2008 saw the introduction of telemedicine onto the OPD and ED departments of Grey Hospital. At the time ED was opposed to this. I needed to get a better understanding as I could see clear benefits not only for the patients but also the staff. Thus I decided to take up the challenge and do a study to find out clinicians perceptions.
my presentation today will be under these sub headings
With regard to the background of this study I wanted to improve the utilization of telemedicine in the emergency department at grey hospital. Since I have already identified the problem of buy in of clinical staff employed by the WCDHB. It was imperative I determined what their perceptions were and to do this I conducted a descriptive study. Challenges facing the West Coast, High use of locums. Specialisation. GP shortages on the Coast has caused problems with sustainability, recruitment and retention. One of the solutions was closer collaboration with CDHB which in the future will mean a move from the traditional ways of delivering healthcare to innovative modes, such as telemedicine as not all specialities will be on site for the West Coast in the future.
First Ethics approval was obtained from the National Ethics committee (Upper South A). Following ethics approval the research question was broken down into five concepts for the literature search. Data bases such as CINAHL, AMED, Medline, EMBASE and Cochrane were searched. The inclusion criteria were, articles written in English and articles published in peer review journals, most articles were written in the last 20 years. Written books were included from 1990’s on. Method Invitations were sent out to clinicians working in rural and remote emergency departments and services on the West Coast. Participants who accepted where interviewed, this included six doctors and five nurses, all with varying degrees of expertise in emergency medicine. Semi-structured interviews were conducted with participants between March and May 2012. The interviews were audio-taped and transcribed and additionally, field notes were utilised as a means of collecting data. Data was analysed using a four step process. Data was collected on tapes listened to and transcribed. Key issues, concepts and themes were identified. themes were made evident through patterns that reoccurred. Each theme had a major heading with sub headings underneath. Guided by the original question, mapping was utilized to determine associations between themes. This is still in progress. The limitations of this study include the small sample of interviews, which may result in a bias to the views of a small number of clinicians and leave out different views that could have been represented by the 11 clinicians who did not participate in this research. The results of the interviews cannot be generalised but can be used to inform the planning of telemedicine in emergency care services throughout New Zealand.
before I go any further I would like to clarify the terminology we use so that we all understand what we are talking about. The buzz word today is e-health the same as e-commerce, E-health is an umbrella term it includes all electronic methods and communication which support healthcare practices such as telehealth, telemedicine and telecare. Telehealth is described as a broader connotation it includes not only the delivery of healthcare to individuals, but also administration and training. This can be delivered in real time, store and forward or pre-recorded information . Telemedicine originated from the Greek, “tele meaning at a distance, hence telemedicine is medicine at a distance. The WHO suggests that telemedicine is more clinically focused thus I have used this in title of my research On the other hand Telecare means the use of telecommunication to provide healthcare and advice to patients in their homes.
I put this slide in here to give you some perspective on the fastness of the region that we cover. You can see when you overlay the region of the west coast on a map of the North Island that it stretches from Auckland to Wellington. As you can now see it is the most sparsely populated DHB in the country. The other important factor that comes into play is that this region which is almost 600km long and 100km wide has only approximately 32000 people. That is a population density of 1.3 people per square kilometre where as Auckland has a population density of 4000 people per square Kilometre and Munmbai has 30000 per square kilometre.
Last year the WCDHB tried to pursue Telemedicine in the Emergency Department after failing in 2008, this time it was the architecture which did not lean itself to telemedicine and thus telemedicine was removed. The photo on your left shows the ED main room, as you can see there is very little room on the bench which is where staff look up diagnostics, write up notes, answer phone calls. The desk is front of the resus beds 1 and 2, the telemedicine equipment went onto this bench and as you can imagine this brought about problems with not only space but also privacy for patients in beds. The picture on the right is telemedicine set up in our OPD consulting room and as you can see it is quite imposing. This should be taken into consideration when designing new Emergency departments.
As you can imagine I started this study with some preconceived ideas about telemedicine. However as I progressed through the study my perceptions changed. In this regard I would like to share my Interim findings with you. I found peoples perceptions fell into these five categories. Lets look at knowledge.
There were concerns around the legal and ethical aspects of care with clinicians asking where they stand with the medical council. I suggest that clear protocols and guidelines be written up prior to implementation with sign of from the HDC. Peoples perceptions were very interesting, I will give you an example of a 65 year old nurse who works in the department. “ She stated, “you know I don’t think I would feel to happy if I was in the last stages of my life and people were watching me die on a TV screen” Another staff member said if you want Clinician buy in then “provide me with a clear problem that telemedicine can solve and a description of how telemedicine is going to solve that problem” With regard to implementation
Issues identified were when setting up equipment it was important to staff, to have the equipment in close proximity to the work place, as it could be a distraction to caring for the other patients in the department. The staff also expressed concerns about privacy for their patients, although they did admit the privacy is always a challenge in emergency departments anyway. One staff member thought of it as purely a cost saving measure where the DHB saved on transport for patients and travel cost for specialist. This of course is true but we have to remember getting cost and sustainability of a service is paramount. Other members of staff felt that telemedicine would enhance patient care and safety. Some clinicians felt that having a coordinator running telemedicine was the answer and they gave the example of paediatrics, where all they had to do was turn up at the right time. The patient was there, the specialist was on the other end and the equipment was on and ready to use. It saved time and was a good example of how it should work.
Clinical staff were concerned that the introduction of telemedicine would result in loss of skills as raised by one staff member who stated: “A potential risk to doctors will be a loss of skills. Doctors can succinctly describe a patient’s condition in as few words as possible and this skill might be eroded ... It’s not necessary a disadvantage … but it is inevitable that people will lose the skill to present a case concisely. It could create a lazy handover culture”. How often do you hear a doctor describing an x-ray to a consultant now a days with digital radiology, they just don’t seem to handover anymore”. Training must not only happen at the initial implementation but on a continuing bases as staff are more mobile these days and for this reason some rural areas have a high turnover, this means the doctor or nurse following may not know how to use the equipment and this in turn will lead to neglect of telemedicine With regard to additional training and education we are now able to video conference into the grand rounds in Christchurch this is already one of the best attended meetings on the coast.
There is no doubt that there are numerous opportunities and benefits in telemedicine and clinical staff interviewed identified many of these. Some of the advantages included better support for patients and clinical staff, more efficient use of specialists time, better quality of care, lower travel costs and improvement in recruitment and retention.
Some of the barriers recognised were the reluctance to change. People liked to go with traditional ways of delivering health care. Challenges facing the Coast were reliability of equipment due to bandwidth coverage, these concerns were reiterated by one staff member, “ You cant even get decent cell phone coverage in a number of areas on the West Coast how are you going to ensure when I turn on the TV that it is actually going to work. We have our own problems with our TV’s with rain fade”. Time was another aspect of concern. Clinicians in the base hospital expressed concerns around workload, they felt this would add so much to their workloads that it would leave the department vulnerable.
Overall, the people interviewed did not have a good understanding of telemedicine and lacked the knowledge on how it was to be used in their workplace. All, except two participants, felt they had no involvement in the implementation of telemedicine in emergency services on the West Coast and their lack of engagement was notable. However, their perception of whether they would use telemedicine or not did not solely relate to this, but rather their knowledge and education around telemedicine in general. All participants agreed that there would be benefits for not only their patients but also themselves in terms of the additional support that would be available. Potential barriers identified by participants were reliable internet connections and speed, related to bandwidth; additional workload; that telemedicine might be a distraction from providing care; access to the technology when it is needed; patient’s perception of telemedicine and also concerns around privacy issues. This study indicates there are many lessons from the perceptions of clinicians working at the front line of emergency health care. These interim findings suggest that although implementation of telemedicine was not seen as important, knowing what telemedicine can do for the patient and how it is to be used is perceived as very important.
This study suggests after the literature and interviews from front line staff, that there are many different definitions which are similar in meaning, however, it is important to use a common language. It can be extremely confusing to those trying to come to grips with the new technology when people are using different terminology. At the Australian telehealth conference last year it was suggested we need to use a common language, I agree. Clinician Buy in is very important you will not get any project off the ground if this does not occur. Many have tried and failed. Resources need to be in place prior to the introduction and maybe utilize the skills of those front line staff who are champions in the use of telemedicine of course these staff must have the respect of other staff in the department. Proper placement to serve the purpose is an important aspect when thinking about equipment . Ask the clinicians on the floor what they feel about what sort of equipment is needed, e.g. a cart, camera’s over beds or monitors on benches. Regional or national coordination is something I would like all in the room to think about. Busy ED departments or clinicians do not necessary have the time to answer telemedicine calls and for this reason telemedicine could fail. Ensure that training is not only given on initiation of telemedicine but also continuously as staff are more mobile these days. I cant stress this more about knowing the team your working with. It helps build relationships and gives everyone an understanding of the situations they are working under, It also gives everyone the opportunity to know the expertise of the staff.
I would like to thank the following the staff and management for their patients and supporting me with this thesis. ECCT for supporting me on a visit to Australia which is the next part of my research. Finally Dr Michelle Honey and Karen Day my wonderful supervisors.
Thank you for attention and I am now happy to take any questions.
Emergency Medicine: Clinicians' Perceptions of Telemedicine Opportunities & Barriers
Recommendations• Common language• Clinician Buy In• Equipment placement• Regional or National Co-ordination Centre• Training• Knowing the team
References Wootton, R., Craig, J., & Patterson, V. (2006). Introduction to Telemedicine(Second ed.). London: Royal Society of Medicine Press Ltd. Moffatt, J. J., & Eley, D. S. (2011). Barriers to the up-take of telemedicine inAustralia--a view from providers. Rural & Remote Health, 11, 1581. Brennan, J. A., Kealy, J. A., Gerardi, L. H., Shih, R., Allegra, J., Sannipoli, L.,& Lutz, D. (1999). Telemedicine in the emergency department: A randomizedcontrolled trial. Journal of Telemedicine and Telecare, 5(1), 18-22.doi:10.1258/1357633991932342 Cary, M. A., & Darkins, A. W. (2000). Telemedicine and Telehealth:Principles, policies, performance and pitfalls. New York, NY: Springer PublishingCompany. Norris, A. C. (2002). Essentials of Telemedicine and Telecare. West Sussex:John Wiley & Sons Ltd Gerrish K. Lacey A. The Research Process in Nursing (6th ed). Oxford: Wiley-Blackwell, 2010
Acknowledgements• Staff and management of the West Coast DHB• ECCT• Dr Michelle Honey• Dr Karen Day