Telehealth is defined by the National Health IT Board as "the use of information and communication technologies to deliver healthcare when patients and care providers are not in the same physical location".
Telehealth is a broad term that can also include activities not directly relating to patients, such as providing education or training sessions and video conferencing for meetings.
There are 3 key areas within the broader telehealth space that are currently being developed: telemedicine, telemonitoring and mHealth (mobile health).
Telemedicine is "the use of telecommunication and information technologies in order to provide clinical health care at a distance". Within New Zealand, the most common types of telemedicine are Video conferencing and Store and forward. You can read more about each of these at NZ Telehealth Resource Centre.
Telemonitoring refers to "remotely collecting and sending patient data so that it can be interpreted and then contribute to the patient's ongoing management". One of the big advantages of telemonitoring is enabling patients to be at home or their usual place of residence, such as an aged care facility, while their healthcare team can monitor vitals such as blood pressure, heart rate or activity levels. It can also be used for alarm systems, such as fall detection and treatment adherence.
Telemetry takes this a step further and refers to collecting and sending data, such as heart rhythm monitoring, in real time.
mHealth (also known as mobile health) describes "the use of mobile communications technologies in medical and public health practice, including the delivery of health information, health services and healthy lifestyle support programmes" (NZ Telehealth Resource Centre). A number of devices can be used to deliver mHealth, ranging from smartphones to tablets and mobile sensors. Mobile communications technology enables additional functionality to be used, such as text messaging (SMS), mobile apps, mobile web browsing, video calling, MMS/pxt, QR code scanning and GPS location. The portability and popularity of mobile devices is obviously a major advantage and newer technologies will keep appearing as technology advances.
Key elements of telehealth
Data type: The type of data you use might be standalone video or audio, combined video and audio, text (eg, blood pressure, weight and symptoms), continuous monitoring streams, alarm signals or specialised recordings (eg, ECG and EEG).
Data transfer: Data transfer can take place in real-time (synchronous), where the patient is usually present, or on a store and forward basis (asynchronous), where the patient is not usually present.
Who it involves: Clinicians and patients, and patients’ family and whānau, are the main parties usually involved in a telehealth consultation. It is possible for a number of people to take part in video conferences. For example, a consultant might be with a medical student at one site, while a patient, members of their whānau and a rural nurse specialist are at another site.
The type of consultation: A number of different types of consultations can take place using telehealth. These include:
initial specialist assessment
follow-up appointments
discharge planning meetings
multidisciplinary team meetings
acute assessments
ward round
triage assessments
therapy/treatment appointments.
Scheduling the consultation: Planned consultations are usually scheduled ahead of time, with locations and equipment booked by both parties. Facilities likely to need to have urgent consultations, such as emergency departments, can quickly make the appropriate equipment available.
What are the benefits of telehealth?
For patients: Faster access to care and shorter wait times. Remote patients can remain close to home, making consultations more convenient and reducing travel.
DHBs: Fairer health system because of better access to care. More educational options for DHB staff via specialist video training.
Specialists/consultants: Less time spent travelling for consultations. Greater control over scheduling. Closer working relationship between specialists and primary care.
Aged care workers/nurses: Reduced need to transfer to older patients. Increased nurses' knowledge through more exposure to specialist consultations.
General practitioners: GPs who serve rural health facilities need to travel less frequently. Store and forward allows for accessible referrals and second opinions.
Allied health workers: Rehabilitation and physiotherapy can take place via video conference, meaning less time and budget spent on travel.
A “promising” new telehealth report shows a significant increase in the number of providers and services using telehealth for the delivery of clinical care.
However, ongoing barriers to uptake and silos of data and knowledge around telehealth means successful pilots have not always translated into business as usual services.
The 2019 Telehealth Survey updates one published four years ago and shows uptake has increased considerably across all 20 district health boards, with more than 1300 telehealth initiatives either active, in pilot or planned.
“Many organisations are turning to telehealth as they strive to improve the services they deliver,” the report says.
“However, uptake of telehealth often relies on local champions and although many barriers have improved (namely interconnectivity and cost) barriers such as lack of clear leadership and governance, difficulty circumnavigating funding models and access to devices and high-speed internet connections remain.”
Whangarei ICU's Dr Michael Whangarei ICU’s Dr Michael Kalkoff discusses a recent case with Kaitaia Hospital Senior Medical Officer Damian Marsh and Registered Nurse John Walker via RITA.Image credit:Northland DHB
Northland District Health Board has developed a new mobile telehealth cart and linked all of its rural hospitals (Kaitaia, Bay of Islands, Dargaville and, in 2020, Rawene) to the intensive care unit at Whangārei Hospital.
The Northland telehealth and mobility team developed this cart in conjunction with Northland DHB intensive care physicians, Connect NZ, healthAlliance and the University of Queensland Centre for Online Health.
The carts allow remote patient assessment and management in the acute clinical setting, enhance assistance and decision making for acute retrieval requests from rural hospitals, and provide Whangārei Hospital with an after-hours telestroke service.
The acute retrieval service is called RITA or Rapid Information Telehealth Assessment and uses Zoom videoconferencing from a computer workstation, tablet or cell phone enabling a much broader and more integrated communication network than previously.
The mobile carts are moved to the patient’s bedside and from there all other functionality is controlled at the ICU end, enabling rural hospital teams to be hands off with the technology and concentrate on their patient. The ICU end can control the call and functions of the two cameras. The second camera has a powerful zoom, which is also remotely controlled.
RITA enhances Whangārei ICU’s remote acute assessment capabilities to rural hospital emergency departments and wards, patient safety through direct rapid patient assessment, as well as advising on patient management of the acutely unwell patient. This includes assisting with decision-making in determining the safest way to transport the patient.
The Waikato DHB renal service covers the Waikato area but also from coast to coast all the way from Raglan on the west coast all the way to Gisborne on the east coast. A video conference solution is reducing the burden of travel for patients and providing more timely access to specialists.
Telehealth renal case study
(Mobile Health, NZ, 2017)
Nelson Marlborough telehealth video
Nelson Marlborough Health is aiming to increase the use of Virtual health clinic clinical consultations to avoid the stress and travel for patients associated with attending appointments in person.
Some clinicians talk about their experiences using telehealth.
Effect of telehealth extended care for maintenance of weight loss in rural US communities
This article evaluates the effectiveness of extended care programs for obesity management delivered remotely in rural communities through the US Cooperative Extension System.
Michael G. Perri et al. Abstract JAMA Netw Open. 2020;3(6):e206764.
Managing patients with chronic pain during the COVID-19 outbreak: considerations for the rapid introduction of remotely supported (eHealth) pain management services
This review examines the use of telemedicine approaches in the management of pain among chronic pain patients during the COVID-19 pandemic.
Eccelston C et al. Abstract Pain 2020;161:889-893.
The effect of augmented speech-language therapy delivered by telerehabilitation on poststroke aphasia – a pilot randomized controlled trial
This pilot trial tested the use of 5 hours of speech-language telerehabilitation per week in addition to usual care in patients with post-stroke aphasia, and found no difference between telerehabilitation and usual care groups in naming or auditory comprehension assessed.
Øra HP et al. Abstract Clin Rehabil. 2020;34(3):369-381.
Telehealth for global emergencies: Implications for coronavirus disease 2019 (COVID-19)
This paper discusses the reasons that telehealth is not a routine part of healthcare systems and identifies strategies to ensure that it becomes a part of regular acute, post-acute and emergency service delivery alongside conventional methods.
Smith AC et al. Abstract J Telemed Telecare. 2020; Mar 20.
Digitally enabled aged care and neurological rehabilitation to enhance outcomes with Activity and MObility UsiNg Technology (AMOUNT) in Australia: A randomised controlled trial
This Australian, multicentre, outcome-assessor-blinded, parallel-group randomised trial examined the use of digital devices, individually prescribed by a physiotherapist to target mobility and physical activity problems and/or usual care among people with limited mobility admitted to aged care and neurological rehabilitation.
Hassett L et al. Abstract PLoS Med 2020;17(2):e1003029.
Digital transformation in the era of COVID-19: Health Informatics NZ (HiNZ) webinar
Health Informatics NZ has produced a free webinar series on topics relevant to digital transformation in the era of COVID-19.
The benefits, challenges and learnings of telehealth in rehabilitation practice: NZ Rehabilitation Association webinar
The NZ Rehabilitation Association (NZRA) hosted a presentation series so that rehabilitation providers and people with lived experience could share their experiences of transitioning to telepractice in the current context.
Plan how to include whānau and support people when appropriate.
Consider equipment and technology requirements for video and telephone consultations. See the NZ Telehealth Forum & Resource Centre. • Talk to your practice manager to ensure your technology meets your telehealth needs. • Understand privacy implications and regulatory standards as they apply to communications technology used for telehealth services. • Review communication systems.
Clinical appropriateness
Telehealth is more likely to be appropriate if:
the patient is known to the general practitioner
it is a follow‑up consultation
it is for managing chronic disease.
Telehealth is unlikely to be appropriate:
for undifferentiated urgent care
when an examination or a procedure is needed
when a lack of technical confidence or co-morbidities (e.g., confusion) affect the patient's ability to use technology (unless relatives are available to help).
Telehealth consultations have been enabled by the Accident Compensation Corporation (ACC) and Work and Income New Zealand (WINZ) when meeting the criteria during the COVID‑19 pandemic.
Management
Prepare for the telehealth consultation: • Set up the consultation in a private place where you will not be overheard or interrupted (especially if consulting from home). • Ensure access to the patient record (ideally a second screen if using computer video). • Arrange interpreter services, if required. • Disable caller ID from your phone, if applicable. • Before any videoconference: ◊ Test audio visual quality and camera position. ◊ Reduce background sounds and check lighting.
Send the patient clear instructions about the telehealth consultation:
Once connected: • Check communications – optimise the technology set up. • Create a safe environment through clear and respectful identification of the people at both ends of the consultation. ◊ Confirm their location, and whether the patient is using a speaker‑phone. ◊ Seek further identify verification if necessary. • Gain consent and confirm confidentiality. • Acknowledge the difference between telehealth and an in‑person assessment. • Advise about the telehealth consultation fees.
Take a history, using telehealth tips.
Examine the patient. • Observations • Patient‑provided readings, when appropriate, if the patient has the skill and equipment to take these. • Photographs
If there are reasons for an in‑person consultation to make safe treatment decisions, arrange one with the patient.
Recap the assessment, diagnosis, management plan and follow up.
Advise the patient about the safety net.
Provide patient information.
Document the consultation as soon as possible, for safe and effective continuity of care for the patient.
Complete any post‑appointment tasks: • pharmacy or prescription • laboratory requests • medical certificates – see RNZCGP COVID-19 Response – Certificates. • send imaging requests via ERMS where possible.
Avoid telehealth fatigue by taking regular visual breaks (focus in the distance) and physical breaks from the workstation between telehealth consultations. Have a mix of phone, video and in‑person consultations when possible.
