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Stocktake of District Health Boards’ Telehealth Activity

The full report and its website summary identify how District Health Boards are managing and supporting telehealth initiatives.

Executive summary

Telehealth is one of the enabling technologies that will underpin the changes we need to make in the delivery of healthcare to the New Zealand public, and the government is committed to increasing its effective and sustainable use.  With this in mind, the National Health IT Board has commissioned the NZ Telehealth Forum to undertake a stocktake to provide a better understanding of the current uptake of telehealth technologies.

This report presents the results of Phase 1 of the stocktake, which has surveyed telehealth activity in New Zealand’s twenty District Health Boards (DHBs).  Phase 2, is a survey of Primary Health Organisations and Non-Government Organisations.

The stocktake provides a baseline from which to measure progress, and an information resource to enable new investment in telehealth to be more effectively deployed.  It will also help to build a network of telehealth expertise, and to identify the barriers to further progress.

The principal conclusions that we can draw from Phase 1 (and early responses to Phase 2) are:

  • New Zealand appears to be close to a tipping point in terms of the uptake of telehealth enabled practices, particularly in relation to videoconferencing.  The last 3-4 years has seen all DHBs utilise these technologies to at least some degree, and the appearance of telehealth specific governance groups and the appointment of telehealth leaders are further manifestations of the increasingly important role telehealth is playing in the delivery of sustainable services.
  • Although this progress is encouraging, it is by no means indicative of a momentum that reflects the true potential of telehealth.  In most cases telehealth services are introduced as a way of making an existing service model more efficient.  Only rarely is it considered as providing a strategic opportunity to reshape the way patients receive care or are empowered to take responsibility for their own care.  This tactical response arises from the lack of understanding and buy-in at the managerial and clinical policy levels of DHBs, and denotes a need for more leadership in this area.
  • Although there is an increasing acceptance of telehealth by individual clinicians, there remains embedded resistance to adopting these technologies, resistance that is bolstered by a lack of nationally agreed approaches to aligning its use with appropriate remuneration frameworks.  In the case of videoconferencing there is a residual concern about utility and especially integration that is only slowly being dispelled, notwithstanding the excellent progress that has been made by the National Health IT Board and the NZ Telehealth Forum in agreeing and implementing standards.
  •  If greater progress is to be made in the adoption of telehealth, it is vital that there is real investment in carrying out credible evaluations of the healthcare and financial benefits that arise from its effective use.  This will enable the investment cases to be made on hard data rather than merely through the aspirational thinking and leadership of individuals.
  •  If, as this stocktake suggests, there is a burgeoning uptake in the use of telehealth, then New Zealand has a moment in time opportunity to ‘do it right’.  This will require not just the effective efforts of individuals, clinical teams and DHB managements, but the ongoing involvement of national bodies such as the National Health IT Board, the New Zealand Telehealth Forum and the Medical Council to ensure a coordinated approach, where lessons are learnt and communicated, and where investments are made based on experience and knowledge.

Summary of results

For the purposes of the stocktake, telehealth is defined as meaning any technology enabled healthcare intervention where people are connected remotely.  Specifically, the categories of telehealth include:

  •  Telemedicine: the use of interactive videoconferencing (VC) and store-and-forward technologies for remote consultations, diagnosis and treatment, including multi-disciplinary team meetings for shared care and health care related education, research and evaluation.  Examples of store-and-forward include teleradiology and teledermatology.
  • Telemonitoring: patients using simple medical devices in their domestic settings to inform their care providers about their condition.
  •  mHealth: the use of mobile communications technology (such as smartphones) to deliver healthcare and healthy lifestyle services.
  • Interactive portals: the use of websites, social networks and supporting triage/consulting services to interact with patients.

The Chief Executive of each DHB was asked to nominate an individual to be responsible for completing the survey, and the questionnaires were sent to the nominees.  Survey questions addressed governance, the use of videoconferencing for current and planned clinical services, the supporting technical infrastructure, and other technologies being used or planned.  Questions were also asked about evaluations, barriers to uptake, and what support the NZ Telehealth Forum and the National Health IT Board should offer DHBs to enable them to increase their use of telehealth.

All twenty DHBs responded to the survey.  The results in this report are predominantly as received in the survey responses, with some clarifications and updates made following direct contact with respondents.  The level of detail in responses varied and we appreciate that in some cases the respondents may not have been aware of all of the operational or planned activities in different departments and services, since few DHBs have a readily accessible telehealth “knowledge hub”.  We are also aware that new developments have taken place between conducting the survey and preparation of the report, and therefore will not be included.

Almost all of the DHBs are making use of telehealth technology to some degree with Northland, West Coast and Canterbury most active in using telehealth technologies for clinical services involving care of patients.  Others that are providing some regular patient services, or are conducting or planning to conduct trials, include Auckland, Waitemata, Waikato, Bay of Plenty,  Lakes, MidCentral, Hawkes Bay, Nelson Marlborough and Southern.

The dominant telehealth technology being used for patient interactions and for clinical networks is videoconferencing, hence the focus on its use in this report.  Store and forward image transmission for radiology and pathology is an inherent part of video-based Multi-Disciplinary Meetings and patient consultations.  Dermatology, particularly in Waikato DHB’s Virtual Lesion Clinics, has been a pioneer in providing store and forward image-based diagnosis services for General Practitioner referrals.

Other technologies and applications are emerging, such as the use of mHealth / smartphone applications, the use of email consultations, and devices for remote telemonitoring.

Governance

This report identified how each DHB provides governance of telehealth activities.

Graph displaying DHB governance in DHBs in 2011 compaired with 2014

Figure 1: Telehealth governance in DHBs in 2011 compared with 2014

There are three column headings identified, DHBs with Telehealth Strategies, DHBs with Clinical Leaders and DHBs with Programme Managers / Facilitators. More explanation about this chart is given in the text that follows.

In 2011 three DHBs had documented telehealth strategies or procedures (Northland, Canterbury and West Coast) and only two had an appointed Telehealth Clinical Leader and a Telehealth Facilitator (Canterbury and West Coast shared).

In 2014 ten DHBs have strategies either in place or being developed.  Most are individual strategies, the exception being the Midland Region, where Waikato DHB’s strategy has been adapted as a regional strategy.  There are now ten DHBs with appointed telehealth clinical leaders, although their roles vary widely in scope.  Six DHBs now have full time telehealth programme manager or facilitator positions and one has a small part time position.

Thirteen DHBs have a Governance Group that provides oversight of telehealth investment.  In most cases these are the Groups that oversee overall ICT governance.  Four DHBs require approval of the Governance Group for equipment and other purchases.  Some handle their equipment investments out of normal operating budgets.

Northland DHB also has an active senior management and clinical leadership Steering Group.  Waikato DHB has a clinically-led Telehealth User Group, and there is now also a Midland Region Telehealth User Group.  Its terms of reference include telehealth promotion, advising senior management on strategy, ensuring the adoption of standards and guidelines for the effective use of telehealth, and liaising with interested parties from other DHBs to promote collaboration.

Five DHBs have formal documentation for telehealth protocols, primarily for videoconferencing interactions.  Two other DHBs are in the process of developing protocols.

While some DHBs have made good progress in terms of telehealth governance, some still lack formal governance structures.  Amongst those DHBs which do have governance structures there is wide variance in the scope and responsibilities of those involved.  Many DHBs also still lack protocols to govern the introduction and use of telehealth services into their organisations.

Videoconferencing (VC) usage

Nineteen DHBs currently use VC for administrative / management meetings and clinical education (South Canterbury was the only DHB that indicated no current usage.)

Sixteen DHBs reported that they are using VC for direct clinician-patient interactions, although only twelve reported specific services in the survey template.  The range of services has grown significantly since a telehealth survey taken in 2005/06, when the only services identified were for telepaediatrics, telepsychiatry, teledermatology, and teleradiology.  Today, a wide range of services using VC are provided across the spectrum of Adult and Emergency, Ambulatory and Allied Health, Paediatrics, and Mental Health services.  DHBs are using VC for follow-up visits, some first specialist assessments, acute assessments, ward rounds and nurse-led clinics.  Most involve services between secondary/tertiary sites and smaller regional sites.  A few services are provided directly to patients in their home.

All of the DHBs are using videoconferencing for multi-site Multi-Disciplinary Meetings or Multi-Disciplinary Team Meetings, or are in the process of establishing fit-for-purpose rooms for these meetings.  Sixteen DHBs have MDM Co-ordinators and twelve indicated that they either have or are developing protocols for multi-site VC meetings.  (Most of the MDM Co-ordinators and MDM protocols relate to the Cancer Networks.)

Other uses directly related to delivery of health services include discharge planning meetings, chart based ward rounds (usually for patients with long term or complex conditions), remote medication monitoring of patients in homes, supervision, and peer support.

Fifteen DHBs are planning on new telehealth services to be added in the next twelve months.  These include extending current services to new sites and adding new services.

Reporting of telehealth events

Despite the breadth of VC usage for patient interactions noted above, there has been little progress in the ability to track usage for patient consultations since a 2005/06 New Zealand Telehealth survey noted: “Usage statistics are hard to come by as there is no consistent method of tracking usage and the level of detail varies considerably from region to region and across services.”

Only five of the DHBs reported having a method of counting telehealth consultations either within, or outside of, their Patient Administration Systems, and one of those is only being done as part of a current international trial.  This capability is essential for telehealth consultations to become mainstream; credible data is necessary for evaluations, for relating the use of telehealth tools to health outcomes, and for appropriate recognition in contract matters and re-imbursement policies.

An important development with regard to reporting is that the Ministry of Health is implementing a change in the National Non-Admitted Patient collection that will allow for accurate counting of telehealth consultation as reported by DHBs.  It is likely that this change will help to improve the quality of data being collected in the future, but its effectiveness will depend on the ability of the DHBs to accurately capture the information at source.

Technical infrastructure

Only five DHBS said that their VC capacity either met or mostly met the demand.  Eight of the remaining fifteen DHBs have, or are developing investment plans to meet unmet demand.

Twelve of the DHBs have centralised booking systems.  Most respondents weren’t sure if their VC systems met current HISO standards for interoperability and interconnectivity; this demonstrates a need for wider communication to users, as it is understood that all recently implemented systems do comply.  Three VC network providers, Vivid Solutions Ltd, Gen-i and Dimension Data, are currently the main VC network providers for DHBs.  These companies are also active members of the Telehealth Forum’s VC Working Group, which has as its main goal the achievement of seamless and cost effective interconnectivity across networks.

Responses to questions about help desk and technical support indicated a need for clarification of the roles of internal IT departments and VC network providers.  The lack of adequate support was also cited as a barrier to uptake.

The majority of VC systems are still hardware-based, but there is a trend toward software-based systems.  A few DHBs have started providing VC clients on desktops and mobile devices that allow for secure connectivity to enterprise networks.

Other telehealth technologies

Three DHBs are providing remote telemonitoring support for patients and five others are planning to provide or considering this type of support.

One DHB (Waitemata) is deploying mHealth and smartphone technologies in programmes for diabetes support, pregnant women and families of young children, and community alcohol and drugs service.  DHBs are also using text messaging tools for communications between health professionals and for appointment reminders.  Two DHBs have provided VC links for GPs to participate in teleconsultations with specialist services and two are planning to provide links.

Three DHBs will be implementing email patient consultations as part of the Shared Care planning initiatives (Waitemata, Hawkes Bay and Auckland).  In all DHBs, email and telephone calls are most likely already being used for some consultations follow-ups, but as this activity is not counted it would be very difficult to quantify.

Telehealth evaluation

Four DHBs have conducted evaluations of an operational service or pilot (Northland, Auckland, Waikato, West Coast), and an evaluation of a tele-stroke pilot at MidCentral is underway.  Although not specifically reported in this survey, we are aware of other evaluations, for example for the Te Whiringa Ora telemonitoring service managed by Healthcare of New Zealand, and a 2011 report on a small telemonitoring trial in Lakes DHB.

Anecdotal information on services and events is also available, and business cases for investment have typically forecast benefits regarding increased access for patients, reduced clinical risk, and more efficient use of health provider resources.  Yet there is a lack of documentation on benefits realisation and health outcomes that would help to justify the level of investment necessary to ensure that telehealth tools become part of mainstream health service delivery.

Barriers to uptake and priorities for NHITB and Telehealth Forum support

The barriers to uptake cited by almost all DHBs are videoconferencing interconnectivity (across provider networks), infrastructure investment (including facilities, technology, and support staff) and adequate technical support.

Half of the DHBs cited the following factors as barriers to uptake:  the lack of appropriate re-imbursement models, protocols and guidelines for care pathways, quality of video/audio, and clinical support. Only three DHBs cited patient acceptance as a barrier.

Respondents felt that the most beneficial support the National Health IT Board and the Telehealth Forum could offer was the provision of generic guidelines and case studies, and telehealth advocacy at local, regional, and national levels.

Commentary

The survey results, particularly the indications of planned growth in services and networks, are very encouraging for telehealth uptake.  The survey shows that the most active DHBs are those that have addressed at least some of the success criteria for sustainable telehealth services.  Agreed strategies, clinical champions, senior management sponsorship, dedicated resources (for programme management, facilitation, and technical support), protocols and guidelines, and appropriate investment in the ICT infrastructure, are absolutely essential to promote uptake.

Progress is certainly being made, but we have a long way to go to realise the full potential for telehealth technologies to improve access for patients, to reduce clinical risk, and to make more efficient use of clinical and administrative resources.  For example, very few organisations are either providing or considering the use of remote monitoring technologies for management of chronic disease.  In addition, more organisations need to be fully committed to making video teleconsultations a mainstream activity in the delivery of outpatient and acute services.

By its very nature, telehealth relies on effective and efficient clinical and technical networks. However, along with the growth in telehealth activity, there are signs of fragmentation that will constrain uptake, if not locally, then at inter-DHB and cross-region levels.  There is also the risk that if the total cost of ownership in providing a telehealth-enabled service isn’t adequately planned for, isn’t clinically supported, and isn’t appropriately resourced, it won’t be sustainable.

Clinical collaboration and seamless technical interconnectivity between health providers is paramount.  The stocktake shows that there are many opportunities for DHBs to share lessons learned regarding governance,  equipment configurations, protocols and procedures used, technical support, and IT systems support.  This collaboration should contribute to increased and sustainable uptake, and reduce unnecessary duplication.

Next steps

This report is intended to be a baseline that can be periodically updated.  The results can be used by DHBs to identify sources for collaboration when planning telehealth services, and to share lessons learned.  A high level set of Key Performance Indicators (KPIs) will also be used by the National Health IT Board and the Telehealth Forum to track progress on telehealth uptake.  The KPIs will initially focus on governance (as shown above in Governance, Figure 1), the capacity to enable uptake, and the services offered.  As the sector matures, there will be increased focus on capturing more evidence of telehealth’s risks and benefits, with the goal of relating these to improved health outcomes.

There are many signposts that can be pursued to take advantage of the progress made.  With the support of the National Health IT Board, the Telehealth Forum will continue, via its working groups and its advocacy role, to respond to the priorities cited in this survey, and to focus on promoting sustainable telehealth services.

Acknowledgments for help with the report:

  • National Telehealth Leadership Group members for input to survey design and testing, and for review of the draft report.
  • National Health IT Board for support in survey distribution and recording responses.
  • DHB respondents for their time in completing the surveys, and for their interest in telehealth.
  • Terri Hawke, Telehealth Forum Project Coordinator, for data and report formatting and graphics.

Further information

To get copies of the full report prepared for the Ministry of Health by Pat Kerr, Principal Consultant, NZ Telehealth Forum, please email: enquiries@ithealthboard.health.nz