The screen doctor
These days, you don’t even have to be in the same room for a doctor to listen to your heartbeat, writes Libby Wilson.
Ruth Large was a second-year doctor, in remote Australia, with a sick 18-month-old on her hands. The toddler was deteriorating rapidly, despite the best efforts of Large and a young GP.
‘‘It’s one of those horrible moments when you realise nothing’s going right,’’ Large said. ‘‘I had certainly never seen a baby that sick and I suspect that GP probably never had either.’’
The pair were in Doomadgee, an Aboriginal settlement in northern Queensland.
Large rang the Royal Flying Doctor Service but help was four to six hours away.
The child died before help arrived, and it got her thinking: surely, there must be a better way.
That sparked a passion for telehealth – providing healthcare remotely – and 20 years later she’s pushing for more of it at the Waikato District Health Board.
Doctors already use devices which allow them to hear heartbeats from another city, or look into ears and check moles from 100km away.
There are between 160 and 231 telehealth consultations a month across Waikato DHB, regional hospitals and the Midland region.
A Hamilton oncologist connected with 14 patients in Thames recently, which saved them 2504km of driving, a report by Large says.
Large is an emergency physician working between Waikato and Thames hospitals, and some have dubbed her ‘‘the virtual doctor’’.
She recently connected a stroke patient in Thames – where she was on her own in ED – to a Hamilton neurologist using a telehealth cart.
The neurologist talked to the patient, examined her, talked to her family, arranged and read the CT scan, Large said.
‘‘Meanwhile, I can do what he asks me to do, but I can actually see another two patients.’’
On another occasion, a patient arrived in Thames ED, losing a lot of blood from a leg wound.
The doctors were capable but hadn’t seen anything like it before, Large said, so they dialled in expert oversight from Hamilton.
Telehealth can also save patient travel – a Taumarunui patient’s skin infection can be reviewed from 160km away or rural patients on home oxygen can have an annual review without lugging tanks to hospital and back.
It hasn’t all been good news on the telehealth front, though – Waikato DHB dropped a costly project linked to its disgraced former boss Nigel Murray. The Ministry of Health-bought Beam devices, a rolling combination of screen, camera and wheels designed to let a user roam a hospital remotely, were said to have broken down and been left to gather dust.
But the move toward bringing medical experts and patients together remotely in an always stretched sector contines.
Some distance care initiatives in NZ aren’t new, such as a radiologist remotely reading an X-ray, or getting over-thephone advice from Healthline.
National phone services got more than 634,000 calls in the year to June 2018, the Ministry of Health said.
And other medical professionals are using telehealth to tap into specialist expertise from larger hospitals.
In July, a sick one-year-old at Bay of Islands District Hospital got expert help from Whanga¯ rei through video conference.
The toddler had a GP, secondary care clinical team, intensive care specialists, and paediatrician involved – plus parents by the bed, too.
Video conferencing meant there was one conversation instead of a series of phonecalls, Northland DHB telehealth and mobility programme manager Roy Davidson said.
In the past, it would have been ‘‘one person calling one person, who then talks to another person, who disseminates information around the team’’.
The DHB plans to start dental therapy clinics at Kaitaia Hospital in the New Year, linking in a dentist 170km away in Whanga¯ rei Hospital.
Telehealth won’t work for every patient, Davidson said, and if a specialist doesn’t feel comfortable using it, they won’t.
In Invercargill, conferencing system Vidyo helped patients get a GP appointment in winter.
WellSouth Primary Health Network connected people who couldn’t otherwise be seen to Dunedin GPs, with the help of a nurse, chief information officer Kyle Forde said.
‘‘It went from two, three, four in a week to 35.’’
NZ is at a turning point with telehealth, Forde said, and his long-term vision is to deliver through a web browser, so patients don’t have to leave the house.
In a Central Otago winter, it could save a trip from Wanaka to Dunedin for a short appointment.
Telehealth will be essential, a Ministry of Health statement said, and it’s working on getting different providers’ systems to talk to each other.
As well as helping patients and health providers in remote areas, the technology could reduce the need for hospital transfers for aged care residents, give GPs easier access to second opinions, and more closely link hospital and community care.
Clinical staff can use it for specialist training or to hold meetings across several sites.
The ministry is working on a national directory of practitioners who can use telehealth, and collaborates with the Telehealth Leadership Group – a voluntary group chaired by Large.
However, it was recently criticised for spending $31,951 on five Beams – essentially iPads mounted on a Segway – which kept breaking down and were mothballed.
There were complaints of flat batteries, missed calls, and a potential hacking risk, Newshub reported.
The beams were for senior staff to use in meetings, instead of video conferencing, a statement from DirectorGeneral of Health Dr Ashley Bloomfield said.
Waikato DHB wanted to use the devices in a clinical setting, Bloomfield said in December, so ‘‘all of them have either been sent or are about to be sent to the DHB’’.
Large wondered if the ministry’s problems were more down to wifi than the Beams themselves – they can stall between networks if wifi isn’t seamless.
Telehealth is so new that there will be some failures, she said, so it’s important to be open about them and avoid repeating mistakes.
However, she has walked a Beam through the ED in Gisborne without problems, and was keen to start using them for meetings and move on to clinical use.
At a September Waikato District Health Board meeting, Large pushed for more telehealth investment and demonstrated by using Dougie to wheel Thames colleague Dr Erik McClain in.
The robot is like an iPad on a stick, she said, and is more person-like than a telehealth cart.
McClain – Thames Hospital medical officer – is another enthusiastic user who once digitally joined a patient’s family meeting despite being on leave.
‘‘We can call in from home, from our iPhone, from the middle of a stairwell. Doesn’t really matter. We can be there for the patient and staff needs,’’ he said.
Specialist doctors from Waikato – for infectious disease, general medicine, pulmonology – join ward rounds in Thames and ‘‘get that higher level of understanding, just through a robot’’.
Travel savings are big, as getting from Hamilton to Thames and back takes about three hours out of a doctor’s day, and it’s hard for patients too.
People in Whitianga travel hours each way, Thames Hospital nurse coordinator of oncology and haematology Fiona Sayer said, which means early starts for morning-only clinics.
‘‘Some of those people are young, they’re having to finish work, there’s childcare.’’
Patients waiting to hear their progress between treatments can have a video conference with haematologist instead of waiting for a face-to-face clinic.
Avoiding interruptions is really important, Sayer said, ‘‘especially to some patients, when they see chemo as their lifeline’’.
Sayer’s seen patients get bad news through video conference – for example, that they had just weeks to live.
People probably think that’s a horrible way to hear it, she said.
‘‘I thought, that beats getting it over the phone,’’ Sayer said. ‘‘You could see the [oncologist], the husband was there, there was time to ask those questions.’’
Virtual health at Waikato DHB had a setback when the Smart Health system championed by former boss Nigel Murray was ditched in April.
It connected people to doctors through a smartphone or computer and cost $16m, but didn’t attract enough users, and aspects are being investigated by the Auditor General.
‘‘When something of that nature happens, people get scared,’’ Large said. ‘‘I think we can very rapidly call things failures for the wrong reasons.’’
HealthTap was too expensive, she said, but an EY assessment gives a good steer on what to do next.
Nationally, some notes of caution have been sounded.
The Medical Council of NZ warns clinicians of ‘‘the inherent risks in providing treatment when a physical examination of the patient is not possible’’ and requires all providing telehealth to NZ-based patients to be registered here.
The council’s position statement mentions two disciplinary proceedings for UK doctors over telehealth consultations, but the council didn’t know of any in New Zealand.
And we need to work out how to share information from international providers such as Babylon, WellSouth’s Kyle Forde said.
Details of Kiwis’ consults don’t go to the usual GP unless the patient shares them, he said, and a small interaction could be significant for their health.
Telehealth works well when clinicians need to see a patient but not physically examine them, Waikato’s Large said.
Waikato uses it for about 30 per cent of speech language therapy consultations, and it could be good for mental health services.
Large and colleagues are developing a business case for virtual health, and expect to bring it back to a Waikato DHB meeting. Telehealth numbers
❚ 160 to 231: number of telehealth consultations a month across Waikato DHB, regional hospitals and the Midland region
❚ 2504km: patient travel saved by an oncology clinic for Thames patients, held by a doctor in Hamilton
❚ 60 per cent: Waikato DHB population who live in a rural area
❚ 30 per cent: number of Waikato’s speech language therapy appointments now done by telehealth
Source: Advancing Telehealth for Waikato DHB, Memorandum to the Board, 26 September 2018; Waikato DHB