Stroke Teleconsultation - Paul McCullaghPresentation Transcript
STROKE TELECONSULTATION Paul McCullagh 1 , Michael Power 2 , Belinda Wroath 2 , Pat Lundy 1 , Mark Beattie 1 , Shumei Zhang 1 1 School of Computing & Mathematics, University of Ulster, UK 2 Ulster Hospital, South Eastern Trust, Northern Ireland, UK
Stoke has a greater disability impact than any other medical condition
Every year an estimated 4,000 people in Northern Ireland have a Stroke ( The Stroke Association 2011 )
Teleconsultation enables the patient to obtain the professional opinion of a healthcare provider remotely
This technology potentially makes the provision of healthcare more efficient and economic
Around a third of people who have suffered a Stroke are living with long term disability and needing home-based rehabilitation
How can teleneurology improve patient care? Victor Patterson and Richard Wootton Nature Clinical Practice Neurology (2006) 2, 346-347
Studies have shown that the teleconsultation can assist
diagnosis, self-management, and professional patient knowledge transfer
methods used for teleconsultation include email, (asynchronous) telephone & videoconference (synchronous)
Email communication method is flexible, but not suitable for patients who have the problem for typing or reading, such as stroke patients. Images can be uploaded as part of the interaction
Telephone can provide good audio quality, but with no visual image during the consultation it is a difficult communication medium for patient / doctor interaction
Videoconference could be the best alternative to face-to-face consultations, however, the video and audio quality depends on connection bandwidth
‘ Digital Britain’ aims for 2Mbps everywhere in the UK by 2014
Stroke initiatives A&E Consultant Consultant HCP
The teleconsultation system is based on low-cost and easy to use software and hardware components
Hardware comprises a laptop with a webcam, microphone/speaker, and 3G dongle or WiFi wireless network connection
The software uses Skype
Require approx 400kbps duplex
UMTS / 3G (O2 provider) 128kbps -500kbps
Developing technology - High Speed Packet Access (HSPA) supports a theoretical peak data rate of up to 10.7Mbps in the downlink , and 5.5Mbps in the uplink
WiFi allows the deployment of wireless local area networks (WLANs) based on IEEE 802.11/a/b/g/n standards (range:32m indoors or 95m outdoors)
Quality of Service protocols, power saving mechanisms and faster bandwidth (2Mbps~100Mbps)
However, the WiFi networks have limitations, such as limited mobile use of telemedicine applications
“ We're not making huge claims for our mobile map - it is after all just a snapshot - but it may provide consumers and the mobile networks themselves with a better picture of the real state of coverage.
And ours is not the only source - a London-based startup called OpenSignalMaps has also been mapping 3G across the UK. They've kindly given us access to their data, collected from 30,000 users of their Android app. You can read more about their research here - but I've pulled out a couple of headlines.
They identified over 22,000 locations where no 3G signal was available - for the most part, as you'd expect, in rural areas. The highest concentration was in Gwynedd in North Wales, closely followed by Cumbria.
But in terms of the amount of time people are spending on 3G, they've got that at 58%, much lower than our 75%.
And their overall conclusion - like ours - is that while most of the big cities are well served by 3G, it can be a real challenge getting a decent connection elsewhere.”
Broadband Speeds BBC survey, August 2011 South Eastern Trust, Northern Ireland
Upload and download data transmission rate changed during a videoconference. This data transmission rate determines the video and audio quality; lost connection some times during a videoconference Variation in Speeds
Image quality reduces when the person is moving (compared to static), although the data transmission rates are similar Image Quality
Data collection issues: location, weather conditions, availability of WiFi, 3G speed, the quality of video and audio
Questionnaires provided for patients, clinicians, technical support
A technician tests the availability of availability of WiFi and/or 3G Internet connection for each participant’s home before a clinical trial takes place in that location
The maximum speeds (upload and download) are tested at the beginning of each clinical trial (monitored during consultation)
Technicians in both sites (patient’s home and hospital) assist to establish a Skype video/audio call and monitor the speed of the Internet connection during the clinical trial
Video/audio quality are assessed during ‘stationary’ and ‘moving’ phases of the teleconsultation. The Consultant will talk with patient at sitting posture, and also ask patient to perform motion such as walking or arm motion, assisted by the health nurse at the patient’s home
Technicians in both sites complete assessment forms and also ask the patient and the Consultant fill a document form after each consultation
Patient Interaction Interaction: History, symptoms, medication, BP, face close up, walking Next appointment The study received a favorable ethical opinion from ORECNI (09/NIR03/84) Any interaction with the patient preserves his/her anonymity and data is stored securely without any patient identifiers All information regarding the consultation process is stored in a secure patient administration system in the hospital Technical information regarding the consultation is held by the university researchers
Bandwidth: what was the maximum 3G upload/download bandwidth at both sites: hospital and patients’ home?
WiFi: was there a WiFi Internet connection at patients’ home?
Quality: what were the video and audio transmission qualities by using 3G connection?
Comfort : were you comfortable with using videoconference?
Ease : was the equipment easy to use for communicating to hospital consultant?
Preference: would you prefer a home-based teleconsultation rather than a hospital appointment?
Acceptability: was the consultation acceptable by using videoconference?
Usefulness: was the consultation useful for reviewing patient progress?
Limitations: were there specific limitations of the teleconsultation process?
Assessment Role Assessment Patient Was the equipment intrusive/acceptable? Were you able to understand hospital consultant? How easy was equipment for communicating/responding to hospital consultant? What was the overall comfort with/acceptability of the procedure? Was there satisfaction with arrangements for the teleconsultation? Preference for teleconsultation as opposed to travelling for a hospital appointment? Primary Care Team What was the acceptability/intrusiveness of equipment? How was communication with hospital consultant? Was there a benefit of consultant availability Were there specific limitations of the teleconsultation process? Any problems arranging the teleconsultation with patient and consultant? Consultant How was the communication with patient? How was the communication with technology team? Did the consultation permit review of patient progress? Were there specific limitations of the teleconsultation process? What were the problems with arrangements? Technical Team Was there a wired Internet/wireless Internet/ in addition to the 3G connection How Easy was it to establish the connection? Were there service interruptions? What was the perceived transmission quality (lag/screen freeze etc.) What were the data transmission bit rates upstream /downstream
Ratings from patients for the comfortableness, easy to use and preference of home-based teleconsultation were positive. Most of participants were comfortable and preferred using videoconference
Ratings from clinicians in the Ulster hospital for the acceptability, usefulness of teleconsultation were mixed. Limitations were that the lower Internet bandwidth leads to lost connection or poor quality images or speech. In addition, more detailed examination was limited by using a videoconference compared to the face-to-face consultation
The results show that teleconsultation for home-based Stroke assessment using mobile wireless technology is feasible where
Patient has broadband internet or a good 3G connection
Dynamic data transmission rates reduces the reliability of the teleconsultation
A BBC crowd-sourcing survey has reported that only 75% of 3G coverage can get a 3G signal successfully, there are still many ‘ notspots’ , including in major towns and cities across the UK in this stage
Telemedicine including synchronous consultation has been available for 20+ years, but based on infrastructure with Quality of Service Guarantees (e.g. 6xISDN)
Teleconferencing is becoming ubiquitous in modern society: Skype, Facetime
Telemedicine is being deployed in Stroke departments (e.g. for confirmation of diagnosis and to expedite thrombolytic treatment)
Protocols and applications such as Skype are not allowed by security conscious ICT departments within the NHS
Deployment of 3G networks is ongoing, but coverage is mainly based around major population centres
3G can support asynchronous telemedicine, e.g. uploading of images
Approx 400kbps can support asynchronous video, but this needs to be sustained over a 30 minute teleconsulation
The public accepts poorer quality video in certain circumstances, e.g. news correspondents reporting from the field, programs such as ‘Embarassing Bodies’
Teleconsultation was well received by patients in trial
Patterson V. Teleneurology in Northern Ireland: a success. J Telemed Telecare. 2002; 8:S3:46-7.
Digital Britain, Jan 2010, http://www.ber.gov.uk/file54154.pdf, accessed Sept 2010.
Wootton R. and Patterson V., Teleneurology. Royal Society Medicine Press, 2005.
NHS National Patient Safety Agency, National Research Ethics Service, Patient Information Sheets and Consent Forms, http://www.nres.npsa.nhs.uk, accessed Sept 2010.
3G mobile data network crowd-sourcing survey by BBC News, http://www.bbc.co.uk/news/business-14574816 , 24 th August 2011
Lee H. Schwamm et al, Recommendations for the Implementation of Telemedicine Within Stroke Systems of Care : A Policy Statement From the American Heart Association Stroke 2009, 40:2635-2660: originally published online May 7, 2009