Diagnosis down the line

NOT LONG ago, a patient was brought to Midland Regional Hospital in Mullingar as an emergency case – she had stroke symptoms. She was interviewed and examined by a stroke specialist and was quickly put on clot-busting medication, which most probably saved her life.

It sounds like a straightforward enough case, but here’s the unusual thing: the stroke specialist, Prof Des O’Neill, was 80km away in Tallaght hospital at the time. He was able to talk to and assess the patient thanks to RP-7, a robotic device with a video link.

Welcome to the world of telemedicine, where clinicians can interact with, monitor and diagnose patients without the need to be with them in person.

The concept of getting health information remotely has been around for a while, notes Dr Rónán Collins, a consultant in geriatric and stroke medicine and director of stroke service at Tallaght hospital.

“It really came to prominence with the British wireless radio service to the merchant navy at sea, where there was no doctor on the ship,” he says. “And doctors have used transmission of images from ultrasound from North Sea oil rigs to help see whether someone there had appendicitis or not.”

But of late, the technology has become more widely used and in some cases more sophisticated, including real-time interactions between medical staff and patients through video links, images that can be stored and sent on for later analysis and home-monitoring systems that transmit streams of data back to clinicians over communication networks.

The factors driving telemedicine include long distances between the doctor and patient, economic benefits and the need for speed in diagnosis, and the approach has gained particular notice in the US, explains Collins.

“One way they use it is for psychiatry – someone goes to their GP and goes into a telemedicine suite, which basically has Skype, and they have a private consultation with the psychiatrist,” he says. “It means the patient, the GP and consultant can have a three-way conversation, which is probably better for the patient.”

Meanwhile, the “store and forward” approach is of particular use in taking images of skin conditions or biopsy slides, which can then be sent to an expert for analysis, says Collins.

And in the home setting, sensors can register data about a patient – perhaps blood pressure or movement – and send them securely back to a database that clinicians can track.

In Ireland, a year-long pilot study is under way between Mullingar, Tallaght and Naas General Hospitals (Portlaoise and Tullamore will likely be added, too) that uses RP-7 robots, so whenever in the day or night a patient is admitted to any of the hospitals, a stroke specialist will be available to assess them either in person or remotely.

Speed is critical, because when a stroke happens “time is brain”, according to Collins, and getting suitable patients on to thrombolytic or clot-busting drugs can help minimise damage to brain tissue and help improve chances of return to a good quality of life.

Such emergency decisions lend themselves well to telemedicine, he notes. “There seems to be good reliability between the assessments done in person and by telemedicine in acute stroke and other issues,” he says.

But he agrees that in less time-sensitive settings subtleties could be lost in translation, that there’s a need to ensure data are protected and that ongoing monitoring must be carried out sensitively.

Nor should we be so dazzled by the technology that it steals thunder from the need to build up other services, Collins argues.

“In thromboylsis, telemedicine is initially about acute treatment and, clearly, as a physician and for the public it captures the imagination, it’s exciting work, it’s dangerous work, it’s great to see a good result. But this is not about boys with expensive toys,” he says.

“There’s a lot more to stroke treatment. The process of stroke care has been really badly neglected in Ireland and we are trying to improve things.”

Collins hopes that Ireland will see similar results to Germany, where telemedicine has helped to improve stroke services generally.

“Not only did the rates of clot-busting drugs being given go up, but also other indicators of stroke care rose on the same tide,” he says.

“By having a system that makes people think about the emergency and importance of stroke, not only do you get improved delivery of the emergency treatment, but the whole consciousness of the health community around stroke improves.”

And as the telemedicine revolution grows, are we ready for it here?

“In Ireland there’s a very tactile culture – we like to see the person we are dealing with, we like to feel we have a physical presence relationship,” says Collins.

“I’m not sure how Ireland is going to react to it. So far it seems to be a mixture of curiosity and happy acceptance, but it’s too early to say in an Irish context how it is going to pan out.”

HEARTPHONE: MONITORING PATIENTS FROM THEIR HOMES

For patients recently diagnosed with congestive heart failure, a rapid increase in weight can signal a problem – the body could be retaining fluid because the heart is failing.

Now a new telemedicine system is being piloted at St Vincent’s University Hospital to remotely monitor patient weight at home in the critical three months after diagnosis with the condition, which affects about 80,000 people in Ireland.

“Traditionally, they would have been monitored using a paper and pen to write down their weight, but it was very unreliable and prone to error,” says Helen McBreen from the National Digital Research Centre, one of the partners on the HeartPhone project.

The new system is faster and more reliable – a patient simply stands on the scales each day and the data are transferred to a mobile phone, which in turn relays the information to the hospital.

The device, which was developed by BiancaMed, a spin-out from University College Dublin, can actively alert clinicians to potential problems and aims to cut hospital re-admissions by between 30 and 50 per cent.

The trial has recruited over 25 patients since it started in July last year, and feedback has been positive, according to McBreen.

“A lot of patients like the security of it, they don’t find it an intrusion,” she says.