IMAGINE this scenario: you are a young rural doctor working in a rural hospital’s emergency department (ED). Over each acute bed is a camera and microphone, and in a bigger centre 1000 km away is an emergency physician monitoring the patients’ vital signs and your actions.

A situation arises and you are required to take action. You’re in the middle of a procedure on another patient when the monitoring doctor, kilometres away, intervenes without your input.

Who is legally responsible for the patient now? Did the patient give permission to be so monitored? What does the rural doctor learn from being sidelined?

The scope of telemedicine is expanding. Hospital authorities are using this technology more and more in rural and remote areas of Australia for various clinical purposes but especially so in EDs, allowing off-site emergency physicians to monitor and manage the rural ED clinical staff.

While there are many obvious benefits for patients and isolated and inexperienced clinicians, not everyone is comfortable about this paradigm shift, as many issues remain unresolved.

Privacy and consent

These are the primary concerns for many parties.

Protocols have been set up in some Local Health Districts (LHDs) that prescribe the activation of the patient camera in defined clinical situations.

Some LHDs are even exploring remote monitoring of all ED patients’ vital signs across their territories, utilising cameras, microphones and electronic medical records.

Some protocols require nurses to turn on the cameras, no questions asked.

Such instructions neither take into account the wishes of the treating doctor on the ground nor the consent of the patient. I know of at least one case where the monitoring physician looking through the camera actively refused to gain patient and family consent.

Privacy concerns also extend to unrelated patients. EDs tend to have open plans, so a camera on one patient may happen to see or hear details of the care of adjacent patients, creating serious privacy concerns.

Furthermore, the camera is sometimes left on for hours at a time, meaning general conversations among hospital personnel and visitors can be heard and seen.

There has been inadequate warning about the privacy pitfalls and this needs very urgent attention.

Clinical autonomy and the expansion of emergency physicians

The role of the camera has been polarising in EDs.

Inexperienced clinicians in rural and remote EDs tend to welcome the help, whereas the experienced physicians often see the camera as a time-wasting hindrance and threat to clinical autonomy.

Experienced physicians are not averse to having access to help when it is needed, but they have concerns about the possibility of the camera-monitoring physician intervening when the doctor on the ground believes a situation is under control. This also raises questions about resource allocation – could the staff monitoring the camera be doing something more useful?

In Australia, the majority of EDs are staffed by rural nurses and rural GPs.

The Australian College of Rural and Remote Medicine has its own guidelines for EDs which take into account the realities of remoteness and resource scarcity. Monitoring the cameras tends to be the role of emergency physicians, so there is a suspicion that the growth in the camera interventions represents an expansion of the role of the Australasian College for Emergency Medicine.

Practicality suggests that it is rare for those on the city side of the camera to have visited the remote sites they’re advising or to have familiarised themselves with the capabilities of the staff and facilities they’re advising. Finding out the intricacies of the remote site and personnel in the heat of an emergency is not acceptable.

No two hospitals are the same and no two towns are the same.

Legal concerns

Beyond what is mentioned above, legal concerns arise with respect to which doctor is in fact responsible for the patient. This is more acute in cases when the doctor on the ground disagrees with the doctor monitoring remotely via the camera.

Regrettably, I have been witness to this several times, with the rural doctors annoyed and frustrated at unrealistic demands from the larger centres.

It is also of serious concern when an emergency physician via a camera or telephone tells a rural doctor that it is licit to over-rule the rural doctor’s decision. A polite discussion of the merits of different treatments would be a better solution.

Many times I’ve asked LHDs, the Australian Medical Association and other concerned parties about the legal ramifications of such situations and I keep hitting brick walls. As a profession, we should not wait for our colleagues to sink in the courts before we get clarity on this. Doctors’ hospital contracts need to be updated to reflect this new paradigm as current contracts do not cover the issue of virtual doctors over-ruling the local doctors.

Deskilling and poor resourcing

The doctors at the larger centres are commonly surprised when the rural doctors tell them that there is no imaging, no blood, no inotropes and no staff to stabilise patients at the small hospitals.

Telemedicine is meant to offer advice and support, but it may easily slip into a command and control model. The more the “camera” becomes mandatory, it may be that the more rural clinicians (nurses included) will become accustomed to not making hard decisions. Over time, this could lead to deskilling and disengagement.

Another danger is that reliance on telemedicine and retrieval will permit an acceptance of understaffing and poor stocking of rural hospitals.

Therefore, it is imperative that protocols governing telemedicine in rural hospitals make it abundantly clear that it is for support to local services and not replacement of local services.

Technical vulnerabilities

The remote monitoring model fails when the internet drops out, telephone lines fail and electricity blacks out; these things all happen more commonly in the bush. The IT techinicians and emergency physicians may be at home or out, and away from cameras, monitors, faxes. Handling such cases with a telephone alone is no longer good enough, especially when mandated by LHD protocols.

It is not uncommon for the telemedicine doctor to have to juggle multiple sites simultaneously, leaving on prolonged hold rural doctors needing urgent advice.

So, there is still much to solve. It isn’t only Facebook that knows what you’re up to.

But what we know for sure is this: smile! Because you’re on camera.

Dr Aniello Iannuzzi, FACRRM, FRACGP, FARGP, FAICD, is a GP practising in Coonabarabran, NSW, and a clinical associate professor at the University of Sydney.

 

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11 thoughts on “Telemedicine in rural EDs: more questions than answers

  1. Adrian Sheen says:

    ….and telemedicine is recorded for “quality assurance and training purposes”??

  2. Anonymous says:

    It’s being a mute spectator with a microphone and camera! There is hardly anything you can do if the patient is crashing unless these systems include teleportation. Ultimately the persons at the scene have to be capable- and if they are capable there is no need for these cameras! The only benefactors are, as usual, the IT people. And of course the hegemonists and empire builders of metropolitan centres who love to ‘watch over you’ when they can’t hold a candle to your field capabilities. When will this gibberish end?

  3. Todd Fraser says:

    Here’s another thought – let’s build the capacity in our rural workforce and assist them to maintain it.

    As you rightly point out, many regional practitioners are called upon at a moment’s notice to perform, and some have either never gained, or are losing their skills due to infrequent opportunities.

    A platform like Osler (http://osler.community) can help clinical staff to learn new skills and practice them under supervision. There is no reason these skills cannot be supervised, assessed and signed off by telemedicine.

    This would provide regional Australians with a more robust, safer system of care, and improve the job satisfaction of those charged with the responsibility of caring for them

  4. Dr Ian Relf says:

    Always start simple and with a position of respect. If the doctor asks for advice then give it directly to the doctor freely and unencumbered. All the other stuff is bureaucratic and legal meddling.

  5. Anonymous says:

    Haha…so Medical training by correspondence course you mean?? No disrespect Todd but the failed junk of cameras, if they have to put to use, the better option will be for entertainment!

  6. Anonymous says:

    And the ‘presumption’ that regional specialists ‘need support’. It is the metropolitan softies that need training. People who have never caught fish in the pond instructing professional anglers?? Perhaps you should turn the cameras around and we could provide training to the metropolitan babies!!

  7. Paul says:

    I’ve increasingly found an acceptance of ‘shared’ care models of patient’s on ward of metropolitan centres, typically a surgical denomination and a medical one. When turning up at dark o clock at an ICU doc because they’re dying and asking ‘who owns this patient?’ it’s a case of shrugged shoulders. I’ve always though how unbelieveably risky that is. It would be no surprise to me to find that doctors taught in Australian metro hospitals, doing internships and post grad training may have known nothing else and be only too happy to crack right on while doing telemedicine thinking nothing of the question ‘am I in an advisory capacity or not?’.

  8. Anonymous says:

    Paul the ‘closed model of Icu care’ must be the norm. But agencies like ACI invent levels of icu to benefit unqualified persons to be Intensivists and buttress them with cameras such as these which connect to their ‘remote masters’. Cameras are not substitutes for a proper Intensivist run Icu or FACEM run ED!

  9. Anonymous says:

    We (the GP/GPO drs on the even-more-rural-than-I location) and I (a rural paediatrician) shared a resusc of a 29 weeks gestation infant via telelink this week; they with hands on in their hospital op theatre, me assisting from afar the same way I would in our own dept (checking on airway position, temperature of the 1kg infant, discussing lines and fluids). The teamwork was worthwhile. The NETS team arrived at 1.5 hours (which was quick as often can take 6 hours to collect the team and get to airport and get to rural site). We are increasingly using the telelinkup with good effect.

  10. Growler says:

    It’s a Godsend when used correctly, and a complete pain in the a***e when not. I also recall being over-ruled in one rural ED by the nursing staff who DEMANDED that telelink be used despite all being under control, and patient recovering, ‘…because it’s protocol.’ Needless to say, I no longer work there, and they wonder why they have so many difficulties obtaining staff, despite the large sums they offer.

  11. Justin Yeung says:

    Dear sir

    It is with some interest that I read your article. To give a slightly alternative perspective, the Emergency Telehealth service (ETS) has within the last 6 months gone “24/7” in country Western Australia. Commencing in late 2012 with a handful of trial sites, we now provide support for 79 health facilities across WA and are on track for 20,000 referrals for this calendar year (over 65,000 consultations to date, and counting). The vast majority of referrals are from regional nurses, many of whom have no local medical support. When there is a local GP available, there is the option for parallel referral (for example trauma, chest pain, respiratory distress or cardiac arrest), where the ETS clinician commences consultation and immediate management, handing over care to the local GP when they arrive on site. The option is then to stay online if requested, assist in simultaneous referral for retrieval and / or tertiary hospital acceptance or advice.

    Very rarely does ETS dial in without an initiation phone call or faxed referral from the site clinician. On these small number of occasions it has been at the request of the retrieval service (RFDS) or a receiving hospital clinical team.

    The patient has to consent for the referral to be made – except for obvious life or limb referrals. Indeed, for resuscitation cases, the “heads up” SOS by the rural site will mean the ETS physician is already on camera and ready for the ambulance hand over.

    The ETS is Emergency Physician led, but also includes GPs, District Medical Officers and registrars. A number of the doctors are regionally based – including several GP / DMOs who works in regional and remote WA. Our doctors provision from a network of sites – the central hub site is based at a metropolitan tertiary hospital (Royal Perth Hospital), but we also have doctors consulting from regional centres (Bunbury, Albany, Geraldton, Kalgoorlie, Carnavan, Margaret River), some from their residences in WA, and also from an office in Sydney.

    Patient confidentiality is an absolute priority. The potential for there to be conversations overheard is no different to a physical ED, with the onus on the referring site to ensure this, but the treating ETS clinician also needs to double check. The video network is secure. Consultations are not recorded.

    The ethos we are trying to espouse is “how can we add value”, not just to the country patient (who in 75% of cases is managed locally), but also for the regional clinicians – nurses and doctors both. In the last month, ETS been requested to broaden referrals from two larger regional sites to assist in medical fatigue management overnight.

    Lastly, the ETS has provided an innovative and very successful education programme available to all country clinicians – with skills based and simulation scenario learning opportunities. The improvement in basic and in some cases advanced skills to broaden, in particular, nursing scope of practice has been extremely well received (with sometimes up to 30 sites dialing into VC education sessions). The importance of this, with ETS clinician oversight, really can’t be overstated.

    Kind regards

    Dr Justin Yeung

    Director Emergency Medicine | Emergency Telehealth Service | WA Country Health Service
    Emergency Physician | Albany Health Campus

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