Information technology, telemedicine

Videoconferencing enables neurology service to cover Northern Ireland

21 November 2006

Faced with a medical emergency at 1.30am in Enniskillen, Northern Ireland, where would you expect a radiologist to contact a consultant neurologist? In Belfast, perhaps? London, maybe? How about Brisbane in Australia?

Impossible, you may think; but not with videoconferencing. This is not a scenario invented to promote the benefits of  videoconferencing, but an actual event quoted by Dr. Victor Patterson of the Northern Ireland Teleneurological Service. And he should know for he was the neurologist in question. “It was 12.20pm over there,” he explains, “so I could treat the case as part of my normal working day.”

The teleneurological service being pioneered by Dr Patterson from Belfast’s Royal Victoria Hospital covers the whole of Northern Ireland which is a largely rural area.

As a result patients and medical staff face extensive travelling time to reach or provide specialist treatment and care. A round trip from Belfast to Enniskillen, in the south-west of the province takes 3½ to 4 hours during which time six or seven patients could be seen. Videoconferencing eliminates much of this wasted time while still allowing patients to receive high levels of diagnosis, monitoring and care. “The challenge,” Victor Patterson explains, “has been to provide an expert service outside of Belfast; an objective almost impossible to achieve without the application of videoconferencing in a clinical environment.”

The solution

Linked by a 384Kb ISDN data connection, each of the nine centres used by the Teleneurology Service is equipped with predominantly Tandberg units supplied and installed by Questmark Limited. The outlying systems are typically installed in District Hospitals such as those at Enniskillen and Omagh, or in Community Centres. Most of the systems have recently been updated to the latest Tandberg 880 set-top systems with a commensurate improvement in performance. The first units used gave a very pixellated picture, but the new systems, together with improvements in bandwidth, now provide near-TV quality and high enough for a consultant to recognise and interpret neurological symptoms in patients.

“In selecting clinical videoconferencing it is important to find a reliable supplier as this critical application is not about providing boxes,” says Victor Patterson. “Integrating the systems into a usable installation that meets the strict requirements of a clinical application is vital. Questmark have achieved this as well as providing on-going support and ensuring all those involved in the Service are properly trained.”

The experience

Starting in 1999 the systems were initially used for presentations to the hospitals since when their applications have been extended to include new patient referrals, and patients’ reviews.

Typical neurological conditions handled include headaches, meningitis, epilepsy, multiple sclerosis symptoms, and strokes. Each centre has a specialist teleneurological nurse to allow full and accurate examinations to be undertaken at the far end watched by a consultant in Belfast who can question the patient; ask them to describe their symptoms and any previous history; and see them perform appropriate tasks. In addition relatives can be interviewed for corrobative information. From this a diagnosis can be made and a management programme for the patient devised.

To aid diagnosis a set of core signs in a patient has been established which the high resolution of the videoconferencing systems show clearly. These include eye movements, facial power and tongue movement which the consultant neurologist can track via pre-set camera positions or by remotely-controlling the camera. In the Brisbane example, the patient complained of a severe headache: via videoconferencing Victor Patterson was able to determine there was no neck stiffness; that eye movements, facial power and tongue movements were entirely normal as were arm and leg power. He could also see that there was no limb ataxia (unsteadiness) and that the patient could walk without significant unsteadiness.

As the CT scan had been emailed to him he had the necessary information from which to make a diagnosis and a course of action could be recommended. His view that this was not a serious problem was validated by further tests and examinations of the patient.

The Brisbane example may appear to be an extreme case of the application of clinical videoconferencing, but, as Victor Patterson observes “it shows the great potential it has for the future.” Nearer to home he quotes the case of a 40-year old man whose back pains could not be diagnosed as an orthopaedic complaint. The Teleneurology Assistant at the Tyrone County Hospital in Omagh arranged for the patient to be seen remotely by a consultant in Belfast who diagnosed a problem with the spinal cord. The patient was admitted to hospital almost immediately to receive treatment; without videoconferencing there may well have been a longer wait.

There is no doubt that clinical videoconferencing is making a major contribution to delivering a neurology service throughout Northern Ireland,” says Victor Patterson. “Since its introduction we have dealt with around 1500 acute admissions, seen 1250 people with epilepsy, 750 outpatients, and 200 review patients.”

Over to IP

The next stage in the development of the service is to migrate to IP transmission over the public internet. As Victor Patterson explains: “The drawback of ISDN has been its call charges. With free calls over the internet, IP will be ideal for expanding the reach of the service provided it can match ISDN’s reliability and security.”

This is being achieved by Questmark conditioning DSL broadband lines to take out ‘the enemies of video’ i.e. packet loss, latency and jitter to ensure the transmission is genuinely in real-time and not subject calls dropping out. The present speed is 192Kbits with the intention to increase this to 384Kbits later in the trial. The lines are connected to Questmark’s management server as a managed service is crucial for this type of application. The server captures and analyses performance data to ascertain whether the IP calls are satisfactory.

Results, so far, have been positive: of the thirty consultations that have taken place via IP only four have failed and these have been due to incorrect operation rather than from IP-related causes. Provided the trial is successful it is likely that the Teleneurology Service will be expanded to include many more locations in Northern Ireland.

A further initiative is to introduce a home care service whereby a ruggedised Sony unit will be taken to patients’ homes by a trained teleneurology nurse who will be able to link with a consultant for a diagnostic and monitoring session.

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