In the late 1990s, child and adolescent psychiatry in Northern Sweden began utilizing videoconferencing in their work. Today, such technology is used in many different applications, primarily administrative but also in family conversations and start-up conversations before treatment and, to a limited extent, in personal meetings with patients and families. Video support is also used for planning and monitoring efforts together with children and parents, in collaboration with schools and social services. Professional groups concerned are, e.g., social workers, psychologists, nurses, attendants and doctors. Video conferencing is also used for tutoring or consultations between staff in relation to individual patient cases.

Some of the benefits identified are reduced travel and the ability to have more meetings, leading to better quality and collaboration management for doctors and other groups of staff. It also provides access to specific competences, such as dieticians supporting treatment of eating disorders. Skills transfer within the team is another advantage mentioned.

This text has been originally released in the following report: Telemedicine Survey in the County Council of Västerbotten -An analysis of the present situation, conditions and areas of improvement.

Already in 2000, the Department of Psychiatry in Västerbotten began utilizing videoconferencing in contacts with neighbouring units and non-healthcare partners. Organisational changes resulted in a significantly larger catchment area and the management realized that telemedicine was the only option to maintain good working relationships and proximity to patients and families.

Today videoconferencing is used widely among outpatient facilities, cottage hospitals and district hospital clinics for to facilitate conferences where local staff discusses referrals together with responsible psychiatrist in Skellefteå, and during treatment conferences with doctors participating from their home unit. In inpatient care, videoconferencing is used to facilitate meetings between the patients and their regular therapist or for planning of discharge. As the distance to inpatient facilities can be considerable, videoconference is also offered to family members that wish to participate in the meetings. Other collaborators using this technology are social insurance providers, unemployment offices and social services.

Although less common, some patients can also meet the doctor during emergencies and to some extent, therapy is provided to individual patients using this technology.

This text has been originally released in the following report: Telemedicine Survey in the County Council of Västerbotten -An analysis of the present situation, conditions and areas of improvement.

The child and adolescence habilitation in Västerbotten offers advice, support and rehabilitation to children and adolescents with mental retardation, autism, physical disabilities or other severe disabilities. As the unit has a clear focus on removing barriers for people in their everyday life, video conferencing is used extensively to avoid unnecessary travel. Above all, it is used for transfer conferences and habilitation conferences that previously meant travels for some of the participants. Video meetings have also been used in the follow-up of acquired brain injuries and since a few years back, such an approach is also employed in the education of parents of children with cognitive and communication impairments. In addition to patients and parents, some of these activities in addition involve staff from schools (principals, student health), psychologists, social workers and physiotherapists. This work model saves time for the staff, which improves the availability and gives more time for follow-up of the patients. Moreover, as the unit has a county responsibility, the opportunity to use videoconference directly increases the availability of specialist teams to the county inhabitants.

This text has been originally released in the following report: Telemedicine Survey in the County Council of Västerbotten -An analysis of the present situation, conditions and areas of improvement.

The Centre for Rural Medicine, GMC, in Storuman has developed a new concept for improving proximity to healthcare for residents in rural and sparsely populated areas. In December 2013, the first health room was inaugurated in the small village of Slussfors, midway between the primary care facilities in Storuman and Tärnaby. In this unmanned health room, residents can measure blood pressure, glucose, haemoglobin, weight and INR. The results are automatically directly accessible via the patient's record. The room is also equipped with a video conferencing system that enables meetings with, for example, doctor, nurse, speech therapist or physiotherapist. A medical camera for closer examination of skin and throat can deliver support for assessments, and in 2016, the system will be complemented with a stethoscope that can stream heart and lung sounds in real time. A few hours every week, the citizens are offered assistance by municipality home care staff, who can facilitate the sampling and help with, for example dressing of wounds. The room is also a meeting place for many other professional and patient groups.

Today there is a policy decision that health rooms shall be established in 20 municipalities in the northern health region. In 2015, there are rooms available in Storuman municipality in Västerbotten and Ragunda and Bräcke municipalities in the county of Jämtland.

This text has been originally released in the following report: Telemedicine Survey in the County Council of Västerbotten -An analysis of the present situation, conditions and areas of improvement.

The aim of collaborative care planning is management of information transfer and planning of a patients’ future care after admission from inpatient facilities. Already in the late 1990s, the first projects with video conference supported care planning were executed in Västerbotten County. Since then, this work model is routine practice in the entire county and has been further developed both as part of the ordinary care and within externally funded projects.

Typically, care planning engages nurses from the inpatient care unit, and when needed other staff categories, such as physiotherapist, dietician, therapists and physicians joins the conference. Municipal health and social care is represented by assistance officers and occasionally district nurses and rehabilitation staff, whereas primary care is represented by GPs or other staff categories when delegated this task. The patient typically participates in the care planning together with staff from the discharging clinic. Relatives sometimes join these meetings by visiting either of the participating units, or remotely by phone or video conference. Units that work routinely with care planning using virtual technology has their own videoconferencing equipment whereas municipal or primary care staff use equipment at the healthcare centre. It is also becoming more and more common for the municipalities to acquire their own videoconferencing equipment.

Managing the care planning via video conference prevents unnecessary travels, mainly for staff from the municipality and primary care who usually have had to travel to the hospitals to participate in care planning using traditional methods. Hence, main benefits is time saved through reduction in travel and that more professional categories can join the meetings. Hence, all co-workers have the opportunity to share information that can be of major importance for the quality of care provided after discharge. Moreover, this work model reduces the administrative load, as fewer stakeholders have to be informed afterwards.

This text has been originally released in the following report: Telemedicine Survey in the County Council of Västerbotten -An analysis of the present situation, conditions and areas of improvement.

The Neonatal Unit at Nus cares for children in need of extra support and monitoring during early life. The unit has the whole Northern Healthcare Region as catchment area and many of the children need care for long periods, sometimes a long way from home. Before leaving the neonatal unit and returning home to the family or to the local hospital after a prolonged stay, a so-called transfer meeting is held to inform parents and local staff thereby facilitating home going. Today, such meetings are sometimes held using video conferencing, particularly for children affiliated with Sundsvall regional hospital. Video conferencing helps parents, local staff and the specialist tem at Nus to meet and share important information aiming to provide support to the parents during their first time at home. The work model is based on a research study executed in collaboration with Sunderby hospital, aiming to investigate what factors influences the experience of bringing home an infant that has been hospitalised for a long time. The major benefit is increased feeling of safety for the children, the parents and the staff.

This text has been originally released in the following report: Telemedicine Survey in the County Council of Västerbotten -An analysis of the present situation, conditions and areas of improvement.

In 2012, a National Children’s Heart Network, Gertrude, was established to improve the support for children and new-borns with suspected heart conditions. Thanks to the Swedish Heart and Lung Foundation, 35 of the Swedish hospitals with paediatric cardiology units have received an advanced video conferencing system with the ability to share stored ultrasound examinations during a video meeting. Gertrud gives newborn babies all over Sweden the opportunity to be assessed by specialists who can detect cardiac abnormalities early, recommend treatment or decide on emergency transportation to specialised units. Cardiac ultrasounds can even be performed on foetuses with suspected heart conditions to be able to discuss and conclude on the best strategy together with the experts. As a University Hospital, Nus is one of the nodes providing support to other hospitals, but this solution also allows paediatric cardiologist at Nus to consult colleagues in case of uncertainties.

This text has been originally released in the following report: Telemedicine Survey in the County Council of Västerbotten -An analysis of the present situation, conditions and areas of improvement.

Since 2009, the paediatric cardiology unit at Nus supports Sunderby and Gällivare Hospitals with emergency assessments of cardiac ultrasound in children and newborns. The child is cared for by a local paediatrician where the ultrasound investigation is performed. The cardiologist at Nus views the ultrasound images in real time via their computer and, if needed, guides the ultrasound operator during the investigation and assists in the assessment. The video output of the ultrasound system is connected to a streaming server and the cardiologist at Nus accesses the images through a secure website via an ordinary computer. The service is provided 2-3 times per month, on average.

This text has been originally released in the following report: Telemedicine Survey in the County Council of Västerbotten -An analysis of the present situation, conditions and areas of improvement.

During 2005-2007, engineers at the Department of Biomedical Engineering and Informatics, R&D at Nus developed a system for remote auscultations that can stream or store signals from a digital stethoscope. Assessments were thereafter done either during a video consultation or by recording and storing the sound for future assessment. The system was evaluated by specialists at the paediatric cardiology unit at Nus and the paediatric clinic in Skellefteå hospital. Evaluation of the trial showed that the system reduced the need for ultrasound examination of children with physiological heart murmurs, and made time for the specialists to address children with more severe cardiac disease. The service also contributed to shortening the waiting lists, reducing the need for staff and patients to travel, thus improving the overall resource utilization. Another important aspect identified was competence improvement of the paediatrician in Skelleftea with respect to assessment of heart murmurs.

Due to technical challenges, the system was idle for many years, but in 2016 an updated solution has been deployed and will make it possible for several units to further improve their telemedicine services.

This text has been originally released in the following report: Telemedicine Survey in the County Council of Västerbotten -An analysis of the present situation, conditions and areas of improvement.

In 2005, the Dermatology Clinic at Nus began evaluating the possibility to assess skin conditions such as acne, psoriasis and eczema remotely through referrals supplemented by digital images. This evaluation was the start of a large-scale expansion of image-based diagnostics and today, the clinic offers consultations based on digital images to all primary care units. Diagnostics is based on a regular primary care visit where the skin condition is photographed by local staff and the image is stored in the patient's medical record. The GP thereafter sends a referral to the dermatology clinic with reference to the image. A dermatologist at Nus assesses the image and decides whether or not the patient needs to be referred to a dermatologist at Nus, or if the patient can be managed in primary care. In about 90 percent of the cases, a physical visit is judged unnecessary.

The approach results in faster assessment of patients and better use of healthcare resources. It also contributes to a more accessible and equitable care as specialist assessment is offered to all, regardless of place of residence. Other benefits are saved time and increased cost-efficiency thanks to a reduction in unnecessary travel and specialist appointments.

This text has been originally released in the following report: Telemedicine Survey in the County Council of Västerbotten -An analysis of the present situation, conditions and areas of improvement.

Early diagnosis is of great importance for the survival of patients with malignant melanoma. Until 2012, Nus offered referral-free appointments with dermatologists to assess moles, but it was concluded that the service only reached a limited number of people, primarily from nearby municipalities. To offer a more equitable service across the county, the clinic therefore launched a pilot study in 2012 to evaluate the opportunity to photograph suspected melanoma in primary care and have the images assessed by a specialist at Nus.
 
The mole is photographed through a mobile phone attached to a dermatoscope, which is a magnifying glass with light reflecting the skin in detail. Images are stored in the patient's medical record and a referral with reference to the images is sent to the Dermatology Clinic. Based on the images, the dermatologist judges whether or not the condition needs surgery or if it is best left unattended. The number of unnecessary surgeries has thus decreased and the lead times to correct diagnosis and treatment have been shortened considerably. Fewer physical visits has also led to less travel for the patients with environmental as well as economical gains. Another major benefit is an equitable treatment for the county's residents. The method was implemented in all healthcare centres in northern Sweden in 2014.

This text has been originally released in the following report: Telemedicine Survey in the County Council of Västerbotten -An analysis of the present situation, conditions and areas of improvement.

The towns of Tärnaby, Storuman, Sorsele and Malå in the inland of Västerbotten have access to extended primary care through the cottage hospitals. These units have since many years a video solution in the emergency rooms that allows external support or guidance during emergencies. Physicians on call at home or at another healthcare facility connect via a computer and a simple video streaming server. Through a controllable camera, they can get a good overview of the room. The communication is today facilitated by phone but the solution will be upgraded in 2016 to bi-directional audio and video communication.

This text has been originally released in the following report: Telemedicine Survey in the County Council of Västerbotten -An analysis of the present situation, conditions and areas of improvement.

The most common form of facial malformation in new-borns is a gap in lip, jaw or palate, known as cleft palate. In Sweden, there are six units that manage these patients, including Nus who are responsible for all babies born in Northern Sweden.

Since 2011, the so-called lip, jaw and palate team (LKG team) at Nus offers long-distance patients with isolated cleft palate their first visit via video or webcam. Östersund Hospital was the first to test the approach. These first visits, which should be held within 1-4 weeks of the child's birth, aims to inform parents and give the team an opportunity to observe the child and gather information needed to plan future treatment. These visits usually involve speech therapists, plastic surgeons and coordinators from the LKG team and nursing staff from the referring unit at the home hospital, usually the ear-nose and throat or paediatric unit. Approximately 80 percent of all first visits for children with isolated cleft palate, 5-10 patients annually, are managed via video.

The main benefits are reduction in travel, better transfer of information to the local medical staff, but also improvement of the skills of the local staff and their capacity to provide professional support to the parents. On occasions, the LKG team in addition provides parental dialogs and follow-ups via video calls.

This text has been originally released in the following report: Telemedicine Survey in the County Council of Västerbotten -An analysis of the present situation, conditions and areas of improvement.

The Centre for Geriatrics at Nus offers psycho-geriatric assistance via video or webcam to primary care facilities in southern Lapland and the Umeå region. The approach has been applied by Skellefteå Hospital to a limited extent since 2004 and by Nus since 2009. In recent years, the concept has been developed further as part of the EU project PrimCareIT (2012-2014), which involved seven countries in the Baltic region and aimed to address opportunities and barriers for tele-consultation and tele mentoring in primary care. The approach, now in routine practice, offers primary care staff support in the diagnosis, treatment and follow-up of psycho-geriatric problems, including dementia and other suspected cognitive disorders. Support is also provided to nursing of behavioural and psychological symptoms. Assistance is provided by psycho-geriatric specialists and, on occasions, specialist dementia nurses from the geriatric clinic and those receiving support are typically primary care GPs, district nurses, occupational therapists and nurses from special accommodations.

The approach contributes to increased availability to specialists and a more equitable health care as staff in primary care is given access to skills, which they had not had otherwise. In addition, the quality of assessment, diagnosis, treatment and care increases. This model also contributes to increased efficiency at the geriatrics department as this aid was previously offered face-to-face to primary care units in the urban areas. There are currently about 20 healthcare centres in the county who use the support. The Centre for Geriatrics at Nus also offer team conferences with nurses at Lycksele Hospital on a regular basis.

This text has been originally released in the following report: Telemedicine Survey in the County Council of Västerbotten -An analysis of the present situation, conditions and areas of improvement.

In Northern Sweden, there are about 170 adults with cochlear implant, CI. A cochlear implant is a high-tech tool that can restore hearing to deaf and severely hearing impaired. The implant, which consists of both implanted and external components, is inserted and tested at Nus for all adult patients in northern Sweden whereas children are treated at Karolinska University Hospital in Stockholm. After surgery, testing and adjustment of the tool is performed iteratively by local engineers and may result in up to ten patient visits during the first year after insertion. Since some time back, patients from Sunderby hospital is offered adjustment remotely. The patient and engineer connect using videoconferencing and the patient's implants are connected via an interface box to a computer that can be remotely controlled by the engineer to make the adjustment. This approach allows patients to have their aids adjusted at their local hospital leading to lower costs and environmental impact through reduced travel for patients and hearing engineers, who previously executed some of their work locally at Sunderby hospital. The approach can be extended to other hospitals in the region but also to the Karolinska University Hospital concerning children with CI.

This text has been originally released in the following report: Telemedicine Survey in the County Council of Västerbotten -An analysis of the present situation, conditions and areas of improvement.

The renal unit at Nus offers remote support to patients with peritoneal dialysis (PD) at the patients nearest primary care unit. The service was established in 2011 as part of the EU project ITTS and is now routine practice. The plan is to develop the concept further to be able to offer services also to the patient’s home. It is mainly patients with long distances to travel that utilize the service and primarily meets with specialist nurses. Appointments where the patient needs to meet with both doctor and nurse remains as face-to-face visits, but on account of the virtual visits with the nurse, the physical visits has been reduced from every sixth to every twelfth week.

In good time before the appointment, the patient leaves a blood sample at the primary care clinic that is later assessed by the PD nurse at the renal unit. Blood pressure and weight is also recorded at this time. At the time of the appointment, the patient utilizes the videoconferencing system at the primary care facility and the visit is then carried out in much the same way as a physical visit.

In addition to the benefits for the patient in terms of timesaving and increased quality of life, this concept is also a significant economic advantage for the county thanks to reduction in subsidised taxi services. Patients with physical disabilities are also given the opportunity to choose peritoneal dialysis when they are not hindered by long journeys to the same degree.

Transplantation nurses for kidney transplant patients have also tested the approach, which is planned to be introduced on a large scale shortly.

This text has been originally released in the following report: Telemedicine Survey in the County Council of Västerbotten -An analysis of the present situation, conditions and areas of improvement.

The Haematology Section at Nus is responsible for delivering highly specialized haematology care to all patients in Northern Sweden. Activities include regular follow-ups and drug recommendations, which today is also offered directly to patients in their homes using video services. Some patients need follow-ups as frequently as twice a week and many need follow-ups for life.

Before the visit, the patient leaves a blood sample at their nearest primary care unit and at the time of the appointment, connects using their personal computer and webcam to the specialist at Nus. Replacing some of the face-to-face visits for remote visits has proven beneficial for both the patient and the healthcare provider. Many of the patients are vulnerable to infection, and avoiding travel means avoiding unnecessary risk of infection. However, the model also results in financial benefits as patients otherwise have to travel alone in a taxi subsidised by the county council. Moreover, for some patients a routine visit to Nus requires over 100 km of travel and two to three days absence from home and work. The service was run as a pilot project in the fall of 2014 with support from the Regional Cancer Centre and is now introduced in routine practice.

This text has been originally released in the following report: Telemedicine Survey in the County Council of Västerbotten -An analysis of the present situation, conditions and areas of improvement.

The Centre for Cardiovascular Genetics, CKG, is a research centre operating within a partnership between the Heart Centre, the Centre for Medicine, the Child and Youth Clinic and Laboratory Medicine. The vision of CKG is to prevent morbidity and mortality in hereditary cardiovascular disease by offering families diagnostics, genetic counselling, monitoring and treatment. Today, CKG offers family receptions to many parts of the country for individuals with known hereditary cardiovascular disease and their relatives. On these occasions, a whole family is invited to a meeting together with referring physicians from their own hometown. Participants from Nus are generally clinical geneticist, cardiologist, cardiologists specialised in children and/or adults, genetic counsellors, and where appropriate, child cardiac nurse and counsellor. As family members are often dispersed geographically and that there is no need for physical examination during such meetings, video conferencing has been identified as a highly suitable solution for the family meetings. The main advantage of this approach is that everyone, including referring physicians at the family residence, receives the same information and at the same time, which increases patient safety. It also brings major time and cost savings as neither the family nor the team needs to travel.

The centre also offers genetic counselling to individuals or organisations, particularly to inhabitants of the northern healthcare region but also to individuals living in other counties and organisations, such as the National Board of Forensic Medicine in Linkoping.

This text has been originally released in the following report: Telemedicine Survey in the County Council of Västerbotten -An analysis of the present situation, conditions and areas of improvement.

Teledermatological visits were introduced in 1996 at the Dermatology Clinic at Nus in collaboration with some of the primary care driven cottage hospitals in the sparsely populated western parts of the county. Physicians and patient in primary care consulted a specialist at the Dermatology Clinic during a video meeting and still images of the patient’s symptoms shown in real time. Today, this work model has largely been replaced by “image referrals”, as described in the section Consultations and on-call support. The main benefits were that the patients did not have to travel to be evaluated by a dermatologist but also that primary care physicians were given the opportunity to develop his or her own expertise. Similar operations are today established with Lycksele and Skellefteå hospitals. Skin lesions/changes are photographed by a nurse at any one of the hospitals and images are stored in the patient's medical record. Thereafter, the patient schedules an appointment with a dermatologist, a meeting that is carried out using videoconference with support from a local nurse. Today, approximately five percent of all new and return visits to the dermatology unit are held remotely via video. Benefits of the work model include increased access to specialist for patients visiting hospitals in Skellefteå and Lycksele, reduction in waiting times to dermatologist and timesaving for patients who avoid travelling to the Umeå-based clinic.

This text has been originally released in the following report: Telemedicine Survey in the County Council of Västerbotten -An analysis of the present situation, conditions and areas of improvement.

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