Remote control

Telemedicine co-ordinator Gary Taylor reviews some of the latest developments in electronic health care

As the availability of internet access and email in the NHS grows, telemedicine, which allows the assessment of injuries, trauma and chronic wounds without the need for specialist clinicians to be present, is bound to become more widely used.

It may come as a surprise to some that remote access to clinicians is not a new idea. In 18th century London for example, some patients could write to their doctors expecting to receive advice and treatment by return of post (Wootton 1998), while for many years airline crews have used radio to obtain advice on the best ways to treat passengers who become ill during flights.

Before the advent of digital imaging, nurses rarely had speedy access to accurate visual records and would usually rely instead on crude drawings, vague descriptions, wound tracings and complicated measuring tools.

This process was impractical and messy, and increased the risk of wound contamination (Hayes and Dodds 2003).

Telemedicine however allows permanent electronic records of injuries or wounds to be made. These can be printed and added to patients’ paper notes if required.

Such electronic patient records (EPRs) allow images to be accessed by all appropriate healthcare professionals, enabling wound care nurses for example to view wounds during healing or non-healing processes.

True ‘tele’, or remote, access to healthcare services has only been realised fully in recent years because of the increasing availability of cheap and simple-to-use personal computers (PCs), the internet and inexpensive digital image capturing devices such as
digital cameras and video recorders.

Access to care

Access to specialist care in specialist centres has become the norm for the UK healthcare system, but capacity and bed availability in the NHS are becoming so limited that such centres will soon be unable to accept new referrals.

Travel to specialist units can also be difficult for patients who are particularly old or young, or who are severely injured or disabled. Out of hours, ambulance services have difficulty in providing non-emergency transport, so that moving patients many miles for assessment is not cost effective and often disrupts patient and hospital routines.

As telemedicine systems and outreach services become available however, the need for patients to travel away from their local services for treatment diminishes.

Serious injuries and trauma

The question usually raised by serious injuries and trauma is not whether but when the patients concerned should be transferred to specialist centres.

Digital imaging of injuries can ensure that the most appropriate care is given in the interim, and that patients are transferred to specialist units in the most appropriate ways, whether this is by emergency helicopter, ambulance or privately owned car.

Health care is the world’s largest industry, which accounts for approximately 12 per cent of the gross domestic product of countries belonging to the Organisation for Economic Co-operation and Development (Downer 1999). If telemedicine can make even modest savings in costs therefore, huge benefits could be accrued.

Norris (2002) reports for example that the introduction of telemedicine to a minor injuries unit (MIU) in Belfast saved £42,000 in its first year, by reducing treatment delay and so increasing productivity. The system also reduced training costs by allowing nurse practitioners to use it to treat locally unfamiliar or rare injuries.

As healthcare costs rocket, the use of remote assessment and advice will surely become more widespread.

Local experience

The Queen Victoria Hospital (QVH) is a specialist burns and plastic surgery unit providing specialist healthcare services, mainly to residents of Kent, Surrey and Sussex.

Telemedicine systems have been developed at QVH in order to:

  • Make permanent records of injury
  • Increase patient accessibility to specialist services
  • Speed up the patient referral process
  • Reduce unnecessary patient attendances and admissions
  • Prevent unnecessary dressing changes
  • Reduce travelling time and costs for patients and their families
  • Minimise disruption for patients
  • Reduce overall healthcare costs.

The system developed at QVH is usually referred to as a ‘store and forward’ system, and it is used by all of QVH’s services including specialist advice, outpatient and inpatient treatment, day surgery and nursing outreach.

This system works by using specially written software to upload images to local PCs, where they are encrypted using 128Kb encryption, the same level used by online banks, and the images are then emailed via the NHS network to QVH.

Here, they are un-encrypted and posted to an intranet site, by which anyone with appropriate access to the hospital network can view them.

All of the telemedicine images used at the QVH are stored digitally and are accessible from 400 or so PCs situated throughout the trust.

The viewing software allows images to be enlarged, sharpened and rotated to obtain the best views, while the original image files remain unchanged. The image files are also backed up each night.

Once these images are viewed by members of the on-call team, advice on the best treatment can be given or referrals to senior clinicians can be made as necessary.

This allows a consultant surgeon for example who is scrubbed in theatre to view the images, advise on best treatment and decide whether patients in remote A&Es or MIUs should be seen at QVH. This saves time for the consultant surgeon, who does not need to see such patients after operating, and the nursing staff at remote units, who do not have to arrange transport for them.

If patients need to be admitted to QVH, further images can be taken on arrival to enhance their records.

Patients can therefore be admitted directly to appropriate wards without having to sit on trolleys in A&E or MIU, or they can be discharged from their referring units and booked for day surgery at QVH on another day, reducing the need for overnight stays or multiple visits to the hospital.

A bespoke intranet site has also been developed to allow quick access to both telemedicine and medical photographic images. This site can also be accessed from laptops that can be plugged into the hospital network, and by using a remote access system that allows selected users to log securely onto the hospital network from anywhere via standard broadband internet connections.

The hospital has installed the telemedicine software in 26 A&Es, NHS walk-in centres and MIUs across its catchment area. When images are uploaded from these, clinicians can telephone the QVH on-call team for advice. This service will be offered to more locations soon.

Conclusion

The perceived complexity of information technology systems including telemedicine makes initial and ongoing training vital to both sender and receiver units.

Initial set-up costs can appear large and may deter some from attempting to establish telemedicine systems but, once in place, ongoing costs are reasonable and, as long as new users are trained, system use can be maintained.

Roll out of electronic systems, such as the picture archiving and communication system, and EPRs, within the NHS is ongoing, so that accessing patient information
electronically will soon be common practice for NHS staff.

The number of referrals to QVH meanwhile via telemedicine is increasing, thereby reducing costs and inconvenience to patients while increasing appropriate referrals and allowing treatment to be started sooner at the point of access.

Gary Taylor is telemedicine clinical co-ordinator at Queen Victoria Hospital, East Grinstead, West Sussex


References

Downer A (1999) Why Health Matters In Foreign Policy. Speech to the UK-Australia Seminar on Health and Foreign Policy, Canberra. September.

Hayes S, Dodds S (2003) Digital photography in wound care. Nursing Times. 99, 42, 48-49.

Norris AC (2002) Essentials of Telemedicine and Telecare. John Wiley and Sons, Chichester.

Wootton R (1998) Telemedicine in the National Health Service. Journal of the Royal Society of Medicine. 91, 12, 614-621.


Reproduced with kind permission from Emergency nurse, vol 15, no 2, May 2007