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TelemedicineA useful tool?
Dr John Milton, Consultant Forensic Psychiatrist
Rampton HospitalNottinghamshire Healthcare NHS Trust
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What I will tell you…..
• why telemedicine at Rampton Hospital was safe, effective, well liked but had limited impactimpact
• why you can’t compare apples and pears
• why the solution might not be telemedicine but a different model of basic healthcare
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Healthcare in secure settings
• Equity
• Safety• Safety
• Value for money
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Background• 2010: Clinical Security Practice Forum
“Rampton has twice as many health-related Leave of
Absences (LOAs) as the other high secure hospitals”
– Issues: a) exposing public to risk– Issues: a) exposing public to risk
b) cost (‘average’ LOA is ~£700: 4 staff, lasting 3-4 hours)
• May 2011 – Apr 2012 Telemedicine pilot
CQUIN target to trial telemedicine intervention
to reduce health LOAs
• July 2012: evaluation completed
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Telemedicine• defined by the American Telemedicine Association as
“the use of medical information exchanged from one site to another via electronic communications to improve patients’ health status”
• separate, but related to, ‘telehealth’ used to encompass a broader • separate, but related to, ‘telehealth’ used to encompass a broader definition of remote healthcare that does not always involve direct clinical provision
• May offer several opportunities and potential efficiencies
– Improved access for some patients (such as prisoners or secure
hospital patients)
• Telemed examination by more senior clinician (consultant > junior)
– Reductions in travel time for both clinicians and patients
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Evidence for telemedicine?• Cochrane review (Currell et al, 2010)
• seven trials on over 800 patients concluded
- “feasible........but
- little evidence of clinical benefits. ....
- variable and inconclusive results for other outcomes such as
psychological measures.......
- no analysable data about the cost effectiveness of telemedicine
systems......
- need for further research ........
- policy makers should be cautious about recommending increased
use and investment in unevaluated technologies”
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Rampton’s patients
• 5 main directorates/services
• ~330 patients
18%
15%15%
37%18%
15%
Women PD
Peaks MH
LD
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Type of ‘Leave of Absence’ episodes (2007 and 2010) at Rampton Hospital
Type of LOA 2010 2007
Total 599 605
Hospital (Routine) 67% 59%Hospital (Routine) 67% 59%
Hospital (Emergency) 9% 5%
Court 6% 10%
Compassionate 1.5% 1.3%
Rehabilitation 9% 15%
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Rampton healthcare arrangements
• Routine– ward team nurses and speciality doctors
– primary care centre: GPs and some specialists eg podiatry, physio
– DGH hospital services (Bassetlaw) & tertiary services eg hepatitis
(Sheffield)
– Quarterly in-hospital neurology clinic (mainly for epilepsy patients)– Quarterly in-hospital neurology clinic (mainly for epilepsy patients)
– ECG reading service by a cardiologist in Nottingham
Additional context• Appointment of two advanced nursing practitioners
• Hand injury litigation
• Emergency (out of working hours)– Speciality doctors resident on-call
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Telemedicine trial• 1 May 2011 to 30 April 2012
• All patient physical health new referrals triaged by GPs
for suitability for telemedicine
• All existing hospital appointments also considered by • All existing hospital appointments also considered by
MDTs for telemedicine
• Contract with Airedale Hospital, established provider of
telemedicine services
• Project team incl GP, healthcentre staff, security, IT etc
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Evaluation plan a priori
• Effectiveness
– Treatment analysis ie Telemed versus TAU
– Basic economic analysis
• Safety
– Any incidents related to telemedicine
• Patient experience
• Staff experience
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Evaluation findings 1
• 425 (potential) LOAs in 12 months
– 24 telemedicine consultations (5.6% of total)• Dermatology 29%, Orthopaedics 18%, Neurology 11%
– 401 actual LOAs– 401 actual LOAs
• 341 routine, 60 emergency
– Reasons for unsuitability for telemed included
• Intervention-type investigation, trauma, pre-op
assessments and specialist clinic (eg oncology)
– Re-audit of LOAs confirmed their
‘appropriateness’
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Evaluation findings 2
• Effectiveness– Mainly anecdotal due to low numbers but
telemed no worse than TAU
• Safety• Safety– No adverse incidents related to telemedicine
• Patient experience– Telemedicine ‘good’ or ‘v good’
• Staff experience– Telemedicine ‘good’ or ‘v good’ v TAU
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Basic economic analysis
• Preliminary analysis
– Mean LOA cost ~£700
– 400 LOAs during 12 month pilot ~£280k
– 24 telemedicine consultations saved ~£17k
(minus set-up costs [£30k] and £200
consultation fee)
• Early figures suggest cost benefits not realised
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Trends in routine LOAs (2007-2012)
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Trends in routine and emergency LOAs (pre- and post-telemedicine)
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Data in context with Broadmoor & Ashworth Hospitals
Direct comparison difficult
1.Different healthcare model ie visiting health
specialists/consultants running internal ‘clinics’
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Specialists attending Ashworth Hospital (over 12 months)
Consultant No. of Patients No. of Consultations
Orthotist 3 3
Cardiologist 50 63
Audiologist 2 2
Neurologist 4 4
Infectious Diseases 8 9Infectious Diseases 8 9
Gastroenterologist 18 32
Surgeon 47 77
Orthopaedic Surgeon 6 6
Urologist 17 21
Endocrinologist 41 100
Opthalmologist 6 7
Haematologist 10 20
ENT Surgeon 4 4
TOTAL 216 348
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Data in context with Broadmoor & Ashworth Hospitals
Direct comparison difficult
1.Different healthcare model ie visiting health
specialists/consultants running internal ‘clinics’
2.Different investigation services available eg
Xray at Ashworth, visiting MRI at Broadmoor
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Data in context with Broadmoor & Ashworth Hospitals
Direct comparison difficult
1.Different healthcare model ie visiting health
specialists/consultants running internal ‘clinics’
2.Different investigation services available eg
Xray at Ashworth, visiting MRI at Broadmoor
3.Proportion of LOAs not vastly different when
comparing relevant hospital patient numbers
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Total number of LOAs between January 2012 and March 2012 for three high secure hospitals
Hospital
Number of health-related LOAs
Jan-Mar 2012 (% of total patients)
Total Number of Patients in Hospital
(in Dec 2011)
Ashworth 48 (23%) 208
Broadmoor 15 (7%) 201
Rampton 104 (32%) 322
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Summary & conclusions
1. Telemedicine appears safe, effective and well-liked but had limited impact on reducing LOAs, making up only 5% of specialist OPAs
2. There are now few ‘inappropriate’ LOAs due to triage by the health centre GPs (as part of a screening process for telemedicine)
3. Some clinical presentations & specialties more appropriate for telemedicine eg dermatology > surgical assessmentstelemedicine eg dermatology > surgical assessments
4. Current telemed format unlikely to realise significant cost savings
5. There may be more fruitful approaches to reducing the number of LOAs, adopting Ashworth and Broadmoor Hospitals model
– visiting consultant ‘clinics’ for high volume specialties (more cost
effective)
– considering the use of radiology facilities on site (esp for trauma)
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In memory of In memory of
Barbara Pryse
Former Modern Matron for Physical Healthcare,
Rampton Hospital