Teleconsultation in Remote Communities: 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.

DID YOU KNOW? Quick Canadian Rural Facts..

Approximately 95% of Canada's land mass is rural (Herbert, 2007)
Almost 30% of the Canadian population lived in rural communities in 2001 (Herbert, 2007).
The rural population increased by 10% since 2001. In 2006, just under one in five Canadians (six million people) lived in rural areas. (Herbert, 2007)
It is estimated that while approximately 30% of Canadians live in rural areas, only 17% of family physicians practice in such areas (Herbert 2007)
Nearly half (47%) of the territories population was living in one of the three capital cities in 2006. (Martel et Al, 2006)
By 2006, the population living in the territories surpassed 100,000 for the first time. (Martel et Al, 2006)
Rural Canadians are more likely to report being overweight or obese (having a body mass index of 25 or greater): 57% in the most rural areas as compared to 47% of urban Canadians. (CIHI 2006)

Sources:
CIHI (2006). Differences in health for rural and urban Canadians. Retrieved from http://www.cihi.ca/cihiweb/dispPage.jsp?cw_page=media_19sep2006_e
Herbert, Rebecca. (2007). Canada’s Health Care Challenge: Recongnizing and Addressing the Health Needs of Rural Canadians. NESA Program, University of Lethbridge, Alberta, Canada retrieved from: http://www.uleth.ca/dspace/bitstream/10133/495/1/Herbert.pdf
Martel, Laurent and Caro-Malenfant, Eric. (2006). Census: Portrait of the Canadian Population in 2006: Findings. Demography Division. Statistics Canada. Retrieved from:http://www12.statcan.ca/census-recensement/2006/as-sa/97-550/index-eng.cfm?CFID=349068&CFTOKEN=10648276

Case Scenario #1 - The Patient Perspective

Mary is a 42 year old woman living in Happy Valley–Goose Bay, who has just been diagnosed with breast cancer. She has been informed that she must travel to St. John’s for her initial visit with an oncologist. Depending on the recommendations of the specialist, Mary may be able to have treatment (which may include surgery and chemotherapy) locally.

Mary’s oncologist is willing to provide consultation and follow up via video conference with Mary and her family physician reducing her need to travel to every six months.

Mary is a mother of two teenage boys (ages 14 and 16) who play competitive hockey, and are very involved in drama. Her husband works in a mine and is away for six weeks and returns home for four. Mary works for the local health centre in the medical records department and has health insurance. Her older sister and brother both live in the same town as do most of her friends.

What are the financial, social/emotional and health considerations in Mary’s case? What benefit can telehealth & teleconsultation offer?

Financial:

The cost of travel is fairly high. There is currently one airline traveling this route and a return ticket costs approximately $1000.

The other cost considerations include accommodations, meals, and ground transportation. At home, cost considerations include time away from work (without sick leave this can be a financial burden), childcare, etc.

Teleconsultation would be of immense financial benefit for Mary. She would be able to remain in her home town for follow appointments and as a result, eliminate the cost of travel, inlcuding time away from work.

Social and Emotional:

A new diagnosis can be a time of high stress and a need for increased support. There can be a relief at being able to stay at home but there can be questions about quality of care. Are there quality of care risks involved in using this technology?

Health:

There is an opportunity for Mary’s family physician and a support person to be with her during the consultations. This improves the communication amongst the care team. Additionally, her local care team can learn from the specialist and continue to be actively involved in her care.

Case Scenario #2 - The Health Care Provider Perspective

Dean is a 32 year old family physician working in a rural health centre. He has a very busy workload due to staff shortages and high demand.

One of Dean's responsibilities is to travel to a small northern community (population approx. 500) once every six weeks to provide a clinic. This clinic is usually staffed by two full time regional nurses, two personal care attendants, a receptionist and two maintenance personnel.

In winter this community is accessible by airplane and snowmobile. During this scheduled visit he is unable to get to the community due to weather. His four day clinic is fully booked and he will be unable to return to this community for another six weeks. When the weather clears he may be able to fit some of the more serious cases into his regular schedule at the health centre. Although weather can sometimes have adverse effects on telecommunications as well as travel, the system usually has delays and can still be used. He has opted to use videoconferencing to see patients from his office.

What are the financial, social/emotional and health considerations in this case, both for Dean and the community serviced by the clinic he conducts?

Financial:

There may be no savings to the health care provider as this physician would have travelled on the chartered flight and stayed in accommodations in the clinic. Access to the telehealth system would add an additional cost however.

Social and Emotional:

As this is a physician would regularly travels to the community there would be more of an element of trust. There would be less stress from having the appointment cancelled until the next visit.

Health:

The patient could access health care directly with his/her doctor regardless of geography.

Why is trust important in Teleconsultation?

Using teleconsultation, individuals are exposed to new technology and processes that result in unfamiliar interactions between health care providers or providers and patients. Technology can alter an individual’s perceptions of verbal and non verbal cues from what is perceived in face to face interactions. Clinicians are co-dependent on assessments and interventions performed by their colleagues at the adjoining sites. In order for teleconsultation to be successful, individuals must trust in the technology and the skills of participants (Weiner & Biondich, 2006). A collaborative, trusting relationship leads to performance and behaviour changes resulting in more positive health outcomes for the patient (Paul & McDaniel, 2004).

Teleconsultation in Remote Communities

Welcome!

Types of Teleconsultation

Areas of Telehealth

Current Disciplines Using Teleconsultation

DID YOU KNOW? Quick Canadian Rural Facts..

Contributors

Have you personally had the opportunity to participate in a teleconsultation?

National Telehealth Services

Case Scenario #1 - The Patient Perspective

Case Scenario #2 - The Health Care Provider Perspective

Why is trust important in Teleconsultation?

Blog Evaluation & Test Your Knowledge Survey

Additional Resources and Useful Links