Hibernia Telemedicine Project

Transcription

1 Hibernia Telemedicine Project Four Month Evaluation Health Research Unit July 1998

2 EVALUATION OF HIBERNIA TELEMEDICINE PROJECT Four Month Report Health Research Unit Dr. Bill Bavington Dr. Sandra LeFort Linda Longerich Ann Ryan Dr. Jorge Segovia July 1998

3 Evaluation of Hibernia Telemedicine Project EXECUTIVE SUMMARY Background A telemedicine link supporting interactive audio-conferencing, still image and digital sound transfer, and video conferencing has been established between the Hibernia oil platform and the Health Sciences Centre. This link provides access to the necessary communication network to conduct medical consultations between platform nurses and shore-based physicians both on a scheduled and emergency basis. The Health Research Unit, in cooperation with the Telemedicine Centre, was asked to carry out the evaluation component of this project. Evaluation Objectives and Methods This 4-month report of the formative evaluation assesses the Hibernia Telemedicine System in terms of its current use by the platform nurses and shore-based physicians, its perceived impact on patient care, as well as nurse, physician and patient satisfaction with the system. Data were collected by means of nurse-completed telemedicine consultation records, patient satisfaction questionnaires, and through key informant interviews with the two platform nurses and four of the five shore-based physicians who provide on-call medical services to the Hibernia rig staff. Consultation Information Approximately 20 to 25% of nurse-patient contacts on the rig resulted in a medical consult with shore-based physicians. For the vast majority of these consults (~95%) only telephone communication was used and that appears to be quite adequate for most cases. More than half of the telemedicine consults were for injuries, and 70% of all telemedicine consults were regarding transfer of a patient to shore. A small percentage of consults made use of the VisiTran system to send still photos and text. Most VisiTran consults involved diagnosis and confirmation of treatment protocol. Full video conferencing was not used during the period of this study. Physician Interviews The physicians are generally satisfied with their telemedicine experience, but felt that additional training would be valuable. They were very impressed with the quality of the VisiTran pictures and over time have now become more comfortable with the consulting process. Physicians would like their role clarified in certain areas, particularly their role during emergency situations on the rig. It was generally agreed that regular quality assurance sessions would be helpful for patient management and for increased comfort with use of the system. Platform Nurse Interviews The platform nurses are very positive about the telemedicine service to the Hibernia oil platform. According to one of the nurses, the telemedicine system has helped keep people on board and get people off when needed. It was also stated that the system and the excellent liaison with the five physicians provides [the platform nurses] with a better comfort level. The nurses, however, agree that improvement is needed. Training and systems familiarity with VisiTran and full video conferencing seems to be where improvement is needed most. The issue of the telephone link being lost during general shut down and crisis situations is a crucial one. Increased use of the VisiTran system and initiation of full video conferencing in the future may depend on resolution of some of the major issues outlined in this report. i

4 Patient Satisfaction The majority of the patients had a very positive opinion of the Hibernia Medical Centre services and the telemedicine system. They stated they were more confident in the health system knowing that on-shore physicians were available for consultation. They have confidence in the platform nurses and believe they are concerned with their problems. The platform nurses, physicians and patients were generally satisfied with the system overall, however, there were a number of difficulties/barriers noted with the use of the VisiTran and full video conferencing system. Both nurses and physicians provided a number of constructive suggestions related to expanding the use of the system to realize its full potential. Recommendations The following recommendations come directly from the results of this study and in many cases represent specific ideas, comments and suggestions put forward by study participants themselves. Telemedicine Should Work with Platform Nurses and the Off Shore Health Services Group To: Set up a quality assurance program Promote emergency protocols which include platform nurse, telemedicine and physician s roles Include platform nurses in any appropriate in-service teleconferences Improve utility of VisiTran system Improve utility of full video system Provide a beeper to on-call physicians which is suitable for use by hearing impaired Telemedicine Should Work with Hibernia Management to: Assure adequate telemedicine consultation in emergency situations Arrange for on-shore physicians to visit the Hibernia rig and medical clinic Provide dedicated time for platform nurses to participate in telemedicine consultation Establish a private room for mental health assessments and consultations Facilitate patient management by on-shore physicians Telemedicine Should Work with the Evaluation Team to: Continue evaluation of the Telemedicine Service to the Hibernia Oil Rig Revise evaluation protocol based on 4-month evaluation report and any subsequent interventions ii

5 Table of Contents Executive Summary... i Table of Contents... iii 1.0 Background Objectives Methodology Consultation Records Physician Interviews Platform Nurse Interviews Patient Satisfaction Summary and Recommendations...13 Appendix 1: Patient Satisfaction Results Appendix 2: Medic Consultation Form Appendix 3: Platform Nurses Interview Guidelines Appendix 4: Physicians Interview Guidelines Appendix 5: Patient Satisfaction Questionnaire Form iii

6 Hibernia Telemedicine Evaluation 4 months BACKGROUND A telemedicine link supporting interactive audio-conferencing, still image and digital sound transfer, and video conferencing has been established between the Hibernia oil platform and the Health Sciences Centre. This link provides access to the necessary communication network to conduct medical consultations between platform nurses and shore-based physicians both on a scheduled and emergency basis. Audio conferencing: The platform nurse is able to obtain 24 hour advice and support from the shore-based physicians. The on-call physician is accessed by the platform nurse either by calling the physician directly or via a paging system. The consulting physicians can contact the platform nurse by telephone via satellite. VisiTran System: This is a computer based system which is capable of transmitting still and moving images, audio and text using VisiTran MD software through a system similar to standard . Pictures of eye, ear, throat and other body areas can be captured using a variety of peripheral devices. Text and still pictures of EKG printouts can also be transmitted. Video conferencing: The platform nurses and shore-based physicians have the option to consult via compressed video conferencing. This is real time interactive consultation with full video and audio. The on-shore VisiTran computer and the full video conferencing equipment are located in a dedicated secure room in the Health Sciences Centre which is available on a 24 hour basis. The equipment on the Hibernia platform is located in the medical clinic. The Health Research Unit was asked to carry out the evaluation component for the Hibernia Telemedicine Project in cooperation with the Telemedicine Centre. The evaluation will consist of an interim report at four months and a final report at the end of the first year. This evaluation was approved by the Human Investigations Committee, Faculty of Medicine, Memorial University of Newfoundland. 2.0 OBJECTIVES The major objectives of the evaluation are: to provide data on how, when and why the telemedicine system is used on an on-going basis and to determine what impact the system has on patient care to evaluate platform nurse and shore-based physician satisfaction with the Telemedicine System. To determine patient satisfaction with the Telemedicine System The Hibernia Telemedicine Project is being evaluated on an on-going basis, a formative evaluation. Objectives of a formative evaluation are to look at potential problems, identify where the program needs improvement, describe and monitor program activities and test for achievement of goals.

7 Hibernia Telemedicine Evaluation 4 months 2 This 4-month evaluation report will include details on telemedicine interactions and platform nurses, shore-based physicians and patient satisfaction with the Telemedicine System. This initial evaluation will assess how well the equipment, telecommunication links and on-shore physician communication protocols are working and make recommendations for improvement will be made based on this assessment. 3.0 METHODOLOGY Data Collection: ongoing information on all telemedicine events is obtained from detailed consult forms which are completed by the platform nurse initiating the interaction. Details recorded include the level of telemedicine use, nature of illness, treatment recommended, outcome and satisfaction with the telemedicine interaction. (See Data Collection Form - Appendix 2) Key Informant Interviews: There are two registered nurses employed as medics on the Hibernia Platform and five family practice physicians who are providing the shore-based consultation. The two platform nurses are to be interviewed at three months, six months and one year. The three month interview has been completed for this report. Physicians were originally to be interviewed at six months, however, because further information was needed for this report, interviews were conducted at four months with all physicians with the exception of Dr. Carl Robbins. Dr. Carl Robbins, as Director of Telemedicine, did not participate in the evaluation process. The interviews assess the satisfaction with this distance medical care system in general, and specifically with the telemedicine equipment and communication protocols used. (See Medic Interview Questionnaire and Physician Interview Guidelines Appendix 3 and 4) Patient Satisfaction: Any patients for which telemedicine interaction was used are asked by the platform nurse to complete a satisfaction questionnaire. The completed questionnaire is then mailed back to the evaluation team. No identifying information appears on the questionnaire itself; thus evaluation researchers remain blinded to all patient identifiers. The patient questionnaire assesses the patient awareness of the telemedicine system, the level of interaction and their general satisfaction with distance medical care provided by this system. (See Patient Questionnaire, Appendix 5) Analysis and Reports: Data entry and analysis of quantitative information is done using Epi-Info software. Qualitative data is analysed for content and themes. This interim four month report will provide information for on-going assessment of the telemedicine project. A final report will be prepared at the end of the first year.

8 Hibernia Telemedicine Evaluation 4 months CONSULTATION RECORDS Telemedicine consult records from February 6 to April 7, 1998 were analysed for this report. Over this two month period, 17 telemedicine consults were recorded. Both platform nurses and physicians stated in interviews (see Sections 5 & 6) that more consults may have occurred during this time which were not recorded on the consult forms. However, these consults would have been concerned with follow-up on a previous consult rather than new consultations. We believe that these 17 consult records are a representative sample of the types of consults taking place. All consultations involved at least a telephone contact with the shore-based physician. Initial phone contact with a physician was made within ten minutes. Only five of the 17 consults analysed used the VisiTran system. All VisiTran messages were sent and received on the same day as phone contact. Often, the platform nurse sent VisiTran information prior to phone contact. No full video conferences were held. Except for training sessions, no consultations have used the full video conference system since the beginning of the telemedicine project in Of the 17 consults recorded, nine were for injuries, six for other illnesses, one for an existing chronic condition and one follow-up. All but five of the consultations involved the transfer of the patient off the oil platform. This is not surprising since procedure requires that a shore-based physician be contacted if a patient is to be transferred off of the rig. Ten of the 12 patient transfers recorded used the regularly scheduled helicopter service. One patient transfer left the platform on the supply vessel due to foggy conditions and one patient with possible appendicitis was transferred by a special evacuation flight. Except for one case dealing with a chronic condition, consults dealing with transfers did not primarily involve discussion of treatment or diagnosis. Cases where the VisiTran, system was used were for clinical consultation rather than routine consultations such as requests for antibiotics or notification of patient transfer. Three of the five VisiTran consults involved diagnosis and all five involved confirmation of treatment protocol. All VisiTran messages were initiated by the platform nurse. Still pictures of the affected site were transmitted in all cases. No audio or video clips were sent using this system.. Only one VisiTran consult involved transfer of the patient. Pictures sent by VisiTran were rated as very good to excellent by the platform nurse. The platform nurse found the VisiTran equipment easy to use and also confirmed that equipment was in good condition and ready to use when needed. In all five cases, the platform nurse strongly agreed that VisiTran was important for the diagnosis and/or treatment of the patient.

9 Hibernia Telemedicine Evaluation 4 months 4 Table 1: Hibernia Telemedicine Consultation Record Feb 1998-Apr 1998 Complaint Transfer Treatment Diagnosis VisiTran Injury 9/17 illness 6/17 12/17 7/17 3/17 5/17 Apr 7 injury x Apr 7 injury x Apr 2 injury x Apr 1 injury x Mar 29 chronic x x x Mar 28 injury x Mar 24 illness x Mar 16 illness x x x Mar 14 injury x x Feb 24 illness x Feb 23 injury x Feb 14 illness x x Feb 13 illness x x Feb 12 injury x Feb 11 injury x x Feb 8 illness x Feb 6 follow-up x x x

10 Hibernia Telemedicine Evaluation 4 months PHYSICIAN INTERVIEWS Original plans for individual interviews with the shore-based physicians were considered to be unmanageable because of their busy schedules. Instead, a joint meeting with three of the physicians was held May 13, A fourth physician was later interviewed independently. Interview discussion followed guidelines as outlined in Appendix 4. The interview sessions were not tape recorded but discussion points and comments by the physicians were hand recorded by the interviewers who were members of the evaluation team. 5.1 Consults The physicians work a 24 hour on-call schedule of one week in every five (from Friday to Friday). They considered this to be fine and that it works well. It was suggested that, if necessary, a physician who was involved in a previous consultation should be available to deal with specific issues arising from that consult, even if they were not the on-call physician at the time. One physician who is hearing impaired, expressed the wish that he have access to a better pager because he could not always hear it. He also noted however that the platform nurses will telephone if their page is not answered. Having only one pager was sometimes a problem when it had to be handed over to the next physician on-call. Three of the four physicians lived fairly close to one another but the fourth was in another part of the city. The physicians claim that they are consulted by the platform nurses approximately 4 to 5 times per week. When asked if this was what they expected most replied that they really didn t know what to expect; one physician said it was less than expected. One said that he talked with the Goose Bay people and they experience approximately the same. Another commented that the platform nurses have tremendous experience and skills and therefore don t need as much (help) from the docs. 5.2 Reasons for consultations Physicians estimate that about half of their total consultations were for injuries and half for other illness and chronic conditions. One physician had expected more consults for diagnosis and treatment, but stated that in all such cases he had agreed with the platform nurse s assessment. One unexpected need for consultations was in the field of mental health. We received at least one record of consultation for anxiety disorder. The physicians agreed that the system was not set up to handle mental health consultations. Some of the physicians thought that live video might be good for this. Reasons for consultation which were mentioned by physicians were: to confirm a medic s diagnosis or management plan, to prescribe antibiotics, to assess medical problems such as skin disorders and to follow-up treatment. Our recorded consultations show that 12 of 17 contacts involve a transfer of the patient to shore. However, the physicians in the group believe that there is about a 50/50 split between contacts for

11 Hibernia Telemedicine Evaluation 4 months 6 transfers and contacts for other reasons. 5.3 Consultations Most cases are resolved through telephone contact (95%) and the doctors find this to be satisfactory in most cases. One problem that they have encountered with the phone is the four second lag in transmission. Both parties in the phone conversation must be careful not to speak over the other person s words. A more serious problem is the possibility of whole system failure. This has apparently happened several times. This problem may have been corrected recently with installation of a back-up system. There were five recorded VisiTran consultations over a two month period, all initiated by the platform nurse. The doctors felt that this was to be expected since they, the physicians, were mostly for back-up. Also they did not feel that it was practical for them to contact the platform nurses since the nurses were on 24 hour call while on the rig and they did not want to call at a bad time. Physicians felt that the number of uses of the VisiTran system was appropriate. Full video conferencing had not been used for medical consultation up to the time of this report. When asked if they thought that there would be any change to their use of the VisiTran or video conferencing in the next six months the physicians replied that this was only likely if quality assurance sessions were introduced on a regular basis or if teaching sessions were introduced. 5.4 Potential Barriers to VisiTran Use: When asked if the location of the VisiTran equipment was a problem for its use, the doctors claimed that they had not had to use it very often yet so they could not consider it a problem. However, if use increases in the future, having to get to the Telemedicine site in the Health Sciences Centre might become a problem. Backup technical support on weekends and after hours at the telemedicine site was a concern. When asked about ease of use of the system, physicians cited some problems in the length of time it took to download the messages from the rig. This was earlier in the start-up of the system and this problem may have been corrected. Some stated that the system was not user friendly. They felt that their operational training for the system had been good, but more training was probably needed. They also mentioned that since their use of the system has been minimal, that they have to refer to their notes each time they use it. The quality of the pictures that the system produces was felt to be excellent. One of the physicians was so impressed with the quality of the pictures of an ear infection that he plans to use them in his teaching. They felt their relationship with the platform nurses on the rig was very good and they were very comfortable with the high level of expertise of the platform nurses and trusted their judgement. However, one of the platform nurse s reluctance to use the system is perceived as a barrier to VisiTran use.

12 Hibernia Telemedicine Evaluation 4 months Appropriate Use Telephone. The physicians felt that the phone was most appropriate for routine illnesses, injuries, questions as to medications and I.Vs and other knowledge-based queries. VisiTran. The most appropriate use of VisiTran was thought to be for dermatology cases, eye, ear and throat infections, neurological cases, range of motion in joint injuries and to view EKG s. Video Conference. Full video conferencing was thought to be appropriate for mental health cases, major accidents and burns. One physician commented that under critical circumstances, the rig medic could do the care while others worked the system. However, even in this latter case the doctors felt the platform nurses were competent to take care of things themselves. 5.6 Improvements to Consultation Process: Hibernia Site The following is a list of suggestions from the physicians as to how the Telemedicine consultation process might be improved at the rig site: The physicians would like to view the work setting of the medics on board the rig to get a better idea of the facilities. The physicians are unsure of their role in the event of a major disaster or potential disaster such as the gas leak that occurred on the rig this winter. In this case, they were not informed and they would like to know if they should be involved in disaster plans. The physicians would like to see a private area at the site to carry out counselling for individuals with mental health problems via video conferencing. Physicians in the Off Shore Health Services Group should be doing all pre-employment physical exams since the Hibernia physicians and medics will have to deal with any fallout. One physician thought that there should be a change in the policy of taking people off the rig if they are not on the job because of a minor medical problem. He felt that sometimes if you wait a short time the condition will clear up and the expense of transporting that person is averted. 5.7 Improvements to Consultation Process: On-shore Site The following is a list of suggestions from the physicians as to how the Telemedicine consultation process might be improved at the on-shore site: The pager that the physicians use was not considered to be loud enough.

13 Hibernia Telemedicine Evaluation 4 months 8 There was some uncertainty as to the procedure for access to the Telemedicine site in the evenings and on weekends and the availability of technical support at these times. The physicians would like some clarification of their role here on-shore in the emergency response exercises that take place on board the rig. All patients that have been taken off the rig are being taken by ambulance directly to the ER even if they could be seen by the physician in his office. This leads to unnecessary expense and paperwork. All patients transferred off the rig for medical reasons should visit the on-call physician both coming off and before going back to the rig, even if they are managed by their personal physician, to avoid a major paper chase and prevent people going out of the loop. 5.7 Conclusions The physicians are generally satisfied with their Telemedicine experience, but feel that additional training would be valuable. It was generally agreed that regular quality assurance sessions would be helpful in this regard. They were very impressed with the quality of the VisiTran pictures and over time have now become more comfortable with the consulting process: There is a greater comfort level now than at the beginning. A few expressed concern with only seeing a picture or hearing about the patient second hand. Participation of the on shore physicians group in pre-employment physicals and in examination and assessment of patients coming off and returning to work was suggested. Physicians would like their role clarified in certain areas, particularly in emergency situations. 6.0 PLATFORM NURSE INTERVIEWS Two separate interviews were conducted with the two Hibernia platform nurses, one by telephone and one face-to-face. The following summarizes the results of those two interviews, and reflects the general opinions of the two platform nurses. 6.1 Rig Employees There are an estimated 280 people on the rig at any one time, on a 3 week rotation. Approximately 265 of these employees are men; approximately 15 are women. There are as many as 1000 people who come to the rig (ie. workers, casuals, land based people who come for a day or week at a time). The sick bay holds charts on all Hibernia employees.

14 Hibernia Telemedicine Evaluation 4 months 9 Hibernia employees have an estimated age range between 21 and 62 years, with an estimated average age of years. According to one of the platform nurses, the employees are overall a very healthy group. Chronic health conditions of employees working on the rig include insulin-dependent diabetes, hypertension, and mental illness. These employees, however, do not use the sick bay any more than others. New guidelines are currently being introduced by Dr. Robbins, for pre-employment assessments. 6.2 Telemedicine Consultations The platform nurses work a 24 hour on-call schedule for 21 days. The shore-based physicians on-call schedule is 24 hours for 7 days (Friday to Friday) every five weeks. Over the time period February 7 to April we have consultation records for 17 contacts with shore-based physicians (See Table 1, page 4). This is about two consults per week. The platform nurses estimate that this represents about 20-25% of their total caseload. Most visits are due to flus, colds, scrapes, etc. and physician consultation is not required. In all cases where a transfer is being made the physician is contacted. Twelve out of 17 consults for which we have records were made with the intent to transfer the patient. 6.3 Telemedicine Experience and Training Both platform nurses have had previous experience with distance medicine. With respect to the training provided for the platform nurses on the current telemedicine system, there were conflicting views. One platform nurse felt that the training provided was adequate for later consults with physicians; one did not. The information provided about the advantages and disadvantages of the three telemedicine consult options, as well as information provided on the capabilities of the VisiTran and full video conferencing systems were rated between good and excellent by the platform nurses. The information provided about the general telemedicine consult procedures and protocols, as well as technical instructions for operating the VisiTran and full video conferencing systems were rated high by one platform nurse; however, the other rated each of these aspects as fair. This platform nurse added that they did not have the VisiTran cameras at the shore-based training sessions; so the first introduction to them was on the platform. We had to learn ourselves. Since there was technical support on the rig, they did learn how to use the cameras; so it was OK. 6.4 Telemedicine Contacts Telephone - The platform nurses agreed that the telephone quality is excellent. It is like next door. Interactions with physicians by telephone are good. The physicians are a great group to work with ; they answer their pager right away. The telephone is used for general consultations such as diagnosis and treatment plan confirmation which exceeds the platform nurse s professional limitations (eg. prescription medications), as well as to arrange for patient transfer.

15 Hibernia Telemedicine Evaluation 4 months 10 When the system was first started up, a number of times the telephone link was lost between the rig and on-shore. This occurred sometimes for days at a time, usually due to weather. This no longer seems to be a problem; however, the link can still be lost in crisis situations when there is a general shut down. During the recent evacuation of the rig in the early spring due to a gas leak, this problem was discovered. This could be a major issue since the telemedicine link would be vital in such a crisis. VisiTran - The platform nurses have experience with writing messages and sending still pictures and video clips. One of the platform nurses has not used the VisiTran system for consultation, but has done approximately six training demonstrations. The platform nurses think the still pictures are the most useful aspect of this system. Patients seem to be very cooperative and interested in the use of VisiTran and are relieved and reassured that such a system is available. With respect to physician interaction using VisiTran, one of the nurses commented, they are coming along. It was suggested that the physicians may need more practice using the system. Since the physicians are only on call one out of every five weeks, they may forget how to do certain things, like open a folder. Usually the platform nurse will send the VisiTran and pictures and then call the physician to look at them. The physicians are very cooperative, but they are not too keen yet, which may be why they do not request VisiTran pictures themselves. The platform nurses think the physicians are not aware of VisiTran s full potential. VisiTran is generally used for diagnosis and treatment confirmation, follow-up cases, and conditions, such as a rash, which is not resolving. Sending visuals, rather than trying to describe a skin condition, makes the process much easier. It does take a long time for information to be transferred using VisiTran, longer than anticipated. This would certainly affect the usefulness of the system in the event of an emergency. Full Video Conferencing - Neither platform nurse has used the full video conferencing for consultation. It was suggested that full video conferencing is of much practical help as it now stands, given some issues outlined below. Although full video conferencing has not been used by the platform nurses for consultation, they felt that it could be most appropriately used for trauma cases, multiple trauma emergencies during a weather shut down, or if the platform nurse wanted the physician s guidance in a procedure they were not accustomed (e.g. Burr holes). The platform nurses strongly suggested full video conferencing be used for continuing education for themselves. If doctors are doing an in-service, then this could be linked to the rig, since full video conferencing goes on frequently from the rig for business meetings. The platform nurses feel the full video conferencing has barriers which significantly affect its practicality and usefulness. The machine is big and unwieldy and wires on the floor create a safety hazard. Because of its size, it would have to be taken out of the sick bay if there were a trauma case with more than two patients. In addition, both platform nurses added that they would not be able to set up the system themselves. In emergency cases, the platform nurse s primary concern is

16 Hibernia Telemedicine Evaluation 4 months 11 to see that the patient is stabilized; therefore, all the medic s attention is on the patient. One of the nurses added,...your hands are tied.... Second, the system is not user friendly and setting it up is time consuming. A back-up support team would need to set up the system and this team would need to be very well trained to get the system set up quickly. Although a critical situation would probably be the most valuable time to have a video conferencing system, it is unlikely it would be used in such a case. Another concern with use of video teleconferencing under emergency conditions was where the shore-based physician would go in such a situation (ie. Hibernia Offices or Health Sciences Centre) and who would set up the teleconference equipment for them. This would be of particular concern on weekends and holidays when regular Telemedicine staff would not be present at the Health Sciences Centre site. 6.5 Suggested improvements to the consultation process The following is a list of suggestions from the nurses as to how the Telemedicine consultation process might be improved: The platform nurses felt that quality assurance approaches should be developed to increase equipment familiarity, particularly with full video conferencing. Suggestions on how to go about this included the following: - A refresher course should be conducted for everyone involved, including the nurses, physicians, and technicians. - Time must be dedicated to the use of the system. The platform nurses are very busy since they have other duties on the rig (ie. sitting in on committees and acting as secretary). This does not allow much time to play with the system. One suggestion was to have Rig Rounds twice a week, allowing planned time to be dedicated to using the system. - Continuing education should be introduced on the rig for the nurses. In addition to increasing the knowledge and education of the platform nurses, it would give them an opportunity to use the equipment. There should be an organized audit of all patient visits, whereby files sent on everyday are reviewed by the on-call physician. The suggestion of Rig Rounds is a similar proposal. This would allow the health care provided on the rig to be reviewed so that the platform nurses know the treatment they are prescribing is the best. In addition, it will address the legality and accountability issues for medical care provided on the rig. The VisiTran system should be improved so that the transmission time is faster. Currently, it takes too long for immediate use and uses a lot of band width.

17 Hibernia Telemedicine Evaluation 4 months 12 There is concern over the accessibility of the physicians to the equipment since a number of physicians are not located in the Health Sciences Centre. Certain issues, with respect to record keeping, must be clarified: - Should client records, including those of Hibernia personnel, be electronically charted? - How should chart information on patients seen by the platform nurse be logged in? - Should information be added to an existing file or entered into a new file? - How should files be identified since some employees do not have an MCP number? 6.6 Conclusion The platform nurses seem to be comfortable with the telemedicine system. According to one of the nurses, the system has helped keep people on board and get people off when needed. It was also stated that the system and the excellent liaison with the five physicians provides [the medics] with a better comfort level. The nurses, however, agree that improvement is needed. Training and systems familiarity, particularly with full video conferencing, seems to be where improvement is needed most. The issue of the telephone link being lost during general shut down and crisis situations is crucial and should be rectified immediately. Although one platform nurse expects to use the VisiTran and full video conferencing systems more in the future, the other mentioned that the telephone is a good service, therefore, it can probably be assumed this platform nurse will continue with telephone consultations until some of the major issues outlined here have been resolved. 7.0 PATIENT SATISFACTION All patients receiving medical care involving telemedicine consultation on the Hibernia rig were asked to complete a brief questionnaire (see Appendix 5). These questionnaires assessed patient satisfaction with the Hibernia health services in general and specifically with the telemedicine consultation process. We had eight patient satisfaction forms returned in the first four month period. 7.1 Specific Patient Comments 7.11 Comments concerning the medical care received at the Hibernia medic station: Very thorough The medic was very good and concerned about my problems. Very good service. I believe that the care I receive on the platform is very good. I am confident with the care I receive from medic. I found medical care I received was excellent.

18 Hibernia Telemedicine Evaluation 4 months Recommendations for changes to improve the present system: More talk with patient. If problem or illness can not be cured, I think the person should be sent ashore before the problem worsens (ASAP). Need X-Ray on rig. 7.2 Summary of Patient Questionnaire Because of such small numbers, a general summary of results is presented here. Specific results for each question are given in Appendix 1. The majority of the patients had a very positive opinion of the Hibernia Medical Centre services and the telemedicine system. However, one patient responded very negatively throughout the entire questionnaire. This patient felt his medical problem was not properly heeded at the time of injury and should have been attended to in a more timely fashion. His comment on the use of telemedicine consultation was that it was good as long as you use it when accident happens not days later. It was this patient that recommended the placement of X-ray equipment on the rig. All but one of the responding patients knew that telemedicine consultation was available from the rig and six out of eight knew that an on-shore doctor had been consulted in their case. No patient had direct contact with a physician and only three said they were present when the physician was contacted. One patient commented that more talk with (the) patient was needed. In this particular case, this seems to have been referring to the platform nurse explaining more about the available telemedicine options to the patient. Aside from the one negative opinion, all patients expressed very positive satisfaction with the Hibernia and Telemedicine services. They stated they were more confident in the health system knowing that on-shore physicians were available for consultation. They have confidence in the platform nurses and believe they are concerned with their problems. 8.0 SUMMARY AND RECOMMENDATIONS This 4-month formative evaluation assessed the Hibernia Telemedicine System in terms of its current use by the platform nurses and shore-based physicians, its perceived impact on patient care, as well as nurse, physician and patient satisfaction with the system. Data were collected by means of nurse-completed telemedicine consultation records, patient satisfaction questionnaires, and through key informant interviews with two platform nurses and four of the five shore-based physicians who provide on-call medical services to the Hibernia rig staff. Results indicated that an estimated 20 to 25% of nurse-patient contacts on the rig resulted in a medical consult with shore-based physicians. For the vast majority of these consults (~95%) only telephone communication was used and that appears to be quite adequate for most cases. A small percentage of consults made use of the VisiTran system to send still photos and text. The

19 Hibernia Telemedicine Evaluation 4 months 14 platform nurses, physicians and patients were generally satisfied with the system overall, however, there were a number of difficulties/barriers noted with the use of the VisiTran and full video conferencing system. A number of suggestions related to expanding the use of the system to realize its full potential were provided by the participants in this evaluation. 8.1 Recommendations The following recommendations come directly from the results of this study and in many cases represent specific ideas, comments and suggestions put forward by study participants themselves TELEMEDICINE SHOULD WORK WITH PLATFORM NURSES AND THE OFF SHORE HEALTH SERVICES GROUP TO: Set up a quality assurance program - initiate weekly rig rounds between platform nurse and physician on-call - establish regular scheduled times for VisiTran interaction - oversee file system, storage and archiving of data sent by VisiTran Promote emergency protocols which include platform nurse, telemedicine and physician s roles Include platform nurses in any appropriate in-service teleconferences Improve utility of VisiTran system - speed up VisiTran download time so that it will be more practical to use interactively in emergencies - implement additional training and quality assurance program for platform nurses and physicians - provide weekend and after hours technical support at the HSC site if needed Improve utility of full video system - arrange for more portability for the video system on the rig - initiate training for rig employees other than platform nurse to set up video system - provide access to technical support at HSC site to set up full video Provide a beeper to on-call physicians which is suitable for use by hearing impaired 8.12 TELEMEDICINE WORK WITH HIBERNIA MANAGEMENT TO: Assure adequate telemedicine consultation in emergency situations - plan for backup system for telephone or radio communication if rig electrical system is shut down - include on-shore physicians in emergency response drills - provide for rig employees to assist the platform nurse in video set up if needed Arrange for on-shore physicians to visit the Hibernia rig and medical clinic

20 Hibernia Telemedicine Evaluation 4 months 15 Provide dedicated time for platform nurses to participate in telemedicine consultation Establish a private room for mental health assessments and consultations Facilitate patient management by on-shore physicians - arrange for patients transferred off the rig to go directly to physician s office instead of to ER if appropriate - require pre-employment physicals be conducted by on-shore physicians group - request follow-up visit with on-shore physician before patient returns to work on rig 8.13 TELEMEDICINE SHOULD WORK WITH THE EVALUATION TEAM TO: Continue evaluation of the Telemedicine Service to the Hibernia Oil Rig Revise evaluation protocol based on this 4-month evaluation report and any subsequent intervention.

21 Appendix 1 Patient Satisfaction Results

22 Patient Satisfaction Results Health Services Evaluation 1. How would you rate the overall health services available to you through Hibernia? (n = 8) 7 said the services available through Hibernia are excellent or very good 1 said services are poor. 2. How would you rate the specific visit on the date entered in the shaded area above? (n = 8) 7 said the specific visit was excellent or very good 1 said the visit was poor. Questions 3 to 5 were answered on a scale of 1 to 6, with 1 indicating strong disagreement with the statement and 6 indicating strong agreement with the statement. 3. I feel more confident of the health system on the rig knowing that on-shore physicians can be consulted through pictures, videos and television. (n = 8) 3 strongly agreed with this statement 4 of the patients agreed or somewhat agreed with this statement 1 strongly disagreed with this statement. 4. I am very satisfied with the medical care I receive. (n = 8) 2 of the patients strongly agreed with this statement. 5 agreed or somewhat agreed with this statement 1 strongly disagreed with this statement. 5. There are some things about the medical care I receive that could be better. (n = 8) 4 of the patients strongly disagreed or disagreed with this statement. 4 somewhat agreed with this statement Telemedicine Evaluation 6. Before receiving this questionnaire and letter, did you know that video consultation with on-shore doctors was available from the oil platform medic station. (n = 8) 7 of the patients knew that the video consultation with on-shore doctors was available from the oil platform medic station. 1 did not know about this availability. 7. Were you aware that an on-shore doctor was consulted concerning your medical care? 6 of the patients were aware that an on-shore doctor was consulted concerning their medical care. 2 were not aware. 8. What components of the telemedicine system were used for this consultation with the on-shore doctor? (n

23 Patient Satisfaction Results = 6) Of the 6 patients who were aware the on-shore doctor was consulted concerning their medical care, 3 said the doctor was consulted by telephone, 2 said the doctor was consulted by VisiTran and 1 said telephone and VisiTran. 9. My contact with the on-shore doctor may be described as follows... (n = 6) 3 of the patients were not present during the consultation 3 of the patients were present during the consultation but did not talk with the on-shore doctor. (2 were not aware that a physician had been consulted ) Questions were answered with a number between 1 to 6-1 meaning the patient strongly disagreed with the statement, 6 meaning the patient strongly agreed. 10. I am very satisfied with explanations given to me about the equipment used (telephone linkage, cameras, recording, video, TV, etc.) (n = 6) 3 of the patients agreed or strongly agreed with this statement 1 strongly disagreed with this statement. 2 said this statement was not applicable to them. 11. I am dissatisfied with some things about the telemedicine care I have received. (n = 6) 4 of the patients disagreed or strongly disagreed with this statement 1 somewhat agreed with this statement. 1 said this statement was not applicable. 12. The telemedicine system of medical care is just about perfect. (n = 6) 4 agreed or strongly agreed with this statement. 1 strongly disagreed with this statement. 1 said this statement was not applicable. 13. The medical care I received from the on-shore doctor was just as good as being in their office. (n = 6) 3 of the patients agreed or somewhat agreed with this statement 3 said this statement was not applicable.

24 Patient Satisfaction Results Contact with On-shore Doctor Questions concerned patient contact with the on-shore doctor. All were not applicable for these patients since none had any direct contact with the physician. General Information 18. Age (n = 7) The ages of the patients ranged from 24 to 46, with an average age of 38.6 One patient did not give his age. 19. Sex (n = 8) All of the patients were male. 20. What is the highest level of education you have received? (n=8) 6 of the patients stated a trades college diploma 2 of the patients stated a high school diploma. Comments 21. Do you have any other comments concerning the medical care you received at the Hibernia medic station? Very thorough The medic was very good and concerned about my problems. Very good service. I believe that the care I receive on the platform is very good. I am confident with the care I receive from medic. I found medical care I received was excellent. 22. Any recommendations for changes to improve the present system? More talk with patient. If problem or illness can not be cured, I think the person should be sent ashore before the problem worsens (ASAP). Need X-Ray on rig.

25 Appendix 2 Medic Consultation Form

26 Appendix 3 Platform Nurses Interview Guidelines

27 Appendix 4 Physician Interview Guidelines

28 Appendix 5 Patient Satisfaction Questionnaire Form