Goal and Objectives

It is our hope, that after reviewing this comprehensive presentation, readers will have a fundamental understanding of teleconsultation and its use in the provision of care. The presentation will take a concentrated look at teleconsultation and its application and use in rural communities.

To achieve this goal there are several key objectives the group has for this presentation.

The objectives are as follows:

1. Introduce the concept and definition of teleconsultation.
2. Explore the various types of teleconsultation.
3. Outline and discuss the costs associated with teleconsultation.
4. Look at the composition of teleconsultation.
5. Outline the process of teleconsultation.
6. Discuss the roles and responsibilities associated with facilitating and participating in teleconsultation.
7. Examine the needs of the health care professional and of the patient, as they relate to teleconsultation.
8. Explore patient satisfaction with the use of teleconsultation.
9. Investigate teleconsultation in rural communities and outline the limitations and benefits of teleconsultation for these populations.
10. Discuss the future of teleconsultation.

What is Teleconsultation?

Teleconsultation is electronic communication between a physician and a client, another physician, or another health professional for the purpose of delivering health care services and information over small and large distances. Transmission may include data, information, images, and /or voice. Most commonly, teleconsultation takes place between a health care professional (HCP) and a patient or between HCPs for diagnostic or therapeutic advice or for educational purposes.

The goal of teleconsultation is to eliminate the barriers of distance and promote equal access to health services to remote areas where immediate consultations are unavailable.

(New Telemedicine Service Soon Cartoon Published on 16 April 1998 issue of the Sunday Times, Singapore by Lee Chee Chew)

Types of Teleconsultation

The vastness of a country like Canada, the climate, and the sheer number of rural communities where there exits a lack of health care resources creates a real challenge for providing health services to all communities. Teleconsultation is quickly being explored and implemented to meet this challenge. A number of teleconsultation mediums are discussed below.

1. Real Time Teleconsultation (Synchronous)

• Real time teleconsultation uses advanced telecommunication technology to exchange information and involves the use of audiovisual technology allowing individuals to communicate live (or synchronously) over a videoconference link.
• Real time services require, at a minimum, video cameras, a sound system, computer displays, and a secure high speed internet connection to transmit data between sites (Deshpande et al., 2008).
• Real time teleconsultation encompasses computer technologies using narrow and high bandwidths for specific types of transmission, full motion video, broadcast video, compressed video and virtual reality (Myers, 2003).
• Real-time services rely on the availability of dedicated videoconferencing facilities, which generally are restricted to institutions.
  
  Example of Real-Time Interaction: Tele-Psychiatry
  · A patient is in the video conferencing room of a rural community telehealth site.
  · At the same time the patient’s psychiatrist is in the videoconferencing room at the specialist centre for psychiatry.
  · Live interactive consultation takes place between the patient and the psychiatrist.

2. Store & Forward Teleconsultation (Asynchronous)

• Asynchronous teleconsultation is often referred to as store and forward, and is the transmission of data without the need for live interaction between individuals. It involves the collection of digital samples of health information (e.x. electrocardiograms, spirometry results, radiological images) at one location and their transmission to a health professional in another location for review.
• Technology can be any device capable of capturing a digital sample, storing it, downloading it, and transmitting it to a remote site. Equipment used includes computers and laptops, computer files, scanners, digital cameras, iPods, audio files, or text files of a patient’s medical history. The internet provides the ability to transmit large files securely, quickly, and inexpensively to almost any location.
• Asynchronous teleconsultation has led to shorter wait times, fewer unnecessary referrals, higher levels of patient care, and patient and provider satisfaction in remote areas that lack health care professionals (Deshpande et al., 2008).
  
  Example of Store & Forward Interaction: Tele-Radiology
• In a rural community telehealth site, a patient’s x-ray is taken, scanned and captured as an electronic file.
• The file, and any accompanying medical notes, is sent electronically to the physician in the tertiary care telehealth site.
• The radiologist in the tertiary care site opens the file, reviews the x-ray and notes in order to confirm and/or determine a diagnosis.
• The file and accompanying notes are then returned to the rural telehealth site.
• The patient is informed of diagnosis without having to meet the radiologist.

While Real Time and Store & Forward can be used separately, they can also be used in conjunction with one another to further enhance the care provided.

Example of Combination of a Real-Time & a Store and Forward
Interaction:

Tele-Dermatology: In a rural community telehealth site, a patient is diagnosed with a skin condition by a dermatologist located in a remote specialist centre using real-time interactive consultation and use of a camera. Following one week of treatment, the patient’s skin condition has improved, and a staff member takes a new photographic image.

The photographic image is forwarded to the dermatologist in the remote location for further follow-up and review.

The Costs of Teleconsultation

Providing health care services within the restraints of finite budgets is a concern of all health care providers. Implementing a telehealth system however is necessary to meet the health needs of patients and communities and not primarily for the purpose of saving money. Further, this may be an area in which the initial expenditures associated with setting up a service may outweigh short term cost savings. Financial benefits may take some time to be seen. Costs may be measured in several terms including: financial, social and health.

Let’s look at this issue of cost from the point of view of the health care provider and the patient.

The Health Care Provider

Costs:
· The purchase of equipment including computers, video equipment & transmission capability.
· Salary costs including:
1. Information Technology (IT) staff to provide services such as installation, maintenance and repairs. The costs of travel to the remote sites for installation and possibly for upgrades and maintenance issues.
2. Administration staff to coordinate booking appointments, arranging videoconferencing, responding to inquires, etc.
· Office space at main and remote sites. Equipment and supplies for Telehealth staff.
· Training
· The cost of the system access fee.
· Promotion of the service to increase confidence in the technology for patients & providers.

Possible Savings:
· Reduction in the number of MediVac or Air Ambulance trips.
· Reduction in the number of referrals to the main center.
· Using a prevention model, access can lead to the avoidance of more serious conditions.
· Health providers in remote areas gain more confidence through increased support. Further access to educational opportunities may encourage staff to stay longer avoiding staff turnover.

Other Considerations:
· The organization must be willing to develop policies and procedures around the technology.
· Ongoing evaluations will be needed to determine the effectiveness in enhancing health status.
· Information relating to confidentiality, information access and storage of information must be made available to the patient.

It is still important for health providers to provide face-to-face contact for patients in rural areas, rather than becoming solely dependent on technology. "Technology must not be used as a substitute for human resources, and maintaining a balance between state of the art technology (videoconferencing) and functional technology (telephone) should be the ultimate goal of using technology to enhance access to care in rural and remote areas" (Peddle, K. 2007. p. 611).

The Patient
Telehealth offers some cost saving opportunities for the patient as well as other social and health benefits. To fully review these, please refer to the case scenarios in the columns to the right.

The Composition of Teleconsultation

Teleconsultation is not just about technology. Teleconsultation requires the support and cooperation of the people and communities involved, in conjunction with expertise from telecommunications, health care, and information technology sectors.

Teleconsultation can be divided into three essential components:

1. People
The individuals participating in teleconsultation are primarily located at either a remote site/hospital or a major urban site/hospital. These individuals can include: health care providers, patients, researchers, and health administrators. Despite the need for advanced technology to deliver teleconsultation, namely videoconferencing, the users are the most important piece in the puzzle. Teleconsultation is in most cases a success, however several key factors can lead to an unsuccessful interaction. These elements may include: a lack of leadership, lack of coordination, a reluctance to change current practices by users and providers, and a failure to provide sufficient health information technology training to health care providers.

2. Telehealth Application Technology
The scope of teleconsultation applications is vast and ever changing with the continual introduction of new applications and technology. These technologies can be classified into three components: hardware, software and peripheral devices. Together they provide a means to receive, capture, process, display and store data, audio or video formats.

3. Telecommunications and Network Links
Between remote and main locations telephone systems, digital telephone lines, the internet and virtual private networks. Telecommunications technology networks provide the means to link sites and to transfer information from one site to another. Presently, telecommunications technology offers five standard media for transmitting information: copper wire, fibre optic cable, co-axial cable, satellite and microwave.

The Teleconsultation Process

In addition to the requirements listed above, when setting up a real time teleconsultation, there are key considerations that need to be addressed to ensure an optimal experience. The closer the teleconsultation process is able to simulate face-to-face interaction, the more positive the experience for both the clinician and the patient.

1. Placement of the Video Monitor

• Optimal position is with video monitors and cameras placed four feet in front of the patient and at eye level
• Clinician’s upper body should be fully visible
• Environment should foster comfort and trust by being clean, adequately lit and free from clutter
• Interactions should take place in a controlled environment to promote patient privacy (Jarvis-Selinger et al., 2008)
• Informed consent should include a discussion of possible limitations to patient confidentiality
• Patient requires an explanation of the equipment and procedures (Jarvis-Selinger et al., 2008)

2. Organizational challenges for the set up of teleconsultation systems

• Coordinating and scheduling various practitioners involved in virtual care
• Development of protocols for using the system
• Provision of training
• Availability and maintenance of equipment
• Clear roles, responsibilities and protocols will assist organization and avoid challenges associated with the set up and delivery of teleconsultation sessions
• User satisfaction and confidence with the system will be enhanced with efficient set up and use of teleconsultation systems

3. Eye contact

• Eye contact is a critical element in the development of a patient/clinician relationship
• Patients surveyed indicated that eye contact by the clinician was an important part of communication and interaction
• The better and more frequent the eye contact, the greater the participant satisfaction
• The closer you sit to the viewing screen, the larger the angle of eye gaze (see picture)
• The clinician looks directly at the monitor in order to assess the patient; however, the video camera is most often located on the top of the screen

(Source: Tam, T., Cafazzo, J.A., Seto, E., Salenieks, M.E. & Rossos, P.G.(2006). Perception of eye contact in video teleconsultation. Journal of Telemedicine and Telecare, 13(1), 38.)

The picture below illustrates how eye contact can be misdirected during teleconsultation. The first image displays the clinician looking at the camera, while in the second image the clinician is looking at the monitor.

Look at image (a). How would you describe the clinician?
Look at image (b). Does your impression change? Now how would you describe the clinician?

(Source: Tam, T., Cafazzo, J.A., Seto, E., Salenieks, M.E. & Rossos, P.G. (2006). Perception of eye contact in video teleconsultation. Journal of Telemedicine and Telecare, 13(1), 37. )

• Indirect eye contact can be perceived as a lack of interest in the patient and conversation.
• Participants described the clinician in image (b) as: reserved, shy, bored, untrustworthy and depressed (Tam et al., 2006).
• Improved eye contact can be attained by moving a distance away from the monitor.
• Ideally the camera should be placed in the centre of the screen to capture direct eye contact.
  

Roles and Responsibilities in Teleconsultation and Videoconferencing

Typical process is that information is sent to the health care provider prior to the session.


Therapeutic Clinician / Patient Relationship

The development of a therapeutic clinician / patient relationship can facilitate understanding and enhance information exchange. Information in a therapeutic relationship follows a pattern of collection of information followed by the interpretation and discussion of that information in order to arrive at a medical decision. Interaction through interpersonal communication is critical for interpretation, discussion and medical decision-making. The following sections will highlight special considerations related to the creation of a therapeutic clinician / patient relationship when using new technologies for teleconsultation.

Early investigations on the use of videoconferencing focused on the use of technology as a direct substitute for face to face communication. Technical system and software issues, led to blurred images and auditory limitations. As a result of technological advances, these system issues have taken a back seat and concerns have shifted to the development of a therapeutic clinician-patient relationship when using teleconsultation as a medium for health care.

Teleconsultation and interprofessional collaboration and professional development

The introduction of telemedicine produces changes in relationships between health care professionals (Nilsen & Moen, 2008). It facilitates knowledge transfer and enhances the quality of care that can be provided in rural centres.

Videoconferencing impacts how health care providers work together to meet the needs of patients.

Remote providers are positive and enthusiastic about the ability to connect with expert consultation in situations where immediate care is required. Videoconferencing offers the potential to reduce existing discrepancies between rural and urban service provision. Through teleconsultation and videoconferencing, remote practitioners are able to gain knowledge and experience allowing them to handle more complex situations and become less reliant on expert consultation (Weiner & Biondich, 2006).

During teleconsultation, care providers are able to share knowledge in order to facilitate effective medical decision making. Teleconsultation allows clinicians and specialists to consult and collaborate on cases. The consultant brings expert knowledge while the clinician seeking consultation often holds the context and patient specific information required for effective decision making.

Traditionally, clinicians and specialists organize their work as separate activities within their own communities (Nilsen & Moen, 2008). Labour between these practitioners is divided with patients moving between providers according to the complexity and severity of their medical issues. The use of teleconsultation technology promotes collaboration resulting in a shared understanding of the medical problem and potential interventions. Teleconsultation bridges gaps between service providers resulting in a seamless chain of treatment across organizational boundaries.

Unique communication skills required when using teleconsultation technologies

In relationship centred care the physicians seek to understand the patient’s perspective, be responsive to patient’s needs and involve patients (and families) in care decisions (shared responsibility). Physicians and patients work together in pursuing shared goals in health care with attention to both illness and personal experiences. Development of a meaningful clinician / patient relationship is dependant on the flow of both subjective and objective information through verbal, visual, emotional and tactile methods.

Physician centred communication is characterized by:

Closed ended questions, hypothesis testing to make a diagnosis, giving medical directions, controlling the interaction. This form of communication is often less successful in addressing patient needs or producing desired outcomes (Agha, Schapira, Laud, McNutt, & Roter, 2009).

Patient centred communication is characterized by:

Open ended questions, partnership building, shared decision making, information sharing, counselling, using statements of concern – agreement or approval (Agha et al., 2009). This form of communication is associated with higher patient satisfaction and improved patient outcomes (Dick, Filler, & Pavan, 1999).

Communication using teleconsultation can benefit and limit relationship focused communication patterns (Agha et al., 2009).

Benefits of teleconsultation to communication pattern

1. New technologies such as videoconferencing allow the flow of both verbal and some non verbal cues between participants
2. Use of teleconsultation can lower personal barriers
3. Interactions are less threatening or judgemental than being in same room with care provider

Limitations of teleconsultation to communication patterns

1. Trust in the IT system can erode the relationship
2. Quality of interaction – time delay in sound / eye contact
3. Design of IT system not conducive to patient interaction
4. Depersonalization of care
5. Lack of physical presence
6. Decreased non verbal communication
7. Inhibition of patient participation (comfort, sensory impairment)
8. Clinician dominance during the interaction

Techniques for enhancing the quality of communication using teleconsultation

• Clinicians require training in the use of IT systems in order to enhance relationship development.
• Clinicians need more training in communication using telemedicine technologies as well as training in communication of empathy using these technologies.
• The clinician needs to be competent and comfortable using the technology so that they may concentrate on the interview versus being distracted by the technology (Tyrrell, Couturier, Montani, & Franco, 2001).
• Given that each program is unique, training must be context-specific and designed to reflect the needs of to the community incorporating videoconferencing (Tyrrell et al., 2001).
• Experience and familiarity with teleconsultation as well as the existence of a past relationship with clinician are conducive to the development of a therapeutic clinician / patient relationship using videoconferencing technologies (Dick et al., 1999).
• Evidence suggests that patients and practitioners are able to quickly adjust to barriers related to teleconsultation and become readily accustomed to the new communication tools (Jarvis-Selinger, Chan, Payne, Plohman, & Ho, 2008).
  

Social Presence in Teleconsultation

Verbal and non verbal communication creates social presence. Social presence assists in developing relationships between patients and their care givers. Lack of verbal and non verbal cues decrease the perception of social presence. Decreased social presence can make people more self-centered and lead to decision making based on personalities rather than facts.

To learn more about social presence in teleconsultation and how it relates to the use of videoconferencing in the provision of care, click here.

Meeting the Users' Needs

Teleconsultation technology is often developed by experts in computers or engineering and lacks a consideration of a health care user in system design (Esser & Goosens, 2009). The health care setting is unique in its reliance on the development of therapeutic relationships between patients and clinicians. This relationship is dependent on both instrumental and affective communication between participants during the teleconsultation process. System designers need to consider the needs and perspectives of the patient as well as the health care professional during interactions (Weiner & Biondich, 2006).

In order to develop user centred systems, the designer must map the theoretical dimensions relevant to user centred teleconsultations.

The following elements are unique considerations related to the health care setting (Esser & Goosens, 2009).

• Background variables such as the individual, organizational, and technological context of the given interaction need to be understood to develop user friendly systems. The designer must appreciate how these interactions occur in traditional settings and which variables are most significant to patient / provider interactions.
• Health care interactions evolve around both instrumental and affective behaviours, so communication technologies must consider not merely the communication of information but rather have to consider how the information is perceived by the user.
• The designer must remember the purpose of the teleconsultation interaction and design technologies most likely to produce positive outcomes for the health care system and its users.
  
  

Patients' Satisfacation with Teleconsultation

Characteristics most determinant of patient satisfaction included perceived specialist comfort, concerns regarding privacy, and comfort with the camera (Dick, Filler, & Pavan, 1999).

Generally patients and families demonstrated a substantial level of comfort and satisfaction using videoconferencing that increased with experience using the new technologies (Dick et al., 1999).

Remote participants in teleconferencing activities generally experience more convenient access to care as well as a personal cost benefit by participating in videoconferencing verses face to face communication in an urban centre (Larcher et al., 2003).

Researchers have identified four domains for the assessment of patient satisfaction using teleconsultation technologies:

1. Assessment of physician’s use of patient centred communication.
2. Assessment of physician’s clinical competence and skills.
3. Assessment of physician interpersonal skills.
4. Assessment of convenience of visit

Teleconsultation in Rural Communities

Teleconsultation in Rural Communities

It has been recognized for some time that Canadians living in rural and remote communities have less access to health professionals and services. It has also been noted that despite having the same universal health coverage as other Canadians, people living in these areas consistently report lower health status. The population as a whole is becoming increasingly urban. According to the 2006 Census more than two-thirds of Canadians live in the country’s 33 largest cities, leaving approximately six million people living in small towns and rural areas (Martel, L. and Caro-Malenfant, E., 2006).

These six million people are spread across an enormous land mass and each area is unique; often having its own culture, language, and socio-economic struggles. It is a challenge to meet the health needs of these communities within the health budgets of each province. Telehealth is one strategy that holds promise in providing improved health care access for Canadians as well as support for professionals in smaller health facilities. The promise of telehealth is in its ability to link patients from across the country to family doctors, specialists and other health professionals. It allows patients to stay in their home communities longer avoiding or reducing the number of trips to larger centers. This means more time spent with support systems (family and friends), less stress from travel to unknown hospitals and locations and less time away from work. In a recent study on the impact of out-of–pocket costs on rural patients’ cancer care decisions the following conclusion was made. Rural residents are more likely than their urban counterparts to take costs related to travel, drugs and child care into account in their decisions about cancer treatment. Developing strategies to reduce financial costs for rural residents is essential to enhancing the accessibility of centralized specialist services such as cancer care (Matthew et al., 2009).

It is unlikely that specialized care will be offered “in person” in small rural communities. It is not cost effective or efficient to serve a small number of people spread over large distances. A specialist would have to devote too much time to travel, taking away clinic hours. Videoconferencing can allow a specialist to provide consultation and care to a patient without either of them having to leave home. In some of the more northern areas, communities are served by nursing staff and a visiting general practice physician. Without roads travel can be very weather dependent. Technology allows doctors to conduct a clinic even if s/he is unable to attend in person. Without this service a patient would have to wait until the doctor is scheduled to visit again or make the trip to a larger centre.

For the health professional in isolated areas, videoconferencing allows for a more thorough patient consultation and provides accessibility to ongoing educational opportunities, which would otherwise be too costly to participate in. This is a very important consideration in recruitment and retention.

Figure Source: 2006 Statistics Canada. Population Urban and Rural in Canada by Province and Territory.

Benefits of Teleconsultations to Rural Communities

The benefits of teleconsultation, namely the use of videoconferencing in rural communities is multifaceted.

The use of this medium in the provision of health care:

• Eliminates the barriers of distance and improves access to health services or information that may not be available in remote communities
• Plays an invaluable role in critical care situations where moving a patient may not be possible
• Facilitates access to specialist health services and support
• Provides patients with access to health information and advice from health care professionals in their homes, schools or community centres, enabling the public to be more active in their own health management
• Lessens the inconvenience and/or cost of patient transfer
• Eliminates the need for patients to incur financial burden to travel elsewhere for specialized care
• Reduces unnecessary travel time for health care professionals and improves the ability to recruit and retain health professionals
• Reduces remote practice isolation by enhancing physician, nurse and allied health professional access to colleagues and specialists (British Columbia Ministry of Health Planning, 2001).

Limitations to Teleconsultations in Rural Communities

Behavioral/Cultural

• Lack of 'hands-on' interaction with patients
• Lack of public awareness
• Fear that telehealth will limit communities' access to direct patient care by health professionals
• Inability to incorporate telehealth into practice
• Resistance from health consumers to use the technology

Financial

• Expensive connection make it hard to expand.
• Internet connection in remote communities is only available via satellite making it very expensive to deliver telehealth in all remote health centres.
• Lack of access to ongoing funding for maintaining the existing equipment and infrastructure

Technological

• Lack of modern telecommunications infrastructure and access to information and communication technologies (ICTs) for aboriginal remote communities
• Bandwidth challenges which limits access to the service
• Limited capacity of local health centres with access to telehealth technology

Legislative

• Privacy, security and confidentiality concerns.
• Variations and lack of consistency in developing a federal strategy for care provider reimbursement and program funding.
• Fear of malpractice suits is a consideration for many physicians, as is acceptance of the technology
• Concerns regarding informed consent, particularly in the care of mental health and Paediatric populations.
• Absence of policies and lack of provincial or national standards on use of telehealth
• Absence of a national universal e-health solution.

Human Resources

• Limited availability of health care professionals
• High turnover of rural staff who require training on the use of telehealth

Gustke S S, Balch D C, West V L, Rogers L O. (2000). Patient satisfaction with telemedicine. Telemedicine Journal, 6(1): 5-13. Retrieved from: http://tie.telemed.org/citations_t2.asp?citation=8249

Scott, R. E. (2007). Telehealth in Canada – been there, done that? Retrieved from: http://www.sct.scot.nhs.uk/documents/RichardEScott.ppt

Video on Alberta First Nations Telehealth Program (2.05 Mins)

This video, will provide a Canadian example of a telehealth system used for Aboriginal people in Alberta.

Click on the video to explore the objectives and outcomes of the program.

The Future of Teleconsultation

Newfoundland and Labrador is experimenting with a new form of teleconsultation that will revolutionize health care in the future.

Click on the video to learn more

Conclusion

Teleconsultation is an increasingly important part of telemedicine as advances in medical and technological continue to grow. This electronic medium may be used in medical care specialties ranging from cardiology, dermatology, and gynecology to psychiatry, trauma and wound care (Nerlich et al, 2002). Canada has an aging population, a vast geographic area, and a limited health care workforce. Teleconsultation programs provide effective and efficient health care services and equitable, fair and sustainable health care delivery for Canadians.

References

Please see slides for a list of references.
http://www.slideshare.net/suziemisk/references-3348592