T Hayward* and J G Mitchell**

*Women’s and Children’s Hospital, Adelaide, South Australia, Australia, haywardt@wch.sa.gov.au
** John Mitchell & Associates, Pyrmont, New South Wales, Australia, johnm@jma.com.au

Acknowledgement: Article published in Journal of Telemedicine and Telecare, Volume 5, Number 3, 1999, The Royal Society of Medicine Press Limited

Introduction

Much has been written in the field of telemedicine about the value of videoconferencing (for example, Mitchell & Disney, 1997), the value of teleradiology (for example, Crowe et al, 1996) and the need to develop economic evaluations of telemedicine (for example, Lobley, 1997; McIntosh & Cairns, 1997). We present a Case Report that involved all three components: the use of videoconferencing and teleradiology in a case conference, and an economic evaluation. The case conference also involved the provision of specialist health care for young Aboriginal patients who live in remote areas.

A number of paediatric patients at Alice Springs Hospital are under the care of sub-specialists in urology and nephrology from the WCH. The patients are seen during the sub-specialists’ six monthly visits to Alice Springs and the patients are occasionally transferred to the WCH. Patient transfer to Adelaide is particularly undesirable for Aboriginal patients, who have a very strong attachment to their tribal land.

A renal case conference involving videoconferencing and teleradiology was conducted in September 1998, between the Women’s and Children’s Hospital (WCH) in Adelaide, South Australia and the Alice Springs Hospital in the Northern Territory, 1600 km apart.

Case report

To prepare for the meeting, the radiology images of the children were transmitted from Alice Springs before the videoconference began. To facilitate the transfer of radiology images from Alice Springs, the WCH installed teleradiology equipment in Adelaide which was compatible with that used at Alice Springs Hospital. The teleradiology facilities at Alice Springs Hospital (Central Data Networks, Australia) were installed and maintained in conjunction with a private radiology practice that services Alice Springs, Dr Jones and Partners. The images were transmitted from Alice Springs using an ISDN line (128 kbit/s). The average time for the transfer of the images was about 3-4 min for one set of, say, ultrasound images.

During the case conference, the staff at the WCH had the radiology images available on a PC hard disk, for viewing on a 21 inch (53 cm) computer monitor. The staff at Alice Springs Hospital used the original images, displayed on a light box in the videoconferencing room. The images included ultrasound images, micturating cystourethrogram (MCU) images and intravenous pyelogram (IVP) films. The ultrasound images had been directly captured, while hard copies of the MCU and IVP films, from previous examinations, were digitised using a CCD scanner (Lumisys L20), before transmission to Adelaide.

The WCH videoconferencing equipment was a rollabout unit with dual screens (System 4000, PictureTel). The videoconferencing unit in Alice Springs was a set-top unit on a standard TV (SwiftSite, PictureTel). Using the remote control keypad, it was possible from the WCH site to move the cameras at both sites, to provide close up images of the speaker.

As this was the first renal meeting involving teleradiology images, a group of specialist staff was involved, to evaluate the session. At WCH the session was chaired by the head of paediatric radiology. At Alice Springs the meeting was chaired by a senior paediatrician. There were six participants at Alice Springs and eight at the WCH.

Images of five paediatric patients were transmitted for the case conference. The patients ranged in age from 11 months to four years and included three males and two females, Table 1. A number of the patients were Aboriginal – one patient’s family refused to travel to Adelaide for the child’s treatment and another’s family was from the Western Desert and rarely visited Alice Springs.

Discussion

The meeting brought together staff from different disciplines and enabled more in-depth discourse and achieved a better outcome than if fewer specialists had been involved. The decisions depended on having a range of specialists present. It was a true multi-disciplinary team approach, with inputs from everybody attending. A number of comments about the value of the session were made by the participants. These included:

the session resulted in two patients not being transferred to Adelaide

the WCH sub-specialists who normally saw the patients on their six-monthly visits felt that the videoconference enabled them to provide better patient management advice

the WCH staff were generally satisfied with the quality of the teleradiology images received

videoconferencing, combined with the teleradiology images, enabled the Alice Springs paediatric staff to engage in group discussion with the WCH sub-specialists about patient management issues

the chairperson at WCH found the equipment easy to use

the participants felt that the meetings could be conducted every three months.

The value to the patients was that the expertise of a wide group of sub-specialists was available for each case. Each case attracted a comprehensive opinion which affected the management. Each case received both a diagnostic opinion from paediatric radiologists and management decisions from sub-specialists in urology and nephrology. The paediatric nurse offered input on the Aboriginal issues. The WCH specialists provided a quick answer to management issues. The session provided an early response to patient issues and enhanced the likelihood of positive outcomes. As a result of this session and suggestions made by WCH staff about micturating cystourethrograms and the method of performing them, Alice Springs Hospital made some changes to its practice, i.e. a potential benefit to children undergoing MCU investigation in future.

Telemedicine balance sheet

McIntosh and Cairns (1997) advocate the use of a ‘balance sheet’ approach to summarise the information about the costs and consequences of telemedicine: “The balance sheet approach outlines the costs and consequences in a descriptive manner, avoiding explicitly trading off costs and consequences”. Table 2 and Table 3 provide a balance sheet for the renal case conference. The case conference avoided the need for two small children to be transferred from Alice Springs to Adelaide, a saving of A$5,600. Other savings included the patients’ families avoiding the financial, social and emotional costs of temporary relocation to Adelaide. In contrast, the costs of the 60 minute session were only A$1,587. The net saving was A$4,013.

Summary

The use of teleradiology images and live videoconferencing to bring together clinicians from both the WCH and Alice Springs Hospital for a renal case conference was very effective and, with a few minor modifications to room set up and meeting management, provides a model for future telecommunication links between hospitals. The benefits of such links for patients, their families, the hospitals and the health system are considerable and the costs are low.

This case conference provides a concrete example of the costs and consequences of telemedicine. This report addresses the challenge put by McIntosh and Cairns (1997) that ‘systematic ways’ need to be developed for outlining the costs and benefits of telemedicine ‘in a realistic manner’.

Acknowledgement

We thank Mr Robert George, Practice Manager, Dr Jones and Partners.; Dr Lloyd Morris, Head of Paediatric Radiology, WCH and Dr.Gavin Wheaton, Paediatrician, Alice Springs Hospital.

References

1. Mitchell J, Disney A. Clinical applications of renal telemedicine. Journal of Telemedicine and Telecare 1997; 3: 158-162
   2. Crowe BL, Hailey DM, de Silva M. Teleradiology at a children’s hospital: a pilot study. Journal of Telemedicine and Telecare 1996; 2: 210-216
   3. Lobley D. The economics of telemedicine. Journal of Telemedicine and Telecare, 1997; 3: 117-125
   4. McIntosh E, Cairns J. A framework for the economic evaluation of telemedicine Journal of Telemedicine and Telecare 1997; 3: 132-139

Table 1. Cases discussed at the renal meeting between the WCH and Alice Springs

Patient details	Number and type of images sent to WCH via teleradiology
2 year 6 month old male infant	3 MCU 3 Ultrasound sheets (32 images) 12 images of 100mm film of MCU 4 IVP
4 year old boy	2 ultrasound sheets (19 images) 2 MCU sheets
Female child	1 MCU sheet (6 images) 2 ultrasound sheets (23 images)
14 month old female infant	5 MCU (56 images)
11 month old male infant	3 ultrasound sheets (29 images) 1 MCU sheet (6 images)

Table 2. Balance sheet of the savings and costs of the renal case conference meeting

Savings	A$	Costs	A$
1. Patient Assisted Transport (PAT): Avoidance of transfer of two patients to Adelaide: transfer costs. Child return airfare Alice Springs/Adelaide $450	900	1. Videoconferencing ISDN transmission time: one hour	48
2. Patient Assisted Transport (PAT): Avoidance of costs of two patients’ families staying in Adelaide. WCH Parent accommodation 2 nights @ $25 per set of parents; two airfares @ $900 per parent (4 parents).	3,700	2. Depreciation* of videoconferencing equipment: $20 per hour at each site.	40
3. Avoidance of hospital in-patient costs for two patients: 1 day (overnight) stay @ $500 per day.	1000	3. Teleradiology ISDN transmission time: half hour	24
		4. Depreciation* of teleradiology equipment: $10 per hour at each site	20
		5. Rental of room at each site and ISDN line rental: $10 per hour	20
		6. Opportunity cost of staff participation ** (10 @ $125 per hour; 3 @ ave. $25 per hour)	1,325
		7. Preparation time** by radiographers at each site: $25 per hour, one hour each site	50
		8. Preparation time by administrative staff (2 hours at each site @ $15 per hour)	60
Total savings		Total costs

*To estimate depreciation, the capital costs of the equipment were amortised over three years. The annual cost was then divided by the available hours for use in one year.

**Staff preparation and participation costs are an interesting issue. On the one hand, to prepare for and support a meeting like this takes additional time. On the other hand, many of these cases may have required time of staff anyway, so not all the hours should be weighted against telemedicine. If some of the hours of the staff were deducted, the total costs would be lowered and the argument in favour of using telemedicine would be strengthened.

Table 3. Tangible and intangible benefits of the renal meeting

Tangible benefits	Intangible benefits
1. Decision taken to not transfer two patients to Adelaide, resulting in savings for the children, their parents and health system	1. The success of the session gave the clinicians confidence to use the technology regularly.
2. Five patients benefited from a multidisciplinary team analysis of their cases.	2. The videoconferencing enabled a group of clinicians and other staff to participate easily in group discussions and decision making.
3. The patients’ cases did not need to wait until the WCH sub-specialists visited some months later.	3. Discussions took place about how to improve the taking of future teleradiology images.
4. Both sets of clinicians were able to view the same images simultaneously.	4. The collaboration between the Alice Springs and the WCH staff was enhanced.
5. The WCH radiologists could manipulate the teleradiology images on screen, by magnifying and changing the contrast.	5. The teleradiology images were transmitted to Adelaide faster than they could have been sent by air.