TelemedicineA useful tool?

Dr John Milton, Consultant Forensic Psychiatrist

Rampton HospitalNottinghamshire Healthcare NHS Trust

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

Healthcare in secure settings

• Equity

• Safety• Safety

• Value for money

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

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

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”

Rampton’s patients

• 5 main directorates/services

• ~330 patients

18%

15%15%

37%18%

15%

Women PD

Peaks MH

LD

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%

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

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

Evaluation plan a priori

• Effectiveness

– Treatment analysis ie Telemed versus TAU

– Basic economic analysis

• Safety

– Any incidents related to telemedicine

• Patient experience

• Staff experience

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’

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

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

Trends in routine LOAs (2007-2012)

Trends in routine and emergency LOAs (pre- and post-telemedicine)

Data in context with Broadmoor & Ashworth Hospitals

Direct comparison difficult

1.Different healthcare model ie visiting health

specialists/consultants running internal ‘clinics’

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

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

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

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

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)

ThanksJohn.Milton@nottshc.nhs.uk

In memory of In memory of

Barbara Pryse

Former Modern Matron for Physical Healthcare,

Rampton Hospital