Telehealth Special Report October 2020

The arrival of Covid-19 and subsequent national lockdown had a significant impact on the use of telehealth at DHBs. To gain an insight into the impact of Covid-19 on telehealth services, eHealthNews.nz contacted DHBs to find out the latest.

TELEHEALTH AT NEW ZEALAND DHBs AND THE IMPACT OF COVID-19

eHealthNews.nz special report

OCTOBER 2020 SPECIAL REPORT PUBLISHED FOR HINZ MEMBERS

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Introduction

To gain an insight into the national impact of Covid-19 on telehealth services, eHealthNews

The number of reported telehealth appointments in August will be higher in Auckland than other parts of the country due to the city’s Level 3 regional lockdown, but all except one DHB is doing more telehealth appointments

contacted all DHBs seeking statistics and case studies.

The arrival of Covid-19 and subsequent national lockdown had a significant impact on the use of telehealth at New Zealand District Health Boards (DHBs). At Alert Levels 3 and 4, the Ministry of Health advised that outpatient appointments should be managed wherever possible via contactless methods such as video or telephone. DHBs worked rapidly to respond to the crisis, leading to a steep rise in telehealth appointments, particularly via phone. A telehealth briefing paper to the Northern DHB board describes a “seismic shift of activity” with a large number of clinicians moving out of hospitals to working from home, as well as the decision to deliver all outpatient clinics remotely to patients outside the hospital environment. Three DHBs were unable to provide any data on telehealth pre-Covid, but the remaining 17 reported doing around 3,300 telehealth consultations per week in a pre-Covid month from November 2019 – January 2020. In April, in the midst of the Level 4 national lockdown, this rose more than tenfold to 34,500 per week. In June-August this year the average weekly number had dropped to around 19,000 per week.

now than before Covid-19 arrived in February this year.

The Ministry of Health has given $7.1m ‘digital enablement funding’ to DHBs to support locally led delivery of telehealth services and digital inclusion and established a digital enablement work programme, “to guide the allocation of further available funding”. DHBs spoken to by eHealthNews say they are assessing their telehealth capability and looking at what support and enablers they need to build a sustainable and quality service for the future.

Special Report written by eHealthNews.nz editor Rebecca McBeth, editor@hinz.org.nz

Published by HiNZ, exclusively for HiNZ members.

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AVERAGE WEEKLY TELEHEALTH APPOINTMENTS AT DHBs

VIDEO CONSULTATIONS WEEKLY AVERAGE

DHBs

VIDEO CONSULTATIONS

258

3807

AUCKLAND

1773

PRE LOCKDOWN 7 280 NATIONAL LOCKDOWN 12 2000 POST LOCKDOWN 16 870

832

BOP

3900

CANTERBURY

1300

357

CAP I TAL & COAS T

2182

689

2984

COUNT I ES MANUKAU

1376

184

905

HAWKE ' S BAY

272

422

1310

HUT T VAL LEY

451

214

LAKES

744

290

Not all DHBs were able to categorise video consultations vs phone.

532

M I DCENTRAL

138

445

2080

NEL SON MARLBOROUGH

319

994

3300

NORTHLAND

1745

2870

SOUTHERN

178

247

SOUTH CANTERBURY

Data source and notes

Data supplied to eHealthNews.nz by DHBs. Some DHBs noted that the numbers likely undercount the actual number of appointments due to the ability of systems to categorise an appointment as ‘telehealth’. This is particularly relevant to the pre-Covid figures. Where monthly figures were provided, an average over four weeks has been calculated. Taranaki DHB was unable to supply any figures.

100 48

TA I RAWH I T I

0 0 0

TARANAK I

208

WA I KATO

147

WA I RARAPA

151

7853

WA I TEMATA

10,078

WES T COAS T

116

422

WHANGANU I

221

p r e l o c kdown No v embe r 2 0 1 9 t o J a nu a r y 2 0 2 0 n a t i on a l l o c kdown Ap r i l 2 0 2 0 po s t l o c kdown J une t o Augu s t 2 0 2 0

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CASE STUDY Southern

Patient Janice McDrury in a telehealth consultation with Southern DHB endocrinologist Professor Patrick Manning.

Southern DHB is developing a telehealth platform using Microsoft Teams. Simon Donlevy, SDHB acting general manager medicine and women’s and children’s health says telehealth was available prior to the arrival of Covid-19 and the DHB had promoted its use. “It’s fair to say there was a degree of concern and apprehension about the utility of telehealth and whether patients and medical staff would take to it, because it’s a significant change in practice,” he says. One week in November last year there were just 28 telehealth appointments. In a week in April 2020, more than 2,800 telehealth appointments were conducted and in the last week of August, clinicians did 178 telehealth appointments with patients. “Covid forced us to make those changes. Feedback from patients and clinicians was that it was very well received, so it provided

a very good proof of concept to move forward and promote telehealth more strongly and convince clinicians that telehealth is a viable option,” says Donlevy. Clinicians use two screens for telehealth appointments, one for interacting with the patient and the other showing Health Connect South, the clinical portal for the South Island. The DHB is now establishing a robust video platform for patients to interact with their clinicians using Microsoft Teams. Immediately post-lockdown, enthusiasm for telehealth remained high as evidenced by the DHB calling for interested staff to be on a telehealth steering group and getting 100 responses. Appointment numbers have significantly dropped since then as Southern has focused on building a video platform and many staff reverted to what they know, which is bringing patients into hospital.

However, Donlevy says the enthusiasm is still there and the DHB continues to do significantly more telehealth appointments than the same time last year. Southern is also better prepared if it has to go into Level 4 lockdown again. “We’re concentrating at the moment on the platform, then we will be very quickly looking to ensure we have the ability for patients, who perhaps don’t have the equipment, to still access telehealth,” he says. “We will never be forcing patients to use telehealth as some will never be comfortable and we can’t forget the need for in- person appointments as well.”

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Building a sustainable service

Chair of the National Telehealth Leadership Group Ruth Large says the impact of the Covid-19 pandemic on interest in, and use of, telehealth has been huge. “I can’t open a medical journal or brief without seeing the word telehealth or virtual health in it, whereas previously we would have difficulty getting interest,” she says. A recent ASMS Telehealth Research Brief notes that whereas telehealth had previously been viewed largely as an optional or exceptional means of delivering health care services, one of the lasting consequences of the pandemic may be that telehealth consultations will become mainstream. But moving to virtual consultations involves “numerous and complex changes, for example, to routines for booking appointments, documenting consultations, and for arranging follow-ups,” it says. By giving clinicians and patients the opportunity to try telehealth and see that it can work, the pandemic has broken down a lot of barriers around clinician culture and change management. However, much work needs to be done to build a sustainable quality telehealth service that serves the needs of those who need it most, particularly the vulnerable. This includes the need for education and support for both clinicians and patients and reliable data collection. “First and foremost, we need to make sure that we upskill clinicians,

so they feel safe in order to be able to deliver good care,” Large says. Clinicians also need digital services such as electronic prescribing and ordering as well as modern booking systems that enable seamless booking of telehealth appointments. “Without those things, clinicians end up spending a lot more time on a consultation and then they lose the, ‘what’s in it for me?’ part,” explains Large. “Most clinicians are really happy to do the best thing for the patient, but if it’s taking them an hour to see one patient, then not only is it frustrating for them, it also means that other patients miss out. And that’s where we see their interest really dramatically drop off.” A report on the uptake of telehealth during lockdown at Manukau SuperClinic also identifies that the shift requires “major changes in roles, routines and processes” and “adjusting to these changes risks increasing clinician workloads, disincentivising the ongoing utilisation of telehealth”, the ASMS report says.

“First and foremost, we need to make sure that

we upskill clinicians.”

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Digital enablers for telehealth

A number of digital services are needed to deliver a quality telehealth experience for clinicians and patients. Electronic prescribing is a key digital enabler of telehealth. Adoption of the New Zealand Electronic Prescription Service (NZePS) has significantly increased since March 2020, particularly amongst GPs with 820 practices now activated to use the NZePS, up from 137 in December 2018. The service enables a prescription to be generated by the prescriber, transmitted to the NZePS health information exchange broker, and downloaded electronically at a community pharmacy. The latest MoH data shows seven DHBs have 100 per cent of all pharmacies scanning ePrescriptions

and settings that are working towards NZePS integration to complete this work.

eOrdering of lab tests is another key digital service linked to telehealth and the arrival of Covid-19 has driven a significant increase in its use. Use of eOrdering for lab tests has jumped from 25 per cent to 80 per cent in the Nelson Marlborough region, driven by the pandemic. Southern DHB has also started trialling the use of eOrdering for laboratory tests using Éclair. Acting general manager medicine and women’s and children’s health Simon Donlevy says this project would not have been started this year if not for the arrival of Covid-19 and the need for wrap- around digital services to support telehealth consultations.

“820 GP practices now

activated to use the NZePS, up from 137 in December 2018.”

and all but one have more than 90 per cent doing so.

There is no data on users of the service outside of GPs and

pharmacies, but the Ministry website says it is “working with providers of hospital, specialist and community care IT systems to enable prescribers to issue electronic prescriptions for hospital discharge, outpatient, specialists, nurse prescribers (not in general practice), and midwife care”. In the meantime, a temporary waiver for non-NZePS signature exempt prescriptions has been extended until 23 December 2020. The Ministry website says the extension of the temporary waiver, which was due to expire in September, enables systems

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CASE STUDY Waitematā

Waitematā DHB has built a toolkit to enable administrators and clinicians to deliver telehealth as part of its long- term strategy to provide virtual care as an option for patients. Waitematā is the only DHB to have delivered more telehealth appointments in a week following the national Level 4 lockdown, than during it. The average number of telehealth appointments conducted per week in November 2019 was 150, rising to more than 7,800 in April 2020, then up to 10,000 telehealth

send a prescription electronically, are key to a sustainable service. The DHB also recently introduced a new tool to allow clinicians to email patients relevant information about their condition, something which used to be given as a paper booklet during consultations. “It’s about having the whole package working. I wasn’t surprised to see our August numbers above April because it’s quite easy to pivot to a greater proportion of telehealth with that in place,” explains Christiansen. The DHB is yet to work out what is a realistic and sustainable number of telehealth appointments post-crisis. During lockdown, people had to have telehealth appointments when in- person would have been preferable and now the DHB is working to catch up on missed appointments. Christiansen says the focus should remain on continuing to provide good quality care and giving patients choice about how they receive that. He says the DHB had a three-year plan to introduce more telehealth between 2019 and 2022, and has already achieved greater numbers than expected in less than a year. “It’s astonishing, not only the numbers of appointments, but how much has changed to achieve those numbers,” he says.

appointments conducted during a week in August.

Chief Medical Officer Jonathan Christiansen in Waitematā DHB’s telehealth pod.

Chief Medical Officer Jonathan Christiansen says telehealth is not just about having the option of a phone or video interaction with a patient. “You need quite a lot of infrastructure and staffing support to make that work and what we’ve been building over the last several years is the toolkit to allow administrators and clinicians to support the telehealth work,” he says. Administrators have worked hard to get the majority of patients on to validated email addresses, which means they can be set up with one-link Zoom appointments. Every clinic room has video capabilities and administrative teams have booking options for telehealth. Tools such as ePrescribing and eOrders, so a clinician can easily order tests or

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Telephone vs video

More than 90 per cent of telehealth consultations done at DHBs during and after lockdown were done via telephone and the proportion of phone over video has increased since before Covid-19 hit. However, the number of DHBs reporting some use of video has risen significantly. Seven DHBs identified doing around 280 video consultations a week pre-Covid. In April, 12 DHBs were able to identify around 2,000 consultations a week being done via video conference. By either June, July or August 2020, all but four DHBs were able to report on telehealth consultations done via video, with an average of 870 per week. Large says it is much easier to upscale a telehealth service if you have something going in the first place and that is what we have seen in New Zealand. “So those places which were already providing little centres of excellence have been able to upscale. But because the support and infrastructure were not there, a lot of telehealth done during lockdown was over the phone.” She says reviews of patient feedback, both in New Zealand and internationally, show the majority of patients were happy to receive contact from the clinicians by any

Northern DHB identified a 20- fold increase in use of Zoom for video conferencing during the national lockdown. “With much of the groundwork completed and the majority of teams and staff who needed it already using Zoom pre-Covid, we were in a good position to scale our service rapidly to support staff shifting to remote working,” a briefing paper to the board says.

"The number of DHBs reporting some use of video has risen significantly."

form possible whilst lockdowns were in place, but they would have much preferred video.

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Patient experience

The opportunity to try telehealth during New Zealand’s lockdown periods has been a positive one for most patients, according to surveys done by DHBs. In May this year, Waitematā surveyed patients who had received a telephone or video appointment during lockdown and 95 per cent of respondents said telehealth appointments are a good service to provide and that they should be offered where clinically appropriate. Chief Medical Officer Jonathan Christiansen says patient feedback has been positive, particularly from people who were able to have a family member or support person join a telehealth consultation, who would not have been able to attend with them in-person. Patients also reported feeling comfortable in their own homes and appreciated not having to take a lot of time out of their day to attend a short hospital appointment. “Offering the choice to patients has been very consistently supported. It’s about what’s the best option for the patient and the clinician at any given time,” he says. At Southern DHB, patient surveys have also revealed that the vast majority of patients were satisfied or very satisfied with their telehealth appointments during lockdown and 80 per cent of patients surveyed on their telehealth experience by Nelson Marlborough DHB said they would use telehealth again. Patients in that region reported that time and money saved

on travel was the best part of the digital consultation.

An assessment of telehealth delivered by Northern DHB’s Mental Health and Addiction Service (MHAS) found the experience of participants during Covid-19 was “significantly positive”. “Most participants indicated they would like to continue to receive some form of telehealth, the majority of those preferring to have the option to have both telehealth and in-person face to face contact,” it says. “There was no clear difference between Maori and non-Maori preference for telehealth.” While not travelling long distances to hospitals is a key benefit of telehealth, having a health professional in the room with the patient is often needed and beneficial for their care. A number of DHBs, including Northern, MidCentral, Nelson Marlborough and Southern, use regional clinics or hospitals as hubs for telehealth clinics, where patients can have a consultant appointment closer to home.

“Most participants indicated they would like to continue to receive some form of telehealth.”

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CASE STUDY Nelson Marlborough

A telehealth survey at Nelson Marlborough DHB found an overall satisfaction rating of 4.05 (five being very satisfied) with patients reporting that time and money saved on travel was the best part of the digital consultation. Also, personal interaction with a specialist when it was a video call. Zoom is the DHB’s platform of choice for clinical processes and it is working with primary

This issue, combined with the pressures of a busy workforce

trying to deal with the backlog of appointments caused by lockdown, means people revert back to what they know and are comfortable with. Livingstone says sending patients an appointment letter is simpler than contacting the patient to ask if they would like a telehealth appointment and ensuring they have the technology available to do it. But lockdown has given people a taste of telehealth and a chance to engage in a new way of doing things, so the DHB is working with clinicians service by service on how to enable telehealth as a seamless process at scale.

health organisations to get more consistency in telehealth use for patients.

Lisa Livingstone, registered nurse and clinical lead IT projects at Nelson Marlborough DHB, says this is important as it can get confusing for patients having to work with several different platforms as they move between providers and places. She believes that a unified approach is key to making telehealth work for patients and that is why the South Island DHBs are looking to promote a regional approach. The South Island Alliance has recently appointed a telehealth facilitator for the region. With the national Health Information Platform on the horizon and the NZTLG doing great things in this space, Livingstone is hopeful of telehealth making “great strides” on the back of the Covid-19 pandemic. However, she says NMDHB does not yet have the maturity in its systems, such as integration with its patient management system, to make telehealth easily available.

Registered nurse and clinical lead IT projects, at Nelson Marlborough DHB, Lisa Livingstone

Ultimately, the goal is a mixed model of telehealth and in- person appointments, where patients have choice.

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Digital inclusion

A key concern about a rapid shift to telehealth is that it may exacerbate inequities in the health system. A report from the Telehealth Resource Centre says up to 20 per cent of the population will not have access or skills to embrace telehealth and this may be higher for high-needs populations. A Waitematā DHB survey released last year found the most common reasons for declining a video appointment were; no access to a device; preference for a personal visit; and do not like/feel comfortable using video calls. The Northern DHB telehealth brief notes that, “introducing telehealth to patients in the home/community has the risk of increasing equity gaps for those lacking technological confidence or with limited access to the technology that is needed. “Careful consideration of this is required and a solution that is more than simply web pages and brochures requires a pro-active patient centred approach,” it says. Large says that digital inclusion is not just ensuring people have the devices and data to use technology, but also providing opportunities and education for potential patients. Waikato DHB is working on a ‘tech checklist’ to go through with patients to see if they can participate in a telehealth consultation and if they can’t, what can be done to help them? Some DHBs, such as Waitematā, are looking at setting up telehealth pods

or hubs in the community as a way of removing technology as a barrier. Southern DHB is also looking into using marae as telehealth hubs and funding data for telehealth interactions for patients. “We have to be careful that we don’t increase inequity of care as we don’t want telehealth to be just available to those people with the necessary computer equipment or phone data,” says acting general manager medicine and women’s and children’s health Simon Donlevy. On a national level, the Ministry of Health has introduced a new sponsored data partnership with telecommunications companies to help reduce the digital divide by ensuring people without data on their smartphones can still access health information and services online. Under the deal, the Ministry of Health pays for all mobile data charges for 11 key health websites and two GP patient portals until June 2021. The Ministry says it is also providing funding to the sector to enable health providers to increase digital inclusion. This could include the use of technology prescriptions, where a device and/ or internet

“Digital inclusion is not just ensuring people have the devices and data to use technology, but also providing opportunities and education.”

connectivity is provided to a patient so they access digital services. However, a Ministry

spokesperson says, “providers will determine what type of technology prescription they may offer and to whom based on need”.

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CASE STUDY MidCentral

who, in some cases, is trained to do physical examinations. MidCentral DHB was doing just under 400 telephone and video appointments a month last November. This jumped to nearly 2200 in April during the national lockdown and has since gradually dropped to 550 in August 2020. Hardie says the cancer service collects data in its own booking system, which previously did not completely integrate with the hospital system, so the DHB’s numbers prior to July 2020 do not tell the whole story. The Covid-19 crisis highlighted this as an issue and work has completed to integrate the systems. “Covid-19 has really helped us to push forward the telehealth agenda,” she says. “Before, people were quite sceptical about how it would work and whether patients would accept it. What Covid has shown is what telehealth can offer in terms of flexibility and options.”

MidCentral DHB has established a telehealth project group to develop it as a regular service and choice for patients and clinicians. Radiation oncologist Claire Hardie says, “we are working on a project to ensure we are going to meet the needs of our patients and clinicians with options for telehealth and how to ensure patients have the accessibility they need”. While a telephone appointment is relatively easy to provide, a video conference involves more technology and potentially cost to patients. “We are working through making it sustainable, ensuring we have the infrastructure at our end to book the appointment and the capability of our patients to access it,” she says. The DHB is also looking at how community groups may be able to support patients in telehealth closer to home, rather than giving devices to patients themselves. “We’re working through how that might look and the partner agencies we might engage with,” Hardie explains. Hardie is based at Palmerston North Hospital and she and her colleagues in the cancer and haematology service had been using video conferencing for patient appointments for some time before the pandemic hit with video links to New Plymouth, Hastings and Masterton hospitals.

Radiation oncologist at Palmerston North Hospital, Claire Hardie

Patients are accompanied by a nurse at the telehealth clinic

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Capitalising on the momentum of Covid-19

Resistance to change is a key barrier to digital transformation. Covid-19 has seen this barrier to implementing telehealth rapidly broken down amongst

through barriers around change management and culture. “With any change process you always have leaders and early adopters and we had quite a number in November last year, but the majority of clinicians hadn’t had the opportunity to experience it,” he explains. “Medical professionals are generally quite conservative about changing patterns of work they’ve been doing for a long time and we do need a bit of a pivot point to say, ‘actually we have to do this differently, it’s not nice to have it’s a must have’, and that’s what Covid-19 gave us.” “They’ve been given the impetus, but we have to support them so their experience of doing telehealth for the first time is reasonable and good and they have the skills to do it,” he says. A Northern DHB telehealth briefing paper says “Covid-19 has converted many to a new way of working and at least a new way of thinking. The focus has now shifted to embedding telehealth into business as usual as a significant contributor to improved patient access, timeliness and quality of care.” For resources on implementing telehealth, see the NZ Telehealth Forum and Resource Centre.

organisations, health care professionals and patients.

DHBs recognise the need to capitalise on that momentum and acceptance of change, but have also in many cases had to put the brakes on telehealth use, while they build a lasting service going forward. Large says there is no easy answer to that problem, but “if we continue to deliver a shoddy technology with poor supporting tools, then we will rapidly lose willing clinicians”. “We need to accept that we should get this right. What I would love to see nationally is people saying, ‘we may be parking the difficult parts for now but here is our roadmap so that we are clear with what we need to deliver and when’,” she explains. While work goes on to get the technology and enablers in place, a lot can be done in parallel to look at services and consider what needs to be done to upskill clinicians and patients, “particularly those who are disadvantaged or those who we know need the service most,” she says. “It’s a really good opportunity for DHBs up and down the country to look at those places that have done these things well at speed.” Chief medical officer at Waitematā DHB, Jonathan Christiansen, says that while the tools were in place to deliver telehealth prior to the pandemic, Covid-19 helped break

"The focus has now shifted to embedding telehealth into business as usual."

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THANK YOU! WE WELCOME YOUR OPINION

eHealthNews thanks those who generously contributed their time and expertise to this special report. HiNZ intends to publish a special report every quarter. What topics would you like us to write about in future reports? To provide feedback on this report, and suggestions for future reports, please email eHealthNews editor Rebecca McBeth at editor@hinz.org.nz To support our work , please consider joining HiNZ. It is only $17 per month or $198 per year. Read more at hinz.org.nz/whyjoin

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