Stroke Teleconsultation - Paul McCullagh


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  • Stroke Teleconsultation - Paul McCullagh

    1. 1. 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
    2. 3. Stroke <ul><li>Stoke has a greater disability impact than any other medical condition </li></ul><ul><li>Every year an estimated 4,000 people in Northern Ireland have a Stroke ( The Stroke Association 2011 ) </li></ul><ul><li>Teleconsultation enables the patient to obtain the professional opinion of a healthcare provider remotely </li></ul><ul><li>This technology potentially makes the provision of healthcare more efficient and economic </li></ul><ul><li>Around a third of people who have suffered a Stroke are living with long term disability and needing home-based rehabilitation </li></ul><ul><li>How can teleneurology improve patient care? Victor Patterson and Richard Wootton Nature Clinical Practice Neurology (2006) 2, 346-347 </li></ul>
    3. 4. Background <ul><li>Studies have shown that the teleconsultation can assist </li></ul><ul><ul><li>diagnosis, self-management, and professional  patient knowledge transfer </li></ul></ul><ul><ul><li>methods used for teleconsultation include email, (asynchronous) telephone & videoconference (synchronous) </li></ul></ul><ul><li>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 </li></ul><ul><li>Telephone can provide good audio quality, but with no visual image during the consultation it is a difficult communication medium for patient / doctor interaction </li></ul><ul><li>Videoconference could be the best alternative to face-to-face consultations, however, the video and audio quality depends on connection bandwidth </li></ul><ul><li>‘ Digital Britain’ aims for 2Mbps everywhere in the UK by 2014 </li></ul>
    4. 6. Stroke initiatives A&E Consultant Consultant HCP
    5. 7. Methodology <ul><li>The teleconsultation system is based on low-cost and easy to use software and hardware components </li></ul><ul><li>Hardware comprises a laptop with a webcam, microphone/speaker, and 3G dongle or WiFi wireless network connection </li></ul><ul><li>The software uses Skype </li></ul>
    6. 8. Internet Connection <ul><li>Require approx 400kbps duplex </li></ul><ul><li>UMTS / 3G (O2 provider) 128kbps -500kbps </li></ul><ul><ul><li>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 </li></ul></ul><ul><li>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) </li></ul><ul><ul><li>Quality of Service protocols, power saving mechanisms and faster bandwidth (2Mbps~100Mbps) </li></ul></ul><ul><ul><li>However, the WiFi networks have limitations, such as limited mobile use of telemedicine applications </li></ul></ul>
    7. 9. Coverage
    8. 10. BBC Survey <ul><li>“ 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. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>But in terms of the amount of time people are spending on 3G, they've got that at 58%, much lower than our 75%. </li></ul><ul><li>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.” </li></ul><ul><li>August 2011 </li></ul>Mobile Broadband
    9. 11. Broadband Speeds BBC survey, August 2011 South Eastern Trust, Northern Ireland
    10. 12. Technical Trials
    11. 13. 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
    12. 14. Image quality reduces when the person is moving (compared to static), although the data transmission rates are similar Image Quality
    13. 15. Protocol <ul><li>Data collection issues: location, weather conditions, availability of WiFi, 3G speed, the quality of video and audio </li></ul><ul><li>Questionnaires provided for patients, clinicians, technical support </li></ul><ul><li>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 </li></ul><ul><li>The maximum speeds (upload and download) are tested at the beginning of each clinical trial (monitored during consultation) </li></ul><ul><li>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 </li></ul><ul><li>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 </li></ul><ul><li>Technicians in both sites complete assessment forms and also ask the patient and the Consultant fill a document form after each consultation </li></ul>
    14. 16. 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
    15. 17. 1 = poor, 2 = ok, 3 = good, 4 = very good, 5 = excellent; Initial Results ID Date Area 3G bandwidth (kbit/s) WiFi Quality From patients From clinicians Patient’s home Hospital Video Audio Comf. Ease Pref. Acce. Usef. Limitations Up. Down. Up. Down. 1 08/06/10 Urban 605 1448 4 5 Yes Yes Yes Yes 3 Slight delay between image/sound. 2 27/07/10 Rural No signal 3 20/10/10 Urban No signal 4 24/11/10 Urban 1448 1256 4 4 Yes Yes Yes Yes 5 Unpredictable coonection 5 09/02/11 Urban 14258 26416 Yes Yes Yes Yes Yes 4 6 14/02/11 Urban 331 1848 4 4 Yes Yes Yes Yes 4 7 31/03/11 Urban No signal 8 Urban 9 16/06/11 Urban 864 3000 4 5 Yes Yes Y/N Yes 4 10 Rural No signal 11 16/06/11 Urban 1474 1112 5 5 Yes Yes Yes Yes 4 Examination possible 12 Urban 13 13/06/11 Urban 1100 4000 4 5 Yes Yes Y/N Yes 4 Lag, jerky 14 Urban 15 21/07/11 Urban 1321 1920 230 390 5 5 Yes Yes Yes Yes 16 26/07/11 Urban 662 1176 1444 1488 4 4 Yes Yes Y/N Yes 5 Signal strength 17 27/07/11 Urban 1471 1032 1172 2168 5 5 Yes Yes Yes Yes 4 Examination possible 18 03/08/11 Urban WiFi 1071 1608 Yes 5 4 Yes Yes Yes Yes 5 Used WiFi. Echo 8152 910 19 20 21 22 23 24
    16. 18. Assessment <ul><li>Technicians: </li></ul><ul><li>Bandwidth: what was the maximum 3G upload/download bandwidth at both sites: hospital and patients’ home? </li></ul><ul><li>WiFi: was there a WiFi Internet connection at patients’ home? </li></ul><ul><li>Quality: what were the video and audio transmission qualities by using 3G connection? </li></ul><ul><li>Patients: </li></ul><ul><li>Comfort : were you comfortable with using videoconference? </li></ul><ul><li>Ease : was the equipment easy to use for communicating to hospital consultant? </li></ul><ul><li>Preference: would you prefer a home-based teleconsultation rather than a hospital appointment? </li></ul><ul><li>Clinicians: </li></ul><ul><li>Acceptability: was the consultation acceptable by using videoconference? </li></ul><ul><li>Usefulness: was the consultation useful for reviewing patient progress? </li></ul><ul><li>Limitations: were there specific limitations of the teleconsultation process? </li></ul>
    17. 19. 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
    18. 20. Discussion <ul><li>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 </li></ul><ul><li>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 </li></ul><ul><li>The results show that teleconsultation for home-based Stroke assessment using mobile wireless technology is feasible where </li></ul><ul><ul><li>Patient has broadband internet or a good 3G connection </li></ul></ul><ul><li>Dynamic data transmission rates reduces the reliability of the teleconsultation </li></ul><ul><li>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 </li></ul>
    19. 21. Conclusion <ul><li>Telemedicine including synchronous consultation has been available for 20+ years, but based on infrastructure with Quality of Service Guarantees (e.g. 6xISDN) </li></ul><ul><li>Teleconferencing is becoming ubiquitous in modern society: Skype, Facetime </li></ul><ul><li>Telemedicine is being deployed in Stroke departments (e.g. for confirmation of diagnosis and to expedite thrombolytic treatment) </li></ul><ul><li>Protocols and applications such as Skype are not allowed by security conscious ICT departments within the NHS </li></ul><ul><li>Deployment of 3G networks is ongoing, but coverage is mainly based around major population centres </li></ul><ul><li>3G can support asynchronous telemedicine, e.g. uploading of images </li></ul><ul><li>Approx 400kbps can support asynchronous video, but this needs to be sustained over a 30 minute teleconsulation </li></ul><ul><li>The public accepts poorer quality video in certain circumstances, e.g. news correspondents reporting from the field, programs such as ‘Embarassing Bodies’ </li></ul><ul><li>Teleconsultation was well received by patients in trial </li></ul>
    20. 22. References <ul><li>Patterson V. Teleneurology in Northern Ireland: a success. J Telemed Telecare. 2002; 8:S3:46-7. </li></ul><ul><li>Digital Britain, Jan 2010,, accessed Sept 2010. </li></ul><ul><li>Wootton R. and Patterson V., Teleneurology. Royal Society Medicine Press, 2005. </li></ul><ul><li>NHS National Patient Safety Agency, National Research Ethics Service, Patient Information Sheets and Consent Forms,, accessed Sept 2010. </li></ul><ul><li>3G mobile data network crowd-sourcing survey by BBC News, , 24 th August 2011 </li></ul><ul><li>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 </li></ul>