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FEATURE
Tele-consultation
The tele-geriatics system in Khoo Teck Puat Hospital (KTPH) in Singapore involves patients at nursing homes using a videoconferencing system to meet with geriatricians for review. Before this tele-geriatics system came into place, the geriatricians supported nursing homes by commuting from the hospital to the nursing homes. KTPH are currently working with four different nursing homes.

However, this was hard to sustain as the frequent commutes took away a lot of time from the geriaticians. The teleconferencing allowed them to 'see' the nursing home patients and provide accessible care without having to leave the hospital premises. Thus, saving them time and allowing them to have more time for their clinical duties.

Rachel Lim speaks to Mr Kenneth Lam, Senior Manager in the Department of Geriatric Medicine at Alexandra Health, to find out more about the system and its benefits.

Q: What is the tele-geriatics work flow like?

A: There are scheduled meetings for nursing home patients; they are consulted over the tele-geriatrics system as opposed to a physical visit. Along with the scheduled appointments, there are ad-hoc appointments/sessions for consultation as well.

For each tele-geriatric consultation, one doctor is needed from KTPH and one trained tele-geriatrics nurse from the nursing home.

Q: How has the system benefited the Geriatrics department and nursing homes?

A: In the past, KTPH's geriatricians physically visited each nursing weekly or 4 times a month (on average). With four nursing homes, this would add up to 16 visits per month with patients having limited access to our geriatricians. With tele-geriatrics, our doctors commit to one physical visit to the nursing homes each month and review the patients over the tele-geriatric system for subsequent weeks.

In the past, all nursing home patient consultations were planned and scheduled. With tele-geriatrics, our geriatricians are able to respond faster to patients in nursing homes, and we can potentially reduce the frequency of patients coming to and being admitted to our A&E and outpatient clinics, hence, freeing up capacity for more urgent cases.

The tele-geriatics system has also given rise to other benefits and initiatives.

  • Geriatricians are able to hold family tele-conferences with nursing home patients and family.
  • Geriatricians can use tele-conferences with nursing home staff to conduct meetings (such as Mortality rounds, Multi-disciplinary rounds, case conferences) necessary for proper clinical governance in the homes.
  • Greater efficiency in training nursing home staff through the network. Currently KTPH has begun a network link-up to three nursing homes simultaneously for Continuous Nursing Education (CNEs). This link-up also allows for case presentations between staff of different nursing homes.

Q: What were the challenges of implementing this project?

A: The technology (its hardware, software and infrastructure) has not reached a reasonable state of maturity in Singapore at an affordable price that is reflective of its intrinsic potential to be a "game changer" to healthcare at a national level. Policy and support for these initiatives are still evolving.

As a result, the impetus for change by clinicians and healthcare agencies is somewhat muted. Commercial and non-commercial industry partners likewise are therefore failing to engage with a sense of urgency and are very risk adverse.

At this juncture the climate that we are operating in is still one that views Telemedicine as a "novelty", but the KTPH team believes this will one day be an absolute necessity in our healthcare system. We are working and aggressively exploring every opportunity with an open mind – our approach is "Let's have it and then see what we can do with it".

Q: Were there any difficulties in setting up this system in the nursing homes and in the hospital?

A: Yes. The level of IT infrastructure in each of the nursing homes varied vastly, as our partners included some of Singapore's oldest and newest nursing homes. All our partners required extensive cabling work to ensure that each room or cubicle has at least one network point to ensure that each and every bed in the nursing homes would be accessible for tele-consultation. There was also a lot of experimenting to discover a stable wireless solution for our teleconference system, but to-date we have been unsuccessful.

Q: How did the staff and patients react to this change? Were there any difficulties in them adapting to it?

A: Initially the nursing home staff were quite intimidated by the programme and the use of technology. While the Tele-Geriatric system helps to bring the nurses closer to our Geriatric consultants, this means the dialogue and consultation session become more intense, as the nurses are required to be the 'hands and feet' of the doctors. Thus, earning the trust and respect of the doctors was one of the biggest challenges for the nurses. The doctors, on the other hand, have to rely on a less direct way of gathering information, making a diagnosis and managing the patient. This took a bit of getting used to for both the doctors and nursing home staff.

Q: Have there been any additional costs on the patients?

A: As we are still in the pilot phase (funded by MOH) there is no additional cost to the patient.

About the Interviewee

Kenneth Lam currently works as a Senior Manager in the Department of Geriatric Medicine in Alexandra Health. His career started 15 years ago as a physiotherapist after graduating from University of Otago, New Zealand. Specialising in Geriatrics all his career, he now leads an operations team working alongside senior clinicians managing elderly services ranging from acute to community care. Together with Dr James Low, he started the Tele-Geriatrics service in support of nursing home patients.

Additionally he is involved in the building of Yishun Community Hospital, as well as projects such as Advance Care Planning and 'Ageing-in-Place' (AIP), which hope to transform care for the elderly in the North.

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