Telemedicine

Home telenursing

In the past decade there has been considerable interest in the possibility of using telemedicine as an aid in home nursing. Various feasibility studies into a range of different kinds of technology have been driven by the hope that care of chronically ill patients can either be provided more cheaply or be of a higher quality than traditional home visits. Although these studies indicate that patient satisfaction is not a problem,5 little hard evidence on cost effectiveness has been obtained.

The Kaiser Permanente organisation recently reported the first formal randomised controlled trial of home videophones. In this trial patients newly diagnosed with various chronic conditions (for example, congestive heart failure, chronic obstructive pulmonary disease, cerebral vascular accident, cancer, diabetes, anxiety, and need for wound care) were nursed at home. Patients in the intervention group were equipped with home videophones, an electronic stethoscope, and a digital blood pressure monitor (fig 1). Over 18 months, patients in the telemedicine group received 17% fewer home visits by nurses than the control patients, but they had more telephone contact with the nursing staff (in addition to the video “visits”). The measures of quality of care in the two groups were similar. The patients receiving telemedicine were pleased with the equipment and were nursed as effectively as the control patients. The average cost of care in the telemedicine group was 27% less than that of the care in the control group.6 This is an important result, but because the practice of home nursing in the United Kingdom is rather different from that in the United States the potential of telenursing is likely to be different, and thus this work will need to be followed up in a British setting.7

Fig 1

Telenursing equipment used by patients in the Kaiser Permanente trial, comprising a low resolution videophone, an electronic stethoscope, and a digital blood pressure monitor. The stethoscope was placed by the patients themselves, or care givers, at sites as requested by the nurse, who could see where the stethoscope was being positioned and recommend adjustments if necessary. (Photo courtesy of Kaiser Permanente)

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Many of the practical problems of implementing telemedicine in the patient's home are reduced in institutional settings, such as nursing homes, because the costs of expensive equipment can be spread across many patients, staff can be specially trained to operate it, and better telecommunications are possible. For this reason telenursing is likely to be easier in a community nursing home than in private homes, even though the economic gain to society may be less. Early trials of telemedicine in a nursing home in Hong Kong suggest that it is clinically effective8; it may also be cost effective (J Woo, personal communication, 2000).

Electronic referrals to specialists and hospitals

For the past 10 years general practitioners in Finland have been able to make electronic referrals to the Peijas Hospital in Helsinki. Many of these referrals can be dealt with by the hospital staff without the patient needing to attend the outpatient clinic, either by electronic messages or by arranging a teleconsultation by video link. A 20 month study found that 52% of the referrals from general practitioners were dealt with electronically. This was a much cheaper method of referral than the traditional method, as used by two control groups of general practitioners with similar patients: the direct costs of a visit to an outpatient clinic in internal medicine were seven times greater per patient than those of an electronic consultation.9

In an extension of the principle of electronic referral, the Swinfen Trust, a medical charity, recently proved the efficacy of email in an ongoing project to support doctors in developing countries such as Bangladesh.10 Advice to doctors is provided by a panel of volunteer consultants, mainly from industrialised countries, and early results indicate that the scheme is likely to be cost effective, at least for the referring doctor and the patient.

Teleconsulting between general practitioners and specialists

In referring a patient to a hospital, the general practitioner hands over management to a third party, the hospital specialist. An alternative is for the general practitioner to retain the patient in primary care and manage the problem by teleconsulting the specialist. Telemedicine may be an attractive option when a conventional referral to a hospital involves much travel on the part of the patient or doctors concerned. A wide range of teleconsulting applications have been trialled in general practice in such areas as cardiology, psychiatry, orthopaedics, and ophthalmology, as well as techniques such as ultrasound examinations.11^–16 These experiments have shown technical feasibility, but obviously it is too early to know whether such applications will come into widespread use.

Dermatology is a specialty that lends itself well to telemedicine. Three trials—in the United Kingdom, Norway, and New Zealand17^–19—have reported the circumstances in which teledermatology in primary care can be considered cost effective. The trials, which all used real time video links (fig 2), concluded that travel must be a considerable burden for patients before telemedicine is cheaper for society than the conventional alternative, sending the patient to hospital to be seen by a dermatologist. This sort of teledermatology is therefore not likely to be cheaper for the NHS in London, though it would almost certainly be more economical in rural regions such as the highlands and islands of Scotland.

Fig 2

A general practitioner in Taupo, New Zealand, consulting a dermatologist in Hamilton, about 160 km away. The computer allows real time videoconferencing. The doctor can use the digital camera to show close up pictures of skin lesions. (Photo courtesy of Waikato Health)

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Fig 3

Teleconsultation between a nurse practitioner in a minor injuries unit and a doctor in the accident and emergency department of a main hospital. The immediate management of a fracture is being discussed. (Photo courtesy of the Ulster Community and Hospitals Trust)

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An interesting question is whether email messages with still pictures attached are better than real time video links. Email has the advantage of being cheaper and more convenient than a video consultation, but forwarded still pictures seem to have a lower diagnostic accuracy.20 If a higher proportion of patients referred by email rather than a video consultation require a face to face consultation in the end, the overall costs and benefits may be rather finely balanced.

Minor injuries telemedicine

One of the most promising applications of real time telemedicine is the use of video links to aid decision making of nurse practitioners running minor injuries units (fig 3). Early work in Scotland showed that using telemedicine to avoid unnecessary transfers of patients from a community hospital resulted in major savings,21 and telemedicine has now been adopted in about 20 minor injuries units around the United Kingdom.22 Although we await a formal study of the cost effectiveness of telemedicine, a substantial follow up study from the Central Middlesex Hospital (one of the first hospitals to use the technique) has shown that it is both clinically effective and safe.23

Call centres and online health

The growth in telephone call centres that provide health information and advice shows that there is a demand from the public for these services. Many such call centres, such as NHS Direct, try to triage callers into those requiring emergency treatment, those who can be referred to primary care, and those who can be advised to treat themselves. Although there is reasonable evidence that these services are safe, little evidence exists that they reduce demand on other parts of the NHS.24 They are therefore unlikely to be cheaper for the health service—a common situation in telemedicine, where a new application often improves the quality of the service but does not reduce its cost. Indeed, a study of 32 paediatric call centres in the United States showed that all were losing money, the average loss being $500 000 (£350 000) a year.25

An analogous telemedicine service for the general public is internet consultation. “Dot.com” consulting companies, many of which are based in the United States, have proliferated, but as yet little evidence has been shown of their safety or cost effectiveness. These services seem to satisfy a public demand, so the implication is that the conventional alternatives are somehow deficient. Therefore, in parallel with an apparently unstoppable rise in online health services for the public, we need to identify the unattractive features of the conventional routes of access to medical care—and then improve them.