STROKE TELECONSULTATION

Paul McCullagh1, Michael Power2, Belinda Wroath2,

Pat Lundy1, Mark Beattie1, Shumei Zhang1

1 School of Computing & Mathematics, University of Ulster, UK2 Ulster Hospital, South Eastern Trust, Northern Ireland, UK

Stroke Stoke has a greater disability impact than any other medical condition Every year an estimated 4,000 people in Northern Ireland have a Stroke (The Stroke

Association 2011) Teleconsultation enables the patient to obtain the professional opinion of a healthcare

provider remotely This technology potentially makes the provision of healthcare more efficient and

economic Around a third of people who have suffered a Stroke are living with long term disability

and needing home-based rehabilitation How can teleneurology improve patient care?

Victor Patterson and Richard WoottonNature Clinical Practice Neurology (2006) 2, 346-347

Background

Studies have shown that the teleconsultation can assistdiagnosis, self-management, and professional patient knowledge transfer methods used for teleconsultation include email, (asynchronous) telephone & videoconference (synchronous)

Email communication method is flexible, but not suitable for patients who have the problem for typing or reading, such as stroke patients. Images can be uploaded as part of the interaction

Telephone can provide good audio quality, but with no visual image during the consultation it is a difficult communication medium for patient / doctor interaction

Videoconference could be the best alternative to face-to-face consultations, however, the video and audio quality depends on connection bandwidth

‘Digital Britain’ aims for 2Mbps everywhere in the UK by 2014

Stroke initiatives

A&EConsultant

ConsultantHCP

Methodology

The teleconsultation system is based on low-cost and easy to use software and hardware components

Hardware comprises a laptop with a webcam, microphone/speaker, and 3G dongle or WiFi wireless network connection

The software uses Skype

3G Dongle 3G Dongle

Patient sideTherapist side

3G/WiFiInternet

Internet Connection

Require approx 400kbps duplex UMTS / 3G (O2 provider) 128kbps -500kbps

•Developing technology - High Speed Packet Access (HSPA) supports a theoretical peak data rate of up to 10.7Mbps in the downlink, and 5.5Mbps in the uplink

WiFi allows the deployment of wireless local area networks (WLANs) based on IEEE 802.11/a/b/g/n standards (range:32m indoors or 95m outdoors)

• Quality of Service protocols, power saving mechanisms and faster bandwidth (2Mbps~100Mbps) •However, the WiFi networks have limitations, such as limited mobile use of telemedicine applications

Coverage

BBC Survey “We're not making huge claims for our

mobile map - it is after all just a snapshot - but it may provide consumers and the mobile networks themselves with a better picture of the real state of coverage.

And ours is not the only source - a London-based startup called OpenSignalMaps has also been mapping 3G across the UK. They've kindly given us access to their data, collected from 30,000 users of their Android app. You can read more about their research here - but I've pulled out a couple of headlines.

They identified over 22,000 locations where no 3G signal was available - for the most part, as you'd expect, in rural areas. The highest concentration was in Gwynedd in North Wales, closely followed by Cumbria.

But in terms of the amount of time people are spending on 3G, they've got that at 58%, much lower than our 75%.

And their overall conclusion - like ours - is that while most of the big cities are well served by 3G, it can be a real challenge getting a decent connection elsewhere.”

August 2011

Mobile Broadband

Broadband Speeds

BBC survey, August 2011

South Eastern Trust, Northern Ireland

Technical Trials

Upload and download data transmission rate changed during a videoconference. This data transmission rate determines the video and audio quality; lost connection some times during a videoconference

(a) Down.: 580 kbpsUp: 300.5 kbps

(b) Down.: 265 kbpsUp: 189 kbps

(c) Down.: 124.9 kbpsUp: 154.6 kbps

Variation in Speeds

Image quality reduces when the person is moving (compared to static), although the data transmission rates are similar

Down: 272.6 kbpsUp: 315.0 kbps

Down: 292.1 kbpsUp: 335.5 kbps

Down: 392.9 kbpsUp: 317.6 kbps

(1) Sitting (3) Sit down(2) Walking

Image Quality

Protocol Data collection issues: location, weather conditions, availability of WiFi, 3G

speed, the quality of video and audio Questionnaires provided for patients, clinicians, technical support A technician tests the availability of availability of WiFi and/or 3G Internet

connection for each participant’s home before a clinical trial takes place in that location

The maximum speeds (upload and download) are tested at the beginning of each clinical trial (monitored during consultation)

Technicians in both sites (patient’s home and hospital) assist to establish a Skype video/audio call and monitor the speed of the Internet connection during the clinical trial

Video/audio quality are assessed during ‘stationary’ and ‘moving’ phases of the teleconsultation. The Consultant will talk with patient at sitting posture, and also ask patient to perform motion such as walking or arm motion, assisted by the health nurse at the patient’s home

Technicians in both sites complete assessment forms and also ask the patient and the Consultant fill a document form after each consultation

Patient Interaction

Interaction: History, symptoms, medication, BP, face close up, walkingNext appointment

The study received a favorable ethical opinion from ORECNI (09/NIR03/84)Any interaction with the patient preserves his/her anonymity and data is stored securely without any patient identifiersAll information regarding the consultation process is stored in a secure patient administration system in the hospitalTechnical information regarding the consultation is held by the university researchers

ID Date Area

3G bandwidth (kbit/s)

WiFi

Quality From patients From clinicians

Patient’s home HospitalVideo Audio Comf. Ease Pref. Acce. Usef. Limitations

Up. Down. Up. Down.

1 08/06/10 Urban 605 1448 4 5 Yes Yes Yes Yes 3Slight delay between

image/sound.

2 27/07/10 Rural No signal

3 20/10/10 Urban No signal

4 24/11/10 Urban 1448 1256 4 4 Yes Yes Yes Yes 5Unpredictable

coonection

5 09/02/11 Urban 14258 26416 Yes Yes Yes Yes Yes 4

6 14/02/11 Urban 331 1848 4 4 Yes Yes Yes Yes 4

7 31/03/11 Urban No signal

8 Urban

9 16/06/11 Urban 864 3000 4 5 Yes Yes Y/N Yes 4

10 Rural No signal

11 16/06/11 Urban 1474 1112 5 5 Yes Yes Yes Yes 4 Examination possible

12 Urban

13 13/06/11 Urban 1100 4000 4 5 Yes Yes Y/N Yes 4 Lag, jerky

14 Urban

15 21/07/11 Urban 1321 1920 230 390 5 5 Yes Yes Yes Yes

16 26/07/11 Urban 662 1176 1444 1488 4 4 Yes Yes Y/N Yes 5 Signal strength

17 27/07/11 Urban 1471 1032 1172 2168 5 5 Yes Yes Yes Yes 4 Examination possible

18 03/08/11 UrbanWiFi

1071 1608 Yes 5 4 Yes Yes Yes Yes 5 Used WiFi. Echo8152 910

19

20

21

22

23

24

1 = poor, 2 = ok, 3 = good, 4 = very good, 5 = excellent;

Initial Results

Assessment

Technicians: Bandwidth: what was the maximum 3G upload/download bandwidth at both

sites: hospital and patients’ home? WiFi: was there a WiFi Internet connection at patients’ home? Quality: what were the video and audio transmission qualities by using 3G

connection?

Patients: Comfort: were you comfortable with using videoconference? Ease: was the equipment easy to use for communicating to hospital consultant? Preference: would you prefer a home-based teleconsultation rather than a

hospital appointment?

Clinicians: Acceptability: was the consultation acceptable by using videoconference? Usefulness: was the consultation useful for reviewing patient progress? Limitations: were there specific limitations of the teleconsultation process?

AssessmentRole AssessmentPatient Was the equipment intrusive/acceptable?

Were you able to understand hospital consultant? How easy was equipment for communicating/responding to hospital consultant?What was the overall comfort with/acceptability of the procedure?Was there satisfaction with arrangements for the teleconsultation? Preference for teleconsultation as opposed to travelling for a hospital appointment?

Primary Care Team What was the acceptability/intrusiveness of equipment?

How was communication with hospital consultant?Was there a benefit of consultant availabilityWere there specific limitations of the teleconsultation process?Any problems arranging the teleconsultation with patient and consultant?

Consultant How was the communication with patient?How was the communication with technology team?Did the consultation permit review of patient progress?Were there specific limitations of the teleconsultation process?What were the problems with arrangements?

TechnicalTeam

Was there a wired Internet/wireless Internet/ in addition to the 3G connectionHow Easy was it to establish the connection? Were there service interruptions?What was the perceived transmission quality (lag/screen freeze etc.)What were the data transmission bit rates upstream /downstream

Discussion

Ratings from patients for the comfortableness, easy to use and preference of home-based teleconsultation were positive. Most of participants were comfortable and preferred using videoconference

Ratings from clinicians in the Ulster hospital for the acceptability, usefulness of teleconsultation were mixed. Limitations were that the lower Internet bandwidth leads to lost connection or poor quality images or speech. In addition, more detailed examination was limited by using a videoconference compared to the face-to-face consultation

The results show that teleconsultation for home-based Stroke assessment using mobile wireless technology is feasible where

Patient has broadband internet or a good 3G connection Dynamic data transmission rates reduces the reliability of the

teleconsultation A BBC crowd-sourcing survey has reported that only 75% of 3G

coverage can get a 3G signal successfully, there are still many ‘notspots’, including in major towns and cities across the UK in this stage

Conclusion

Telemedicine including synchronous consultation has been available for 20+ years, but based on infrastructure with Quality of Service Guarantees (e.g. 6xISDN)

Teleconferencing is becoming ubiquitous in modern society: Skype, Facetime Telemedicine is being deployed in Stroke departments (e.g. for confirmation

of diagnosis and to expedite thrombolytic treatment) Protocols and applications such as Skype are not allowed by security

conscious ICT departments within the NHS Deployment of 3G networks is ongoing, but coverage is mainly based around

major population centres 3G can support asynchronous telemedicine, e.g. uploading of images Approx 400kbps can support asynchronous video, but this needs to be

sustained over a 30 minute teleconsulation The public accepts poorer quality video in certain circumstances, e.g. news

correspondents reporting from the field, programs such as ‘Embarassing Bodies’

Teleconsultation was well received by patients in trial

References

Patterson V. Teleneurology in Northern Ireland: a success. J Telemed Telecare. 2002; 8:S3:46-7.

Digital Britain, Jan 2010, http://www.ber.gov.uk/file54154.pdf, accessed Sept 2010. Wootton R. and Patterson V., Teleneurology. Royal Society Medicine Press, 2005. NHS National Patient Safety Agency, National Research Ethics Service, Patient

Information Sheets and Consent Forms, http://www.nres.npsa.nhs.uk, accessed Sept 2010.

3G mobile data network crowd-sourcing survey by BBC News, http://www.bbc.co.uk/news/business-14574816, 24th August 2011

Lee H. Schwamm et al, Recommendations for the Implementation of Telemedicine Within Stroke Systems of Care : A Policy Statement From the American Heart Association Stroke 2009, 40:2635-2660: originally published online May 7, 2009