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Prepared for the World Telemedicine Symposium for Developing Countries, Portugal, 30 June- 4 July 1997

John Mitchell & Associates

The benefits of telemedicine can be optimised immediately by a change of attitude towards the boundaries of telemedicine. For many people, telemedicine means the delivery of medical or health services, at a distance, using telecommunications. For such people, telemedicine normally means the traditional consultation between the clinician and the patient. This is a very narrow definition of telemedicine and it will be argued in this paper that not only is this definition unnecessarily restrictive, it does not reflect what often happens in practice.

An Integrated Telemedicine System is a phrase we have devised to describe a system which is available to more than just the clinician, for consultations. The system consists of both the technology and the organisational structure supporting the innovation. Ideally, the system will be available to the full range of patients, the full range of health industry staff and for a full range of applications, from clinical, to educational, to professional development, to administrative applications.

Three reasons to expand the definition

I have formed the belief that the definition of telemedicine needs to be expanded, for three reasons.

1. Many applications of the one technology.

The first reason why I believe that the definition of telemedicine needs to be expanded stems from my background, which is not medical, but is in educational and project management. I became involved in telemedicine in 1994 when I was asked to evaluate a new telepsychiatry network in South Australia, following my earlier evaluation of the development of videoconferencing in the higher education in Australia. The telepsychiatry project used one major technology: videoconferencing. From my educational management background, I brought to my study of telemedicine the knowledge that the one technology (e.g. videoconferencing) could be used for staff development, the delivery of education, interviews, meetings and a range of other applications.

2. Non-threatening applications.

The second reason why I believe that telemedicine can be much more than the conventional doctor-patient consultation, arises from my experience in the project management of technological innovations. From project management of new technology, I knew that people embraced change at different paces and that some changes are less threatening than others. I knew that meetings are usually less threatening or demanding than educational or clinical applications and that to use the technology for non-threatening administrative purposes often accelerates the adoption of the technology. Non-threatening applications also provide opportunities for many more people to be exposed to the new technology, than would be possible if the technology was exclusively for the use of one group, such as clinicians.

3. In practice, users develop new applications.

The third reason why I believe that telemedicine can be much more than the conventional doctor-patient consultation is that, in practice, users tend to deploy telemedicine technology for a range of uses. My experience in working with hospitals and health departments and university departments around Australia has convinced me that if users are given any latitude to experiment, they will use telemedicine technology for a variety of purposes. To gain the optimum benefits from an innovation, it is often wise to give users free rein to experiment.

The above beliefs are substantiated by the following two case studies.

Case study, No.1 : Renal Telemedicine

It has been our privilege to project manage the Renal Telemedicine Network at The Queen Elizabeth Hospital in Adelaide, South Australia, since 1994. The network links Woodville, Wayville and North Adelaide in the metropolitan area and Port Augusta, 300km from Adelaide. Occasional links are also made to Clare (150km), Berri (250km), Mount Gambier (400km), Whyalla (400km) and Alice Springs (1,500km).

The renal telemedicine network at TQEH has attracted international interest for the range of clinical applications made possible by the technology. Regular users include nephrologists, registrars, pharmacist, dietitian, social worker, nurse educators and clinical nurses. The project has been professionally managed and thoroughly evaluated and is considered a model of good practice for other networks.

The network is used about 3,000 times per year for many different uses. Following is a list of clinical uses of telemedicine within the renal unit, where ‘clinical’ is defined as any activity related to management of the patient. This topic is developed in more depth in an article by Mitchell, J.G. and Disney, A.P.S, the Journal of Telemedicine and Telecare, Vol. 3, 1997.

Types of Clinical Uses

• Dialysis access assessments
• Elective and emergency assessment
• Elective and emergency consultation
• Review of clinical dialysis problems and transplant investigational results
• Visual assessment of skin, joints, signs of cardiac failure, infection, peripheral vascular disease, neuropathy
• Decision making re transfer to central hospital
• Routine elective and outpatient consultations
• Use of separate room for confidential discussions
• Explanation of prescribed drug treatment and side effects
• Assessment of drug taking compliance
• Display of drugs for assisting process
• Explanation of prescribed dietary regime
• Display of food types
• Discussion of social services, housing, transport issues
• Counselling, personal and family matters
• Induction of nurses at satellite centres, for management of new patients and changes to current management
• Advice regarding cannulation
• Assessment of peritoneal catheter exit site.

Note that many of the uses are administrative, e.g. discussion of social service, housing, transport issues; counselling, personal and family matters; use of separate room for confidential discussion. Additionally, many of the uses are related to professional development, e.g. advice regarding cannulation; induction of nurses at satellite centres, for management of new patients and for changes to current management.

The Renal Telemedicine Network is also used for other administrative and educational/professional development purposes, as follows:

• tutorial assistance for nurses based in country districts, undertaking the Graduate Diploma in Nephrology Nursing;
• staff training on new equipment or on new procedures, delivered from TQEH to the satellite dialysis centres;
• weekly renal transplant meetings between two of Adelaide’s major hospitals, TQEH and the Royal Adelaide Hospital, with the Royal Darwin Hospital, in the Northern Territory.

This case study demonstrates that if the renal telemedicine facilities were limited to conventional doctor-patient consultations, the benefits of the technology would be greatly reduced. The Renal Unit at TQEH is a practical example of one section of a hospital developing the Integrated Telemedicine System.

Case study, No. 2 : The Queen Elizabeth Hospital, South Australia

The Queen Elizabeth Hospital installed videoconferencing facilities for telemedicine in mid-1995, primarily to assist in the amalgamation of TQEH with the Lyell McEwin Health Service, 25km away, in Adelaide’s northern suburbs. It has been interesting to observe the uses made of the facilities since then. Initially, the main uses were education and professional development:

• Physicians’ Workshop: 40-80 staff participate in seminars each week;
• Psychiatry Workshop: 40-50 staff attend weekly presentations;
• Medical Students’ Training: 50 fourth and sixth year students attend weekly lectures by videoconferencing.

More recently, a combination of clinical and educational/professional development uses has been added to the network:

• Breast consultations by videoconferencing: x-rays and breast biopsies are transmitted from LMHS to TQEH, to confirm diagnosis and to determine treatment;
• Neurological Diagnosis: EMG signals are transmitted from LMHS to TQEH, for diagnosis;

Additionally, the Endocrine and Diabetes Service has installed desktop videoconferencing facilities to link to General Practices and Community Health Centres around South Australia.

TQEH is, then, a lively example of the Integrated Telemedicine System being applied across a whole hospital.

The Integrated Telemedicine System

The development of the Integrated Telemedicine System is the result of many factors, including:

• the one technology (e.g. videoconferencing) can be used for staff development, the delivery of education, interviews, meetings and a range of other applications;
• use of telemedicine technology for non-threatening administrative purposes often accelerates the adoption of the technology;
• if users are given the latitude to experiment, they will use telemedicine technology for a variety of purposes.

Our experience in telemedicine has convinced us that the Integrated Telemedicine System is the most effective way to optimise the benefits of installing telemedicine equipment. The Integrated Telemedicine System is a multipurpose network, available for clinical, educational/professional development and administrative purposes. While individual organisations may prefer to prioritise uses, such as clinical as the top priority, it is cost effective to use the same facilities for a range of other purposes.

Future directions

The Integrated Telemedicine System is at an early stage of providing a mechanism for using telemedicine technologies and support systems for multiple applications.

My company is now working with hospitals to ensure that in future the Integrated Telemedicine System becomes more sophisticated, by users:

• developing continuous improvement principles in the clinical application of telemedicine;
• improving communication, planning and decision making through the use of telemedicine facilities;
• increasing staff productivity through the use of telemedicine;
• refining the cost effectiveness of telemedicine;
• integrating other technologies with videoconferencing, such as the Internet and computerised patient management systems.

When we enter this more advanced stage of telemedicine, we will be dramatically optimising the benefits of telemedicine. Countries newly adopting telemedicine could optimise benefits immediately, by planning to build an Integrated Telemedicine System from the start, not as an afterthought.