • Consider the potential technology platform
      • Real-time limited vs Store and forward or both
      • Use existing networks
      • Avoid vendor driven telemedicine solutions
      • Size the human needs especially co-ordinator role within your service - omit support and it will fail
    • Integration into specific clinical services - consider
      • Emergency services
      • Haematology and Oncology
      • Cardiology
      • Dermatology
      • Neurology
      • Surgical specialities - ENT, Ophthalmology,
      • Renal
      • Palliative care, aged care
      • Education and professional development
    • Integrated and compatible with national telemedicine projects
    • Funding and project development
      • NGO, public partnership model
      • Avoid “pilot-itis”