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Understanding Telemedicine: Reflections on a Danish Attempt to Introduce a Videoconference Service Between Two Hospitals

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Understanding Telemedicine: Reflections on a Danish Attempt to Introduce a Videoconference Service Between Two Hospitals Understanding Telemedicine: Reflections on a Danish attempt to introduce a videoconference service between two hospitals Arjen P. Stoop, MA, PhD Finn Kensing, MA, PhD 1. Introduction Notwithstanding the successes of telemedicine within for example radiology, cardiology or dermatology, there is a big discrepancy between the promises in published papers and conferences regarding telemedicine and the status of telemedicine applications in practice [1-3]. The ‘track record’ of telemedicine, in other words, is not too good. How can this discrepancy be explained? Are the promises of telemedicine unrealistic, are the users unwilling, or are daily health care practices too complex for telemedicine to become successful? In this paper we reflect on these questions based upon a literature study and upon preliminary findings from a telemedicine project that is still going on in Denmark between The University Hospital in Copenhagen (Rigshospitalet) and Bornholms Hospital. Bornholm is an island close to Sweden that is a part of Denmark. We compare the reasons for the limited use of telemedicine often mentioned in the literature with our experiences and data from the project. We especially react to the assumption that the use of telemedicine itself is unproblematic and that implementation of telemedicine is hampered by ‘external’ circumstances like willingness of politicians to invest money or knowledge and willingness of users. We show that by focusing on such external circumstances as the reasons for the limited success of telemedicine - without reflecting on the necessary conditions for the fruitful implementation and use of 1 telemedicine – the successful development of telemedicine services is hindered instead of stimulated. 1.1 The telemedicine context between The University Hospital and the outer regions The University Hospital in Copenhagen, with 1100 beds and about 7500 employees, is a tertiary hospital that delivers highly specialized care to patients within Denmark, including the Island of Bornholm, Greenland and the Faro Islands. The political constellation between Denmark and Greenland and the Faro Islands is special: Greenland and the Faro Islands are self-governed which means that they for example are responsible for their education system and social welfare. Other parts of the political system, i.e. defense and foreign politics are taken care of together. Regarding health care there has always been a close collaboration between these two outer regions and The University Hospital. The University Hospital has for example two coordinators especially dedicated to visiting patients and their relatives from these two countries. In addition, there is a patient hotel that gives patients the opportunity to stay very close at The University Hospital without the need to stay at a hotel (for example when their investigations take place on separate days). The amount of patients that visit The University Hospital from these outer regions is considerable. In 2006, for example, 4060 patients visited The University Hospital: 2531 from the Island of Bornholm, 599 from Greenland and 930 from the Faro Islands. To give an impression of the distances patients have to travel to get to The University Hospital: the island of Bornholm is about 35 minutes by plain, the Faro islands are about three hours from Copenhagen by plain and Greenland is about four hours by plain. 2 Besides the distance to Copenhagen, these outer regions are hardly comparable with Denmark looking at for example size, culture and psychological ‘closeness’ to Denmark. Greenland, for example, is many times the size of Bornholm and the Faro Islands. Even though it is more close to Sweden than Denmark, Bornholm is considered to be just as Danish as the other parts of the country, in contrary to Greenland and the Faro Islands. On Greenland and the Faro Islands, for example, Danish is the second language. Despite these differences, the amount of inhabitants (between 40.000-50.000) and the circumstances under which the local hospitals in these outer regions and The University Hospital work together, are partly comparable. First, the hospitals in these outer regions are relatively ‘unspecialized’ compared to The University Hospital. Several medical specialties are not represented (especially on Greenland and Bornholm), partially caused by problems of recruiting personnel but also because of the Danish governments’ decisions on what patients are allowed to be treated where and how. Cancer patients, for example, are not allowed to be operated or radiated on the island of Bornholm. The problem of a lack of specialization is partially solved by sending consulting physicians from Denmark to these outer regions on a regular basis. Second, because of the relatively low degree of specialization, the distance to Copenhagen, and the considerable amount of patients that are sent to the University Hospital there is increasing pressure on the potential use of telemedicine. The above-mentioned contextual characteristics have lead to many telemedicine projects between The University hospital and these outer regions (we will not go into the use of telemedicine between The University Hospital and other Danish hospitals on the shore). Between The University Hospital and the island of Bornholm, for example, it is because of telemedicine that diabetes patients do not have to travel to 3 Copenhagen for routine controls of their eyes. In addition, two trauma systems using a special camera are installed on Bornholms Hospital (for eye investigations and for teeth investigations) that make it possible to send pictures to the first aid department of The University Hospital. Between The University Hospital and the Faro Islands and Greenland, for example, PACS is used to transmit pictures. As often with telemedicine systems, very few are anchored in the daily practices (for example the use of PACS and the fundus camera to diabetes patients), many other systems are installed but hardly or never used, or uninstalled again after a while. 1.2 Background of this study In this study, the primary focus has been on exploring the potentials of more telemedicine ‘traffic’ between The University Hospital and Bornholms Hospital. In case of successful implementation the project was meant to investigate the telemedicine potentials on the Faro islands and Greenland in the same way. More specifically, the management of The University Hospital and the management of Bornholms Hospital decided in 2005 to explore the possibilities of using a videoconference system. The videoconference system was meant to supplement or replace existing ambulatory routine control visits (in which there is no need of physical contact) at The University Hospital. The system would make it possible for patients to go to their local hospital, instead of traveling to Copenhagen. A local doctor was meant to be present during the consultation. The assumption was that the system would save a considerable amount of expenses for transport and that especially patients and perhaps doctors at both ends (Bornholms Hospital and The University Hospital) would be interested. Patients would not have to travel to Copenhagen any more and the local doctors would get the 4 opportunity to work together more closely with their ‘expert’ colleagues and by doing this, enhance their knowledge. The assumption that it was in patients’ interests to implement a videoconference system was seen as crucial and was based on the impression that relatively many patients traveled to Copenhagen only for a blood sample or a five-minute conversation with their doctor and were dissatisfied with that. The use of a videoconference system to replace the existing time consuming and costly way of consultations, therefore, seemed to offer a good solution for these visits. 2. Methods A review of the literature was carried out. Further, we used both qualitative and quantitative methods for the empirical study. We gathered data by studying the Hospital Information System in order to find the number of patients from the island of Bornholm visiting The University Hospital, for how long and what the reason was for their visit. In addition, we held two workshops to find out whether there was a clear need to use telemedicine: One for both medical specialists and managers and one for the medical specialists only. Furthermore, we talked to management, health care professionals and patients at both hospitals individually. We asked management and health care professionals whether they could see any potential in telemedicine and if so, for which (groups of) patients and whether they were interested in a pilot project. We asked patients whether they were of the opinion that traveling to The University Hospital was cumbersome and whether they would prefer to go to their local hospital, if they could see and talk to their consulting physician using telemedicine. Finally, on the basis of these qualitative data, we made a questionnaire that we sent to all the patients from Bornholm that visited the The University Hospital during the period 01/11-2006 until 5 15/12-06. We asked them about their experiences of traveling to the University Hospital, their experiences with the treatment, whether they preferred the University Hospital or their local hospital, and whether they could imagine talking to their consulting physician by using a camera and a microphone. Because of the argument we want to make in this paper and because the data from the questionnaire have not yet been fully analyzed, our argument will be based on the analyses of the Hospital Information System and the workshops and interviews with health care professionals and managers. It should be mentioned that the authors each played a role in the project analyzed here. The first author was the project manager, while the second author took part in formulating the application that led to the financing of the project, and subsequently was a member of the steering committee. 3. Results First, we present often mentioned promises as described in the literature. Then we present findings from an analysis of the initial phase of our telemedicine project applying an analytical framework presented by one of the reviewed papers.
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