TELEHEALTH SERIES

Practical aspects of telehealth: establishing telehealth inan institutionS. Sabesan,1,2 D. T. Allen,3,4 P. Caldwell,5,6 P. K. Loh,7 R. Mozer,8 P. A. Komesaroff,9,10 P. Talman,11,12,13

M. Williams,14 N. Shaheen15 and O. Grabinski,16 on behalf of the Royal Australasian College of PhysiciansTelehealth Working Group

1School of Medicine and Dentistry, James Cook University, 2Department of Medical Oncology, Townsville Cancer Centre, Townsville, 14Department of

Child and Adolescent Health, Mackay Hospital, Mackay, Queensland, 3Quality Occupational Health, 4University of New South Wales, 5Discipline of

Paediatrics and Child Health, 6Centre for Kidney Research, The Children’s Hospital at Westmead Hospital, 15Aged Care Services, Royal North Shore

Hospital, 16Communications Unit, The Royal Australasian College of Physicians, Sydney, 8Rehabilitation Medicine, Rankin Park Centre, Newcastle, New

South Wales, 7Department of Geriatric Medicine, Royal Perth Hospital, Perth, Western Australia, 9Department of Medicine, 10Monash Centre for the

Study of Ethics in Medicine and Society, 13Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, 11Neurosciences

Department, Geelong Hospital and 12Deakin Medical School, Geelong, Victoria, Australia

Key wordstelehealth, video consultation, telemedicine,

Townsville Teleoncology Network,

teleoncology.

CorrespondenceOdette Grabinski, Communications Unit,

The Royal Australasian College of Physicians,

Sydney, NSW 2000, Australia.

Email: telehealth@racp.edu.au

Received 17 September 2013; accepted 28

October 2013.

doi:10.1111/imj.12339

Abstract

The fifth in a series of papers on practical aspects of telehealth, this paper discusses

telehealth models that can facilitate the provision of specialist services to rural and

remote patients closer to home. Some of the barriers to successful implementation of

these models relates to workforce, funding and infrastructure at rural sites, as well as the

traditional mindset of healthcare professionals. Therefore, the rural sector needs to be

adequately resourced for telehealth models to be substantive and successful. This paper

describes the development of a large teleoncology network over a vast geographical area

in North Queensland. Adequate resourcing for the rural sites and undertaking quality

improvement activities has continually enhanced the model over a 5- to 6-year period.

The benefits of this model of care are twofold: (i) patients received their care closer to

home and (ii) the workforce, service capabilities and infrastructure for the hospital in Mt

Isa (a rural town 900 km away from its tertiary centre) has improved.

Introduction

The provision of specialist medical services in manyrural and remote towns is hampered by workforceshortages, narrow scope of practice and limited servicecapabilities.1,2

Telehealth models in cancer care (hereafter referred toas teleoncology) can facilitate the provision of specialistcancer services closer to home. Teleoncology has beenadopted by many centres to provide specialised care torural and remote communities in many countries.3,4

A successful telehealth model relies on motivated pro-viders, an adequate workforce and sufficiently resourcedremote facilities. Consequently, to build a telehealthnetwork, it is important to ensure the growth of capacityat remote sites in parallel with the providing sites.5 In the

literature, many factors have been identified as barriersto the uptake of telehealth.6 These include: lack offunding; extra time commitment for rural doctors andthe resultant impact on workload; insufficient infrastruc-ture, equipment, technology and skills; and a preferencefor a more traditional approach.

The department of medical oncology of the TownsvilleCancer Centre (TCC), the tertiary cancer centre forNorthern Queensland (Australia), services a large geo-graphical area of more than 300 000 km2. The largestrural town in its catchment is Mt Isa, 900 km west ofTownsville with a population of 20 000. In 2007, TCCembarked on establishing a network to provide cancercare to rural towns through telehealth. Because mostrural Queensland health hospitals were already fittedwith videoconferencing technology at the time, the coor-dination and mobilisation of human resources were thenext steps in establishing the Townsville TeleoncologyNetwork (TTN).

Funding: None.Conflict of interest: None.

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Internal Medicine Journal 44 (2014)

© 2014 The AuthorsInternal Medicine Journal © 2014 Royal Australasian College of Physicians202

Objective

In this paper, we attempt to show that service capabilityand scope of practice in rural hospitals can be enhancedby providing specialist services in rural towns throughtelehealth services modelled on the Townsville-Mt Isaexperience.

Case study: development of theTTN model

To illustrate the gradual and reflective development ofthe Townville-Mt Isa model within the TTN, the sequenceof events leading to the current operational structure hasbeen summarised as:1 Service capability of Mt Isa Hospital prior to the estab-lishment of the TTN2 Selection of levels of services to be provided3 Establishment of the TTN model of care4 Expansion and refinement of the model.

Service capability of Mt Isa Hospitalpre-teleoncology model of care

Prior to the introduction of teleoncology, cancer patientswere managed by the emergency department at Mt IsaHospital on a goodwill basis. There were two nurses whohad some competency in administering chemotherapy.

Mt Isa Hospital had an internal medicine physicianwho could be called upon for help, a radiology facilitywith computer tomography and biopsy capability, anintensive care unit for less complex cases and pathologyhad a turnaround time of less than 60 min for blood tests.

In terms of cancer care services, there were threechemotherapy chairs occupied for 2 days a week. Allpatients had to travel to TCC for their first consultationand for reviews. All the first doses of chemotherapy weregiven at the TCC. Moderately toxic regimens were givensubsequently at Mt Isa Hospital. Highly toxic regimenswere given at TCC.

Selection of level of activities

The selection of sites for chemotherapy was based on theservice capability of each site as per the QueenslandHealth Service Capability Framework (SCF).7 In the SCF,hospitals are assigned levels from 3 to 6. A Level 3 serviceprovides low-risk ambulatory care, whereas a Level 6service provides comprehensive cancer care includingbone marrow transplant and high-risk chemotherapyprotocols. Mt Isa Hospital was selected for providing morecomprehensive medical oncology services given thealready existing Level 3 chemotherapy facility.

Establishment of TTN

2007–2009

The network between Townsville and the rural sites wasestablished in May 2007 by informal arrangementsbetween the TCC department of medical oncology andhealth professionals at rural sites. Videoconferencingequipment was installed in meeting rooms at rural sites. Atthe tertiary centre, equipment was installed in meetingrooms and offices. Patients were booked via medicaloncology clinics in Townsville, and consultations wereundertaken using the videoconferencing equipment.Prior to the commencement of each consultation, patientswere asked to sign an informed consent form for partici-pation in this model of care. Patients declining consentwere offered the option of travelling to Townsville, as wasthe usual practice prior to 2007.

Mt Isa Hospital staffing and professionaldevelopment

Extra training was provided at the TCC for two nurses togain competency in administering complex regimens atMt Isa Hospital. Senior Medical Officers from the Emer-gency Department were formally rostered to facilitate thevideoconference sessions. The medical oncology hand-book used for junior doctors at the TCC was shared withthe doctors in Mt Isa for reference purposes.8 Each casediscussion via video link also served as an occasion forcontinuing medical education for rural doctors.

Service capabilities

Between 2007 and 2009, patients travelled to Townsvillefor the first consultation with medical oncologists. Patientsfrom Mt Isa were subsequently managed throughvideoconferencing. For chemotherapy treatment, patientstravelled to Townsville for their first treatment and wereable to receive subsequent doses in Mt Isa, except for toxicregimens like bleomycin, etoposide and platinum;ifosfamide; and methotrexate infusions.

Expansion and refinement of TTN model

2009–2012

Given the increased activity at Mt Isa Hospital, TCC wassuccessful in securing additional funds from QueenslandHealth to build capacity for the TTN in Mt Isa. Once allinvolved parties became comfortable with this model ofcare and the increased work force, the following deci-sions were made: (i) all new patients could be seen firstvia videoconferencing to make sure their future care was

Townsville-Mt Isa telehealth services

© 2014 The AuthorsInternal Medicine Journal © 2014 Royal Australasian College of Physicians 203

coordinated if, and when, patients travelled to Towns-ville; (ii) patients from Mt Isa did not need to travel toTownsville unless requested by the patients or the treat-ing teams; (iii) all solid tumour chemotherapy regimenscould be administered in Mt Isa; and (iv) all admittedinpatients were to be seen by medical oncologists in wardrounds via videoconferencing.

Clinic model

Details of the clinic model have been published previ-ously.4 Patients and their families were joined by chemo-therapy competent nurses, senior and junior medicalofficers, and allied health practitioners during consulta-tions. At other sites, either a doctor or a nurse sat in withpatients, if required. Details of the consultations weredocumented in medical charts and summary letters sentto general practitioners and referring doctors.

Quality assurance

As part of refining the model, several quality assuranceactivities were undertaken:1 Patient satisfaction surveys (these revealed satisfactionof more than 96% by patients)9

2 Indigenous and non-indigenous health professionalperspectives (there was overwhelming support from bothfor this model)9,10

3 Audits of safety of remote supervision of chemo-therapy (study ongoing)4 Mortality and morbidity meetings.

Outcomes on workforce and service capabilities

As the result of the teleoncology model of care, the levelof services provided at Mt Isa Hospital has escalated, as in

Table 1, to SCF Level 4. The numbers of oncology specificstaff have also increased to a part time Senior MedicalOfficer, a shared basic physician trainee rotating fromCairns, a Resident Medical Officer, a Cancer Care Coor-dinator, two chemotherapy nurses, Aboriginal liaisonofficers and others, as required.

Increased staff numbers, outpatient and chemotherapyoccasions of service, together with comprehensiveness ofthe service provided locally, led to success in securingregional cancer centre funds from the CommonwealthGovernment to build a five-chair state of the art chemo-therapy facility in Mt Isa.

Discussion

One of the main reasons for the success of theteleoncology model of care was the expansion and capac-ity building of remote sites to accommodate services fromTCC. As most of the barriers are related to the resourcinglevels at the receiving rural sites, it is logical to identifyand rectify them at the outset to enable buy-in from ruralsites.

The selection of sites for chemotherapy was based onthe service capability of each site as per Queensland HealthSCF. SCF can be followed in two ways. One approach is toavoid sites that do not meet the criteria for further devel-opment and the other, more proactive approach, might beto select the sites for new service developments and workon resourcing them adequately, to the point that theymeet the SCF, as has been done for Mt Isa.

Over the years, as depicted in Figure 1, Mt Isa hasbecome a complete medical oncology unit with specia-list medical oncologists available on demand throughvideoconferencing supported by rural health profession-als. Now, it has the capacity to provide all solid tumour

Table 1 Service capability of Mt Isa Hospital in 2013

Town Specialist cancer clinic via videoconference Patient types Chemotherapy Comment on travel to and from Townsville

Mt Isa 3–4 times per week and on demand All new and reviews,

urgent ward consults

All solid tumour

regimens

No need for travel by patients and specialists

Mount Isa Cancer Care Unit

Staff Services provided by the telehealth network

• Allied health professionals

• Local senior and junior medical officers

• Nursing staff

Specialist clinics − new, routine and on-demand Ward consultations Urgent reviews Most cancer types All chemotherapy regimensIn-patient admissions

Townsville Cancer CentreMedical oncology staff specialists

Telehealth services Figure 1 A model of a rural specialist unit

with specialist support via a telehealth model

of care.

Sabesan et al.

© 2014 The AuthorsInternal Medicine Journal © 2014 Royal Australasian College of Physicians204

chemotherapy regimens. In addition, savings as a resultof a reduction in patient travel to Townsville can be usedto make this model of care self-sustainable.

Conclusion

Exposure to combined rural generalist/specialist tele-health service models and high-quality training at rural

centres networked with tertiary centres may attract train-ees and a mature workforce to rural communities. Thiscould further improve the rural service capabilities in thefuture.

References

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LETTERS TO THE EDITOR

Clinical-scientific notes

Disease progress in patients withMorbus Fabry after switching fromagalsidase beta to agalsidase alpha

In Fabry disease (FD), two recombinant substances,agalsidase-alpha (Replagal; Shire Corp., Lexington, MA,USA; produced in human fibroblasts) and agalsidase-beta(Fabrazyme; Genzyme Corp., Cambridge, MA, USA; pro-duced in a Chinese hamster ovarian cell line) allowenzyme-replacement therapy (ERT) that leads at least toshort-term stabilisation of renal and cardiac manifesta-tion, the main drivers of mortality.1–10 In June 2009,Genzyme Corp. halted production after a virus (vesivirus-2117) was discovered in the production equipment at itsplant in Allston, MA, USA, which finally led to a relevantglobal shortage of agalsidase-beta.11 As a consequence,

many patients that were treated with algasidase-betareceived a reduced dose or had to be switched toalgasidase-alpha.

We assessed the effects of the shortage in our FD cohortdatabase in Zurich/Switzerland in five male patients thathad to be switched compared with five matched, malepatients under continuous treatment with agalsidase-alpha (‘control group’). Both groups were matchedregarding age, disease severity and additional drugtherapy (e.g. angiotensin-converting enzyme inhibitors).The intention to start ERT with either one of the twosubstances, initially, based on the personal choice of thephysician and not on specific clinical conditions (e.g.disease severity).

Our data confirmed the results of two formersurveys,12,13 and according to their end-point definitions,

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© 2014 The AuthorsInternal Medicine Journal © 2014 Royal Australasian College of Physicians 205