The Final Conference REMEDY

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The Final ConferenceREMEDY
Final conference REMEDY 11th of May 2005
European Union

• Welcome to Umeå!

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Programme
Final conference REMEDY 11th of May 2005
European Union

• SECOND SESSION
• Carelink, an organisation devoted to
  ITdevelopement
• What are the planes to exploit the remote
  consultation model in Finland
• Remote consultations in Diabetes treatment

• FIRST SESSION
• How to successfully implement a telemedicine
  service
• The REMEDY Guidelines
• The REMEDY Ethics
• Evaluation of the Migra training programme

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Final conference REMEDY 11th of May 2005REMEDY
Guidelines
European Union
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REMEDY GuidelinesDr. Eileen BrebnerUniversity
of Aberdeen

• The Importance of Setting and Evaluating
  Standards
• of
• Telemedicine Training

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If telemedicine is to be regarded as highly
professional then all health care professionals
should be appropriately trained in advance of
service establishment. (Brunel C. 1995)The
effectiveness of training is often ignored
(Cronin et al. 2001 Gul, Wan, Darzi 1999).
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All technology requires training. Simply
installing videoconferencing equipment in a
hospital or health centre, and leaving the
manufacturers manual nearby, is not sufficient
to encourage or maintain its use for telemedicine
(Bignault I, Kennedy C, 1999)
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The importance of appropriate training in the use
of videoconferencing technology, for clinical
purposes, is often underestimated when
telemedicine projects are established.
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General Aim of Project

• To develop, deliver and evaluate telemedicine
  user training programmes in Scotland, Sweden and
  Finland.

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Examples of user competencies

• Adjusting near end camera angle (pan tilt zoom)
• Adjusting near end brightness
• Making a call
• Adjusting the volume
• Use of picture in picture
• Use of mute button
• Controlling far end camera

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Examples of user competencies

• Saving a still image
• Viewing a saved image
• Use of document camera for clinical image and
  x-ray transmission
• Disconnecting a call

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Suggested Training Process

• Preparation of training booklet
• Construction of questionnaire
• Pilot study
• Modification to training/booklet/questionnaire
• Delivery of training programme
• Distribution of training booklets
• Distribution of questionnaires after training
• Analysis of data

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Conclusions

• A skills based, one to one, telemedicine user
  training programme can achieve high levels of
  user satisfaction.
• High levels of user competency can be achieved
  and maintained.

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Recommendations

• A skills based, one to one, telemedicine user
  training programme should be developed and
  delivered prior to the introduction of a
  teleclinical service.
• Required user competencies should be identified
  and utilised in the training programme.

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Recommendations (cont.)

• A specific training booklet should be developed
  and distributed to all students.
• Competency levels should be measured.
• Users require to have at least weekly practice to
  maintain skill levels.

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Electronic web-based Training ManualCurrently
under Construction

• Online Training Manual
• The following documents are available to download
  in Word format
• Guide to the Effective use of Videoconferencing
  for Teaching
• Glossary of Terms and Acronyms
• Conducting an Evaluation of a Training Programme
• Guidelines for Future Clinical Services
• Confidentiality, and Legal components of
  Telemedicine
• Ethics
• Basic Instructions for Conducting a
  Teleconsultation including Protoype manual Sony,
  Migra and Tandberg

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Funding Acknowledgements

• European Northern Periphery Programme Interreg
  111B

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Final conference REMEDY 11th of May 2005REMEDY
Ethics
European Union
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The REMEDY Guidelines-ethics The Importance of
focusing on ethical issues of telemedicine
Training Anita HelgessonDevelopement
ManagerSocial Welfare DepartmentVännäs
Municipality
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The presentation is structured as
follows Background -TSE- project ( Helgesson
et., al, 2005). - The Northern Periphery
Programme (NPP). - What we found after the TSE-
evaluation - Proceses in the REMEDY- ethics
work - The REMEDY Guidelines ethics - What we
have learnt
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Coordinated care planning for elderly patients
using videoconferencing

• A Helgesson1, U-B Johansson2, K
  Walther-Stenmark1, J Eriksson3, M Strömgren4
  and R Karlsson5
• 1 Social Welfare Department, Vännäs, Sweden
• 2 The Geriatric Centre, University Hospital of
  Northern Sweden,Umeå, Sweden
• 3 Vännäs Health Care Centre, Vännäs, Sweden
• 4 Spatial Modelling Centre (SMC), Kiruna, Sweden
• 5 Family Medicine, Department of Public Health
  and Clinical Medicine, Umeå University, Umeå,
  Sweden

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Objective

• To develop the transfer of information between
  different care providers in coordinated care
  planning by means of videoconferencing.

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Design

• The transfer of information between one hospital
  and one local health care centre/social welfare
  department was studied. Sessions were conducted
  by means of either videoconferencing or
  face-to-face conferencing.

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Setting

• Primary and municipal health care. Geriatric
  care at a University hospital.

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Main outcome measures

• Number of participating professional categories,
  time requirement, and quality of documentation
  during information transfer.

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Results

• The videoconferencing technique reduced the time
  required for each coordinated care planning
  session.
• There was an increase in the number of
  participating professional categories.

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• Use of a care planning report during the sessions
  resulted in an enhancement in the quality of
  documentation, which contributed to an
  improvement in the care following discharge.
• The technical problems that occurred did not
  detract from the beneficial experience of
  participating.
• Interviews with next of kin showed that they had
  been able to influence the content of the care
  during the care planning sessions.

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Conclusion

• The videoconferencing technique proved useful in
  coordinated care planning. It resulted in time
  saved due to reduced travel time, participation
  by more staff categories and an enhancement of
  the documentation quality.

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Experiences from the project Coordinated care
planning by means of the videoconferencing
technique showed

• Deficiencies in the organisation of training
  Deficiencies in communication Deficiencies in
  the conduct towards patients
• Deficiencies in professional stance
• Lack of ethical reflection

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The REMEDY- project 2002-2005

• INTREREG IIIB Northern Periphery Programme
• (Remote telematic solutions for patient diagnoses
  and the training of health care professionals in
  sparsely populated areas).

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Led by Vännäs municipality in collaboration with

• Vännäs health centre
• Geriatric centre at Umeå University hospital
• Geriatric department at Umeå University
• The Kainuu region in Finland (health care
  district and special services).
• Aberdeen University
• Highlands and Islands Health Research Institute
  in Inverness, Scotland

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Purpose

• To develop forms for skills enhancement in the
  use of telemedical equipment.
• To develop systematic methods for communication
  and information transfer.

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REMEDY ETHICS

• Hippocrates, also called
• The Father of the Art of healing stated in one
  of his writings approx. 2300 years ago
• sometimes cure
• often alleviate pain
• always provide comfort

• Today, in the year 2005
• Legal and ethical norms protect the individual
• Do no harm
• To allow self determination
• To do good
• To exercise justice

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REMEDY- ethics focusing on ethical issues
related to REMEDY

• The introduction of IT within healthcare and the
  care services makes it important to focus on
  ethics and ethical thinking and reasoning

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• Health care and the care services are
  responsible for the weakest and most vulnerable
  members of society.

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• Patients and members of the general public place
  increasing demands on the different healthcare
  professionals.

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• The concept of care comprises respect for human
  rights,
• including the right to life, dignity and to be
  treated with respect

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• How can theoretical ethical reasoning be
  transferred in clinical practice?
• An example

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• Ethical reflection in the area of telemedicine.

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Cross-professional team(30 persons) from three
care levels

• University hospital
• Health centre
• Municipal care and care services

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Organisation

• Persons with medical ethical responsibility
• Persons with responsibility for training
• Broadly based team from 3 care levels 30 persons
• Team responsible for analysis 3 persons
• Local evaluation 4 persons
• Scientific evaluation 3 persons
• Reference persons 5 persons
• Patients and next of kin

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Mapping of the factors affecting different levels

• During IT supported communication
• The coordinated care planning process

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Sender and receiver

• Preparation
• Implementation
• Reflection after the session
• Patient procedures
• Collaboration
• Managerial responsibility

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• Refinement of the completed mapping
• Linking of different processes
• Control process
• Clinical process
• Communication process

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• To develop a working method that takes account
  of ethics, approach to patients and professional
  stance.

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Preparation
Ethical approachThe Golden Rule don no harm
do good practiseFairnessAutonomyIntegrity

• Team planning for SVPL Co ordinated
  careplanning - Who takes part in the SVPL Co
  ordinated careplanning - What type of SVPL is
  to be carried out - Why was this type of SVPL
  chosen - Who is to inform the patient and
  his/her next of kid?
• Calling an SVPL for the purpose of preparing and
  approving a care plan
• Oral and written information - To the Patient
  - To Next of kin - To the Receiving Units
  Municipality and Primary care

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Implementation
Ethical approachThe Golden Rule don no harm
do good practiseFairnessAutonomyIntegrity

• Focus on the patient even when he/she is not
  present
• Technical arrangements
• The video conference
• Summary and reflection

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Post reflection
Ethical approachThe Golden Rule don no harm
do good practiseFairnessAutonomyIntegrity

• Feedback on the implementation
• Post connection

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Learning

• Encounters are characterised by mutual respect

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Learn how to talk to each other

• When you meet a friend in the street or square,
  let the spirit inside you move your lips and
  direct your tongue. Let the inner voice of your
  voice speak to the ear of his ear because his
  soul shall preserve your hearts truth in the
  same way as we recollect the taste of the wine
  long after the colour has been forgotten and the
  chalice gone (from the Prophet by Kahlil
  Gibran).

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Contact information

• Anita Helgesson Organizational developer in
  the Care Services Administration of Vännäs
  municipality, County Council of Västerbotten,
  Sweden
• anita.helgesson_at_vannas.se
• Address Drottninggatan 2, SE- 911 81 Vännäs,
  Sweden
• Phone[phone] Fax[phone]

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Final conference REMEDY 11th of May
2005Evaluation of the Migra training programme
European Union
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Evaluation of the Migra Training Programme

• Magnus Strömgren, Ph.D.

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Introduction

• As part of the REMEDY project, education about
  and training in using the videoconferencing
  equipment (Migra system) has been arranged
• The participants consisted of staff at the
  Geriatric Centre, NUS, Vännäs Health Care Centre,
  and the Municipality of Vännäs
• The education and training was evaluated by means
  of a questionnaire
• This presentation will summarize the key findings
  of the evaluation

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Structure

• The questionnaire
• Respondents
• Results
• Knowledge and competence acquired
• Education and training process
• Summary

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The Questionnaire
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The Questionnaire (2)

• Questions about
• Background of respondents (sex, age, etc.)
• The education and training process
• The knowledge and competence acquired
• Types of questions
• Possible answers Yes, Yes, partly, and No
• Open-ended questions

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Respondents

• About 60 filled-in questionnaires in total
• Some answers missing in some questionnaires
• Sex and age
• Sex
• Overwhelming majority females
• Age
• More gt25 years old compared to the younger age
  category

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Respondents (2)

• Workplace and profession
• Workplace
• Geriatric Centre (60)
• Municipality of Vännäs (30)
• Vännäs Health Care Centre (10)
• Profession
• Most common
• Nurse
• Assistant nurse
• Occupational therapist

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Knowledge and Competence

• Q Able to initiatate videoconference?
• Q Able to position camera?
• A majority think there should be a designated
  person handling the camera

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Knowledge and Competence (2)

• Age differences
• Q Able to initiate videoconference?
• When question is able to initiate
  videoconference/position camera using manual,
  knowledge is generally higher (not surprisingly)

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Knowledge and Competence (3)

• Q Problem with audio/video, know what to do?
• Q Problem with audio/video, know whom to
  contact?

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Knowledge and Competence (4)

• No major gender differences
• Differences between workplaces, but mainly due to
  varying age composition

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Education and Training (1)

• Q Have you been able to practice enough on your
  own after completed education?
• Q Time spent on training on your own?
• Few participants have spent more than 30 minutes
  training on their own
• Barriers
• Lack of time
• Lack of motivation
• Several comments suggesting scheduled time for
  self-training

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Education and Training (2)
Final conference REMEDY 11th of May
2005Evaluation of the Migra training programme
European Union

• Q Were there anything missing in the education?
• Most participants satisfied
• More training desirable

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Summary

• The majority of the participants have wholly or
  at least partly learnt how to initiate a
  videoconference and how to position the camera
• Knowledge is especially good in the younger age
  group
• A majority think there should be a designated
  person handling the camera
• Even though many are unsure about what to do in
  case of technical problems, most know whom to
  contact
• Overall, most participants are satisfied with the
  education and training process
• However, few were able to practice enough on
  their own after the education, above all due to
  time constraints

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Final conference REMEDY 11th of May 2005Remote
consultations in Diabetes Treatment
European Union
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REMOTE CONSULTATION IN DIABETES TREATMENT

• Jaana Korkiakoski, MD
• Olavi Timonen, MD, PhD
• Liisa Hiltunen, MD, PhD
• Sirkka Keinänen-Kiukaanniemi, MD, Professor
• University of Oulu, Department of Public Health
  and General Practice

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Background

• Incidence of diabetes is increasing
• The effect on national health and public economy
  longterm complications of diabetes
• Main responsibility of treatment public health
  care
• Economic recession and shortage of doctors

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Background (II)

• Quality and accessibility of care geographical
  differences
• Technical development has made it possible to
  find new ways of organizing health care

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Background (III)

• Research done by Olavi Timonen The
  teleconsultation in general practice.
• The study group consisted of two random groups of
  500 patients (traditionally treated groups and
  remotely treated group)
• The patients were equally satisfied and the
  transfer of information in teleconsultations was
  good enough to make reliable diagnoses
• Teleconsultation enables an efficient transfer of
  information and know-how regardless of distance

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Purpose of the study

• To develope a new method of treating diabetic
  patients in order to improve quality and
  accessibility of care in remote areas
• Re-assess the traditional roles of doctor/nurse
• Improving the work of the diabetes team
• Organizing services for diabetic patients

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Research objects

• Function of the technic
• Patient satisfaction questionnaires
• Evaluating the success of diabetes treatment
• Economical impact
• Evaluating the interaction between patient and
  the doctor

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Working method

• Registeries of diabetics were created
• Diabetics treated in the public health care were
  invited to participate the research programme
• Patients were treated by a team of the local
  nurses and the doctor from Oulu University

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Working method (II)

• The patient was with the nurse in the far end
  health care center and the doctor using
  videoconferency system in oulu university
• The doctor had an access to the patients
  electronic medical history and electronic x-ray
  database
• The diabetic nurse was specifically trained for
  diabetic issues as well as using videoconference
  system and also to help the doctor when physical
  examination was done

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Preliminary results

• Remote consultations four days and about 26
  hours per week
• In average 8 to 10 patients per day
• Patients first appointment took about 45 minutes
  and the follow-up visits 30 minutes
• Close to 2000 patient visits

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Preliminiary results (II)

• In general the technic has worked well
• Both the personnel and patiens have accepted the
  new working method well

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Preliminary laboratory data from Suomussalmi
municipality

• 402 diabetic patients 216 (53.7) were male and
  186 (46.3) were female
• Age range between 30 and 89
• Type two diabetics (T2D) 382 (95)
• HbA1c median when the last value taken between
  1998 and 2002 was taken into account was before
  the start of the research 7.6

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Preliminary laboratory data from Suomussalmi
municipality (II)

• The result of HbA1c was missing from 52 (12,9)
  diabetics
• 196 (48.8) diabetics were using statin
  medication and 170 (42.3) anti-thrombotic
  medication

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Preliminary laboratory data from Suomussalmi
municipality (III)

• 308 diabetic patients were treated using
  videoconference method
• Of that group the HbA1c median was in the
  beginning of the study 8.7 for type 1 diabetics
  (T1D) (n17) and 7.8 for type 2 diabetics (T2D)
  (n290)
• After 6 month the HbA1c median was 8.6 for T1D
  (n15) and 7.5 for T2D (n207)

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Preliminary laboratory results of Suomussalmi
municipality (IV)

• After 12 months the result of HbA1c was 8.1 for
  T1D (n13) and 7.0 (n175) for T2D
• After 18 months the result was 6.9 for T2D group
• Anti-thrombotic medication was started for 116
  (28.9) diabetics and statin medication for 38
  (9.5) patient

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Significance of the results

• Access and continuity of care have improved
• Glucose values improved in both groups
• Based on literature with more intensive care and
  improved results we can reduce the incidence of
  long-term complications of diabetes and cut down
  the rising costs of diabetes treatment

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Significance of the results (II)

• The information between team members is changed
  more effective common targets
• The importance of the learning process of the
  nurse

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Summary

• Short-term experiences of the new working method
  are good
• Based on these good results this working method
  is still in use in Kainuu area
• Thorough analysis of the costs etc. are still to
  be done
• Long-term follow-up and more research are still
  needed