Delivering virtual health care a positive experience
Dr Michelle Downie, Southland Hospital General Physician and Endocrinologist, during a telehealth session.
Dr Michelle Downie has been using telehealth since the beginning of the pandemic last year and says delivering health care remotely has exceeded her expectations.
“I was initially unsure if I could do it successfully, but after a good six months of using telehealth consistently, I found there were only a couple of follow up patients who I really needed to see in-person subsequent to their remote consultation. I was surprised there was such a low proportion of people where I couldn’t do what I needed to do over a phone or video call.”
Dr Downie, a Southland Hospital General Physician and Endocrinologist, says the majority of feedback from patients has been “really positive”.
“Endocrinology is a specialty that is particularly suited to Telehealth. It works especially well with follow-up patients, as you usually know each other or have met before and are often just checking in to review treatment plans and test results.”
A follow-up consultation by telehealth also often means patients can be seen much earlier by their consultant than an in–person appointment and has the obvious advantage of reducing travel time for patients, she says. “Because we are based in Invercargill, it is such a big geographical catchment so it’s a lot of driving for people. For example, patients in Queenstown would previously make a four-hour round trip, potentially for just a 20-minute follow-up appointment.”
Using telehealth is a huge advantage for rural patients, as there’s no need to take a day off work or travel. “Even for those who live closer, most of them are happy to find a quiet room and take 20 to 30 minutes out of their work day for a video call, rather than the time it would take to get to the hospital, find a park, and sit in the waiting room until they get called up. This is what many patients tell me they appreciate the most.”
Dr Downie says telehealth has also changed the appointment model for clinicians, so it’s now more flexible and manageable to be able to fit into smaller blocks of time. Another advantage is the ability to include patient’s family members in the session. “This works really well via video conference, as they may have family who want to be involved in the appointment, but they live elsewhere in the country. It also means other health care providers can be involved in the call if they want to, which is great.”
Southland Hospital is also about to launch regional MDM telehealth clinics for patients with Type 1 Diabetes in Queenstown. This is just one example of attempts to further expand Telehealth services in the region.
The use of telehealth means less disruption to health care in general, regardless of lockdowns and current community restrictions. “An increasing amount of people are using video calls and video conferencing as it becomes more commonplace both in the workplace and socially,” says Dr Downie.
“We use a mixture of video and phone calls here. I think video calls work better than phone calls if you haven’t met someone before – after that we give the patient the choice. Roughly a third choose a video call and about two thirds are happy for a follow-up over the phone. Different people have varying degrees of comfort with technology, but it’s still surprising who chooses video sometimes. My mum is in her 70s and she capably uses and prefers video consultations.”
The main disadvantages of telehealth include not being able to physically examine patients, technology issues such as bad internet connection, and no reassurance from reception for patients in a virtual waiting room if the clinician is running late from another appointment.
Initial rapport building for new patients could also be a theoretical disadvantage, says Dr Downie. “It’s always better to meet in-person for the first time, but I think as you get more comfortable with using the technology, it’s possible to overcome that and still create a good initial patient-doctor rapport over video link. People are becoming more used to it and it gets easier and easier.”
Transforming the delivery of healthcare
The South Island Alliance Data & Digital Health Strategy 2020-2030 has officially been released.
The regionally-agreed living document is reviewed annually in response to emerging opportunities and priorities. It recognises the enormous potential of data and digital to drive change and transform the way healthcare is delivered.
The development of the Strategy was a collaborative effort from an extensive range of health professionals across the region, including clinicians, experts, analysts and developers, as well as consumers. Successful implementation of the Strategy will require support of the whole South Island system, by continuing to combine resources and work collectively.
In recognising this potential opportunity for change, the Strategy sets out to:
- Drive the South Island to realise the potential data and digital transformation in supporting improved outcomes from the individual and their family, whānau and caregivers.
- Provide a foundation for the South Island for the next 10 years, with an explicit expectation that this is a living document.
- Provide a reference point for what we do collective – when, how and with whom.
Gabe Rijpma, Independent Chair of the Information Services Service Level Alliance (ISSLA), says as the health system is strengthened and modernised for the future, the digital strategy further defines the path to take. “A system of care supported by digital ensures that we empower providers, and the people in their care, to have a positive experience.”
The South Island is moving from a set of digital improvement projects to a system of integrated outcomes, with clear objectives that digital will align to. “This is critically important as we move to increase accountability to make our health system better, by making the experience more predictable and participatory for patients trying to organise, coordinate and receive their care.”
Gabe says the transition to Health New Zealand is a positive step towards improving health for all New Zealanders, and the strategy reflects its purpose of better cohesion and cross-system collaboration. “The South Island health system has a long history of collaborating and working together, and the digital strategy leans in on how to improve our system of care and further amplify collaboration and decision making – exciting opportunities are ahead.”
Streamlining Service Delivery Across the South Island with ePharmacy
Some of the ePharmacy implementation team in Wairau: (From left) Eliza Hooper (Pharmacist), Sharon Elrick (Pharmacist), Helen Martin (Pharmacy Technician), Rachel Powell (Pharmacist), Abby Edwards (Pharmacy Technician), Liz Jones (Pharmacy Technician) and Caro Aberhart (Pharmacist).
An electronic pharmacy management solution is now live across the five South Island DHBs, enabling hospital pharmacy inventory to be managed within a single system, improving service delivery and saving time.
ePharmacy provides full inventory management, dispensing, compounding, and repacking functionality for hospital pharmacy services, and integrates with patient management systems, financial systems, and MedChart prescribing and administration software.
Developed in close consultation with hospital pharmacy expertise, ePharmacy replaces end-of-life software, WinDose. The upgrade will allow more efficient and productive ways of working, improved functionality and regional patient information sharing to pharmacy services.
Since August, all five DHBs are now using ePharmacy. For Nelson Marlborough DHB and West Coast DHB, the project involved ‘on-boarding’ to a Canterbury DHB hosted instance of ePharmacy, which was already live. The Southern DHB and South Canterbury DHB ePharmacy projects were configured separately and hosted by Southern DHB. Pharmacy workflows and business requirements were standardised and aligned across the regional instances.
Anna Mitchell, Regional ePharmacy Programme Specialist, says despite project delays due to Covid-19, the go-lives across the South Island went smoothly and are a credit to the dedication of the teams. “The project involved a real regional collaboration and I personally formed valuable working relationships with the project teams. It was nice to share the knowledge I gained with others and learn technical aspects of the software, and also learn how other DHB pharmacies work. The project teams worked really hard to configure the software, which involved setting up each medicine kept at their pharmacy, testing the software multiple times and implementing it on top of their regular work.”
Sonja van Alphen, Team Leader at Nelson Hospital Pharmacy, says the go-live transition was seamless and the new system provides multiple levels of functionality. “It’s a better, more collaborative way of working and it’s nice to know we are part of a wider, supportive community of ePharmacy users.”
Electronic Acp Solution Live Across The Region
News
09 Sep 2020
A digital solution designed to capture conversations around Advance Care Planning (ACP) has gone live across the South Island.
The ACP Progress Note provides a single, regional solution for clinicians to document and access important discussions with patients about their future health care planning and end-of-life wishes.
Canterbury Initiative ACP Facilitator Jane Goodwin says it’s a consistent way for clinicians to log those conversations, which can then be electronically shared securely. “Advance care planning conversations don’t always lead to a person creating or completing an ACPlan. So, the ACP Progress Note allows clinicians to document discussions in a consistent location that can be accessed by other health care staff across the sector.”
Canterbury DHB initially had a locally-developed version of electronic progress notes. The improved South Island version enables health care professionals using HealthOne and Health Connect South to record or document ACP conversation with the patient.
Conversations about what’s important to a person and their priorities for care if they become unwell are even more important in the current environment – especially if a person has underlying medical conditions, Jane says. “For example, a man with terminal melanoma was referred to our team for support to create his ACPlan. We used the ACP Progress Note to capture our phone conversations ahead of the home visit.
“Unfortunately, a couple of days before that appointment, he had a significant stroke and could no longer communicate his wishes. Discussions with his whānau and the information captured in the ACP Progress Note helped the medical team ensure his care aligned with his preferences.”
The ACP Progress Note was fast-tracked during the pandemic to include the newly-released national Serious Illness Conversations Guide (SICG), providing a consistent regional solution to the electronic capture of these important discussions – either as a free text electronic record or using the SICG template (embedded in ACP Progress Notes) to support the conversation. This could include discussions with critically ill patients during COVID-19 restrictions.
Helen Sawyer, Palliative Care Clinical Nurse Specialist at Southern DHB, says the tool provides a convenient way to document a conversation that couldn’t be formalised in any other way at the time. “It’s easy to use, find and read – so we can easily record discussions with our patients, that will contribute to the development of their ACPlan.”
Congratulations eHealth IT All Stars: Ryan Papps And Aleisha Whitehead
25 May 2020
Congratulations to the recently announced eHealth IT All Stars, not least to our own all-round superstars Ryan Papps and Aleisha Whitehead.
As part of the COVID-19 response, Ryan, a programme specialist with the South Island Alliance Programme Office (SIAPO), developed a daily ICU dashboard for South Island DHBs and infographic summary of the national COVID-19 picture.
The dashboard is largely an extension of the regional ICU capacity dashboard established last year but includes additional information not consistently available electronically across all sites (such as ventilated, isolated or high acuity patients, as well as staffing levels). Ryan had been working with the regional ICU group since July 2019 and his relationships with key stakeholders and the trust he had developed were critical in getting manual data entered every day to complete the dashboard.
Ryan also set up an infographic summary of the national COVID-19 picture (example below), with an additional focus on South Island information. This was initially included in the daily ICU updates but quickly gathered a larger audience as a ‘one-pager’ of useful information covering the national picture.
Ryan was nominated as an eHealth IT All Star by Janice Donaldson, on behalf of the South Island ICU Project Group. Aleisha, portfolio quality assurance lead at SIAPO, was also acknowledged for the support she provided to the SIAPO team during the COVID-19 response. The team needed the ability to facilitate meetings, collaborate and communicate effectively from their homes all over the South Island. For consistency and ease of use, Microsoft Teams was chosen as the single solution for all Alliance meetings.
While working remotely and facilitating virtual meetings was familiar to some, there was still a lot of technical support required get the whole team up and running. Aleisha’s time, patience and perseverance in this area was invaluable. Aleisha was nominated by Mark Leggett, SIAPO General Manager.
Ryan’s daily Covid-19 infographic
Telehealth Takes Off In The South Island
News
23 May 2020
Dr Peter McIlroy, lead paediatrician at Nelson Hospital.
The rapid growth of telehealth in response to COVID-19 has given clinicians across the South Island increased confidence to continue offering online care as part of their toolkit.
Dr Peter McIlroy, lead paediatrician at Nelson Hospital, says a swift expansion of equipment enabled a range of clinical services to be carried out during lockdown via Zoom – cloud-based video-conferencing technology – such as assessments, consultations and clinical meetings. Nelson Marlborough DHB went from an average of 13 telehealth consultations per week, to 766.
One of the many successful services included a virtual paediatric diabetes multi-disciplinary clinic, he says. “We linked with a dietician who was based at home, as well as a diabetes nurse educator and myself in separate rooms at the hospital, connecting with multiple families in their home environment. The ease of use and the experience of all being in a virtual room together worked very well. While we couldn’t carry out finger-prick tests, we could do everything else, as well as use ‘screen sharing’ to provide relevant information. The families could show us their child’s results, which we then discussed in real-time. The experience exceeded my expectations.”
However, to ensure ease of access and a consistent, seamless process for both staff and families, Dr McIlroy says more work needs to be done. “It wasn’t always smooth sailing, as it also highlighted the digital divide – some vulnerable families may have less access to technology and data requirements, and there also needs to be a good process of teaching them how to use it. It has significantly increased the workload for clerical staff as the administration software is not currently designed to fully support virtual appointments – but that can change.”
Smart device technology was already being used across a wide range of services in the South Island and a new strategy to improve and expand telehealth services was agreed upon by the five South Island DHBs in 2019. As part of the strategy, recruitment is underway for a telehealth regional programme facilitator.
The advantages of telehealth are encouraging, says Dr McIlroy, such as less travel time, less stress of dealing with traffic and finding a car park, and it also provides more flexibility to find a suitable appointment time, outside of the clinical structure. “Children are a lot more relaxed when they’re at home, especially those with behavioural difficulties who find it stressful coming into hospital. The downsides are, it’s harder to observe the child, how they interact, and of course you can’t physically examine them. I do feel it’s more suited to follow-up appointments rather than the first, because you’ve already built that trusting therapeutic relationship. But going forward, we’ll definitely be offering all families the option of either an in-person or a telehealth appointment.”
Canterbury DHB clinical manager Bronwyn Suzana says while some clinicians had trialled the use of telehealth with clients who live outside of Christchurch, COVID-19 prompted a huge upskill amongst staff. “Prior to COVID-19, we had been looking at different ways we could provide expertise around stroke rehabilitation. So, this situation really made things happen faster and enabled us to increase our skills very quickly. Now, 100 percent of our staff are competent and confident in using telehealth.”
The Community Stroke Rehab Service moved to providing most of their assessment and intervention via telehealth during lockdown. The team also trialled new initiatives and developed several online stroke rehabilitation groups. One of the staff physiotherapists has been leading virtual Pilates classes from home. “It was an option to get everyone together at the same time,” says Bronwyn. “Travelling can be quite difficult for people who have had recent strokes, and meeting virtually also provided opportunities for interaction with others.”
She says while telehealth has its limitations, it provides a convenient option, especially those who live rurally. “It could also help increase the potential frequency of visits. It doesn’t replace meeting in-person, but it could change how often you see your clients and provide choices as to how they receive rehabilitation. And we were pleasantly surprised at the number of people who were happy to use telehealth, across all ages and stages. They were really positive about interacting in that way during lockdown. As community teams, we are exploring the learning we’ve had during this time and what could work in the future.”
See more info about the telehealth regional programme facilitator role.
GP Uptake In E-ordering A Positive Outcome From Lockdown
Laura Anderson, Medical Laboratory Technician at MedLab South, Nelson.
Electronic ordering of lab tests has been available around the country for some time now, but the uptake from GPs has been relatively low in some regions.
With COVID-19 forcing the country into lockdown, and for many GPs – taking them online, e-ordering lab tests to support virtual consults saw significant uptake in the Nelson Marlborough district.
MedLab South Lab Manager Rebecca Brosnan says to have more GPs move to e-ordering and be able to continue providing their consults, albeit virtually, is one of the silver linings from the level 4 lockdown. “It’s good for GPs and a real win for us at MedLab South where we’ve seen great gains in efficiencies and in accuracy of data as a result of the increase in e-ordering,” says Rebecca.
Rebecca has been working closely with Clinical Information Systems Director Dr Bev Nicolls at Nelson Marlborough Health since April 2019 to get GPs and clinicians in the region to order their tests electronically through the e-ordering platform.
Rebecca says many were geared up to use e-ordering well before lockdown and initial uptake last year was encouraging, but only about 25% were actively using it in place of the traditional order form method. The traditional method of ordering tests requires a lot of manual data entry for lab staff, and in some cases with bulk test orders from clinicians, it presented a real challenge when the patient presented for their test.
GP and Clinical IS Director Dr Bev Nicolls says not only is the new e-ordering process saving significant time for the lab team, it is giving GPs much needed information and control.“When you’re handing a patient their lab test order details on paper, once they leave the room there’s no way to know if they’ve had the test, you can’t easily change the test order, nor can you see where the testing process is at. If they are using e-ordering, then they’ll have that information and that control,” says Dr Nicolls.
Like other e-referral systems, lab e-ordering is interfaced into a variety of practice management systems allowing GPs to request a test easily with relevant information available, get patient test results sooner, improve the patient experience at the testing centre, removal of double handling of information, improved accuracy, and freeing up resources in the lab.
Following level 4 lockdown restrictions, the lab saw an immediate jump to around 50% of the region’s GPs using e-ordering for lab tests, with many more who knew about it now requesting to access the platform soon after. With the support of MedLab South, GPs were provided with remote installs of the platform and online video training to learn how to use e-ordering. This brought the use of e-ordering from 25% to well over 80% in a matter of weeks. MedLab South are now rapidly trying to get all GPs and hospital clinicians to be using e-ordering to further build on the gains seen during the COVID-19 level 4 lockdown period.
Southern Community Lab Group CEO, Dr Peter Gootjes says much of the success of e-orders in the region can be attributed to the leadership of the clinical teams and lab staff. “The clinical leads have been highly engaged with the lab which allows us to continue innovating in the way we work together and the way we deliver services. That’s vital when we face a health crisis like COVID-19,” says Dr Gootjes.
MedLab South hopes to see e-ordering continue to have high-levels of use when GPs return to more in-person consults, as well as continue to see further uptake across general practice and hospital outpatients and the hospitals overall.
Planning For Our Shared Digital Future
The Alliance Training and South Island Data and Digital Health Strategy Workshop was held on 14 February.
As healthcare and information technology constantly evolves, reviewing new ways of working is an integral part of collaborating as an alliance.
The Alliance Training and South Island Data and Digital Health Strategy Workshop was held on 14 February in Christchurch, to refresh and upskill, reflect on the past and talk about how to face the challenges of our shared digital future.Attendees included Information Services Service Level Alliance (IS SLA) members, South Island CIOs, Clinical Informatics Leader, South Island Information Services Programme Leads, as well as South Island health professionals who are involved in regional Information Services alliance activity.
The morning session covered the history and principles of alliancing, how to participate in an alliance model, how to measure regional alliancing framework for large system transformation, as well as identifying ‘wicked’ problems faced regionally in an alliance framework. In the afternoon session, the South Island Data and Digital Health Strategy was discussed, with attendees working in groups to talk about ways to operationalise the strategic programmes, of innovation and transformation, empowering the healthcare workforce, data and insights, patient participation, and future of work.
Karl Rivett, Change Delivery Manager for IT at Southern DHB, says the workshop was a good opportunity to understand the purpose of the Alliance and to discuss implementation of the strategy. “Looking at the different compositions of resource (clinical, corporate, IT, public representation), what they need to consider and how they work going forward, is of great interest to me and the role that I have. It’s clear the world of healthcare is never standing still, so whether you experience it as a patient, clinician or supporting staff, we need to constantly consider how we best leverage new ways of working, solutions and processes – and that’s what working in an alliance can do for us.”
Dr Peter Gent, a GP in Dunedin, has been a member of the IS SLA for the past five years. He says the workshop was a useful opportunity to refresh knowledge of the Alliance structure. “One of the main benefits of the workshop was to talk about alliancing as a collaborative working method. It was also great to discuss the Information Services strategic plan with the wider members of the Alliance, not just the SLA.”
South Islands New Telestroke Service A Success At Lakes District Hospital
News
Elizabeth Hanan, of Dunedin, was Lakes District Hospital’s first stroke patient to recieve thrombolysis treatment via telehealth technology.
Elizabeth Hanan was just sitting down to dinner on Christmas Eve last year with family at their holiday home in Arrowtown, when her two daughters noticed her face looked lopsided and her speech was slurred.
Concerned their mother may have suffered from a stroke, an ambulance was called, and Mrs Hanan was admitted to Lakes District Hospital in Frankton. She then became the hospital’s first stroke patient to receive thrombolysis treatment via telehealth technology.
Lakes District Hospital implemented the South Island’s new telestroke service early December 2019, enabling neurologists and stroke specialists in Christchurch to provide advice and support via video link to doctors treating stroke patients in smaller centres and after hours.
The 82-year-old Dunedin resident was treated by Dr Jenny James in Frankton, who performed an examination with Christchurch neurologist Dr Teddy Wu, via video link to Christchurch. Mrs Hanan received ‘clot-busting’ thrombolysis treatment and was then flown by helicopter to Invercargill Hospital, due to bad weather in Dunedin. Two days later she was sent home to the acute stroke unit at Dunedin Hospital. She has since made a full recovery, with no residual symptoms.
Dr James says the entire telehealth process went very smoothly. “Having an expert there who can see the patient and their scan with his own eyes to decide on the treatment with you really gives you confidence. It also provides families with the reassurance that their loved one is getting the best care possible. Thankfully, Elizabeth’s family brought her in straight away, so the treatment was administered to her within three hours – which research shows has the biggest benefit following a stroke.”
Dr Susan Weggery was the lead clinician setting up the telestroke pathway in Queenstown. She says after the redevelopment of the hospital’s emergency department, the addition of a CT scanner meant they could now offer thrombolysis treatment. “Up until then, the standard policy for all patients who presented with a stroke would be flown by helicopter to Dunedin Hospital, bypassing Lakes District Hospital altogether. So, for the past few years, we have been more focused on rehabilitation services for stroke, rather than acute management.”
After liaising with a wide range of specialities and services to link the telehealth service to Queenstown, Dr Weggery hired actors and ran a series of comprehensive simulations with Dr Wu in Christchurch to practise using the dedicated video conferencing and CT image technology. “The simulations were a learning experience on both sides and helped us iron out any kinks. Setting up the service was a real collaborative effort and it’s fantastic that we got the first patient through and it went as smoothly as it should have. We really appreciate all the support we’ve had to help make the service happen.”
The South Island telestroke service helps to ensure smaller communities across the South Island can access the same 24/7 neurological expertise and care as city patients. Ideally, it will also lead to more South Islanders receiving the life-saving clot retrieval procedure, which is currently available only at Christchurch Hospital.Mrs Hanan is grateful for the service and feels lucky she had such a quick recovery, without the need for any post-stroke therapy. “Once you get to my age, you really need to be close to health services. I’m extremely lucky – I feel like I dodged a bullet.”
Faster Treatment For South Island Stroke Patients
From left: Dr Teddy Wu of Canterbury DHB, and West Coast DHB stroke physician Dr Daniel Salazar.
The South Island’s new telestroke service has been launched between the West Coast and Christchurch, giving more people faster access to potentially life-saving acute stroke treatment.
Using dedicated video-conferencing and CT image technology, the telestroke service enables neurologists and stroke specialists to provide advice and support via video link to doctors treating stroke patients in smaller centres and after hours.
Dr Teddy Wu, one of six neurologists at Christchurch Hospital, says the service has transformed stroke care. “This is real-time care – it’s like watching a movie and giving instructions. While we can’t touch the patient, we can ask the doctor to examine them on our behalf. Potentially, one of the key aspects is deciding whether we need to fly them to Christchurch Hospital for a clot removal procedure. What this means is, more people who experience paralysis from a major stroke will be able to walk out of hospital within a few days.”
Following the successful 2016 telestroke pilot between Wellington and four smaller centres, including Nelson and Wairau in the South Island, the Ministry of Health provided funding for the equipment and implementation costs for a similar service across the South Island. Through the South Island Alliance, the five South Island DHBs developed a hub-and-spoke model, comprising six ‘spoke’ hospitals (Grey Base, Timaru, Oamaru, Dunedin, Dunstan and Southland) supported by a ‘hub’ hospital (Christchurch). If a person presents to a ‘spoke’ hospital emergency department (ED) with a suspected stroke, the local ED team can notify an on-call neurologist or stroke specialist at Christchurch Hospital, who can then read the patient’s CT scan, provide advice and make a diagnosis.
The South Island telestroke service will help to ensure smaller communities can access the same 24/7 neurological expertise and care as city patients. Ideally, it will also lead to more South Islanders receiving the life-saving clot retrieval procedure, which is currently available only at Christchurch Hospital.Dr Wu anticipates the remainder of the South Island telestroke service will be linked up by the end of the year.
