Journal of Telemedicine and Telecare http://jtt.sagepub.com/
Case study: the Interact home telehealth project Owen Katalinic, Ashley Young and David Doolan J Telemed Telecare 2013 19: 418 DOI: 10.1177/1357633X13506513 The online version of this article can be found at: http://jtt.sagepub.com/content/19/7/418
Published by: http://www.sagepublications.com
Additional services and information for Journal of Telemedicine and Telecare can be found at: Email Alerts: http://jtt.sagepub.com/cgi/alerts Subscriptions: http://jtt.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> Version of Record - Nov 10, 2013 What is This?
Downloaded from jtt.sagepub.com at University Library Utrecht on May 24, 2014
RESEARCH/Original article Journal of Telemedicine and Telecare 19(7) 418–424 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1357633X13506513 jtt.sagepub.com
Case study: the Interact home telehealth project Owen Katalinic, Ashley Young and David Doolan
Summary Two home telehealth technologies (the Intel Health Guide and the Apple iPad) were trialled by four clinical services of the Hunter New England Local Health District. The iPad was selected by the Paediatric Palliative Care Service, the Stroke Service and the Brain Injury Rehabilitation Service. The Intel Health Guide was selected by the Cardiac Coaching Service. The telehealth devices were loaned to a total of 102 patients for different lengths of time, depending on clinical needs, but typically for about 3 months. A total of 42 clinicians were involved. During the trial, 16 technical problems were recorded and resolved, most concerning problems with connectivity. Nonetheless, the use of home telehealth technologies was positively received by clinicians, management and patients alike. Telehealth is now being integrated into the standard practices of the health district. Accepted: 24 August 2013
Introduction The Interact Home Telehealth Project was a sub-project of the Digital Regions Initiative,1 a joint venture between the Hunter New England Local Health District (HNELHD) and the Department of Broadband, Communication and the Digital Economy. Home telehealth was trialled for rural and remote patients in the HNELHD. The objectives were to improve access to services, self-management of health conditions and health education, and to reduce social isolation. The HNELHD provides services to a population of about 850,000 in an area of about 130,000 km2. The district has one major metropolitan centre (Newcastle / Lake Macquarie; population 310,000). The rest of the district contains regional and rural centres, and many remote communities.2 Supporting patients and clinical staff in rural communities by providing efficient access to specialist medical skills is a challenge. Conventionally this has been addressed either by providing remote telephone support, or by physically moving the patients to the specialists, or moving the specialists to the patients. The HNELHD therefore developed a telehealth strategy3 which outlined the use of telemedicine in four areas: critical care, ambulatory care, home based care and workforce support. The home telehealth project set out to answer the following questions: 1. Does the use of home telehealth improve access to services and clinical outcomes, particularly for people living in regional and rural areas? 2. Are videoconferencing and remote patient monitoring acceptable modalities that integrate well with established clinical services?
3. What are the relative advantages and disadvantages of the technologies used in the trial? 4. What does it take to implement and support the technology?
Methods The project was managed by the Clinical Systems Team, part of the Information Technology and Telecommunications Department. A total of 1.5 FTE Business Analysts were dedicated to the project and were responsible for governance, management, training, support, documentation and reporting. The project ran for one year (May 2012 to April 2013).
Technologies Equipment was selected based on: 1. The requirements of patients and clinicians 2. Usability of the device by patients 3. Integration with existing videoconferencing systems installed throughout the district
Clinical Systems Team, Information Technology and Telecommunications, Hunter New England Local Health District, New South Wales, Australia Corresponding author: Ashley Young, Clinical Systems Team, Information Technology and Telecommunications, 149 Turton Road, Waratah NSW 2298, Australia. Email: [email protected]
Downloaded from jtt.sagepub.com at University Library Utrecht on May 24, 2014
Katalinic et al.
419
4. New South Wales (NSW) health privacy and data protection policies. No single device met the differing requirements of the clinical teams. The two technologies that were trialled were: 1. Intel Health Guide (model PHS6000). The Intel Health Guide is a remote patient monitoring system that provides patients with interactive health sessions that can be personalized to their situation and condition. Other functions include viewing a variety of multimedia content and two-way video calling between a clinician and patient (Figure 1). 2. Apple iPad. The iPad is a tablet computer. It is capable of multi-media playback and recording, Internet browsing and email communication. Additional applications can be installed by the user through the App Store (Figure 2).
Following pilot testing, the project team perceived the benefits and disadvantages of the two devices as summarised in Table 1.
Device setup and workflow The telehealth devices were loaned to patients for different lengths of time, depending on clinical needs, but typically for about 3 months. All set-up and device management was provided by the clinical systems team. At the end of the loan period, the devices were cleaned and all data were removed from them. The devices were then prepared for new patients according to the requirements of the relevant clinical team. The types of clinicians using the devices, and the numbers of patients, are shown in Table 2.
Health Guide The Intel Health Guide was selected by the Cardiac Coaching Service. Customised protocols (decision-support pathways) were developed which were loaded into the Health Guide system. These included a mixture of locally developed videos and educational content, as well as other health questionnaires and guidelines that were targeted at the patient (see Figure 3). The health guide protocols were assigned to the patient on a weekly basis by the cardiac nurse and were paced according to the patient’s progress through the coaching process. Bodyweight, blood pressure and heart rate were collected routinely. The questionnaire responses and the physiological measurements were sent via the Internet and accessed through a web portal by the cardiac nurse. Clinical business analysts were trained by the vendor on the use and administration of the Health Guide system. The business analysts were then responsible for training clinicians and patients to use the system, as well as
Figure 1. Health Guide and blood pressure monitor.
installing the devices in the patients’ homes. An Internet connection was obtained either via the patient’s own broadband router or, in the absence of this, with a mobile broadband router owned by the HNELHD.
iPad To comply with the privacy and Internet safety policies of NSW Health, a mobile device management application4 was used to enforce security protocols and asset management. A third-party application5 was used to prevent access to inappropriate content from the Internet. The iPad was selected by three clinical groups: the Paediatric Palliative Care Service, the Stroke Service and the Brain Injury Rehabilitation Service. Prior to deployment, iPads were loaded with a range of apps and content that was deemed appropriate for the patient by the clinical teams. Apps were grouped into folders relevant to the impairment or therapy being targeted, for example, folders such as Communication, Dexterity, Memory, Cognition and Relaxation. On occasions, clinicians also created specific folders for their patients with apps that they felt would best suit the patient’s needs. Other content that was loaded included relevant videos and health and wellbeing factsheets.
Videoconferencing The Health Guide uses a proprietary videoconferencing system to establish a videoconference between patient and clinician. Calls can only be initiated from the clinician portal. The videoconferencing system does not integrate with other videoconferencing systems so other methods were sought to facilitate home-based videoconferencing. Videoconferencing between the iPad and HNELHD videoconferencing systems was achieved through a videoconferencing bridge (Scopia Radvision). This allowed relatively seamless and secure videoconferencing between devices that were internal and external to the HNELHD
Downloaded from jtt.sagepub.com at University Library Utrecht on May 24, 2014
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Journal of Telemedicine and Telecare 19(7)
Figure 2. Screenshot of the iPad as provided to patients of the Stroke Service.
Downloaded from jtt.sagepub.com at University Library Utrecht on May 24, 2014
Katalinic et al.
421
Table 1. Perceived advantages and disadvantages of the two technologies. Benefits
Disadvantages
Health Guide
Allows advanced remote monitoring of variables such as blood pressure, bodyweight, oxygen saturation Allows automatic triaging of patients according to their latest biometric readings and their answers to questionnaires Can use decision logic to customise the health care session for the patient
iPad
Advanced videoconferencing functionality (with the use of a third party Scopia app) Works over 3G networks (depending on coverage) Little setting up required High usability ratings Ability to use publicly available apps to assist in healthcare needs Different applications available through iTunes which may be more suitable for differing patients Mobility could allow device to be used in different environments
Videoconferencing unable to integrate with existing HNELHD systems Unable to use the device for any other purpose, apart from health education and remote monitoring Device must remain in a fixed location within a patient’s home and be connected through an ethernet cable Relatively time consuming to customise the decision logic Needs to be installed in the patient’s home by a trained installer Limited (if any) ability to remotely monitor patient biometric variables Complex licensing and application purchasing processes Difficulties with scaled or customised implementation using corporate-owned devices Possible increased likelihood of theft
firewall. The Apple iPad (using the Scopia V3 Mobile App) could then establish videoconferences with all HNELHD systems. Each iPad had the app loaded on the device and was pre-configured to use the Scopia bridge. Each iPad was assigned a virtual room that could be launched with the click of a single button from within the application. Other sites dialled into the virtual meeting room using a 6-digit meeting room number.
computer, then the team was able to load the videoconferencing software onto it at no cost. If patients also had a broadband Internet connection and a web-cam enabled device then videoconferencing could be performed after the installation of the Scopia application and dialling into a clinician’s virtual meeting room.
Satisfaction surveys
Patient training for the Health Guide proved to be relatively simple, although it involved the business analyst attending the patient’s home to install the device and train the patient. Setup took approximately 90 min at the patient’s home and device pick up approximately 30 min. Because of the large area covered by the HNELHD, driving times could be several hours in each direction. Some efficiencies were gained through combining installations in similar geographical areas within a single installation day. Nonetheless, installations required substantial resources, and would not be suitable for high-turnover situations. Patients using the iPad were shown how to use the device by their treating clinician and were provided with the loan device either on discharge home or in an outpatient setting. The degree of training varied depending on the number of apps being used and the condition of the patient. As each loaned iPad had a 3G/4G mobile broadband Internet connection, little setting up was required once the patient returned home. In some instances however, telephone based support was required to link the devices to the patient’s own (often more reliable) Internet connection for videoconferencing.
Staff and patients (by proxy) were asked to complete satisfaction surveys at the end of each videoconference or when deemed appropriate by the relevant clinical team as part of standard service improvement practice. The surveys were designed to assess the usability and usefulness of the videoconferencing and home telehealth devices, as well as any clinical advantages of using the technology.
Results A total of 102 patients participated in the project. The characteristics of the patients, teams and key results are summarised in Table 2. A key reason for using the iPad was to provide a lowcost method of home based videoconferencing. The capital cost of the iPad was approximately half that of the Health Guide. The recurrent monthly costs of the iPad were approximately one quarter of those of the Health Guide. Furthermore, if the patient or a family member already owned an iPad, Android device or personal
Training and support
Downloaded from jtt.sagepub.com at University Library Utrecht on May 24, 2014
Life limiting illness in children and adolescents Inpatient and community
Videoconferences for clinical review, case conferences and bereavement follow-up
Email, Internet search; socialisation apps; relaxation and mood apps; children’s movies; children’s e-books
Condition(s)
Primary use of the device
Secondary uses of the device
Service type
Apple iPad 14 6 (6) 64 6 Staff specialist; Occupational Therapist; Social Worker; Clinical Nurse Specialist
Paediatric Palliative Care Service
Device No. of patients Average age, years (SD) Patients living in Regional Area (%) No. of clinicians involved Clinician disciplines
Table 2. Results.
Inpatient, outpatient and community Speech Pathology applications (including Dragon Dictation, Pocket SLP Articulation and Language TherAppy) and Occupational Therapy applications (including Dexteria, Fruit Ninja and LetterReflex) Videoconferencing; camera, email, Internet search; socialisation apps; e-book reader
Apple iPad 39 67 (14) 62 25 Speech Pathologists; Occupational Therapists; Physiotherapists; Social Workers Moderate to severe stroke
Stroke Service
Community Health coaching and selfmanagement of chronic cardiac conditions
Lifestyle advice and information
Speech Pathology applications (including Proloquo2Go, Small Talk and Pocket SLP Articulation)
Case management; email; Internet search
Heart failure and cardiac disease
Brain and spinal cord injury Community
Intel Health Guide 28 66 (11) 96 3 Registered Nurse
Cardiac Coaching Service
Apple iPad 21 42 (17) 100 8 Speech Pathologists, Social Workers, Occupational Therapists
Brain Injury Rehabilitation Service
422 Journal of Telemedicine and Telecare 19(7)
Downloaded from jtt.sagepub.com at University Library Utrecht on May 24, 2014
Katalinic et al.
423
Figure 3. Protocol used for the cardiac coaching programme.
Technical problems A total of 16 technical problems were recorded and resolved during the project. The main problems were: 1. Intermittent corporate firewall outages, which affected all external Internet traffic, and therefore videoconferencing (n ¼ 8) 2. Latency during videoconferencing (causing delayed audio and video) when participants were in areas of patchy 3G Internet coverage (n ¼ 4) 3. System and integration bugs with the Scopia Radvision system, which caused intermittent connection problems. These were later resolved (n ¼ 3)
4. Internet bandwidth limitations at the patient end which sometimes caused videoconferencing to be unusable (n ¼ 1). One problem remained unresolved, concerning the difficulty in establishing videoconferences between the Intel Health Guide and corporate computers on the HNELHD network. Unfortunately this resulted in a fluctuating and relatively unstable experience.
Discussion The project was a feasibility study to investigate the use of two home telehealth technologies in a NSW Local Health
Downloaded from jtt.sagepub.com at University Library Utrecht on May 24, 2014
424
Journal of Telemedicine and Telecare 19(7)
District (LHD). A limitation of the project was that the clinical outcomes reported were weak, because control groups and outcome assessment blinding were not used. Therefore any results must be interpreted with caution. The main findings were: 1. Telehealth can play a useful role in improving access to services, particularly for those who live in rural areas. 2. Detailed planning and high-level support for telehealth is essential in establishing a framework for telehealth. 3. Rapid resolution of problems is essential in maintaining clinician engagement. 4. Both patients and clinicians readily accept and learn how to use new technologies, particularly where using them saves significant amounts of time. 5. Usability and ease of use are critical in ensuring the acceptance of the technologies. 6. The lack of broadband Internet in some regional and rural areas rules out the use of telehealth in those areas. 7. Internet bandwidth and latency plays a critical role in the quality and experience of the videoconference. 8. Latency and quality of videoconferencing over mobile broadband networks is highly variable, depending on the local signal strength. 9. Technical problems that affect the Wide Area Network can have serious effects on the delivery of home-based telehealth services. 10. Initial concerns that equipment would be lost or stolen from patient’s homes have proved unfounded. To date, there have been no losses of home telehealth equipment. 11. Age does not appear to be a barrier to using home telehealth technologies and videoconferencing technology. 12. The use of iPads for clinical therapeutic purposes has significant potential and is well accepted by clinicians and patients. This will continue to be explored.
While these findings may not be new, the project has allowed home telehealth to gain a strong foothold in the HNELHD amongst clinicians, management and the executive based on its ease of implementation and patient benefits. The roll out of the National Broadband Network in the district will further drive the introduction of home telehealth. In summary, the use of home telehealth technologies was positively received by clinicians, management and patients alike. An important outcome is that the LHD has funded the continuation of the programme on a permanent basis with the aim of integrating telehealth into the usual business process of clinical teams throughout the LHD. Acknowledgements The Interact Project was a joint funded venture between Hunter New England Local Health District and the Commonwealth Department of Broadband, Communication and the Digital Economy.
References 1. Department of Broadband, Communications and the Digital Economy. Chronic Disease Management for Regional and Rural Communities - Hunter New England. See http:// www.dbcde.gov.au/funding_and_programs/digital_regions_ initiative/chronic_disease_management_for_regional_and_ rural_communities_hunter_new_england (last checked 14 August 2013). 2. Australian Bureau of Statistics. National Regional Profile 2007-2011. See http://www.ausstats.abs.gov.au/ausstats/ nrpmaps.nsf/NEWþGmapPages/nationalþregionalþprofile (last checked 14 August 2013). 3. Hunter New England. HNE Health Telehealth Clinical Strategy 2010-2014. Available from Hunter New England Area Health Service. 4. Airwatch. Enterprise Mobility Management. See http:// www.air-watch.com/solutions (last checked 14 August 2013). 5. Mobicip. Mobile Web Filter for iPad. See http://www.mobicip. com/online_safety/ipad (last checked 17 August 2013).
Downloaded from jtt.sagepub.com at University Library Utrecht on May 24, 2014
Case study: the Interact home telehealth project Owen Katalinic, Ashley Young and David Doolan J Telemed Telecare 2013 19: 418 DOI: 10.1177/1357633X13506513 The online version of this article can be found at: http://jtt.sagepub.com/content/19/7/418
Published by: http://www.sagepublications.com
Additional services and information for Journal of Telemedicine and Telecare can be found at: Email Alerts: http://jtt.sagepub.com/cgi/alerts Subscriptions: http://jtt.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> Version of Record - Nov 10, 2013 What is This?
Downloaded from jtt.sagepub.com at University Library Utrecht on May 24, 2014
RESEARCH/Original article Journal of Telemedicine and Telecare 19(7) 418–424 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1357633X13506513 jtt.sagepub.com
Case study: the Interact home telehealth project Owen Katalinic, Ashley Young and David Doolan
Summary Two home telehealth technologies (the Intel Health Guide and the Apple iPad) were trialled by four clinical services of the Hunter New England Local Health District. The iPad was selected by the Paediatric Palliative Care Service, the Stroke Service and the Brain Injury Rehabilitation Service. The Intel Health Guide was selected by the Cardiac Coaching Service. The telehealth devices were loaned to a total of 102 patients for different lengths of time, depending on clinical needs, but typically for about 3 months. A total of 42 clinicians were involved. During the trial, 16 technical problems were recorded and resolved, most concerning problems with connectivity. Nonetheless, the use of home telehealth technologies was positively received by clinicians, management and patients alike. Telehealth is now being integrated into the standard practices of the health district. Accepted: 24 August 2013
Introduction The Interact Home Telehealth Project was a sub-project of the Digital Regions Initiative,1 a joint venture between the Hunter New England Local Health District (HNELHD) and the Department of Broadband, Communication and the Digital Economy. Home telehealth was trialled for rural and remote patients in the HNELHD. The objectives were to improve access to services, self-management of health conditions and health education, and to reduce social isolation. The HNELHD provides services to a population of about 850,000 in an area of about 130,000 km2. The district has one major metropolitan centre (Newcastle / Lake Macquarie; population 310,000). The rest of the district contains regional and rural centres, and many remote communities.2 Supporting patients and clinical staff in rural communities by providing efficient access to specialist medical skills is a challenge. Conventionally this has been addressed either by providing remote telephone support, or by physically moving the patients to the specialists, or moving the specialists to the patients. The HNELHD therefore developed a telehealth strategy3 which outlined the use of telemedicine in four areas: critical care, ambulatory care, home based care and workforce support. The home telehealth project set out to answer the following questions: 1. Does the use of home telehealth improve access to services and clinical outcomes, particularly for people living in regional and rural areas? 2. Are videoconferencing and remote patient monitoring acceptable modalities that integrate well with established clinical services?
3. What are the relative advantages and disadvantages of the technologies used in the trial? 4. What does it take to implement and support the technology?
Methods The project was managed by the Clinical Systems Team, part of the Information Technology and Telecommunications Department. A total of 1.5 FTE Business Analysts were dedicated to the project and were responsible for governance, management, training, support, documentation and reporting. The project ran for one year (May 2012 to April 2013).
Technologies Equipment was selected based on: 1. The requirements of patients and clinicians 2. Usability of the device by patients 3. Integration with existing videoconferencing systems installed throughout the district
Clinical Systems Team, Information Technology and Telecommunications, Hunter New England Local Health District, New South Wales, Australia Corresponding author: Ashley Young, Clinical Systems Team, Information Technology and Telecommunications, 149 Turton Road, Waratah NSW 2298, Australia. Email: [email protected]
Downloaded from jtt.sagepub.com at University Library Utrecht on May 24, 2014
Katalinic et al.
419
4. New South Wales (NSW) health privacy and data protection policies. No single device met the differing requirements of the clinical teams. The two technologies that were trialled were: 1. Intel Health Guide (model PHS6000). The Intel Health Guide is a remote patient monitoring system that provides patients with interactive health sessions that can be personalized to their situation and condition. Other functions include viewing a variety of multimedia content and two-way video calling between a clinician and patient (Figure 1). 2. Apple iPad. The iPad is a tablet computer. It is capable of multi-media playback and recording, Internet browsing and email communication. Additional applications can be installed by the user through the App Store (Figure 2).
Following pilot testing, the project team perceived the benefits and disadvantages of the two devices as summarised in Table 1.
Device setup and workflow The telehealth devices were loaned to patients for different lengths of time, depending on clinical needs, but typically for about 3 months. All set-up and device management was provided by the clinical systems team. At the end of the loan period, the devices were cleaned and all data were removed from them. The devices were then prepared for new patients according to the requirements of the relevant clinical team. The types of clinicians using the devices, and the numbers of patients, are shown in Table 2.
Health Guide The Intel Health Guide was selected by the Cardiac Coaching Service. Customised protocols (decision-support pathways) were developed which were loaded into the Health Guide system. These included a mixture of locally developed videos and educational content, as well as other health questionnaires and guidelines that were targeted at the patient (see Figure 3). The health guide protocols were assigned to the patient on a weekly basis by the cardiac nurse and were paced according to the patient’s progress through the coaching process. Bodyweight, blood pressure and heart rate were collected routinely. The questionnaire responses and the physiological measurements were sent via the Internet and accessed through a web portal by the cardiac nurse. Clinical business analysts were trained by the vendor on the use and administration of the Health Guide system. The business analysts were then responsible for training clinicians and patients to use the system, as well as
Figure 1. Health Guide and blood pressure monitor.
installing the devices in the patients’ homes. An Internet connection was obtained either via the patient’s own broadband router or, in the absence of this, with a mobile broadband router owned by the HNELHD.
iPad To comply with the privacy and Internet safety policies of NSW Health, a mobile device management application4 was used to enforce security protocols and asset management. A third-party application5 was used to prevent access to inappropriate content from the Internet. The iPad was selected by three clinical groups: the Paediatric Palliative Care Service, the Stroke Service and the Brain Injury Rehabilitation Service. Prior to deployment, iPads were loaded with a range of apps and content that was deemed appropriate for the patient by the clinical teams. Apps were grouped into folders relevant to the impairment or therapy being targeted, for example, folders such as Communication, Dexterity, Memory, Cognition and Relaxation. On occasions, clinicians also created specific folders for their patients with apps that they felt would best suit the patient’s needs. Other content that was loaded included relevant videos and health and wellbeing factsheets.
Videoconferencing The Health Guide uses a proprietary videoconferencing system to establish a videoconference between patient and clinician. Calls can only be initiated from the clinician portal. The videoconferencing system does not integrate with other videoconferencing systems so other methods were sought to facilitate home-based videoconferencing. Videoconferencing between the iPad and HNELHD videoconferencing systems was achieved through a videoconferencing bridge (Scopia Radvision). This allowed relatively seamless and secure videoconferencing between devices that were internal and external to the HNELHD
Downloaded from jtt.sagepub.com at University Library Utrecht on May 24, 2014
420
Journal of Telemedicine and Telecare 19(7)
Figure 2. Screenshot of the iPad as provided to patients of the Stroke Service.
Downloaded from jtt.sagepub.com at University Library Utrecht on May 24, 2014
Katalinic et al.
421
Table 1. Perceived advantages and disadvantages of the two technologies. Benefits
Disadvantages
Health Guide
Allows advanced remote monitoring of variables such as blood pressure, bodyweight, oxygen saturation Allows automatic triaging of patients according to their latest biometric readings and their answers to questionnaires Can use decision logic to customise the health care session for the patient
iPad
Advanced videoconferencing functionality (with the use of a third party Scopia app) Works over 3G networks (depending on coverage) Little setting up required High usability ratings Ability to use publicly available apps to assist in healthcare needs Different applications available through iTunes which may be more suitable for differing patients Mobility could allow device to be used in different environments
Videoconferencing unable to integrate with existing HNELHD systems Unable to use the device for any other purpose, apart from health education and remote monitoring Device must remain in a fixed location within a patient’s home and be connected through an ethernet cable Relatively time consuming to customise the decision logic Needs to be installed in the patient’s home by a trained installer Limited (if any) ability to remotely monitor patient biometric variables Complex licensing and application purchasing processes Difficulties with scaled or customised implementation using corporate-owned devices Possible increased likelihood of theft
firewall. The Apple iPad (using the Scopia V3 Mobile App) could then establish videoconferences with all HNELHD systems. Each iPad had the app loaded on the device and was pre-configured to use the Scopia bridge. Each iPad was assigned a virtual room that could be launched with the click of a single button from within the application. Other sites dialled into the virtual meeting room using a 6-digit meeting room number.
computer, then the team was able to load the videoconferencing software onto it at no cost. If patients also had a broadband Internet connection and a web-cam enabled device then videoconferencing could be performed after the installation of the Scopia application and dialling into a clinician’s virtual meeting room.
Satisfaction surveys
Patient training for the Health Guide proved to be relatively simple, although it involved the business analyst attending the patient’s home to install the device and train the patient. Setup took approximately 90 min at the patient’s home and device pick up approximately 30 min. Because of the large area covered by the HNELHD, driving times could be several hours in each direction. Some efficiencies were gained through combining installations in similar geographical areas within a single installation day. Nonetheless, installations required substantial resources, and would not be suitable for high-turnover situations. Patients using the iPad were shown how to use the device by their treating clinician and were provided with the loan device either on discharge home or in an outpatient setting. The degree of training varied depending on the number of apps being used and the condition of the patient. As each loaned iPad had a 3G/4G mobile broadband Internet connection, little setting up was required once the patient returned home. In some instances however, telephone based support was required to link the devices to the patient’s own (often more reliable) Internet connection for videoconferencing.
Staff and patients (by proxy) were asked to complete satisfaction surveys at the end of each videoconference or when deemed appropriate by the relevant clinical team as part of standard service improvement practice. The surveys were designed to assess the usability and usefulness of the videoconferencing and home telehealth devices, as well as any clinical advantages of using the technology.
Results A total of 102 patients participated in the project. The characteristics of the patients, teams and key results are summarised in Table 2. A key reason for using the iPad was to provide a lowcost method of home based videoconferencing. The capital cost of the iPad was approximately half that of the Health Guide. The recurrent monthly costs of the iPad were approximately one quarter of those of the Health Guide. Furthermore, if the patient or a family member already owned an iPad, Android device or personal
Training and support
Downloaded from jtt.sagepub.com at University Library Utrecht on May 24, 2014
Life limiting illness in children and adolescents Inpatient and community
Videoconferences for clinical review, case conferences and bereavement follow-up
Email, Internet search; socialisation apps; relaxation and mood apps; children’s movies; children’s e-books
Condition(s)
Primary use of the device
Secondary uses of the device
Service type
Apple iPad 14 6 (6) 64 6 Staff specialist; Occupational Therapist; Social Worker; Clinical Nurse Specialist
Paediatric Palliative Care Service
Device No. of patients Average age, years (SD) Patients living in Regional Area (%) No. of clinicians involved Clinician disciplines
Table 2. Results.
Inpatient, outpatient and community Speech Pathology applications (including Dragon Dictation, Pocket SLP Articulation and Language TherAppy) and Occupational Therapy applications (including Dexteria, Fruit Ninja and LetterReflex) Videoconferencing; camera, email, Internet search; socialisation apps; e-book reader
Apple iPad 39 67 (14) 62 25 Speech Pathologists; Occupational Therapists; Physiotherapists; Social Workers Moderate to severe stroke
Stroke Service
Community Health coaching and selfmanagement of chronic cardiac conditions
Lifestyle advice and information
Speech Pathology applications (including Proloquo2Go, Small Talk and Pocket SLP Articulation)
Case management; email; Internet search
Heart failure and cardiac disease
Brain and spinal cord injury Community
Intel Health Guide 28 66 (11) 96 3 Registered Nurse
Cardiac Coaching Service
Apple iPad 21 42 (17) 100 8 Speech Pathologists, Social Workers, Occupational Therapists
Brain Injury Rehabilitation Service
422 Journal of Telemedicine and Telecare 19(7)
Downloaded from jtt.sagepub.com at University Library Utrecht on May 24, 2014
Katalinic et al.
423
Figure 3. Protocol used for the cardiac coaching programme.
Technical problems A total of 16 technical problems were recorded and resolved during the project. The main problems were: 1. Intermittent corporate firewall outages, which affected all external Internet traffic, and therefore videoconferencing (n ¼ 8) 2. Latency during videoconferencing (causing delayed audio and video) when participants were in areas of patchy 3G Internet coverage (n ¼ 4) 3. System and integration bugs with the Scopia Radvision system, which caused intermittent connection problems. These were later resolved (n ¼ 3)
4. Internet bandwidth limitations at the patient end which sometimes caused videoconferencing to be unusable (n ¼ 1). One problem remained unresolved, concerning the difficulty in establishing videoconferences between the Intel Health Guide and corporate computers on the HNELHD network. Unfortunately this resulted in a fluctuating and relatively unstable experience.
Discussion The project was a feasibility study to investigate the use of two home telehealth technologies in a NSW Local Health
Downloaded from jtt.sagepub.com at University Library Utrecht on May 24, 2014
424
Journal of Telemedicine and Telecare 19(7)
District (LHD). A limitation of the project was that the clinical outcomes reported were weak, because control groups and outcome assessment blinding were not used. Therefore any results must be interpreted with caution. The main findings were: 1. Telehealth can play a useful role in improving access to services, particularly for those who live in rural areas. 2. Detailed planning and high-level support for telehealth is essential in establishing a framework for telehealth. 3. Rapid resolution of problems is essential in maintaining clinician engagement. 4. Both patients and clinicians readily accept and learn how to use new technologies, particularly where using them saves significant amounts of time. 5. Usability and ease of use are critical in ensuring the acceptance of the technologies. 6. The lack of broadband Internet in some regional and rural areas rules out the use of telehealth in those areas. 7. Internet bandwidth and latency plays a critical role in the quality and experience of the videoconference. 8. Latency and quality of videoconferencing over mobile broadband networks is highly variable, depending on the local signal strength. 9. Technical problems that affect the Wide Area Network can have serious effects on the delivery of home-based telehealth services. 10. Initial concerns that equipment would be lost or stolen from patient’s homes have proved unfounded. To date, there have been no losses of home telehealth equipment. 11. Age does not appear to be a barrier to using home telehealth technologies and videoconferencing technology. 12. The use of iPads for clinical therapeutic purposes has significant potential and is well accepted by clinicians and patients. This will continue to be explored.
While these findings may not be new, the project has allowed home telehealth to gain a strong foothold in the HNELHD amongst clinicians, management and the executive based on its ease of implementation and patient benefits. The roll out of the National Broadband Network in the district will further drive the introduction of home telehealth. In summary, the use of home telehealth technologies was positively received by clinicians, management and patients alike. An important outcome is that the LHD has funded the continuation of the programme on a permanent basis with the aim of integrating telehealth into the usual business process of clinical teams throughout the LHD. Acknowledgements The Interact Project was a joint funded venture between Hunter New England Local Health District and the Commonwealth Department of Broadband, Communication and the Digital Economy.
References 1. Department of Broadband, Communications and the Digital Economy. Chronic Disease Management for Regional and Rural Communities - Hunter New England. See http:// www.dbcde.gov.au/funding_and_programs/digital_regions_ initiative/chronic_disease_management_for_regional_and_ rural_communities_hunter_new_england (last checked 14 August 2013). 2. Australian Bureau of Statistics. National Regional Profile 2007-2011. See http://www.ausstats.abs.gov.au/ausstats/ nrpmaps.nsf/NEWþGmapPages/nationalþregionalþprofile (last checked 14 August 2013). 3. Hunter New England. HNE Health Telehealth Clinical Strategy 2010-2014. Available from Hunter New England Area Health Service. 4. Airwatch. Enterprise Mobility Management. See http:// www.air-watch.com/solutions (last checked 14 August 2013). 5. Mobicip. Mobile Web Filter for iPad. See http://www.mobicip. com/online_safety/ipad (last checked 17 August 2013).
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