There are many definitions of and applications for telemedicine and telehealth. The US Centre for Connected Health Policy (CCHP) describes the phenomenon as “a collection of means or methods for enhancing healthcare, public health and health education delivery and support using telecommunications technologies.”

The sheer extent of the growth in telemedicine resources in recent years might well send even the most ‘techie’ GP into a panic, concerned not least with the potential for error in any new type of ‘virtual’ healthcare delivery.

The CCHP stresses that telehealth is not a specific service, but a collection of means to enhance care and education delivery. A video consultation with one’s own patient, a video consultation initiated by a patient with a random GP, an electronic referral from a GP to a hospital, a secure dedicated health service email system or an educational ‘webinar’ can all to some extent contribute towards improving how care is delivered. However, they are a means to an end and not an end in themselves. 

You can have every modern telemedicine facility at your disposal, but ultimately if a patient cannot get a bed in a hospital, or if there is inadequate GP manpower at the coalface, the service cannot be delivered effectively.

Also, despite the rapid growth of new telemedicine developments at both primary and secondary care levels, there remain familiar problems of interconnectivity – systems not joined up, deficiencies in inter- and intra-hospital and hospital-GP communication and perhaps the most serious overall deficit, the lack so far of a national electronic health record/patient identifier. 

So should we all just ‘calm down and get on with it’, or fervently embrace the new order? This will be one of the questions to be debated at the forthcoming ICGP annual conference in Wexford. The conference will be looking at the GP of the future and examining how technology might be used to enhance practice development and patient care. A keynote speaker will be Richard Corbridge, chief information officer of the HSE and chief executive of eHealth Ireland.

Current state of play

Looking at the current state of play with telemedicine, Conor O’Shea, national co-ordinator of the GPIT Group, says the recent success story has been e-referrals, which have gone from a slow start to over 100,000 e-referrals sent  by GPs to hospitals last year. He points out that all GPs are now able to refer to all public hospitals electronically, and to date around half of all GPs have signed up to the system.

“It still probably only accounts for just over 20% of the total volume of referrals in the public system, but it has had a very good start and we are working on trying to improve it.”

Conor says there are still some issues with the interface which makes it more convenient to make paper referrals in some cases. “People are wary of change so it may take some time for GPs generally to get used to this new system. We need to make it something that GPs want to do.”

Individual health identifier

The individual health identifier is being progressed, albeit slowly. “It will happen,” says Conor. “We performed the first trial run on it, importing test numbers into GP software in two practices just before Christmas. The technology seems to work but the implementation is a little bit off yet. It will probably be another year or two before it becomes widely available. It will streamline electronic communication between GPs and other parts of the health service.” 

By and large, most of the data protection issues involved have been sorted out; the legislative issues are currently being dealt with, Conor says.

Regarding online/video consultations, he doesn’t think there is a clear answer yet as to where all of it fits into general practice. “People are trying out different solutions, and the facility to offer video consultation is likely to be readily available for most GPs in the near future. The commercial models are filling a niche for limited types of consultations, but I could certainly see out-of-hours GP services adopting video consults a lot more. I would imagine that it will become more of a part of our day-to-day practice.”

Conor points out that a lot of general practice involves hands-on care and face-to-face consultations, and deciding what types of consultations suit ‘hands-on’ or video is going to be a challenge. 

Digital development in hospitals

Conor believes the hospital sector has seen the greatest amount of digital development in recent times. “In addition to e-referrals and Healthmail, the maternity and newborn system (MN-CMS) was introduced into CUMH just before Christmas. This confers newborn babies with electronic records and is set to be rolled out to all maternity hospitals.” 

The system allows patient information to be shared with relevant providers, eg. consultants, midwives, dietitians, community services, etc as and when required.

“Unfortunately,” Conor points out “this system was not initially integrated fully with general practice, causing difficulties for GPs trying to provide combined antenatal care. We are now working very hard to try to rectify this and it is certainly a lesson learned for future hospital-based initiatives of this type.”

Making life easier

Brian O’Mahony, who has a background in general practice and now works full-time in health IT, says the pace at which IT change is happening can be head-spinning, but it is clear that many developments will ultimately make life much easier for doctors and patients. 

He says a glance at the HSE’s eHealth Ireland website (www.ehealthireland.ie) will provide an idea of the breadth and scope of projects in primary, hospital and other types of care that form a part of the delivery of the country’s e-health strategy. The developments that stand out thus far are those that improve communication between GPs and hospitals and vice versa, he says.

“The e-referral system, which went nationwide to all acute hospitals last year, allows GPs to send referrals directly to hospitals from their GP practice software systems. It uses the Healthlink messaging broker and the information is transmitted electronically in a highly structured message formatted to an international standard. The message is acknowledged automatically, and the official target for a response following triage by the hospital is five working days.”

However, Brian says in some specialties this can take longer due to the length of waiting lists; a sign perhaps, that in spite of major IT advances, the health system still faces challenges in terms of capacity to provide a ‘real-time’ service. This is not, however to underestimate the importance of the IT revolution in health. Brian O’Mahony also points to the recently launched Maternal and Newborn Clinical Management System (MN-CMS). 

“This is essentially an electronic health record for all women and babies in maternity services in Ireland.” 

Sharing of information with GPs for combined antenatal care and discharge summaries should be available by the second quarter of 2017, Brian says. MN-CMS is essentially a smaller-scale version of the planned national Electronic Health Record, which will enable, subject to necessary data protection, the sharing of information about all users of health and social services. 

Ahead of the game

Brian says GPs are in many ways ‘ahead of the game’ compared to other parts of the health service when it comes to IT. “Already we are sending e-referrals and receiving lab and radiology results electronically, in addition to the high levels of digital activity in everyday practice. This is in stark contrast to most hospitals, where there would, as yet, be nothing like the same level of digitisation or connectivity between staff, departments and other hospitals and services. 

“However, this is an evolving process, and other aspects of health and social services will eventually embrace more of the IT revolution.”

Brian says he is less sure of the advantages of online/video consultations. “Time will tell how this pans out, but I feel at present there are many risks involved with patients relying on video consultations for their care. It has uses; for example, when GPs themselves use the technology for some level of communication with patients in their practices, but ultimately, how can you really replace the value of the time and effort put in to face-to-face and hands-on care and how do you properly monetise online care? 

“It is always important to consider privacy and confidentiality with electronic communications and to ensure that the data protection systems in place are as robust as they can be, says Brian. 

E-health – what’s out there?

www.icgp.ie

As well as being the membership site for the ICGP covering all aspects of general practice, the website also includes the e-portfolio of GPs who are included in the general practice speciality for professional competence purposes. It records CPD activities for official purposes. Among the host of other features it offers are accredited e-learning modules, library access and clinical guidelines. It also has a detailed IT section to help GPs keep up to date in this area, and it includes regular webinars.

www.ehealthireland.ie

This is the website of the HSE’s national technology programme. It has recently been redesigned. It details all the unconnected different projects that are ongoing from various bodies and institutions and lists upcoming events.

www.healthlink.ie

The National Healthlink Project is the secure exchange platform used for bloods, electronic referrals, discharges and other clinical patient information between GPs, hospitals and healthcare agencies. Healthlink messaging is at the core of the National Electronic General Referral Project, the National Cancer Control Programme and other referral initiatives. 

www.healthmail.ie

Healthmail is a secure email service for GPs and other health professionals. It is a way to securely pass information between white-listed email addresses. GPs can access their Healthmail accounts on desktops, laptops, tablets and smartphones to share patient information. Healthmail is a service of the HSE and is supported by the Department of Health and the ICGP. The HSE and ICGP are currently evaluating Healthmail.

www.videodoc.ie

VideoDoc will allow GPs to offer video consultations for minor ailments and straightforward consultations. VideoDoc will be available on HealthOne and other GP software this year.  

www.gpbuddy.ie

GPBuddy.ie is an online medical directory to help GPs and other healthcare staff find medical professionals and services. It also provides clinical information and education for GPs.

www.gp-online.ie

GP Online is a video health and cloud-based practice management system which is under development by the National Association of General Practitioners (NAGP).

www.nationalgpforum.com

GPs can sign up to the National GP Forum, available via a smartphone/device app. Membership of this forum is by registration and restricted to practising GPs in the Republic of Ireland. 

www.irishhealthpro.com

An Irish produced online resource with a range of clinical content and features of interest to GPs from a large panel of Irish doctors. It has 36 clinical channels containing a range of different articles plus an events calendar. It also includes the best of the international journal abstracts. It is available to registered health professional users only.

www.aviva.ie 

‘Babylon Health’ is offered to Aviva Health Insurance members providing online GP consultations. Prescriptions can be posted to the member’s home, office or local pharmacy.

www.vhionlinedoctor.ie

Vhi Online Doctor offers online GP video consultations. Healthcare professionals are available on demand from 8am to 10pm Monday to Sunday.

www.careoncall.ie

CareOnCall by Laya Healthcare offers GP video consultations, an online prescription service and phone access to GPs, nurses and physios. GPline, Nurseline and Physioline are free of charge for Laya members, and a 20% discount is offered to members for GPLive (online video consultations) and the prescription service.

www.irishlifehealth.ie

Irish Life Health members offers online consultations with a GP, a private prescription service, access to health, disease, lifestyle and travel information, as well as fitness and nutrition services.

www.myclinic.ie

This provides users with online access to a team of Irish doctors for general medical consultations and a range of prescriptions. MyClinic also provides a same-day fax service to pharmacies to enable collection of prescriptions without delay.

www.lloydsonlinedoctor.ie

Online doctor service where patients can connect with doctors on a range of specific medical conditions. A medical questionnaire is completed, which is assessed by a doctor and, if suitable, a paper prescription is posted. 

www.webdoctor.ie

Offers online consultations and delivers prescriptions to the patient’s door.

www.meedoc.com 

Part of an international group with an Irish service, offering online consultations with prescriptions faxed to a local pharmacy.

www.dred.com

DrEd.com is an online doctor service enabling users to obtain prescriptions for specific conditions, following a detailed online medical assessment. A prescription can be faxed to the patient’s pharmacy or sent to their home.

www.healthwave.ie

Healthwave.ie is an online pharmacy subscription service, which offers members savings on prescription medication as well as free nationwide home delivery.